Pneumonia

Question 1

Mechanism of pathogenesis of pneumonia:

Answer 1

Aspiration of oropharyngeal secretions
inhalation of aerosols
hematogenous spreading

Question 2

Epidemiology of pneumonia

Answer 2

3 cause of hospitalisaion

most common infectious cause of hospitalisations
most common cause of death from infectious diseases

Question 3

S/S of pneumonia

Answer 3

cough, chest pain 
SoB, hypoxia 
Fever >38 deg, chills, fatigue, anorexia, nausea 
tachypnea, tachycardia, hypotension 
leukocytosis

Question 4

Physical examination

Answer 4

Diminished breath sounds overaffected area

inspiratory crackles during lung expansion

Question 5

Radiologic findings:

Answer 5

Chest xray/CT
new/progressive infiltrates
Dense consolidations

Question 6

Lab findings (C-reactive protein, procalcitonin)

Answer 6

Non-specific
limited discriminatory potential
not reccomended for routines use to guide initiation/discontinuation

Question 7

Respiratory cultures:

Answer 7

sputum

LRT samples

Question 8

Aim of blood culures:

Answer 8

Rule out bacteremia

Question 9

Aim of urinary antigen tests:

Answer 9

look for S. pneumoniae, legionella pneumophilia

Question 10

Limitations of urinary antigen tests:

Answer 10

indicate exposure to respective pathogens

remain positive for days-weeks despite abx treatment

Question 11

Classifications of pneumonia:

Answer 11

Hospital acquired: onset≥48 hr after hospital admission
Ventilator associated: onset ≥48 hr afrter mechanical ventilation
Community acquired: onset in community/<48 hr after hospital admission

Question 12

CURB-65 criteria:

Answer 12

confusion 
urea > 7 mmol/L 
RR> 30 breaths per min 
SBP< 90 mmHg or DBP ≤ 60 mmHg
age ≥65 yo 

score 0-1: outpatient
score 2: inpatient
score ≥3: inpatient, consider ICU

Question 13

Treatment of CAP in generally healthy population (outpatient):

Answer 13

amoxicillin 1g PO OD/

Levofloxacin 750 mg PO OD

Question 14

Treatment of CAP in patients with CVD issues (outpatient)

Answer 14

Augmentin 625 mg PO TDS / Cefuroxime 500 mg PO BD
+
Clarithromycin 500mg PO BD/Azithromycin 500 mg PO OD/Doxycycline 100mg PO BD

Levofloxacin 750mg PO OD

Question 15

Non-severe inpatient CAP treatment:

Answer 15

Augmentin 1.2g IV q8h/Ceftriaxone 1-2g q24h
+
Clarithromycin 400mg PO BD; 500 mg IV q12h/Azithromycin 500mg PO OD; 500 mg IV q24h/Doxycycline 100mg PO BD

Levofloxacin 750mg IV q24h

Question 16

Severe inpatient CAP treatment:

Answer 16

Pen G 4MU IV q6h/(Augmentin 1.2 IV q8h + Ceftazidime 2g IV q8h)
+
Clarithromycin 500mg PO BD; 500mg IV q12h/Azithromycin 500mg PO OD; 500mg IV q24h/Doxycycline 100mg PO BD

Levofloxacin 750mg IV q24h + Ceftazidime 2g IV q8h

Question 17

Anaerobic coverage for CAP (lung abscess, empyema)

Answer 17

Clindamycin 300mg PO qds;600mg IV q8h

Metronidazole 7.5 mg/kg IV q6h

Question 18

MRSA coverage for CAP (prior respiratory isolation of MRSA in the past 1 year/in severe cases, hospitalisation and received IV antibiotics within last 90 days and locally validated risk factors)

Answer 18

Vancomycin 15 mg/kg IV q8h

Linezolid 600mg IV q12h

Question 19

Pseudomonal coverage for inpatient CAP (prior respirator isolation of P.aerugiosa in past 1 yr):

Answer 19

Piperacillin/tazobactam 4.5 g IV q6h
+
Clarithromycin 500mg PO BD; 500mg IV q12h/Azithromycion 500mg PO OD; 500mg IV q24 h

Levofloxacin 750mg IV q24h

Question 20

Main considerations for using FQs in pneumonia

Answer 20

Delay diagnosis of TB

Question 21

Adjunctive corticosteroid therapy:

Answer 21

decrease inflammation in the lungs
may decrease length of stay and time to clinical stability
ay impact is small and likely outweighed by increased hyperglycemia
Dexamethasone 50mg IV q24h 4d/ Prednisolone 40 mg PO q24h 7d

Question 22

Treatment modifications

Answer 22

Empiric coverage for MRSA/P.aeruginosa can be stopped in 48 hrs if not found in culture and patient improving 
May step down if: 
Hemodynamically stable+
clinical improving+
Afebrile ≥24h +
able to digest PO medications+
Normally functioning GI tract

Question 23

benefits of switching from IV to PO antibiotics

Answer 23

increased patient comfort and mobility
decreased risk of nosocomial acquired bloodstream infections
decreased phlebitis
decreased preparation and administration time
decreased costs
facilitates discharge

Question 24

Treatment duration of CAP:

Answer 24

At least 5 days – must achieve clinical stability in 48-72 hr
If MRSA/Pseudomonas: 7d
Burkholderia: 3-6 mths

Question 25

Risk factors for CAP:

Answer 25

≥ 65 yo
Previous hospitalisation for CAP
Smoking
COPD, DM, HF, cancer, immunosuppression

Question 26

Risk factors for HAP:

Answer 26

Patient related: 
- Elderly 
- Smoking 
- COPD, cancer, immunosuppression 
- Prolonged hospitalisation 
- Coma, impaired consciousness
- Malnutrition 
Infection control related factors 
- Hand hygiene compliance 
- Contaminated respiratory devices 
Healthcare related factors 
- Prior antibiotic use 
- Sedatives 
- Opoid analgesics
- Mechanical ventilation 
- Supine position

Question 27

Prevention of HAP and VAP:

Answer 27

practice constant hand hygiene
judicious use of antibiotics ad medications with sedative effects
Limit duration of mechanical ventilation
minimise duration and deep levels of sedation
elevate head of bed by 30 deg

Question 28

Microbiology of CAP:

Answer 28

Outpatient: 
S. pneumoniae 
H. influenzae 
Mycoplasma pneumoniae
Clamydia pneumoniae
Non-severe inpatient: 
S. ppneumoniae
H. influenzae 
Mycoplasma pneumonia, chlamydia pneumoniae, legionella pneumophilia 
Severe inpatient: 
S. pneumoniae
H. influenzae
Atypicals 
S. aureus 
Klebsiella pnneumoniae, Burkholderia pseudomallei

Question 29

Microbiology of HAP/VAP:

Answer 29

Strep pneumoniae 
S. aureus 
H. influenzae 
E. Coli 
Proteus 
Serriata marcescens 
Enterobacter spp
Kleb pneumoniae 
acinectobacter 
P. aeruginosa

Question 30

Multidrug resistant organisms risk factors:

Answer 30

HAP:
- Prior IV antibiotics within 90 days
VAP:
- Prior IV abx within 90 days
- Septic shock at time of VAP onset
- Acute respiratory distress syndrome preceeding VAP onset
- ≥5 days hospitalisation prior to VAP onset
- acute renal replacement therapy prior to VAP

Question 31

Backbone treatment regimen for HAP/VAP

Answer 31

Pip/tazo 4.5g IV q8h 
Cefepime 2g IV q8h
meropenem 1g IV q8h
imipenem 500mg IV q6h
Levofloxacin 750mg IV q24h

Question 32

empiric MRSA coverage for HAP/VAP:

Answer 32

Vancomycin 15mg/kg IV q8h

Linezolid 600mg IV q12h

Question 33

Additional gram neg coverage for HAP/VAP:

Answer 33

Gentamicin 5-7mg/kg IV q24h
Amikacin 15mg/kg IV q24h
Ciprofloxacin 400mg IV q8h
Levofloxacin 750mg q24h