Pneumonia Flashcards
Mechanism of pathogenesis of pneumonia:
Aspiration of oropharyngeal secretions
inhalation of aerosols
hematogenous spreading
Epidemiology of pneumonia
3 cause of hospitalisaion
most common infectious cause of hospitalisations
most common cause of death from infectious diseases
S/S of pneumonia
cough, chest pain SoB, hypoxia Fever >38 deg, chills, fatigue, anorexia, nausea tachypnea, tachycardia, hypotension leukocytosis
Physical examination
Diminished breath sounds overaffected area
inspiratory crackles during lung expansion
Radiologic findings:
Chest xray/CT
new/progressive infiltrates
Dense consolidations
Lab findings (C-reactive protein, procalcitonin)
Non-specific
limited discriminatory potential
not reccomended for routines use to guide initiation/discontinuation
Respiratory cultures:
sputum
LRT samples
Aim of blood culures:
Rule out bacteremia
Aim of urinary antigen tests:
look for S. pneumoniae, legionella pneumophilia
Limitations of urinary antigen tests:
indicate exposure to respective pathogens
remain positive for days-weeks despite abx treatment
Classifications of pneumonia:
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
CURB-65 criteria:
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
Treatment of CAP in generally healthy population (outpatient):
amoxicillin 1g PO OD/
Levofloxacin 750 mg PO OD
Treatment of CAP in patients with CVD issues (outpatient)
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
Non-severe inpatient CAP treatment:
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
Severe inpatient CAP treatment:
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
Anaerobic coverage for CAP (lung abscess, empyema)
Clindamycin 300mg PO qds;600mg IV q8h
Metronidazole 7.5 mg/kg IV q6h
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)
Vancomycin 15 mg/kg IV q8h
Linezolid 600mg IV q12h
Pseudomonal coverage for inpatient CAP (prior respirator isolation of P.aerugiosa in past 1 yr):
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
Main considerations for using FQs in pneumonia
Delay diagnosis of TB
Adjunctive corticosteroid therapy:
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
Treatment modifications
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
benefits of switching from IV to PO antibiotics
increased patient comfort and mobility
decreased risk of nosocomial acquired bloodstream infections
decreased phlebitis
decreased preparation and administration time
decreased costs
facilitates discharge
Treatment duration of CAP:
At least 5 days – must achieve clinical stability in 48-72 hr
If MRSA/Pseudomonas: 7d
Burkholderia: 3-6 mths
