Pneumonia and Immunizations Flashcards
Types of PNA
- Community acquired
- outside healthcare facilities
- Aspiration
- aspiration of oral or GI content
- Hospital Acquired
- PNA occurs 48+ hours after admission
- Ventilator Associated
- 48-72 hours after intubation
- Health Care Associated
- hospitalized at least 2 days within 90 days
- SNF and LTC
- IV abx, wound care, chemo, HD within last 30 days
- Resemble HAP; more resistant bacteria
Common Pathogens associated with each type of PNA
- CAP
- Hflu, Moraxella, Strep pna
- Atypical: mycoplasma, chlamydia, legionella
- Hflu, Moraxella, Strep pna
- Aspiration:
- anaerobes
- strep viridans, Gram - bacilli
- anaerobes
- Hospital/ VAP/ HCAP
- MSSA, klebsiella, E.coli, Strep pneumo
- MRSA, ESBL+, Klebseilla, pseudomonas, acinetobacter
- atypical: mycoplasma, chlamydia (rare)
CURB-65
1 point per positive: (1 = treat outpatient; 2+ = hospitalize)
- age 65+
- confusion
- uremia (BUN19+mg/dL)
- RR >30/min
- BP <90/60
SOAR Score
1 point per positive: (<2 = non severe; 2+ = severe)
- SBP <90
- Oxygen (Pa02; Fi02 <250)
- age 65+
- RR 30+/min
Assessing Severity of PNA: Step 1
is yes to ANY of these then proceed to step 2; if all no = RISK CLASS I
-
Presence of:
- >50 yo
- AMS
- P: 125+/min
- RR >30/min
- SBP<90mmHg
- Temp <35C or 40+C
-
Hx of:
- neoplastic disease
- congestive heart failure
- cerebrovascular disease
- renal disease
- liver disease
Assessing Severity of PNA: Step 2 (demographics)
Male
Female
SNF resident
Assessing Severity of PNA: Step 2 (Comorbidities)
- Cancer
- liver disease
- CHF
- Cerebrovascular
- Renal Disease
Assessing Severity of PNA: Step 2 (PE findings)
- AMS
- P125+/min
- RR >30/min
- SBP <90mmHg
- Temp <35C or 40+
Assessing Severity of PNA: Step 2 (Lab/Radiology)
- Arterial pH <7.35
- BUN 30+
- Na+ <130
- Glucose 250+
- Hct <30%
- PaO2 <60mmHg
- Pleural Effusion
Assessing Severity of PNA: Step 2 Scores
- <70 = Risk Class II
- 71-90 = Risk Class III
- 91-130 = Risk Class IV
- >130 = Risk Class V
- all are outpatient until IV (Moderate Risk) and V (High Risk) = hospital admission
Treatment of CAP with CURB-65 = 1 with no co-morbidities
- Amox 1gm TID
- Macrolides
- Doxy 100mg BID
- Prior Abx
- azith/clarith + HD amox/HD aug or fluoroquinolones
Treatment of CAP with CURB-65 = 1 with co-morbidities
- gemi, levo, moxi
- azith/clarith or doxy + HD amox/HDaug
- axith/clarith or doxy + cefdinir, cefpodoxime, cefprozil, cefuroxime
Tx of PNA with CURB-65 score 2+ (non-ICU)
tx 5 days or 48-72s without fever
- azith + ceftriaxone
- azith + ertapenem
- levo, moxi
ICU PNA txs (pseudomonas risk, no risk, and MRSA)
- pseudomonas risk?
- cefepime or ceftazidine, or zosyn, or imipenim, or meropenem, + cipro or levo or aminoglycoside
- no pseudo risk?
- cefotaxime or ceftriaxone + azith
- levo/moxi
- MRSA?
- add vancomycin or linezolid to above
HAP/VAP/HCAP empiric tx without risk factors for MDR
- ceftriaxone/cefotaxime
- gemi/levo/moxi
- unasyn
- ertapenem
HAP/VAP/HCAP empiric tx with risk factors for MDR
- cefepime/ceftazidime
- cipro/levo
- zosyn/timentin
- imipenem/meropenem
- aminoglycosides
HAP/VAP/HCAP empiric tx with risk for MRSA
vancomycin, linezolid
duration of tx for adult outpatient CAP
5 days if levo or azith
7-10 days for other agents
duration of tx for pediatric uncomplicated CAP
10 days, except azith = 5 days
duration of tx for HAP
blood cx (-) = 7-10 days
blood cx (+) = 14 days
HCAP/VAP = 10-21 days (no pseudomonas? 7 days)
PCV-13
for =5 and 65+
6 yo+ with high risk (immunocompromised)
PPSV-23
65+
2-64 yo with high risk (should not receive second dose at/after age 65 if within 5 years of last PPSV-23 vaccine or within 1 year of last PCV-13 vaccine)
- inffective in children <2yo
Pts 19yo+, high risk, and the PCV-13 and PPSV-23 dosing
PCV-13 then at least 8 weeks apart PPSV-23
then at least 5 years later PPSV-23
then at least 5 years later AND 65+ PPSV-23
Antiviral Medications for Influenza
- Adamantanes
- amantadine (Symmetrel)
- Rimantadine (Flumadine)
- Neuraminidase Inhibitors
- Zanamivir (Relenza)
- Oseltamivir (Tamiflu)
- Peramivir (Rapivab)
- Cap-dependent Endonuclease inhibitor
- Baloxavir marboxil (Xofluza)
tx of Diptheria
diptheria antitoxin (DAT)
Macrolides IV (erythromycin) or Penicillin G IV
Pertussis
aka whooping cough
tx: macrolides or septra (trimethoprim/sulbactam)
Who should NOT get the flu live vaccine?
- age 2-4 years with diagnosis of asthma or had wheezing/asthma in the past 12 months
- immunocompromised
- close contacts of severely immunocompromised
- pregnant women
- pts who have received influenza antiviral within the previous 48 hours
Influenza Vaccines
- Live intranasal:
- approved for 2-49 yo; non-pregnant
- Injectable:
- egg based:
- IIV3 (inactive influenza vaccine trivalent)
- IIV4 (quadrivalent)
- Cell-cx based:
- IIV4
- Recombinant Hemagglutinin (HA)
- RIV4
- egg based:
Non-Egg Based Flu Vaccines
IIV4: Flucelvax (Cell cx based)
RIV4: Flublok (Recombinant Hemagglutinin (HA)
Zanamivir (Relenza)
inhaled
inhibits influenza neuraminidase
SEs: Bronchospasm, SJS, TEN, Seizures
prophylaxis: 10 mg inhaled qday x 10 days
Oseltamivir (Tamiflu)
Oral
inhibits influenza neuraminidase
SEs: abdominal pain, conjunctivitis, ear disorder
epistaxis, insomnia/delirium, NVD
DDI: clopidogrel = decrease levels of tamiflu
Peramivir (Rapivab)
Administered IV
inhibits influenza neuraminidase
SEs: Delirium, anaphylaxis/SJS. neutropenia, diarrhea/hyperglycemia
Baloxavir Marboxil (Xofluza)
inhibits DNA synthesis
prodrug
not recommended in pregnant/breastfeeding, complicated outpt, or hopsitalized
SEs: diarrhea, bronchitis
