Pneumonia/influenza pharm Flashcards
What are the types of pneumonia?
CAP
Nosocomial - includes:
1. HAP (>=48 hours after admission); includes…
2. VAP (>= 48 hours after endotracheal intubation)
Atypical
Aspiration
Chemical pneumonitis
What organisms cause atypical pneumonia?
Atypical bacterial pathogens:
- Legionella
- Mycoplasma
- Chlamydia
- Coxiella Burnetii
What is chemical pneumonitis?
Inflammation of the lungs or breathing difficulty due to inhalation of chemicals
What is the first step in CAP management?
Outpatient or inpatient care?
When is microbiologic testing NOT necessary?
ambulatory care setting with mild disease;
empiric therapy is usually successful
What are some co-morbidities to look out for with pneumonia?
DM
Heart
Lung
Liver
Kidney
AUD
What are the most common bacterial causes of CAP in normal, healthy patients?
Strep pneumoniae
Haemophilus influenzae
Atypicals
What are the most common causes of CAP in patients with comorbidities, recent AB use, smokers, and elderly patients?
Beta lactamase producing H. flu
Moraxella catarrhalis
MSSA
What are the most common bacterial causes of pneumonia in patients with structural lung disease? (Advanced COPD)
E. Coli
Klebsiella
What general type of antibiotic should be used to target S. Pneumoniae?
Beta Lactam
What general type of antibiotic should be used to target atypical pathogens?
Macrolides or doxycycline
REVIEW - what groups are what bacteria?
Gram +:
MRSA
Staph
Strep
Enterococcus
Gram -:
E. coli
H. flu
M. cat
Pseudomonas
Atypicals (mycoplasma, chlamydia, rickettsia, legionella, mycobacteria)
ESBL
Anaerobes:
Strep (+)
Clostridia (+)
Bacteroides (-)
Beta - Lactams - important points?
All the -cillins
Cephalosporins get more gram negative coverage as generations go up
-3rd gen: cefotaxime & ceftriaxone
-4th gen: cefepime
What are the macrolides?
erythromycin
clarithromycin
azithromycin
Vancomycin is a ___?
glycopeptide
Which ABx inhibit cell wall synthesis?
Beta-lactamases + vancomycin
Which ABx inhibit bacterial protein synthesis?
Aminoglycosides
Macrolides*
Tetracycline
Linezolid
Clindamycin
Which ABx inhibit nucleic acid synthesis?
Fluoroquinolones
Rifampin
Which ABx inhibit folic acid synthesis?
Sulfonamides
Trimethoprim
Which ABx inhibit free radical formation?
Metronidazole
What side effects will result from most the majority of ABx?
N/V/D
Rash
Thrush
Cephalosporins cause ___?
C Diff
Macrolides cause ____?
Hepatitis
QT interval prolongation
Quinolones cause ___?
QT prolongation
tendonitis
convulsions
Vancomycin causes ___?
Red man syndrome
Tetracyclines cause ___?
hepatotoxicity
stained teeth
photosensitivity
dysphagia
What are the top 3 options for treating CAP if no comorbidities? (outpatient)
Amoxicillin
Doxycycline
Clarithromycin
What should be given for a patient with CAP + comorbidities? (out-patient)
Option 1 - respiratory quinolone monotherapy
Option 2 - Beta-lactam PLUS macrolide of doxycycline
How should non-severe CAP be treated inpatient?
*IV not oral!
Option 1: monotherapy with a respiratory quinolone
Option 2: Beta-lactam + macrolide
*if isolate P aeruginosa, make sure you use beta-lactam that is anti-pseudomonal
How should severe CAP be treated inpatient?
*IV not oral!
Option 1: Beta-lactam + macrolide
Option 2: Beta-lactam + respiratory fluoroquinolone (levo or moxi)
How long should a patient with CAP be treated (w/ specific cases)?
min - 5 days, continue until patient is clinical stable
Legionella - azithromycin x 3 days
MRSA or P. aeruginosa - 7 days
When is a routine follow-up CXR NOT recommended?
symptoms resolution in 7 days
When is influenza season and peaks?
October to May
Peak December and February
What populations are at a high risk for developing influenza complications
- Person ages < 5 years old
- Persons with chronic medical conditions
- Immunosuppressed/ immunocompromised
- Women who are pregnant or <= 2 weeks post-partum
- Children and adolescents aged <= 18 years old who are taking meds with salicylates
- American indian/alaskan native persons
- Residents of nursing homes or chronic care facilities
- Persons with extreme obesity (>=40 BMI)
What are the two influenza tests and which should be used in hospitalized patients for greater S&S?
rapid influenza diagnostic tests
Rapid molecular assays ***
What are the benefits of antiviral influenza treatment?
- Early treatment shortens duration of symptoms/hospitalization
- Reduces risk of influenza-related complications
*should be initiated early as possible (w/i 48 hours best)
In what patients is antiviral treatment indicated in?
Hospitalized patients
Severe complicated/progressive illness
Increased risk of influenza complications
Which antiviral is recommended for patients with severe complicated or progressive illness who may or may not be hospitalized?
oral oseltamivir
What are the options for influenza antiviral treatment?
- Neuraminidase inhibitors:
- Oseltamivir
- Zanamivir
- Peramivir - Baloxavir Marboxil
- prodrug
- endonuclease inhibitor
- LONG HALF LIFE
- single dose
What are the antiviral options for acute uncomplicated outpatients
- oral oseltamivir
- inhaled zanamivir
- IV peramivir
- oral baloxavir
What is the preferred antiviral for pregnant patients
oral oseltamivir
Severe/complicated in patient NOT hospitalized preferred antiviral?
oral oseltamivir
What is Oseltamivirs dosage for treatment
Adults and children >=13 years:
75mg PO BID x 5 days
Age 2 weeks-12 years:
weight-based dose BID x 5 days
What is Oseltamivirs dosage for chemoprophylaxis?
Adults and children >=13 years:
75 mg po daily
Age >= 1 years:
weight-based dose daily
What is Oseltamivirs side effects and considerations for use?
GI upset, insomnia, behavioral changes
What antivirals are NOT recommended for prophylaxis?
peramivir and baloxavir
What is the route and duration for each antiviral (treatment)?
- oseltamivir - oral (5 days)
- zanamivir - inhaled (5 days)
- peramivir - IV (single dose)
- Baloxavir - oral (single dose)
What is the duration for antiviral prophylaxis?
7 days after last known exposure
For outbreaks in an institution - min 2 weeks continuing 1 week past last identified case
baloxavir is approved for post-exposure prophylaxis if 12+
What is the relationship between the antivirals and the ILAIV?
vaccine efficacy decreased:
O and Z - wait 48 hours
P - wait 5 days
B - wait 17 days
If not followed, should revaccinate with alternative vaccine
What class and meds are not recommended for influenza treatment?
Adamantanes
- amantadine
- rimantadine
What are the pneumococcal vaccines?
PCV13
PCV15
PCV20
PCV21
PPSV23
What are the guidelines for the influenza vaccine?
- Annual for all patients >= 6 months (inactivated influenza vaccine)
- only 18+ - recombinant vaccine
- adjuvant and high dose inactivated - only 65+
- approved in pregnancy
- Still acceptable to give if egg allergy
Who should NOT get the flu shot?
- <6 months
- severe life threatening allergies to ingredients (not egg)
- severe previous allergic reaction to a dose of influenza vaccine
What brands of flu vaccine can be given according to age group?
Fluzone - 6-35 months
Fluarix - 18+
FluLaval - 18+
Fluvirin - 4+
Afluria - 18+
FluMist - 2-49 years (only NS)
Childhood guidelines for Pneumococcal conjugate vaccine?
All children < 5 years:
-2 mos
-4 mos
-6 mos
-12-15 mos
What pneumococcal vaccine is appropriate for adults 50 years of age and older?
PCV15
PCV20 or
PCV21
*no pneumococcal vaccine previously
If PCV15 is chosen, PPSV23 must be given one year later
Minimum 8 weeks can be considered if:
-Immunocompromising condition
-cochlear implant
-cerebrospinal fluid leak
What are the pneumococcal vaccine guidelines in adults 65+
-Shared clinical decision making
-Option to get PCV20 or PCV21 or to not get additional
OR
PCV 20 or PCV21 can be administered if they have received both:
-PCV13 at any age
-PPSV23 at 65+
What are the guidelines for immunocompromised patients with specific conditions aged 19-49
PCV20 or 21
* wait 1 year if PPSV23 or PCV13 alone in the past
*wait 5 years if PCV13 + PPSV23 in the past
