Pneumonia VAP, CAP, Atypical Walking, Influenza Flashcards
mycoplasma pneumoniae is
smallest free living organisms and do not have a cell wall.
presentation of mycoplasma pneumonia infection
generalized aches, pains, low grade fever, temperature >102 and non productive cough and non exudative pharyngitis headache, myaglias, chills without rigors and nasal congestion with coryza and pneumonia.
flu like symptoms with higher fever and dry cough. see pharyngitis, chills, nasal congestio nand coryza
labs related to mycoplasma pneumonia infection
subclinical hemolysis,
positive coombs (DAT) and low complement levels
and elevated cold agluttin titer. Diagnosis is clinical but can get serology
may have underlying EBV infection.
Treatment of hemolytic anemia and cold agluttin dx related to this is avoidance of cold (even in warm weather) and heavy socks and coats to prevent agluttination.
treatment of mycoplasma
azithromycin.
moraxella catarrhalis is associated with people who have
COPD, pneumoconiosis, asthma, malginancies, or immuno suppressions.
VAP is
ventilator associated pneumonia happening after 48-72 hrs after ET higher risk for aspiration of organisms colonizing the oropharyngeal tract
Common VAP organisms
staph aureus (MRSA and MSSA) and P aeruginosa, Stenorophomonas maltphilia and acinetobacter
which antibody is not recommended for treatment of MRSA pneumonia? Linezolid or daptomycin
daptomycin because the pulmonary surfactant inhibits drug Daptomycin is approved for treating skin and soft tissue infectiosn and bacteremia with and without endocarditis
treatment of MRSA is with
vancomycin or linezolid. Linezolid is preferred in hospitals where majority of MRSA isolates have a vancomycin minimum inhibitory concentration (MIC)>2 mcg/ml.
azithromycin treats
gram positive and atypical and some gram negative bacteria. Not effective to MRSA.
who is at high risk for complications from influenza infection?
<2 yrs or >65 yrs
<19 on chronic aspirin therapy
women who are pregnant and up to 2 weeks post partum
underlying chronic medical illness (chronic pulmonary, cardiovascular, neurocognitive dx, renal or hepatic)
immunosuppressed (HIV too)
morbidly obese
Native Americans
nursing home or chronic care facility residents
DM2
pt has fever + cough and sore throat and high clinical suspicion for influenza should get
treatment for influenza with oseltamivir
risk factors that make influenza infection likely:
winter season, abrupt symptom onset, sick contact
What is the benefit for starting early antiviral therapy for influenzae
decreases symptom duration,
illness severity,
complication rates,
when should we start oseltamvir for suspected or confirmed influenza infections?
48 hrs of symptom onset (neuramindase inhibitor - like oseltamivir or zanamivir)
who should not get zanamivir for treatment of influenza?
chronic pulmonary disease (COPD and asthma) as it can precipitate bronchospasm and respiratory function decline?
can you start oseltamivir before getting results for rapid antigen for flu?
yes. don’t delay treatment. Also should NOT be stopped due to a negative rapid antigen test result in pts who the suspicion for influenza is high. This is because rapid antigen test is low sensitivity in diagnosing influenza. Reverse transcriptase PCR is more sensitive but less readily available.
When do we use ribavirin?
treat immunosuppressed pts with suspected lower respiratory tract infection from RSV not effective against influenza.
do we ever use amantidine or rimantadine for influenza?
no because of high drug resistance
Can you still get the flu after vaccination?
yes it only works about 40-60% of older individuals and outbreaks happen in vaccinated pts
how to stop spread of influenzae in a SNF or nursing home?
if 2 or more residents in a SNF develop a flu like illness within 72 hrs of each other , need to get tested. If positive for flu, residents at the facility (whether vaccinated or not and regardless of ward or floor) gets prophylactic antiviral therapy.
Prophylactic influenza therapy should last until
14 days or for 10 days after onset of illness in the last person affected, whichever is longer.
how to prevent spread of flu in healthcare settings?
immunize all healthcare workers standard isolation precautions (hand hygiene : gloves, hand washing with soap and water) and gowns
Droplet precaution measures for suspected or confirmed influenza pts in a SNF include:
droplet isolation precautions for 7 days after illness onset or 24 hrs after symptom resolution put pt in private room face mask on all personnel entering room N95 respirator for aerosol generating procedures (bronchscopy, intubation, extubation, sputum induction) limit visitors to infected room.
Cormorbid conditions that require a respiratory floroquinolone for treatment of CAP are:
DM2, CHF, lung dx, liver dx, renal dx, alcoholism, malignancy, asplenia and immunosuppression.
Criteria for needing respiratory floroquinolone (levofloxacin or moxifloxacin) for CAP?
risk factors for drug resistant Strep pneumo,
antibiotic use in the last 3 months
cormobid conditions: DM2, CHF, lung dx, liver dx, renal dx, alcoholism, malignancy, asplenia and immunosuppression.
why do we need to use a respiratory fluoroquinolone in diabetes?
because hyperglycemia can impair neutrophil chemotaxis, phagocytosis and cell mediated immunity and
contribute to increased susceptibility to infection in DM2
Pt who has suspected CAP and has no risk factors for tx resistant Strep and antibiotic use in the past 3 months and no comorbid conditions should be treated with
azithromycin or doxycycline.
what does CURB 65 stand for?
Confusion Uremia Respiratory rate Blood pressure
>65 yrs old used to determine how to triage pt
if 1-2 should get hospitalized
3-4 should go to the ICU
0 - outpatient treatment.
CURB 65 chart and algorithm
Name the clues that should increase your index of suspicion for Legionella pneumonia
Also can see renal acidosis too.
Cough, new infiltrate on CXR
Risk factors for legionella (elderly age, COPD, SNF resident) and confusion with high fever with bradycardia and hyponatremia and thrombocytopenia with LFTs and failure to respond to vancomycin and zosyn suggest
legionella infection.
Need to treat with respiratory quinolone or newer macrolide like azithromycin for suspected Legionella pneumonias
Legionella bacteria like living in
What is seen on CXR with Legionella pneumonia?
lakes, streams, man made reservoirs or standing water.
Intracellular gram negative bacilli.
On XR they have unilateral pulmonary infiltrate that forms lobar pneumonia
Diagnosis of Legionella
urinary legionella antigen test (detects only L pneumophilia serotype 1) and respiratory sample with (sputum or BAL) for legionella culture.
Pneumococcal vaccination schedule
Remember that PCV13 gives lifelong immunity.
Way to think of this is at 65 yrs, everyone gets PCV13 for lifelong coverage then PPSV23 1 year later.
People at greater risk - CHF, COPD, cirrhotics, DM2, smokers, ETOH, get PPSV 23 before age 65 yrs then get PCV13
People at greatest risk - CKD, HIV, cochlear implants, CSF leaks, get PCV13 NOW then PPSV23 in 8 weeks.
who gets post PNA CXR (7-12 weeks after)
pts who have higher risk of:
>50 yrs
male sex
history of smoking
To rule out presence of underlying lung cancer
Follow up measures for someone who has recovered from pneumonia are:
If high risk, get a CXR in 7-12 weeks (smoking, >50, male)
quit smoking
pneumococcal vaccination who are >65 yrs or DM2 or other risk factors.
who is high risk for influenza complications?
adults >65
women pregnant and up to 2 weeks post partum
underlying chronic medical illness (COPD, CAD, CKD, chronic liver)
immunosuppressed
morbidly obese
Native Americans
SNF or chronic care residents
what happens if someone has influenza and transiently improves and then worsesn with lower respiratory manifestations of cough, pleurisy and dyspnea
secondary bacteria pneumonia by Strep or Staph. H influenzae also can happen.
Need to treat with CAP (ceftriaxone and azithromycin) + MRSA coverage (vancomycin)
Only add antiviral treatment in pts who develop influenzae complications as secondary pneumonia are typically treated with antivirals even if they present >48 hrs of onset.
Tx of post influenzae secondary pneumonia
Need to treat with CAP (ceftriaxone and azithromycin) + MRSA coverage (vancomycin)
Only add antiviral treatment in pts who develop influenzae complications as secondary pneumonia are typically treated with antivirals even if they present >48 hrs of onset.
what are the risk factors for pneumonia for MRSA and gram negative organisms (pseudomonas and strep) :
history of MRSA infection so may be colonized
risk factors for pseudomonas: prior abx therapy, recent hospitalization, multiple medical cormobidities like ETOH, DM2, immunosuppression, possible aspiration and structural lung dx
drug resistant Strep Pneumo risk factors: age>65 and medical comorbidities, exposure to kids at day care and immunosuppresion and recent beta lactam, macrolid or floroquinolone
MRSA risk factors for pneumonia:
history of MRSA infection so may be colonized
IVDA
recent antibiotics
Risk factors for pseudomonal pneumonia
risk factors for pseudomonas:
prior abx therapy,
recent hospitalization,
multiple medical cormobidities like ETOH, DM2,
immunosuppression,
possible aspiration
and structural lung dx (COPD, bronchiectasis)
Risk factors for development of multidrug resistant strep pneumo
age>65
and medical comorbidities,
exposure to kids at day care and immunosuppresion
recent beta lactam, macrolid or floroquinolone
Tx for pneumonia with new right lung infiltrate and has history of MRSA, risk factors for strep pneumo and pseudomonas
Vancomycin and cefepime
if allergic to vancomycin:linezolide and cefepime. Don’t use daptomycin (D for don’t or daptomycin) as surfactant inactivates it in the lugns.
Treatment of legionella pneumonia
gram negative rod with poor gran stain. grows on charcoal yeast with iron and cysteine
treat with macrolide (azithromycin) or fluoroquinolone
Drug induced optic neuropathy is caused by these drugs
Toxicity associated with linezolid:
bone marrow suppression
peripheral neuropathy - can be irreversible see below
optic neuropathy - can be irreversible due to mitochondrial toxicity
No more than 28 weeks of this; need weekly CBC for bone marrow and periodic eye and neuro exams for >4 weeks.
Treats: MRSA and VRE and strepococcus and used for skin, soft tissue, and pneumonia.
Treatment of RSV in immunocompromised pts
give ribavirin and IVIG for immunocompromised or those with hematopoetic stem cell transplant
contraindicated in pregnant pts and men with close contact with pregnant pt. need to remain not pregnant for at least 6 months after taking it due to long half life.
Legionella causes two types of syndromes:
Legionnaires dx and Pontiac fever
Legionnaires dx - primary pneumonia due to Legionella.
Treatment of Legionella Pneumonia is with
Legionella is treated with atypical coverage with
azithromycin 1000 mg x1 then 500 mg for 6 days (total of 1 week)
Levofloxacin 750 mg daily for 7 days.
IV antibiotics are recommended until fever is cleared
treat with a longer course instead of typical azithromycin 500 mg x1 then 250 mg daily for 4 days.
can use clarithromycin and ciprofloxacin and ofloxacin moxifloxacin, doxycycline minocycline tetracycline or tigecycline or bactrim.
Remember ceftriaxone and zosyn are ineffective against legionella pneumonia.
Hospital acquired pneumonia empiric abx coverage
HAP - pneumonia that develops >48 hrs after hospitalization and not present at admission. Cover for MRSA and pseudomonas
vancomycin and cefepime
will need to double coverage if pt needs ICU Level of care (antipseudomonal beta lactam and aminoglycoside)
what kind of bacteria is a non lactose fermenting aerobic gram NEGATIVE bacteria
pseudomonas.
empiric coverage for VAP pneumonia
Treat with cefepime/pipercillin/carbapenem + vancomycin + atypical coverage (levoquin)
Need to cover for pseudomonas, MRSA and atypicals
