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PANCE Prep > Pulm > Flashcards

Pulm Flashcards

1
Q

Acute respiratory distress syndrome (ARDS)

A

Acute, diffuse inflammatory form of lung injury and respiratory failure due to many causes.

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2
Q

Risk factors for ARDS

A

Gram-negative sepsis most common cause

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3
Q

Other causes of ARDS

A

Trauma, severe pancreatitis, aspiration pneumonia (gastric contents), near drowning

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4
Q

Signs and symptoms of ARDS

A

Acute onset with in 1 week of insult or worsening of resp status. Bilateral infiltrates with no other explanation. Edema not from fluid overload or CHF.

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5
Q

Clinical manifestations of ARDS

A

Acute dyspnea, hypoxemia despite O2 supplementation. In severe, multiorgan failure.

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6
Q

Dx and labs for ARDS

A

Chest xray shows bilateral diffuse pulm infiltrates, but spares costophrenic angles.
PaO2/FiO2 ratio less than 300.
PCWP less than 18 mm (will be greater than 18 in cardiogenic pulmonary edema)

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7
Q

Diagnosis of ARDS is made with

A

chest xray, labs, history (key is acute onset within 1 week of lung injury/insult/illness mentioned under causes and no other explanation for infiltrates or edema.

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8
Q

Management of ARDS

A

6Ps: PEEP management, Prone position (decreases mortality in 50% of cases, paralysis in some cases, peeing (fluid management), pulmonary vasodilators (nitrous oxide) or prostacyclins, perfusion (VV ECMO if refractory to other treatment options)

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9
Q

Foreign body aspiration

A

FB enters airway causing choking.

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10
Q

Most Common cause of FB aspiration

A

Food

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11
Q

Location of most FB aspirations

A

Main bronchus or lobar bronchus (R>L)

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12
Q

Risk factors for FB aspiration

A

Institutionalized, elderly, poor dentition, alcohol, sedative use

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13
Q

Clinical manifestations of FB aspiration

A

Inspiratory stridor if high in airway, wheezing, decreased breath sounds if low in airway

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14
Q

Dx/labs for FB aspiration

A

Chest xray may show expanded lungs, hyperinflation of affected side. ABG is necessary to follow progression and to assure proper ventilation.

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15
Q

Management of FB aspiration

A

Remove FB by bronchoscopy (rigid for kids, flexible for adults.

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16
Q

Complications of FB aspiration

A

Pneumonia, ARDS, asphyxia

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17
Q

Hyaline membrane disease

A

Common problem in preterm infants (less than 30 weeks GA) Deficiency in surfactant production in an immature lung resulting in high surface tension leading to instability of lung at end expiration, low lung volume, decreased compliance which then leads to hypoxemia due to atalectasis.

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18
Q

When is surfactant released in lungs

A

20 weeks gestation

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19
Q

Hist/PE/CM for Hyaline membrane disease

A

Preterm infant, tachypnea, nasal flaring, expiratory grunting, cyanosis, intercostal, subxiphoid, and subcostal retractions.

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20
Q

Dx Labs for Hyaline membrane disease

A

Chest XR shows low lung volume, diffuse reticulogranular ground glass appearance, air bronchograms
ABG hypoxemia that responds to O2
PCO2 initially normal to slightly elevated. Increases as disease worsens. Progresses to hyponatremia.

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21
Q

Management for hyaline membrane disease

A

Betamethasone antenatal IM x2. Initially use positive pressure (neonatal CPAP or NIPPV). Surfactant administration via endotracheal intubation.

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22
Q

Acute bronchiolitis Scientific concepts/definition

A

Infection or inflammation of the bronchioles. MCC viral infections like RSV, rhinovirus, influenza, parainfluenza, adenovirus. RSV MCC for 2 mos to 2 years old.

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23
Q

Risk factors for acute bronchiolitis

A

Premies (less than 37 weeks), No breastfeeding, less than 6 months old, smoke exposure, crowded living conditions.

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24
Q

CM/Hist/PE for acute bronchiolitis

A

Viral prodrome (fever, URI syx) for 1-2 days, then progresses to respiratory distress. Expiratory wheeze, crackles, hyperinflation, tachypnea, incr RR, grunting, intercostal retractions, nasal flaring.

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25
Q

Dx labs for acute bronchiolitis

A

clinical DX or nasal swab. CXR nonspecific: Incr bonchovascular markings, hyperinflation.

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26
Q

Management of acute bronchiolitis

A

Palivizumab (synagis) for children less than 29 weeks gestation birth for first year of life. Supportive care (fluids, suction, antipyretics, bronchodilators), cough may persist for weeks.

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27
Q

Acute bronchitis SC and definition

A

Lower respiratory infection characterized by inflammation of bronchi. MCC is viral (over 90% of cases), i.e. influenza A or B, parainfluenza, adenovirus, RSV, rhinovirus, coronavirus. Bacterial is about 6% with bordatella pertussis for unvaxxed, mycoplasma or chlamydia for vaxxed.

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28
Q

History/PE/CM for acute bronchitis

A

cardinal syx cough for 1-3 weeks with or without sputum, with or without wheeze or mild dyspnea, prolonged cough can lead to chest wall soreness. Acute bronchitis is MCC of hemoptysis (along with cancer). URI syx before and during including headache, congestion, sore throat, malaise.

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29
Q

Diagnostics/labs for acute bronchitis

A

clinical Dx: Acute onset but persistent cough without clinical findings suggestive of pneumonia (fever, tachypnea, rales). On CXR: only used to rule out pneumonia. Will often be normal or nonspecific with peribronchial thickening.

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30
Q

Management of acute bronchitis

A

Self limiting disease process. Supportive care, i e rest, fluids, analgesics, OTC cough meds, Antibiotics not indicated for most cases.

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31
Q

Acute epiglottitis SC/Definition

A

Potentially life threatening epiglottic inflammation. Most common in kids ages 3-6 years, males MC 2x more than females. RF: Diabetes mellitus in adults. Etiology: H flu (Hib) for unvaxxed, Strep species such as strep pneumo, or Group A strep in vaxxed. Cocaine use in adults.

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32
Q

Hist/PE/CM for acute epiglottitis

A

Three D’s: Dysphagia, drooling, distress. Fever, odynophagia, inspiratory stridor, dyspnea. Hoarseness, muffled “hot potato voice”, tripod position, retractions, cyanotic lips.

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33
Q

Dx/Labs for acute epiglottitis

A

Definitive laryngoscopy preferably when securing airway will show cherry red epiglottis with swelling. Lateral cervical x-ray “thumbprint sign”

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34
Q

Management of acute epiglottitis

A

Most important part is securing airway. Then dexamethasone for airway edema. Antibiotics: Ceftriaxone or cefotaxime with or without ampicillin, PCN, or vancomycin. To prevent: Rifampin to all close contacts, Hib vax.

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35
Q

Croup SC/Define

A

inflammation of larynx and subglottic aireay MC 6 mo to 6 YO especially in fall and winter. Etiologies: Parainfluenza type 1, mycoplasma, RSV 2nd MCC.

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36
Q

Hist/PE/CM of Croup

A

“seal-like” “barking cough”, inspiratory stridor, hoarseness, dyspnea, low-grade fever, URI syx (coryza) prior to or during or after.

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37
Q

Dx/Labs for croup

A

Clinical dx. AP cervical xray may show “steeple sign”

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38
Q

Management for croup

A

If mild: No stridor at rest, no resp distress, then supportive care (cool mist humidifier, O2 if less than 92%) with or without dexamethasone.
If mod: Stridor at rest with mild or moderate retractions: Dexamethasone PO or IM and supportive care. Nebulized epinephrine. observe 3-4 hours for improvement.
If severe: Stridor at rest with marked retractions: Dexamethasone plus supportive care, neb epi, hospitalize.

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39
Q

Influenza SC/Define

A

Viral Flu A more severe outbreaks than Flu B. Transmitted mostly by airborne resp droplets (cough, sneeze, talking, breathing) or contaminated surfaces. Incr risk age over 65, pregnant, immunocompromised. MC in kids. If over 65, at risk for complications.

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40
Q

Hist/PE/CM influenza

A

Abrupt onset, headache, fever, chills, malaise, URI syx, sore throat, pneumonia, myalgias.

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41
Q

Complications of influenza

A

pneumonia, resp failure, death, meningitis, encephalitis, rhabdomyolysis, kidney failure

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42
Q

Dx/Labs for influenza

A

Rapid flu swab, viral culture

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43
Q

Management of influenza

A

mild disease in otherwise healthy pt: Supportive care (tylenol, motrin, rest, fluids). Oseltamivir if within 72 hours of onset, also for age over 65, cardiovascular disease, pulmonary disease, immunosuppression, chronic liver disease, hemoglobinopathies. For prevention: VAX. Adverse drug reactions to vax: fever, myalgias, irritability. Vax contraindicated in: those allergic to vax, Guillian Barre w/in 6 weeks of previous vaccine, high fever, infants less than 6 MO.

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44
Q

Bordatella/Pertussis SC/Define

A

Gram-negative bacterial transmitted by droplet. PRevent with vax in DTAP at 2, 4, 6 months each visit, then once between 15 and 18 most, once between 4 and 6 years old.

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45
Q

Hist/PE/CM of bordatella/pertussis/Whooping cough

A

Catarrhal stage: Most contagious time: URI syx for 1-2 weeks. Paroxysmal phase: severe paroxysms of coughing fits with inspiratory whoop sound after cough. Many have post-tussive vomiting. Often lasts 2-4 weeks. Convalescent phase is when cough is resolving.

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46
Q

Dx/Labs for Whooping cough

A

throat culture rule out other illness. PCR swab. Lymphocytosis common.

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47
Q

Management of Whooping cough

A

supportive care, O2, nebulizers, mechanical ventilation if needed. Antibiotics: Azithromycin or erythromycin. Complications: Pneumonia.

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48
Q

Empyema SC/Define

A

Collection of pus in pleural space between lung and chest wall. Caused by bacterial infection spread from lungs or abscess, or surgery or trauma, TB.

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49
Q

Hist/PE/CM of empyema

A

Decreased tactile fremitus, decreased breath sounds, dullness to percussion, pleural friction rub. Fever, chest pain, SOB, cough, night sweats, malaise.

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50
Q

Dx/Labs for empyema

A

CXR, CT, pleural fluid analysis, blunting of the cosphrenic angle on XRAY/CT. Thoracentesis is therapeutic and diagnostic. LIghts criteria: 1. pleural fluid LDH >2/3 upper limits of normal serum LDH. 2. PLeural protein/serum >0.5. 3. Pleural LDH/Serum LDH >0.6.

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51
Q

community acquired pneumonia

A

Pneumonia acquired outside of hospital setting or within 48 hours of being admitted.

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52
Q

RF for CAP

A

Older age, tobacco use, excessive alcohol use, comorbid conditions (esp COPD), recent viral URI, immune suppression

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53
Q

Organism association: Streptococcal pneumoniae

A

Young adults, post-influenza

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54
Q

Org association: Haemophilus influenza

A

COPD, elderly

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55
Q

Org association: Moraxella cararrhalis

A

COPD, immune compromise

56
Q

Org association: Klebsiella

A

alcoholics, diabetics

57
Q

Org association: Staphyloccus aureus

A

Post-influenza

58
Q

Org association: Mycoplasma

A

Kids, teens, colleges, military

59
Q

Org association: Chalmydia pn

A

Kids, teens, military

60
Q

Org association: Chlamydia psittaci

A

Exposure to birds

61
Q

Org association: Legionella

A

air conditioning, hot tubs

62
Q

Org association: Coxiella burnetti

A

Farm animals

63
Q

Org association: Franciesella tulerensis

A

“tuleremia” rabbits

64
Q

Org associations: Viral

A

RSV, CMV, influenza, parainfluenza, adenovirus, covid.

65
Q

Signs and Sxs of CAP

A

Acute onset fever, cough with or without sputum, dyspnea

66
Q

Hist/PE/CM for CAP

A

Tachycardia, tachypnea, crackles (rales) rhonchi. incr tactile fremitus, egophony, dullness to percussion.

67
Q

Path assoc: Legionella

A

Atypical pneumonia, gram neg, 2-1 days incubation, fever, fatigue, then cough and SOB. GI sxs (NVD), hyponatremia, elevated liver enzymes, CRP >100

68
Q

Path assoc: Mycoplasma

A

MCC atypical pneumo. School aged kids and adolescents, schools, colleges, prisons, military. Gradual onset, HA, malaise, low-grade fever +/- sore throat, cough +/- sputum, SOB, pleuritic CP, chest soreness from coughing, persistent cough. URI sxs of rhinorrhea, otitis media, sinusitis, cervical LAD

69
Q

Path assoc: Mycoplasma in nonrespiratory disease

A

autoimmune hemolysis (Incr IgM cold aglutinins), erythema multiforme, JSJ, urticaria, mucositis; Cardiac (pericarditis, myocarditis), MSK (arthralgias, myalgias), mild elevations in liver enzymes.

70
Q

Nosocomial pneumonia/HAP
Ventilator associated pneumonia/VAP

A

Hospital acquired pneumonia. Acquired >48 hours after admission.
VAP: Acquired >48 hours after endotracheal intubation.

71
Q

Pathogens associated with HAP/VAP

A

Pseudomonas (cystic fibrosis), enterobacter, acinetobacter, S aureus (esp MRSA), strep pneumo

72
Q

RF for HAP/VAP

A

Freq abx use, extended hospitalization >5 days.

73
Q

To Diagnose HAP/VAP, you need

A

New lung infiltrate AND 2 or more clinical features of infection such as: New onset fever, leukocytosis, leukopenia, purulent sputum, decline in oxygenation.

74
Q

Pseudomonas VAP RF:

A

IV Abx in last 90 days; structural lung disease like cystic fibrosis, bronchiectasis.

75
Q

Sxs of pseudomonas VAP

A

Fever, cyanosis, hypotension, rapid cavitation <72 hours on CXR, green sputum

76
Q

Dx/Labs for pneumonias

A

CBC: Leukocytosis w/left shift. CMP with incr ESR and CRP

77
Q

Procalcitonin for pneumonia

A

<0.25 = viral; > or = 0.25 = bacterial

78
Q

CXR for pneumonia

A

AP and lateral views will show lobar consolidation, interstitial infiltrates, cavitations

79
Q

CXR for viral pneumonia

A

bilateral multifocal, patchy ground glass opacities. DENSE CONSOLIDATIONS, PLEURAL EFFUSIONS, AND ABSCESSES WILL BE ABSENT

80
Q

CXR bacterial pneumo

A

dense lobar or alveolar consolidations

81
Q

Sputum color assoc: Rust

A

Strep pneumo

82
Q

Sputum color assoc: green

A

Pseudomonas or Hib

83
Q

Sputum color assoc: current jelly

A

Klebsiella

84
Q

CURB65 criteria for pneumonia

A

C= confusion
U=BUN >19 mg/dL or >7mmol/L urea +1
R=RR>30
B=SBP <90, DBP<=60 mmHg
65=age >=65
0-1 outpatient
2 admit
3 assess need for ICU, espec if score 4-5

85
Q

Microbiology tests for pneumo (if inpatient)

A

Blood cultures x2, MRSA nasal PCR swab
Sputum gram stain and culture
pneumococcal urine antigen
influenza nasal swab (NAAT)
PCR for pneumonia (BioFire PN)
Respiratory BioFIre (viruses)

86
Q

Management/Treatment for CAP outpatient

A

Amoxicillin plus macrolide is preferred. Can do doxycycline as macrolide alternative.

87
Q

Mgt/Tx for CAP outpatient if any of the following are true: heart, liver, kidney dz, diabetes, alcoholism, malignancy, asplenia, immune suppression or use of other antibiotics in the last 3 months

A

Augmentin plus macrolide (doxy as macrolide alternative) OR respiratory fluoroquinolone monotherapy as alternative.

88
Q

CAP inpatient NOT ICU

A

antipneumococcal beta lactam plus macrolide OR resp FQ monotherapy

89
Q

CAP inpatient ICU

A

antipneumococcal beta lactam plus azithromycin preferred. can do antipneumococcal beta lactam plus resp FQ

90
Q

If suspect MRSA CAP add

A

vancomycin or linezolid

91
Q

If suspect pseudomonas CAP

A

Betalactam plus FQ but both have to have antipseudomonal coverage.

92
Q

Nosocomial Pneumo Tx/Mgt

A

Need pseudomonas coverage
Zosyn or cefepime
If risk of MRSA, add vanco or linezolid

93
Q

Anti-MRSA abx

A

Vancomycin or linezolid

94
Q

Respiratory fluoroquinolones

A

Levofloxacin
Moxifloxacin
Gemifloxacin (PO)

95
Q

Antipseudomonal FQ

A

ciprofloxacin
levofloxacin

96
Q

antipseudomonal beta lactam

A

augmentin
Ampicillin sulbactam (Unasyn)
Ceftriaxone
Cefotaxime
Ertapenem

97
Q

Antipneumo/antipseudomonal beta lactam

A

Piperacillin tazobactam (Zosyn)
Imipenem
Meropenem
Cefepime
Ceftazidime

98
Q

Macrolides

A

Azithromycin
Clarithromycin

99
Q

Histoplasmosis

A

Organism Histoplasma capsulatum
Transmitted through inhalation of moist soil that contains bird or bat droppings in Mississippi or Ohio river valley

100
Q

Histoplasmosis RF

A

Immune compromise.
AIDS defining illness, esp if CD4 is less or equal to 100.

101
Q

Hist/PE/CM Histoplasmosis

A

Most often asymptomatic. Could have flu like sxs. Atypical pneumonia may have fever, nonproductive cough, myalgias (mimics TB)
Dissemination (if immune compromised): Hepatosplenomegaly, fever, oropharyngeal ulcers, bloody diarrhea, adrenal insufficiency.

102
Q

Dx/Labs for histoplasmosis

A

Increased ALP and LDH, pancytopenia.
CXR: pulmonary infiltrates, hilar or mediastinal LAD
Antigen PCR of sputum or urine
Cultures: Most specific + if disseminated or HIV.

103
Q

Mgt/Tx for histoplasmosis

A

If asymptomatic: None.
Mild or moderate disease: itraconazole is first line
If severe: Amphotericin B

104
Q

Cryptococcal pneumonia/cryptococcus

A

Etiology: inhaling pigeon or bird droppings, organism cryptococcus neoformans. AIDS defining illness.

105
Q

Hist/PE/CM for cryptococcal pneumonia

A

meningoencephalitis. MCC of fungal meningitis. HA, neck stiffness, nausea/vomiting, photophobia
Pulmonary: Pneumonia (cough, peuritic CP, dyspnea, nodules, abscesses, pleural effusions)

106
Q

Dx/Labs for cryptococcal pneumonia

A

LP: Fungal CSF pattern of incr WBC (lymphocytes), decr glucose, increased protein.
ELISA cryptococcal antigen.
India ink stain shows encapsulated yeast

107
Q

Tx/MGt for cryptococcal pneumonia

A

meningoencephalitis: Amphotericin B plus flucytosine x2 weeks.
THEN PO fluconazole x10 weeks
HIV prophylaxis: fluconazole if CD4 <100

108
Q

pneumocystis pneumonia

A

Interstitial pneumonia caused by the yeast-like fungal organism pneumocystis jerovecii. Transmitted airborne.
AIDS defining illness - CD4 < 200
RF: Immune compromised, chronic steroid therapy, malignancy such as leukemia or non Hodgkin lymphoma, maluntrition.

109
Q

Hist/PE/CM Pneumocystis pneumonia

A

Gradual onset fever, dry cough, dyspnea, progressing over days to weeks. Fatigue, chills, CP, wt loss
5-10% of patients are asymptomatic. On PE, tachypnea, crackles and rhonchi, O2 less than 90%

110
Q

Dx/Labs for pneumocystis pneumo

A

CD4 <200, incr LDH, Incr 1-3 beta D glucan.
Hypoxemia: Incr A-aO2 gradient (ref of 5-10 mmHg), decr PaO2, decr DLCO.
CXR: diffuse, bilateral perihilar infiltrates.
HiRES CT bilateral patchy or nodular ground glass opacities
Microbiologic ID via staining and or PCR of a respiratory specimen. PCR preferred.
Direct fluorescent antibody (DFA) stain: cystic or trophic forms.

111
Q

Severity of illness pneumocystic pneuo

A

Mild to moderate PaO2 >/= 70 mmHg and A-a gradient <35
Mod-severe PaO2<70 mmHg and A-a gradient >/=35.

112
Q

Mgt/Tx of pneumocystis pneumonia

A

TMP/SMX x21 days.
Alternatives:
1. Dapsone plus trimethoprim
2. PRimazuine plus clindamycin
If HIV + with moderate to severe PCP, add prednisone.
PCP prophylaxis indicated if CD4 less than 200: Low dose TMP SMX.

113
Q

RSV

A

MCC of low respiratory infection in children worldwide. VIrtually all children will contract by age 3. Leading cause of pneumonia and bronchiolitis in infants.

114
Q

Hist/PE/CM RSV

A

Rhinorrhea, wheezing, cough (can last months), low-grade fever, nasal flaring/retractions, nail bed cyanosis.

115
Q

Dx/Labs for RSV

A

RSV antigen test by nasopharyngeal swab.
CXR diffuse infiltrates.

116
Q

Tx/Mgt of RSV

A

Indications for hospitalizaion: Feeding difficulties, decreased O2, visible retractions.
Supportive care with albuterol nebs, antipyretics, humidified O2.
Steroids (controversial). Symptoms usually resolve 5-7 days.

117
Q

PRevention of RSV

A

Palivizumab (synagis) for infants <12 months if premie <29 weeks gestation, chronic lung dz of prematurity, hemodynamically significant CHD, congenital airway abnormality or NMD that decreases ability to manage secretions.
Infants/children <24 mos old who also have chronic lung disease of prematurity requiring medical therapy such as O2, bronchodilators, diuretics, steroids, w/in 6 months prior to beginning of RSV season, cystic fibrosis, profound immune compromise, undergoing cardiac transplant during RSV season.

118
Q

Tuberculosis

A

Mycobacterium tuberculosis
Bacilli = rod shaped
strict aerobe
Acid fast = won’t Gram stain.
Transmitted by air droplets.
RF: HC workers, immune compromised, drug use, homeless, crowded living conditions like prisons and nursing homes, close contact with persons with active TB, travel to endemic areas. NOT CONTAGIOUS

119
Q

After primary infection, TB progresses three ways

A
  1. Latent TB infx: state of constant immune response stimulation due to TB.
  2. Active primary TB: Active TB occurring after first time exposure to TB. CONTAGIOUS. (1-5% of cases. This one can become progressive severe TB in patients with compromised immune systems, ie HIV, malnutrition, children.
  3. Reactivation TB (secondary infection). Active TB developing after endogenous reactivation of LTBI or exogenous re-infection. CONTAGIOUS.
120
Q

Hist/PE/CM TB

A

Pulm TB: PRogressive cough: Dry to productive to hemoptysis. Pleuritic CP, fever, night sweats, anorexia, wt loss.
Extra-Pulmonary disease:
1. Vertebral: Osteolytic lesions on plain film.
2. Lymphadenitis (scrofula): single swollen nontender cervical lymph node.
3. Meningitis, ocular, renal, pericarditis, salpingitis, peritonitis, intestine.

121
Q

Dx/Labs for TB

A

CXR: findings are variable and nonspecific.
1. Primary (middle and lower lobes) consolidation, hilar LAD, pleural effusion, Ghon complex (Ghon focus + hilar LAD).
2. Ranke complex: Calcified primary TB with Ghon complex.
3. Reactivation (post primary): Fibrocavitary lesions in upper lobes.
4. AIDS, CD4<200: Diffuse military, hilar, and mediastinal LAD.

122
Q

DX/Labs for TB Biopsy

A

Caseating granulomas.

123
Q

Dx/Labs for TB: Sputum

A

3 samples at least 8 hours apart and one must be early morning specimen. AFB smear/culture with NAAT.
+ NAAT with or without +AFB is considered sufficient for Dx of TB.
Definitive +sputum culture

124
Q

Screening for TB

A

PPD skin test. Read at 48-72 hours. IGRA preferred if BCG vaccine given.

125
Q

How to read TB skin test: >=5 mm induration

A

> = 5 mm is positive if HIV, immune suppression (ie TNF inhibitors, chemo, organ transplant, steroid therapy), close contact to active contagious case, abnormal CXR w/fibrotic changes consistent with TB infx.

126
Q

How to read TB skin test: >= 10 mm induration

A

clinical conditions that increase risk of re-infection (silicosis, CKD on dialysis), diabetes mellitus, some cancers, underweight. IV drug use, bypass surgery, children under 4 YO, foreign from countries w/>25/100,000 cases annually. High risk settings such as prisons, health care facilities, homeless shelters.

127
Q

How to read TB skin test: >=15 mm induration

A

Healthy individuals over 4 YO without risk factors.

128
Q

Mgt/Tx TB

A

Traditional regimen: RIPE Intensive phase 2 months. Continuation phase RI 4 months
Rifampin
Isoniazid
Pyrazinamide
Ethambutol

Rifapetine - moxifloxacin based 4 mos regimen:
1. Intense phase (8 weeks) rifapentine, isoniazid, pyrazinamide, moxifloxacin.
2. Cont phase (9 weeks) rifapentine, isoniazid moxifloxacin

Adjunct treatment: Pyridoxine to prevent Vit B6 deficiency and neuropathy from isoniazid.

129
Q

Criteria for stopping therapy for TB

A

2 consecutive cultures -AFB smear and culture.

130
Q

Monitoring required during treatment for TB

A

baseline LFTs/screening and Q1 month throughout treatment due to risk of hepatotoxicity.

131
Q

Latent TB infection treatment options

A

3HP: isoniazid, rifapetine Q1 week x3 months.
4R: Rifampin QD x4 months
3HR: isoniazid + rifampin QD x3 months

132
Q

Postexposure protocol for TB

A

If positive skin test: CXR to exclude active TB. CXR normal, treat for latent TB. If CXR abnormal, work up for active TB.
If negative skin test: No further evaluation if >8-10 weeks from exposure. If less than 8-10 weeks from exposure and immune competent over 5 YO: No treatment, repeat screen at the 8-10 weeks from exposure time. If immune compromised or less than 5 YO, start tx for LTBI until repeat screen at 8-10 weeks after exposure. If repeat screen at that time is negative, discontinue treatment. If positive, CXR, then treat accordingly.

133
Q

Rifampin

A

MOA inhibit bacterial DNA dependent RNA-polymerase, preventing transmission and inhibiting protein synthesis causing cell death (bactericidal). ADR: histamine release (flushing, rash, pruritus, flu-like sxs), red-orange body fluids (tears, saliva, urine, sweat), hepatitis.

134
Q

Isoniazid

A

MOA: prodrug converted by bacterial catalase-peroxidase to its active metabolite, which prevents cell wall synthesis by inhibiting synthesis of mycolic acid. Pyroxidine supplement to prevent peripheral neuropathy. ADR: neurotoxicity (peripheral neuropathy), hepatotoxicity, cytochrome p450 inhibitor.

135
Q

Pyrazinamide

A

MOA: Not fully understood. Prodrug converted into active form of pyrazinoic acid, most effective at acidic pH, bactericidal effect. ADR: hepatotoxicity, hyperuricemia (avoid in gout).

136
Q

Ethambutol

A

MOA: inhibits arabinosyltransferase, which decreases carbohydrate polymerization and prevents mycobacterial cell wall synthesis (bacteriostatic). ADR: dose-dependent optic neuritis (decreases visual acuity, red-green color blindness), decreases urate excretion (exacerbates gout).

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