Pulmonary Txs Flashcards
You made the Dx, now what are your Tx location options for CAP?
1) Outpatient
2) Inpatient
3) General ward
4) ICU
CAP Environment of Care:
1) What decisions need to be made?
2) Based on what? What should you assess?
1) Outpatient vs. admission
-Admitted, then general ward, vs. ICU
2) Clinical judgment
+
Validated clinical tools – assess risk of mortality
CAP Empiric antibiotic therapy:
1) For all patients, inpatient or outpatient, what is recommended in Tx?
2) Define clinical recovery
1) At least 5-day course of Rx followed by evaluation for clinical recovery
2) Normal VS + Baseline mental status + No difficulty eating
*(May need to extend duration of coverage or change to different Rx)
What is the Initial Empiric Management for outpatient, low risk CAP w/o comorbidities? (1 Tx, 3 medication options)
Monotherapy:
1) Amoxicillin PO
Or
2) Doxycycline PO
Or
3) Macrolide if local resistance < 25% (not common)
a) Azithromycin 5 days (Z-pack)
Or
b) Clarithromycin (Biaxin)
Re-evaluate after 5 days of therapy for stable VS, MS, and able to eat
Initial Empiric Management CAP outpatient: who would be considered low risk and without comorbidities? (3 criteria)
1) No recent hospitalizations & treatment with parental antibiotics past 90 days
2) No previous isolate for MRSA or Pseudomonas sps.
3) No comorbidities: chronic CV, lung, liver, or renal disease, alcoholism, asplenia, DM, or malignancy
What is initial empiric outpatient Tx for CAP with comorbidities
1) ** Combined therapy**
Augmentin (amoxicillin/clavulanate) PO
Or
Ceftriaxone (3rd gen Cephalosporin) PLUS Macrolide or Doxycycline
OR
2) ** Monotherapy**: Gemifloxacin, levofloxacin, or moxifloxacin (Respiratory fluroquinolone)
What are the 2 main initial empiric Tx options for outpatient CAP with comorbidities?
1) Combined therapy
2) Monotherapy: Respiratory fluroquinolone
-Both: Re-evaluate after 5 days of therapy for stable VS, MS, and able to eat
What is the initial empiric combined therapy for CAP when outpatient w. comorbidities?
Combined therapy
1) Augmentin (amoxicillin/clavulanate)
500/125 mg PO TID, 875/125 mg PO BID OR 2000mg/125 mg PO BID
OR
2) 3rd gen Cephalosporin - Ceftriaxone
For both: PLUS Macrolide or Doxycycline
What is the initial empiric monotherapy for CAP when outpatient w. comorbidities?
Respiratory fluroquinolone: Gemifloxacin, Levofloxacin, or Moxifloxacin
How would you empirically manage CAP inpatient (gen. ward)? (2 options)
(assume Non-severe CAP, no risks for MRSA or Pseudomonas)
1) Combined therapy
Ceftriaxone (Rocephin) 1-2 grams daily IV
+
Macrolide PO or IV
OR
2) Monotherapy: Respiratory fluroquinolone
What is the empiric mgmt of severe CAP when inpatient (general ward)?
(assume no risks for MRSA or Pseudomonas)
Combined therapy: Ceftriaxone + Macrolide or resp. fluroquinolone
How should you Tx atypical CAP? (2 options, incl. which is preferred)
1) Doxycycline: first line Tx
OR
2) Macrolide: resistance is emerging and may not be a good choice
1) Can you use systemic corticosteroids in non-severe CAP?
2) What abt in severe CAP?
1) Not recommended routine adjunct therapy in non-severe CAP
2) Using adjunct corticosteroids in adults with severe CAP reduced 30 day all cause mortality, ICU and hospital stay, and no increase in adverse events
Describe influenza Tx
1) Supportive care
2) Anti influenza treatment: Neuraminidase inhibitors
-Work against Influenza A & B; should be taken within 48 hours of symptom onset for effective treatment
a) Oseltamivir phosphate ( generic or Tamiflu) – pill or liquid, PO BID x 5 days
-FDA approved for ages 14 days +
b) Zanamivir (Relenza) – powder inhaler, BID x 5 days
-FDA approved for ages 7 years +
-Not recommended for patients with chronic respiratory issues - asthma , COPD, etc.
What is the common influenza exposure prophylactic Rx?
Neuraminidase inhibitors (Oseltamivir and zanamivir) taken within 48 hours of exposure
PJP
1) Tx?
2) For how long?
1) Anti pneumocystis medications + concomitant steroids
Trimethoprim/sulfamethoxazole (Septra): most common if tolerated
2) 21 days (with steroids to decrease inflammation)
PJP: What other meds can be used alone or in combination to Tx, besides the main Tx options discussed?
Pentamidine inhalations – infrequent use due to acute pancreatitis, renal and hepatic toxicity, etc.
Trimetrexate
Dapsone
Primaquine
Atovaquone
Clindamycin
Acute bronchitis Tx?
Supportive – most are viral
1) SABA for wheezing or ASTHMA exacerbation
2) ECOPD – treat with SABA, corticosteroids, antibiotics if appropriate
3) Macrolides, 2/3rd generation cephalosporins (cefuroxime), Augmentin, respiratory fluoroquinolone (Levo, Moxi, Gemifloxicin)
4) Antibiotics also considered for:
Elderly, underlying cardiopulmonary disease, cough for more than 2 weeks/worsening s/s, any compromised patient
Anaerobic pneumonia treatment? (incl 1st and 2nd line)
1) 1st line: Clindamycin IV until improvement, then PO
OR
Augmentin
2) 2nd line: Pen G + Metronidazole PO or IV
-for both: Rx continued until CXR improves/resolution of the abscess cavity….a month or more
3) Empyema usually needs to be drained via tube or open thoracostomy
What would you Rx for HAP/VAP in adults? (do not memorize)
Often GS and culture sputum and or blood and imaging
Empiric management:
Low risk for multi drug resistance (MDR) – monotherapy with beta-lactam or respiratory fluoroquinolone
Risk for MDR– antipseudomonal beta-lactam (piperacillin-tazobactrum; Zosyn) or carbapenem + respiratory fluoroquinolone
Risk for MRSA – add vancomycin
MDR - MRSA and vancomycin resistance enterococcus
Risk factor for MRSA or pseudomonas = previous isolated, frequent antibiotics
