Respiratory Tract Infections Flashcards by Carolyn Hardie

Severe CAP (minor criteria)

> = 3: higher level care

RR >30
Pao2/Fio2 ratio <= 250
Multilobar infiltrates
Confusion/disorientation
Uremia (BUN >=20)
Leukopenia (WBC <4)
Thrombocytopenia (plt <100,000)
Hypothermia (<36 C)
Hypotension requiring aggressive fluids

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CAP common organisms

Mycoplasma pneumoniae
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia pneumoniae
Legionella pneumoniae
Virus

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CAP organisms in alcoholism

S. pneumoniae
anaerobes
gram-negative bacilli (K. pneumoniae)

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CAP organisms in nursing home

S. pneumoniae
H. influenzae
Gram-negative bacilli
S. auerus

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CAP organisms in COPD

S. pneumoniae
H. influenzae
M. catarrhalis

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CAP organisms in postinfluenza

H. influenzae
S. aureus
S. pneumoniae

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CAP organisms after exposure to water

Legionella

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CAP organisms in HIV

Pneumocystitis jirovecii
S. pneumoniae
M. pneumoniae
Mycobacterium

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Empiric CAP tx non-hospitalized pts, no comorbidities

Amoxicillin 1gm TID
Doxycycline
Macrolide if local resistance <25%

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HAP organisms

S. aureus*
Pseudomonas aeruginosa*
Enterobacter spp
K. pneumoniae
Acinetobacter spp
Serratia marcescens
Escherichia coli
S. pneumoniae

*empiric tx should be active against

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Empiric CAP tx non-hospitalized pts with comorbidities

COPD, diabetes, alcoholism, chronic renal/liver failure, CHF, malignancy, asplenia, immunosuppression

Respiratory FQ (Moxifloxacin or levofloxacin 750mg daily)
Macrolide OR doxycycline PLUS augmentin or cefpodoxime or cefuroxime

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Empiric CAP tx inpatient with non-severe pneumonia

Respiratory FQ (Moxi or Levo)

Unasyn OR ceftriaxone OR ceftaroline
PLUS
Macrolide OR respiratory FQ

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Empiric CAP tx inpatient with severe pneumonia necessitating ICU stay

Unasyn OR Ceftriaxone OR Ceftaroine

PLUS

Respiratory fluoroquinolone OR macrolide

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Duration of CAP therapy

5 days
guided by clinical stability

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CAP and risk factors for MRSA/P. aeruginosa

Prior respiratory isolate for MRSA or P. aeruginosa
Severe pneumonia and locally validated risk factors (ESPECIALLY hospitalization & IV ABX within past 90 days)

Add on vancomycin or linezolid (MRSA) or
zosyn, cefepime, ceftazidime, imipenem, meropenem, or aztreonam (p. aeruginosa)

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Two anti-pseudomonal agents needed for HAP when

-Received ABX in last 90 days
-High risk of mortality (ventilator need, septic shock)
-Structural lung disease (bronchiectasis or cystic fibrosis)

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Two anti-pseudomonal empiric tx for HAP/VAP

First agent: B-lactam: ceftazidime, cefepime, imipenem, meropenem, zosyn, aztreonam

Second agent: aminoglycoside, FQ (cipro or levo), polymyxin

Single agent anti-pseudomonal for HAP/VAP

Zosyn
Cefepime
Levofloxacin
Imipenem
Meropenem

Use if pt does not meet criteria for 2 anti-pseudomonal agents

Risk factors for MRSA in HAP

-Risk for MDR organisms
-MRSA incidence in hospital is >20%
-Pt high mortality risk (ventilator, septic shock)

HAP/VAP duration of therapy

7 days

Risk factor for MDR organisms in VAP

IV ABX within past 90 days
Hospitalization of >= 5 days before VAP
Septic shock
ARDS preceding VAP
Acute renal replacement therapy before VAP

MRSA nasal screen in HAP/VAP

if MRSA respiratory infection in hospital is <10%, negative MRSA PCR indicates no empiric MRSA coverage needed

If >10%, still need empiric coverage

Oseltamivir

Neuraminidase inhibitor - must start within 48 hours of symptoms. Symptoms resolve 1-1.5 day sooner

Treatment:
75mg BID x5 days
CrCl 31-60: 30mg BID
CrCl 11-30: 30mg daily

Prophylaxis:
75mg daily

AE: GI, CNS (anxiety, headache, insomnia)

Zanamivir

Neuraminidase inhibitor - must start within 48 hours of symptoms. Symptoms resolve 1-1.5 day sooner

Treatment:
Two INHALATIONS BID x5 days

Prophylaxis:
Two inhalations daily

Can cause bronchospasm, cough - avoid in asthma or COPD

Peramivir

Neuraminidase inhibitor - must start within 48 hours of symptoms. Symptoms resolve 1-1.5 day sooner 600mg IV x1 CrCl<50: 200mg x1 CrCl <30: 100mg x1 AE: diarrhea, elevations of liver enzymes, CPK, glucose

Baloxavir

Endonuclease inhibitor Treatment & Prophylaxis: 40-79kg: 40mg x1 >80mg: 80mg x1 aE: GI, bronchitis, HA

Paxlovid dose decrease

CrCl 30-59 ml/min

Hospitalized COVID treatment

Remdesivir 200mgx1 then 100mg daily x5 days Dexamethasone 6mg PO or IV x10 days. Do not continue after discharge unless patient still on oxygen.

Major symptoms of sinusitis

Purulent anterior nasal discharge Purulent/discolored posterior nasal discharge Nasal congestion, obstruction Facial congestion, fullness Facial pain/pressure Hyposmia or anosmia Fever

Minor signs of sinusitis

HA Ear pain, pressure, fullness Halitosis (bad breath) Dental pain Cough Fever Fatigue

Viral sinusitis

Clear nasal discharge - purulent possible on day 4-5 No fever Peak symptoms days 3-6 Duration 5-10 days

Bacterial sinusitis

Purulent nasal discharge for more than 10 days or early & severe High temperature Daytime cough Persistent symptoms for >10 days, early & severe symptoms, or improved symptoms that then worsen Usually >10 days duration

Bacterial sinusitis first line therapy

Augmentin High dose (90mg/kg/day or 2/0.125g) if severe infection, day care, <2 or >65, recent hospitalization, recent ABX in past month, or immunocompromised

Bacterial sinusitis second line therapy

Doxycycline Cefixime or cefpodoxime with clindamycin Respiratory FQ Intranasal saline irrigation Intranasal corticosteroids (prolonged >15 days use)

Bacterial sinusitis therapy duration

Adults: 5-7 days Children: 10-14 days

Bacterial sinusitis inpatient therapy

Children, all IV: Unasyn, ceftriaxone (q12h), cefotaxime, levofloxacin Adults: Levaquin (po or iv), moxifloxacin (po or iv), ceftriaxone (q12-24), cefotaxime iv

Bacterial sinusitis supportive care that is not recommended

oral steroids oral antihistamines oral/nasal decongestants

Strep throat first line treatment

Child Penicillin V 250mg PO BID-TID Amoxicillin 50mg/kg daily (max 1g) Benzathine Penicillin G (<27kg = 60,000 units IM x1) Adult Penicillin VK 250mg QID or 500mg BID Amoxicillin 500mg BID Penicillin 1.2 million units IM X1 10 days

Strep throat treatment if penicillin allergic

Cefadroxil 30mg/kg daily Cephalexin 20mg/kg/dose BID Azithromycin 12mg/kg daily (5 days) Clarithromycin 7.5mg/kg BID Clindamycin 7mg/kg TID

Strep throat supportive care

Do not give steroids Do not give benzocaine to children NSAID, tylenol

Respiratory culture + gram stain needed in these groups

- Severe disease - Empiric tx targeting MRSA/Pseudomonas - Prior history of MRSA or Pseudomonas - Hospitalization & IV antibiotics in past 90 days