Respiratory Tract Infections Flashcards
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
CAP common organisms
Mycoplasma pneumoniae
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia pneumoniae
Legionella pneumoniae
Virus
CAP organisms in alcoholism
S. pneumoniae
anaerobes
gram-negative bacilli (K. pneumoniae)
CAP organisms in nursing home
S. pneumoniae
H. influenzae
Gram-negative bacilli
S. auerus
CAP organisms in COPD
S. pneumoniae
H. influenzae
M. catarrhalis
CAP organisms in postinfluenza
H. influenzae
S. aureus
S. pneumoniae
CAP organisms after exposure to water
Legionella
CAP organisms in HIV
Pneumocystitis jirovecii
S. pneumoniae
M. pneumoniae
Mycobacterium
Empiric CAP tx non-hospitalized pts, no comorbidities
Amoxicillin 1gm TID
Doxycycline
Macrolide if local resistance <25%
HAP organisms
S. aureus*
Pseudomonas aeruginosa*
Enterobacter spp
K. pneumoniae
Acinetobacter spp
Serratia marcescens
Escherichia coli
S. pneumoniae
*empiric tx should be active against
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
Empiric CAP tx inpatient with non-severe pneumonia
Respiratory FQ (Moxi or Levo)
Unasyn OR ceftriaxone OR ceftaroline
PLUS
Macrolide OR respiratory FQ
Empiric CAP tx inpatient with severe pneumonia necessitating ICU stay
Unasyn OR Ceftriaxone OR Ceftaroine
PLUS
Respiratory fluoroquinolone OR macrolide
Duration of CAP therapy
5 days
guided by clinical stability
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)
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)
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
