Respiratory Tract Infections II (Kays) Flashcards
What are the risk factors for HAP/VAP?
- advanced age
- severity of underlying disease
- duration of hospitalization
- endotracheal intubation
- mechanical ventilation
- presence of nasogastric tubes
- AMS
- surgery
- previous
- antimicrobial therapy
What is the predominant organism implicated in HAP/VAP?
P. aeruginosa
What are the factors associated with an increased risk of MDR VAP?
- prior IV antibiotics within 90 days
- 5+ days of hospitalization prior to occurrence of VAP
- septic shock at the time of VAP
- ARDS before VAP
- acute RRT before VAP
What are the risk factors for MRSA HAP/VAP?
- IV antibiotics in last 90 days
- late onset
What should all empiric VAP regimens provide coverage for?
- S. aureus
- P. aeruginosa
- other Gram (-) bacilli
In what situations would you use TWO antipseudomonal antibiotics for VAP?
- risk factors for resistance
- patient in an ICU where >10% of Gram (-) isolates are resistant to monotherapy
- patient in an ICU where local resistance rates are unknown
What antipseudomonal β-lactams can be used empirically for VAP?
Zosyn
OR
cefepime
OR
ceftazidime
OR
carbapenems (mero- or imipenem)
OR
aztreonam
What antipseudomonal non-β-lactams can be used empirically for VAP?
fluoroquinolones (cipro- or levofloxacin)
OR
aminoglycosides
OR
polymyxins
What empiric therapy is recommended for HAP patients without high mortality risk and no MRSA risk factors?
Zosyn
OR
cefepime
OR
carbapenems (imi- or meropenem)
OR
levofloxacin
What empiric therapy is recommended for HAP patients with low mortality risk, but MRSA risk factors?
One of the following: Zosyn, cefepime, ceftazidime, imipenem, meropenem, levofloxacin, ciprofloxacin, aztreonam
PLUS: vancomycin or linezolid
What empiric therapy is recommended for HAP patients with high mortality risk or prior IV antibiotics in the last 90 days?
Two of the following: Zosyn, cefepime, ceftazidime, imipenem, meropenem, levofloxacin, ciprofloxacin, aztreonam, aminoglycoside
PLUS: vancomycin or linezolid
Why would aminoglycosides generally be pretty poor treatment for HAP/VAP?
- poor lung penetration
- nephro- and ototoxicity
- associated with lower clinical response rates
Polymyxins aren’t highly desirable agents to use in HAP/VAP…what scenario would you reserve the use of these drugs for?
patients with high prevalence for MDR pathogens
What pathogen-specific treatment is recommended for MSSA HAP/VAP?
cefazolin
OR
nafcillin
OR
oxacillin
What pathogen-specific treatment is recommended for MRSA HAP/VAP?
vancomycin
OR
linezolid
Why can’t daptomycin be used for HAP/VAP with MRSA?
because it’s inactivated by surfactant
What pathogen-specific treatment is recommended for ESBL-producer HAP/VAP?
carbapenem
OR
ceftazidime/avibactam
What pathogen-specific treatment is recommended for MBL-producer HAP/VAP?
aztreonam + ceftazidime/avibactam empirically
OR
aztreonam alone if susceptible
What pathogen-specific treatment is recommended for KPC-producer HAP/VAP?
ceftazidime/avibactam
OR
meropenem/vaborbactam
OR
imipenem/cilastatin/relebactam
What pathogen-specific treatment is recommended for HAP/VAP with MDR P. Aeruginosa?
ceftolozane/tazobactam
OR
ceftazidime/avibactam
OR
imipenem/cilastatin/relebatam
OR
cefiderocol
What pathogen-resistant treatment is recommended for HAP/VAP with Acinetobacter species?
carbapenem OR Unasyn if susceptible
cefiderocol if resistant to either above agent
What is the recommended duration of treatment for HAP/VAP?
7 days
What is the etiology of acute bronchitis?
respiratory viruses (AKA, don’t use antibiotics, dumbass)
What can be used for symptomatic acute bronchitis?
antitussives and/or antipyretics, adequate hydration
What are the 3 cardinal symptoms of AECB (Anthonisen Criteria)?
- increased cough/dyspnea (SOB)
- increased sputum volume
- increased sputum purulence
Define chronic bronchitis.
presence of a chronic cough, productive of sputum on most days for at least 3 consecutive months, each year for 2 consecutive years
What are increased PMNs indicative of in AECB?
continued bronchial irritation
What bacteria are most commonly involved in AECB?
- H. influenzae
- S. pneumoniae
- M. catarrhalis
- Enterobacterales, P. aeruginosa (seen in end-stage COPD)
What is the recommended treatment duration for AECB?
5-7 days
With what antibiotics is the infection-free interval for AECB significantly longer?
- fluoroquinolones
- Augmentin
- azithromycin
What are the risk factors for AECB?
- age
- severity of illness
- >4 exacerbations/year
- cardiac disease
- home oxygen use
- antibiotic use in last 90 days
- recent corticosteroids
What would you give initially for uncomplicated AECB?
macrolide
OR
2nd/3rd generation cephalosporin
OR
doxycycline
OR
amoxicillin
OR
Bactrim
What would you give initially for complicated AECB?
respiratory FQ
OR
Augmentin
What would you give initially for complicated AECB with risk of P. aeruginosa infection?
antipseudomonal FQ
OR
Zosyn
if hospitalized, you should automatically be empirically covering Pseudomonas!!!
What is the most common etiology for pharyngitis?
viruses
What bacterial pathogen is most commonly implicated in pharyngitis?
Streptococcus pyogenes (group A, β-hemolytic)
What are some marked signs and symptoms of pharyngitis?
- sudden onset of sore throat/dysphagia
- fever
- pharyngeal hyperemia
- tonsillar swelling (+/- exudates)
- enlarged/tender lymph nodes
- red, swollen uvula
- petechiae on soft palate
What is the preferred diagnostic test for pharyngitis?
rapid antigen detection tests (RADT)
What therapies can be used for Group A streptococcal pharyngitis?
Penicillin V (drug of choice)
OR
amoxicillin (2nd line)
OR
1st/2nd generation cephalosporins
OR
macrolides
OR
clindamycin
OR
cefdinir
OR
cefpodoxime
What is the recommended treatment duration for Group A streptococcal pharyngitis?
10 days (with a few exceptions)
When can viral rhinosinusitis be diagnosed?
when signs and symptoms of acute rhinosinusitis are present <10 days and symptoms are not worsening
When can acute bacterial rhinosinusitis be diagnosed?
clinical presentation + signs and symptoms >10 days
What bacterial agents are implicated in ABRS?
- H. influenzae
- S. pneumoniae
- M. catarrhalis
What are the major symptoms of acute rhinosinusitis?
- purulent nasal discharge
- nasal congestion/obstruction
- facial congestion/fullness
- facial pain/pressure
- hyposmia/onosmia
- fever
What is the 1st line empiric therapy for ABRS in children?
Augmentin
What drug should be used in pediatric ABRS with type 1 β-lactam hypersensitivity?
levofloxacin
What drug should be used in pediatric ABRS with non-type 1 β-lactam hypersensitivity?
clindamycin + cefixime OR cefpodoxime
What therapy options are available for pediatric ARBS with risk for antibiotic resistance or failed initial therapy?
- Augmentin
- clindamycin + cefixime OR cefpodoxime
- levofloxacin
What therapy options are available for pediatric ABRS with severe infection that requires hospitalization?
- Unasyn
- ceftriaxone
- cefotaxime
- levofloxacin
What is the 1st line initial empiric therapy for adult ABRS?
Augmentin
What is the 2nd line initial empiric therapy for adult ABRS?
doxycycline
What therapy would you recommend for adult ABRS with a β-lactam allergy?
- doxycycline
- levofloxacin
- moxifloxacin
What therapy would you recommend for adult ABRS with risk of resistance or failed initial therapy?
- Augmentin
- levofloxacin
- moxifloxacin
What therapy would you recommend for severe adult ABRS requiring hospitalization?
- Unasyn
- levofloxacin
- moxifloxacin
- ceftriaxone
What is the recommended treatment duration for adult ABRS?
5-7 days
What is the recommended treatment duration for pediatric ABRS?
10-14 days
