Stable CAD and CAP guidelines

Question 0

How do you dx CAP?

Answer 0

CXR (+/- culture evidence)

Question 1

How do you determine if a patient with CAP needs ICU admission?

Answer 1

Major criteria (if they meet 1, they're in!): 1) Septic Shock (req vasopressors) or 2) Acute respiratory failure (req ventilation). 
OR 3+ minor criteria:
1) RR>30
2) PaO2 : FiO2 <250
3) Multi-lobar infiltrates
4) Confusion/disorientation
5) Uremia
6) Leukopenia
7) Thrombocytopenia
8) Hypothermia
9) Hypotension (req fluid resus.)

Question 2

Describe outpatient treatment for CAP:

Answer 2

Use a Macrolide (Azithromycin, Erythromycin, clarithromycin) or Doxycyclin, unless you are in a resistance area (>20%) OR the pt has comorbidiites, then use Moxifloxacin (gema-, levo-…these are 4th gen fluoroquinolones).

Question 3

When do you admit a patient with CAP (non-ICU)?

Answer 3

CURB-65 score > or = 2. 
Confusion
Uremia
RR>30
BP=65

Question 4

Describe non-ICU inpatient treatment for CAP:

Answer 4

Moxifloxacin, Gemfolxacin, or Levofloxacin (or B-lactam plus macrolide). Give PO if tolerated.
Switch to an oral antibiotic as soon as pt is hemodynamically stable/improving.

Question 5

Describe ICU treatment for CAP:

Answer 5

B-lactam + macrolide (if pseudomonas use pipercillin + ciprofloxacin). If MRSA use B-lactam, Macrolide, AND Vancomycin.

Question 6

When do you switch to oral ABs in CAP? When do you discharge?

Answer 6

Treatment must be for a minimum of 5 days. Pt. must be afebrile for 48-72 hours.

Switch to oral AB as soon as pt is hemodynamically stable, improving.

Question 7

How do you manage a pt with stable coronary artery disease?

Answer 7

1. BP control- If pt has HT, DM, kidney disease, or left ventricular dysfunction, give ACE inhibitor. (If they have Hx of MI, add B-blocker). If they cannot tolerate ACE inhibitor, give ARB. You can give a Ca channel blocker if they can’t tolerate a Beta blocker and have had an MI.
2. Nitrates for angina
3. Aspirin (Clopidogrel only if aspirin CI)
4. Lipid lowering- Use a Statin to get LDL<70. Use ezetimibe if intolerant of statins. Use Fibrates (if TG is 200-299) and/or Nicotinic acid (niacin) to raise HDL.