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D&D Infectious Disease FINAL > Therapeutics - CAP > Flashcards

Therapeutics - CAP Flashcards

1
Q

true or false

the treatment for community acquired vs hospital acquired pneumonia is the same

A

FALSE – very different

in hospital acquired, the pathogens are much more resistant

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2
Q

true or false

pneumonia is an upper respiratory tract infection

A

FALSE - lower

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3
Q

define CAP

A

acute infection of the pulmonary parenchyma. acute infiltrate is present on chest x ray OR positive ausultatory findings – in patients who have NOT been institutionalized for more than 14 days before symptom onset

(COMMUNITY ACQUIRED)

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4
Q

Name 4 routes of infection associated with CAP

which 2 are the most common?

A

most common = direct inhalaton or local (contiguous) spread

others = aspiration or hematogensous

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5
Q

give an example of CAP acquired through local/contiguous spread

A

you have a sinus infection and then it spreads to the lower respiratory tract

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6
Q

how can aspiration be a route for CAP infection

A

you lose gag reflux

goes down trachea instead of esophagus – all those pathogens can infect lower repsiratory tract and you can have a MULTIPATHOGEN infection

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7
Q

3 main therapeutic considerations associated with cap

A

patient, drug, bug (organism)

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8
Q

true or false

comorbidities do not influence the pathogen that causes CAP

A

false - it does

for ex, for COPD patients and smokers, we would need a broader spectrum antibiotic

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9
Q

which bacteria can cause CAP in alcoholic patients and what is the concern

A

anaerobes and gram (-)’s
linked to potential GI bleeds

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10
Q

for which comorbid disease state are they able to get FUNGAL pneumonia when it’s almost always bacterial?

A

HIV

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11
Q

name some signs and symptoms associated with CAP

include both local and systemic symptoms

A

local - cough with or without sputum
dyspnea (shortness of breath)
fever
breath sounds
chest pain

systemic - fatugue, headahce, altered chest x ray, increased WBC etc

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12
Q

how can color change of sputum give a clue to the organism that is causing the pneumonia

A

if it’s changed colors - probably bacterial

if clear - probably viral

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13
Q

***name the 5 most common pathogens associated with CAP

which 3 are atypical??

A

strep pneumonia
h. influenzae

3 atypicals - mycoplasma pneumoniae, chlamydia pneumoniae, legionella pneumophila

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14
Q

~___% of the time, CAP is caused by _____.

is it easy to treat

A

70% strep pneumoniae

fairly easy to treat

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15
Q

h. influenza is gram positive or negative

A

negative

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16
Q

true or false

streptococcus pneumoniae is the leading bacterial cause of CAP

A

true

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17
Q

strep pneumoniae CAP infection frequently follows what?

A

an upper respiratory tract infection like the flu

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18
Q

as mentioned, CAP caused by strep pneumoniae is usually fairly easy to treat

when does it become more difficult?

A

there is growing resistance. 25-35% are now resistant to penicillin through beta lactamase production

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19
Q

true or false

strep pneumoniae is very common in the environment

A

true

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20
Q

strep pneumoniae infection is observed in ____ patients and those with chronic ___ and ____

A

asplenic patients and with chronic CV and pulmonary disease

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21
Q

effective antibiotics against strep pneumoniae:

-pen susceptible (MIC <0.1mg/L)

-preferred agents

-alternative agents (name 5)

A

PREFERRED: pen V or V, ampicillin/amoxicillin

alternatives:
1st gen cephalosporins
macrolides (any)
fluoroquinolones (the respiratory ones - levo and moxi - NOT CIPRO - poor (+) coverage
clindamycin
doxycycline

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22
Q

**which fluoroquinolone CANNOT be used against strep pneumoniae and why

A

ciprofloxacin - has poor gram (+) coverage

can only use the respiratory fluoroquinolones - moxifloxacin and levofloxacin

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23
Q

true or false

all fluoroquinolones can be used against strep pneumoniae

A

FALSE - only the respiratory fluoroquinolones and NOT cipro

can use moxi, levo

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24
Q

Strep pneumoniae has intermediate PCN resistance (MIC 0.1-1mg/l) B lactamase producing

name 4 preferred agents

A

-parenteral pen g, amp/amox HIGH DOSE

-ceftriaxone (3rd gen) IV 1g Q24

-cefotaxime (3rd gen) IV 1g Q6-8H

-fluoroquinolones (RESPIRATORY ONES - NOT CIPRO)

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25
Q

strep pneumoniae with HIGH LEVEL pen resistance (MIC>2mg/l) – change in PBP binding site

name the 2 preferred agents

A

vancomycin (per renal fxn)

fluoroquinolones (RESPIRATORY)

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26
Q

H. influenza is a gram negative ____ ____

A

pleomoprhic rod

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27
Q

H. influenzae most commonly infects what kind of patients?

A

smokers, COPD, asplenics, kids less than 5

NOT in normal, healthy adults – only if they have conditions mentioned above. otherwise, only kids less than 5

28
Q

can H. influenza produce beta lactamase? do we cover H. influenzae empirically?

A

yes and yes

29
Q

preferred agent for NON beta lactamase producing H. influenzae

A

ampicillin/amoxicillin

30
Q

preferred agents for beta lactamase producing H. influenzae

A

mixed or gram (-) cephs

augmentin (b lactamase inhibitor)

fluoroquinolones

doxycycline

31
Q

____ and ____ bacterial infections are not typically observed in the community

A

staph aurues and pseudomonas

32
Q

2 most common atypical pathogens that cause CAP

A

mycoplasma pneumoniae
legionella pneumophilia

33
Q

can we identify mycoplasma pneumoniae on a culture or by assay?

A

no

34
Q

why is mycoplasma pneumoniae considered “atypical”

A

it does not have a cell wall!!! nothing that acts on the cell wall will work

35
Q

mycoplasma pneumonia usually causes CAP in which population

A

young adults

36
Q

CAP caused by ________ is often called “walking pneumonia” explain why

A

mycoplasma pneumonia

it has a gradual onset (long incubation after contact) - cough, sore throat, nasal discharge. the chest x ray is much worse than the actual symptoms.

usually affects young adults and the symptoms not that bad - dont even know they have pneumonia, even tho chest x ray looks terrible

37
Q

how long does CAP infection caused by mycoplasma pneumoniae typically last?

what is duration of treatment and what are 3 potential treatments?

A

it’s a persistent infection and lasts longer than 4 weeks

may need up to 21 days of therapy with:

-macrolides or doxycycline or a fluoroquinolone (ANY)

-notice - none of these act on the cell wall - mycoplasma pneumoniae doesnt have one

38
Q

symptoms of CAP caused by LEGIONELLA PNEUMOPHILIA

A

a lot different than mycoplasma pneumoniae - legionella has more systemic symptoms

-high fever, low sodium (hyponatremia), CNS effects - headache, confusion, lactate dehydrogenase greater than 700u/mL, GI effects - lot of ABDOMINAL PAIN

39
Q

2 patients in which we would suspect their CAP being caused by legionella pneumophilia and why

A

-it’s a water-borne pathogen, so patients who have recently traveled or changed plumbing

-all patients with lung disease (smoking, age, immunocomp)

40
Q

is there an antigen test for legionella pneumophilia?

A

yes there is a urine antigen test - but not that accurate - has 70% sensitivity

therefore, if patient is at increased risk, we should cover legionella

41
Q

2 preferred agents for legionella

what is duration of treatment

A

azithromycin or a fluoroqionolone

14-21 days

42
Q

true or false

legionella is gram negative

A

true

43
Q

true or false

according to the guidelines, if the patient has suspected community acquired CAP, we should wait for the cultures to come back before starting antibiotics

A

FALSE

pneumonia is a severe infection. we can start empiric therapy immediately based on likely pathogens

44
Q

4 potential diagnostic evaluations for patients with CAP

A

chest x ray - ALMOST ALWAYS DONE

sputum examination

body fluid culture

serological studies and antigen detection for legionella nd mycoplasma (not that accurate tho)

45
Q

explain how a chest x ray can be misleading when evaluating CAP.

A

the opaque areas (WBC and infiltrates) takes a LONG time to resolve, even if the patient is better

therefore, chest x rays are NOT recommended to be used to monitor patients with CAP

46
Q

explain the relationship between examining a patient’s sputum and epithelial cells

A

there should only be a few epithelial cells in the sputum sample.
if there are a lot, this means that the sample is not from the lungs

47
Q

how can a sputum sample be used as a method of diagnostic evalutation of patients with CAP

A

can look for moderate-many WBC

can do GRAM STAIN which is very beneficial

48
Q

empiric treatment for pneumonia is based on ____

A

the setting

outpatient vs inpatient vs ICU

49
Q

**3 different regimens for healthy outpatient adults with CAP - include dosing

A

amoxicillin 1g PO TID (HIGH DOSE)

doxycycline 100mg BID

macrolides: azithromycin 500mg/250mg regimen, clarithromycin XL 1000mg daily

50
Q

as mentioned, there are 3 different regiments for healthy outpatient adults with CAP

explain the use of amoxicillin

A

amoxicillin does NOT cover the atypicals - however, this efficacy was established from inpatient data and we are treating outpatient

amox is good vs haemophilus BUT NOT ATYPICALS. therefore, do not use amox in smokers and those prone to atypicals

also avoid in pen allergy (obviouslt)

51
Q

true or false

doxycycline 100mg PO BID can be used in healthy outpatient adults with CAP. however, it does not cover the atypicals

A

FALSE - it does

everuthing else is correcr

52
Q

**true or false

doxycycline should be avoided in pregnancy

A

TRUE

teratogenic + increased risk of liver disease in moms

also avoid in less than 8 years olf

53
Q

1 of the 3 regimens for healthy outpatient adults with CAP included macrolides

is this recommended on a normal basis?

A

NO

only conditionally recommended ONLY in areas where pneumococcal resistance to macrolides is less than 25%

if greater than 25%, DO NOT USE MACROLIDES

54
Q

name potential regimens for patients with CAP who have COMORBIDITIES

A

combination therapy:
-augmentin OR cefpodoxime OR cefuroxime
PLUS a macrolide OR doxyxyline (covers the atypicals that b lactams dont cover)

OR can do single drug therapy with a RESPIRATORY fluoroquinolone - levo, moxi, gemi

55
Q

dose of each of the 3 respiratory fluoroquinolones for patients with CAP who have comorbidities

A

levo - 750mg QD
moxi - 400mg QD
gemi - 320mg QD

56
Q

as mentioned patients with CAP who have comorbidities are treated differently than healthy patients

name these comorbidities in which the treatment would be different

A

chronic heart, lung, liver, or renal disease

diabetes

alcoholism

malignancy

asplenia

57
Q

2 patients in which we should NOT use fluoroquinolones

A

pregnant
children

*caution with side effects in ALL patients

58
Q

inpatient therapy, non-ICU setting treatment regimens

A
  1. combo therapy: beta lactam + azithromycin
  2. monotherapy with RESPIRATORY fluoroquinolone
  3. combo therapy of beta lactam + doxycycline
59
Q

as mentioned, for inpatient therapy (NON ICU) for cap, we can use combination therapy with a beta lactam + a macrolide (azithromycin) or doxycycline

what is the purpose of using either of these combination therapies?

A

azithromycin and doxycycline cover the more resistant pathogens AS WELL AS the atypicals that the beta lactams do not cover

60
Q

true or false

we cannot use monotherapy to treat CAP in inpatient, NON icu setting

A

FALSE

we can use just a respiratory fluoroquinolone - actually shown to have fewer incidences of clinical failure and less diarrhea vs combo therapy

61
Q

beta lactam + azithromycin is a combination therapy that can be used for inpatient therapy in non-ICU setting

name these specific beta lactams and any warnings

A

ampicillin-sulbactam (1.5-3g q6)
cefotaxime (1-2g q8)
ceftriaxone (600mg q12)

caution with c diff, esp for ceftriaxone

also, caution wiht pen allergy

62
Q

true or false

for inpatient therapy non ICU setting, beta lactam + doxycycline is 1st line therapy

A

FALSE - only conditionally recommended for patients contraindicated to both macrolides AND fluoroquinolones

low quality of evidence for beta lactam + doxy

63
Q

true or false

for inpatient non ICU therapy for CAP, we give oral antibiotics

A

FALSE

if they’re sick enough to hospitalize - we are giving IV antibiotics for at LEAST 48 hours

64
Q

inpatients should only receive empiric therapy for MRSA or pseudomonas when……

A

risk factors are present

otherwise, we do NOT cover for them

65
Q

_____ days of antibiotic therapy is sufficient for many patients with CAP

however……

A

5 days

however, consider prolonging to 7 days if the patient is immunocompromised, lung disease (NOT asthma), or did not have an adequate clinical response within 72 hours

also may need longer duration for legionella, pseudomonas, or staph aureus

66
Q

name some monitoring parameters to see if the antibiotics are working for CAP

what specific thing is NOT recommended for monitoring

A

temp reduction, WBC reduction, improved oxygenation, better signs and symptoms

ROUTINE CHEST X RAYS ARE NOT RECOMMENDED FOR MONITORING!!!!! takes so long to resolve even if the patient is better

67
Q
A

D&D Infectious Disease FINAL (21 decks)

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