Therapeutics - CAP Flashcards
true or false
the treatment for community acquired vs hospital acquired pneumonia is the same
FALSE – very different
in hospital acquired, the pathogens are much more resistant
true or false
pneumonia is an upper respiratory tract infection
FALSE - lower
define CAP
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)
Name 4 routes of infection associated with CAP
which 2 are the most common?
most common = direct inhalaton or local (contiguous) spread
others = aspiration or hematogensous
give an example of CAP acquired through local/contiguous spread
you have a sinus infection and then it spreads to the lower respiratory tract
how can aspiration be a route for CAP infection
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
3 main therapeutic considerations associated with cap
patient, drug, bug (organism)
true or false
comorbidities do not influence the pathogen that causes CAP
false - it does
for ex, for COPD patients and smokers, we would need a broader spectrum antibiotic
which bacteria can cause CAP in alcoholic patients and what is the concern
anaerobes and gram (-)’s
linked to potential GI bleeds
for which comorbid disease state are they able to get FUNGAL pneumonia when it’s almost always bacterial?
HIV
name some signs and symptoms associated with CAP
include both local and systemic symptoms
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
how can color change of sputum give a clue to the organism that is causing the pneumonia
if it’s changed colors - probably bacterial
if clear - probably viral
***name the 5 most common pathogens associated with CAP
which 3 are atypical??
strep pneumonia
h. influenzae
3 atypicals - mycoplasma pneumoniae, chlamydia pneumoniae, legionella pneumophila
~___% of the time, CAP is caused by _____.
is it easy to treat
70% strep pneumoniae
fairly easy to treat
h. influenza is gram positive or negative
negative
true or false
streptococcus pneumoniae is the leading bacterial cause of CAP
true
strep pneumoniae CAP infection frequently follows what?
an upper respiratory tract infection like the flu
as mentioned, CAP caused by strep pneumoniae is usually fairly easy to treat
when does it become more difficult?
there is growing resistance. 25-35% are now resistant to penicillin through beta lactamase production
true or false
strep pneumoniae is very common in the environment
true
strep pneumoniae infection is observed in ____ patients and those with chronic ___ and ____
asplenic patients and with chronic CV and pulmonary disease
effective antibiotics against strep pneumoniae:
-pen susceptible (MIC <0.1mg/L)
-preferred agents
-alternative agents (name 5)
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
**which fluoroquinolone CANNOT be used against strep pneumoniae and why
ciprofloxacin - has poor gram (+) coverage
can only use the respiratory fluoroquinolones - moxifloxacin and levofloxacin
true or false
all fluoroquinolones can be used against strep pneumoniae
FALSE - only the respiratory fluoroquinolones and NOT cipro
can use moxi, levo
Strep pneumoniae has intermediate PCN resistance (MIC 0.1-1mg/l) B lactamase producing
name 4 preferred agents
-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)
strep pneumoniae with HIGH LEVEL pen resistance (MIC>2mg/l) – change in PBP binding site
name the 2 preferred agents
vancomycin (per renal fxn)
fluoroquinolones (RESPIRATORY)
H. influenza is a gram negative ____ ____
pleomoprhic rod
H. influenzae most commonly infects what kind of patients?
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
can H. influenza produce beta lactamase? do we cover H. influenzae empirically?
yes and yes
preferred agent for NON beta lactamase producing H. influenzae
ampicillin/amoxicillin
preferred agents for beta lactamase producing H. influenzae
mixed or gram (-) cephs
augmentin (b lactamase inhibitor)
fluoroquinolones
doxycycline
____ and ____ bacterial infections are not typically observed in the community
staph aurues and pseudomonas
2 most common atypical pathogens that cause CAP
mycoplasma pneumoniae
legionella pneumophilia
can we identify mycoplasma pneumoniae on a culture or by assay?
no
why is mycoplasma pneumoniae considered “atypical”
it does not have a cell wall!!! nothing that acts on the cell wall will work
mycoplasma pneumonia usually causes CAP in which population
young adults
CAP caused by ________ is often called “walking pneumonia” explain why
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
how long does CAP infection caused by mycoplasma pneumoniae typically last?
what is duration of treatment and what are 3 potential treatments?
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
symptoms of CAP caused by LEGIONELLA PNEUMOPHILIA
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
2 patients in which we would suspect their CAP being caused by legionella pneumophilia and why
-it’s a water-borne pathogen, so patients who have recently traveled or changed plumbing
-all patients with lung disease (smoking, age, immunocomp)
is there an antigen test for legionella pneumophilia?
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
2 preferred agents for legionella
what is duration of treatment
azithromycin or a fluoroqionolone
14-21 days
true or false
legionella is gram negative
true
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
FALSE
pneumonia is a severe infection. we can start empiric therapy immediately based on likely pathogens
4 potential diagnostic evaluations for patients with CAP
chest x ray - ALMOST ALWAYS DONE
sputum examination
body fluid culture
serological studies and antigen detection for legionella nd mycoplasma (not that accurate tho)
explain how a chest x ray can be misleading when evaluating CAP.
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
explain the relationship between examining a patient’s sputum and epithelial cells
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
how can a sputum sample be used as a method of diagnostic evalutation of patients with CAP
can look for moderate-many WBC
can do GRAM STAIN which is very beneficial
empiric treatment for pneumonia is based on ____
the setting
outpatient vs inpatient vs ICU
**3 different regimens for healthy outpatient adults with CAP - include dosing
amoxicillin 1g PO TID (HIGH DOSE)
doxycycline 100mg BID
macrolides: azithromycin 500mg/250mg regimen, clarithromycin XL 1000mg daily
as mentioned, there are 3 different regiments for healthy outpatient adults with CAP
explain the use of amoxicillin
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)
true or false
doxycycline 100mg PO BID can be used in healthy outpatient adults with CAP. however, it does not cover the atypicals
FALSE - it does
everuthing else is correcr
**true or false
doxycycline should be avoided in pregnancy
TRUE
teratogenic + increased risk of liver disease in moms
also avoid in less than 8 years olf
1 of the 3 regimens for healthy outpatient adults with CAP included macrolides
is this recommended on a normal basis?
NO
only conditionally recommended ONLY in areas where pneumococcal resistance to macrolides is less than 25%
if greater than 25%, DO NOT USE MACROLIDES
name potential regimens for patients with CAP who have COMORBIDITIES
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
dose of each of the 3 respiratory fluoroquinolones for patients with CAP who have comorbidities
levo - 750mg QD
moxi - 400mg QD
gemi - 320mg QD
as mentioned patients with CAP who have comorbidities are treated differently than healthy patients
name these comorbidities in which the treatment would be different
chronic heart, lung, liver, or renal disease
diabetes
alcoholism
malignancy
asplenia
2 patients in which we should NOT use fluoroquinolones
pregnant
children
*caution with side effects in ALL patients
inpatient therapy, non-ICU setting treatment regimens
- combo therapy: beta lactam + azithromycin
- monotherapy with RESPIRATORY fluoroquinolone
- combo therapy of beta lactam + doxycycline
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?
azithromycin and doxycycline cover the more resistant pathogens AS WELL AS the atypicals that the beta lactams do not cover
true or false
we cannot use monotherapy to treat CAP in inpatient, NON icu setting
FALSE
we can use just a respiratory fluoroquinolone - actually shown to have fewer incidences of clinical failure and less diarrhea vs combo therapy
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
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
true or false
for inpatient therapy non ICU setting, beta lactam + doxycycline is 1st line therapy
FALSE - only conditionally recommended for patients contraindicated to both macrolides AND fluoroquinolones
low quality of evidence for beta lactam + doxy
true or false
for inpatient non ICU therapy for CAP, we give oral antibiotics
FALSE
if they’re sick enough to hospitalize - we are giving IV antibiotics for at LEAST 48 hours
inpatients should only receive empiric therapy for MRSA or pseudomonas when……
risk factors are present
otherwise, we do NOT cover for them
_____ days of antibiotic therapy is sufficient for many patients with CAP
however……
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
name some monitoring parameters to see if the antibiotics are working for CAP
what specific thing is NOT recommended for monitoring
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
