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Therapeutics Final > Therapy of Pneumonia > Flashcards

Therapy of Pneumonia Flashcards

1
Q

Pneumonia is one of the most common causes of:

A

1) Severe sepsis
2) Infectious cause of death

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2
Q

Pneumonia’s clinical manifestations are most severe in:

A

1) The very young
2) The elderly
3) The chronically ill

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3
Q

The most prominent pathogen causing community-acquired pneumonia (CAP) in otherwise healthy adults is:

A

Streptococcus pneumoniae

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4
Q

Streptococcus pneumoniae causes:

A

Community-acquired pneumonia (CAP)

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5
Q

What are some other common pathogens (besides Strep. pneumoniae)?

A

1) H. influenzae
2) Atypical pathogens:
a) Mycoplasma pneumoniae
b) Legionella sps
c) Chlamydia pneumoniae
3) Viruses, including influenza viruses

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6
Q

The leading causative agents in hospital-acquired pneumonia (HAP) are:

A

1) Gram-negative aerobic bacilli
2) S. aureus
3) Multidrug-resistant (MDR) pathogens

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7
Q

Ventilator-associated pneumonia (VAP) is
associated with:

A

Multidrug-resistant (MDR) pathogens

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8
Q

In pneumonia that follows the aspiration of gastric or oropharyngeal contents, ____ are the most common etiologic agents.

A

Anaerobic bacteria

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9
Q

Pneumonia in infants and children is caused mostly by:

A

Viruses

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10
Q

Which viruses can cause pneumonia in infants and children?

A

1) RSV
2) Parainfluenza
3) Adenovirus

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11
Q

____ is an important pathogen in older children.

A

Mycoplasma pneumoniae

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12
Q

Beyond the neonatal period, what are the top 3 pathogens in order?

A

1) Strep. pneumoniae
2) Group A Streptococcus
3) Staph. aureus

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13
Q

Why has H. influenzae type b become an infrequent cause of
pneumonia?

A

Because of the introduction of active vaccination against it

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14
Q

Supportive care for pneumonia?

A

1) Humidified oxygen for hypoxemia
2) Bronchodilators when bronchospasm is present
3) Chest physiotherapy and postural drainage with evidence of retained secretions
4) Adequate hydration
5) Optimal nutritional support
6) Control of fever

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15
Q

Recommendations are generally for __(specific/class of) antibiotics rather than for a specific drug.

A

Class of

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16
Q

Recommendations for the management of CAP in adults depend on:

A

1) The treatment setting: inpatient or outpatient
2) The severity of infection
3) The presence of comorbidities
4) The presence of risk factors for drug-resistant pathogen

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17
Q

All patients with CAP should be treated __ for bacterial infection.

A

Empirically

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18
Q

Any patient with CAP who was recently exposed to one class of antibiotics should be treated using:

A

A different class

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19
Q

Risk factors for MRSA and P. aeruginosa include:

A

1) Prior respiratory isolation of the pathogen
2) Hospitalization with administration of parenteral antibiotics within the last 3 months
3) Locally validated risk factors for these pathogens and prevalence of MRSA or P. aeruginosa in CAP patients

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20
Q

In outpatient settings of CAP pneumonia, patients without comorbid conditions or risk
factors for drug-resistant pathogens should take:

A

Monotherapy with Amoxicillin, Doxycycline, or a Macrolide (Azithromycin or Clarithromycin)

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21
Q

Macrolide monotherapy has shown resistance and should not be used if the local rate of
resistance of Pneumococcus is greater than __%.

A

0.25

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22
Q

In outpatient settings of CAP pneumonia, patients with comorbid conditions or risk
factors for drug-resistant pathogens should take:

A

1) Monotherapy with a respiratory Fluoroquinolone
(Levofloxacin, Moxifloxacin, or Gemifloxacin)

OR

2) Combination therapy with (Amoxicillin-Clavulanate or a Cephalosporin) + (A Macrolide
or Doxycycline)

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23
Q

Inpatient setting of CAP pneumonia patients recommendations are based on:

A

1) Severity of pneumonia
2) Prior respiratory isolation of MRSA or P. aeruginosa
3) The presence of risk factors for these pathogens

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24
Q

For inpatients with non-severe pneumonia use:

A

1) Beta-lactam + Macrolide

OR

2) A respiratory Fluoroquinolone alone.

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25
Alternative treatment for inpatients with non-severe pneumonia?
Beta-lactam + Doxycycline
26
For inpatients with severe pneumonia, use:
Beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) + A macrolide (azithromycin) or a Fluoroquinolone
27
Don’t use ___ for Acinetobacter VAP
Tigecycline
28
Acinetobacter HAP/VAP = use:
Carbapenem or Ampicillin/sulbactam
29
Resistant Acinetobacter HAP/VAP = use:
Inhaled Polymyxin B AND IV Colistin
30
empirical antimicrobial agent for pneumonia with activity against which pathogens:
MRSA and P. aeruginosa
31
empirical antimicrobial agent for CAP
*(vancomycin or linezolid) for MRSA AND *(antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) for P. aeruginosa + either ciprofloxacin or levofloxacin; should be added in all inpatients With prior respiratory isolation of the pathogen.
32
Once the etiology of CAP has been identified on the basis of reliable microbiological methods, what should be the next step?
antimicrobial therapy should be directed at the specific pathogen.
33
For patients admitted through the emergency department (ED), when should be the first antibiotic dose:
For patients admitted through the emergency department (ED), the first antibiotic dose should be administered while still in the ED
34
when Patients should be switched from intravenous to oral therapy for CAP
when they are 1)hemodynamically stable and 2)improving clinically, 3) are able to ingest medications, and 4)have a normally functioning gastrointestinal tract.
35
when Patients should be discharged for CAP?
Patients should be discharged as soon as they are clinically stable, have no other active medical problems, and have a safe environment for continued care. ( Inpatient observation while receiving oral therapy is NOT necessary)
36
is Inpatient observation while receiving oral therapy necessary for CAP?
NO, NOT necessary
37
Patients with CAP should be treated for a minimum of____ days, and should be afebrile for _____days for CAP
5 Days , 2-3 days
38
when A longer duration of therapy may be needed for CAP?
1- if initial therapy was NOT active against the identified pathogen, 2-or if it was complicated by extra-pulmonary infection such as meningitis or endocarditis.
39
How is it advised to manage HAP/VAP?
It is advised that each hospital generate its specific antibiogram.
40
why It is advised that each hospital generate its specific antibiogram?
It is suggested that patients with suspected HAP (non-VAP) be treated according to the results of microbiological studies rather than being treated empirically.
41
In patients with suspected VAP, what should you cover in your empiric regimens?
cover for S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli
42
what is the empiric coverage for MRSA?
either vancomycin or linezolid is recommended.
43
what is the empiric coverage for MSSA (not-MRSA)?
piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem is recommended.
44
what are the preferred drugs proven MSSA?
oxacillin, nafcillin and cefazolin are preferred (these agents are not necessary for empiric treatment of VAP if one of the above agents is used)
45
For patients being treated empirically for HAP, cover for _______
S. aureus
46
For patients with HAP/VAP due to Pseudomonas aeruginosa, the choice of antibiotic for definitive (not empiric) therapy should be based on ___________
the results of antimicrobial susceptibility testing.
47
For patients with HAP/VAP, a ____ day(s) course of antimicrobial therapy is recommended
7 days (traditionally it was 7-14 days)
48
Pseudomonas aeruginosa may require_____ 7 days.
more than
49
when the empiric broad spectrum regimen should be converted to more narrow and specific coverage?
When the final culture and sensitivity results are available
50
Cefiderocol (5th GCS) has been approved for HAP/VAP to which microorganisms?
1- Acinetobacter baumannii complex, 2- Escherichia coli, 3-Enterobactercloacae complex 4- Klebsiella pneumoniae, 5- Pseudomonas aeruginosa 6- Serratia marcescens.
51
in empirical treatment for HAP, what should you cover?
MSSA should be covered unless the patient has risk factors for MRSA:
52
what are the risk factors for having MRSA?
1. IV antibiotics within the preceding 90 days. 2. Exposure to a hospital unit where > 20% of S. aureus isolates are MRSA. 3. High risk of death (need for ventilatory support due to septic shock) so, Vancomycin or linezolid should be used for empiric therapy (guided by local antibiogram).
53
when should Vancomycin or linezolid should be used for empiric therapy for HAP patient?
when the patient has risk factors for MRSA
54
what are the empiric coverage of MSSA for HAP patient?
piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem is recommended.
55
what are the definitive therapy for proven MSSA?
oxacillin, nafcillin and cefazolin are favored
56
For empiric coverage against Pseudomonas aeruginosa use ______ coverage in patients at high risk of death (need for ventilatory support and/or septic shock). * For all other cases _______ coverage is indicated.
double, single
57
when you should use double coverage against Pseudomonas aeruginosa in empiric HAP treatment ?
in patients at high risk of death (need for ventilatory support and/or septic shock)
58
In Empiric treatment of VAP, what should you cover?
S. aureus, Pseudomonas aeruginosa, and other gram negative bacilli.
59
when MRSA should be covered empirically in VAP patient?
in patients with any risk factors for antimicrobial resistance
60
Which patients are at risk for antimicrobial resistance and you should cover MRSA?
1. Patients located in a unit where > 10-20% of S. aureus isolates are MRSA. 2. Patients in units where prevalence of MRSA is unknown
61
For MRSA infection, When linezolid is preferred over vancomycin?
1. Patients with renal insufficiency. 2. Patients infected with high MIC MRSA isolates.
62
for VAP, A ______ antibiotic with activity against Pseudomonas aeruginosa should be administered except in patients with risk factors for ________ organisms:
single, multidrug-resistant (MDR)
63
Which patients are at risk for multidrug-resistant (MDR) organisms, and you should give double antibiotic with activity against Pseudomonas aeruginosa
1. Intravenous antibiotic use within the preceding 90 days. 2. Septic shock or ARDS preceding VAP onset. 3. Five or more days of hospitalization prior to VAP onset. 4. Acute renal replacement therapy prior to VAP onset. 5. The patient is located in a unit where > 10% of gram negative isolates are resistant 6. Patients in ICU where antibiotic sensitivity rates are not available
64
Double-drug coverage for Pseudomonas aeruginosa combine agents with high degree of antipseudomonal activity and low resistance potential examples
piperacillin-tazobactam, cefepime, ceftazidime, imipenem, meropenem, or aztreonam + levofloxacin, ciprofloxacin or aminoglycoside (amikacin, gentamicin, tobramycin), or polymyxins (polymyxin B, colistin).
65
what are the drug that should be avoided in therapy of VAP?
aminoglycosides and colistin
66
why aminoglycosides and colistin should be avoided in therapy of VAP?
due to poor penetration of these agents in the lung tissues in addition to the potential nephrotoxicity.
67
VAP due to Pseudomonas aeruginosa has a______ failure rate (~_____%), regardless of the antibiotic regimens.
high, 40
68
what is the role of inhaled antibiotic therapy in VAP?
should be limited to cases of VAP produced by gram negative bacilli that are sensitive only to aminoglycosides and polymyxins (colistin and polymyxin B), which should also be administered intravenously.
69
* A __________ or ____________ should be used for Acinetobacter HAP/VAP.
carbapenem, ampicillin/sulbactam
70
If Acinetobacter HAP/VAP is resistance to carbapenem or ampicillin/sulbactam, what is the substitution?
they should be substituted by inhaled and intravenous colistin. (The guidelines are against the use of tigecycline for Acinetobacter VAP.)
71
(Do/ Don't )use of tigecycline for Acinetobacter VAP.
Don't
72
what are the Clinical Caveats in Selecting an Empiric Antibiotic Regimen?
The administration of the antibiotics should not be delayed for the sole purpose of performing diagnostic tests. 2. If the patient received antibiotics in the recent past, the new antibiotic should be from a different class. 3. When an appropriate and adequate initial antibiotic regiment is started, the duration of therapy should be shortened ( from the traditional 14-21 days to 7 days), except for P. aeruginosa. 4. False negative cultures occurs in patients who have been taking antibiotics for 24-72 hours before collection of respiratory specimens. 5. Aerosolized antibiotics may be used as adjunct to systemic antibiotics. They are not effective as sole therapy. 6. Certain organisms (E. coli, Klebsiella spp, Enterobacter spp) produce extended-spectrum β-lactamase. These are usually susceptible to carbapenems.
73
When an appropriate and adequate initial antibiotic regiment is started, the duration of therapy should be ________ ( from the traditional 14-21 days to_____ days), except for ____________
shortened, 7 days, P. aeruginosa.
74
_____________ cultures occurs in patients who have been taking antibiotics for 24-72 hours before collection of respiratory specimens
False negative
75
when are the onset of Neonatal Pneumonia?
1) May be within hours of birth, and as part of a generalized sepsis syndrome. 2) After 7 days (most commonly in neonatal ICUs among infants who require prolonged endotracheal intubation because of lung disease)
76
what are usually the Organisms in Neonatal Pneumonia?
Organisms that acquired from the maternal genital tract or the nursery, and include.
77
what are the Organisms that acquired from the maternal genital tract or the nursery?
a) Gram-positive cocci (groups A and B streptococci, both methicillin-sensitive and methicillin-resistant Staphylococcus aureus) b) Gram-negative bacilli (E. coli, Klebsiella sp, Proteus sp). c) Pseudomonas, Citrobacter, Bacillus, and Serratia in infants who have received broad-spectrum antibiotics
78
what is the Treatment of Neonatal Pneumonia ?
Antimicrobial therapy in early-onset disease is similar to that for neonatal sepsis: Vancomycin and a broad-spectrum β-lactam drug such as meropenem, piperacillin/tazobactam, or cefepime are the initial treatment of choice.
79
what should you take in consideration in choosing empiric antimicrobials for Neonatal Pneumonia?
Local patterns of infection and bacterial resistance
80
when the neonate expose to Chlamydial? and when it develops chlamydial pneumonia?
1- Exposure to chlamydial organisms (Chlamydia trachomatis) occurs during delivery. 2- development of chlamydial pneumonia at 2 to 18 wk.
81
what is the Treatment for Neonatal Pneumonia?
Erythromycin or azithromycin. (Erythromycin may cause hypertrophic pyloric stenosis in neonates.)
82
which drug may cause hypertrophic pyloric stenosis in neonates?
Erythromycin
83
when neonate is diagnosed with Chlamydial pneumonia, who should also treated ?
The mother and father should also be treated for chlamydia.
84
In Community-Acquired Pneumonia in Children, The most likely etiology depends on the ______ of the child.
age
85
In Community-Acquired Pneumonia in Children,____________ pneumoniae infections are most common in preschool-aged children, whereas ________ pneumoniae is common in older children.
Viral and Streptococcus, Mycoplasma
86
Community-Acquired Pneumonia in Children Preschool-aged children with uncomplicated bacterial pneumonia should be treated with _______ , for older children give __________
amoxicillin , Macrolides
87
how can you reduce the severity of childhood pneumococcal infections?
by Immunization with the 13-valent pneumococcal conjugate vaccine
88
what is Recommended Empiric Outpatient Treatment of Childhood CAP with 60 days to 5 years of age?
* Preferred regimens: Amoxicillin for 7-10 days. * Alternative regimens for patients allergic to penicillin or beta-lactam antibiotics: Azithromycin (5 days), clarithromycin (7-10 days), or erythromycin (7-10 days).
89
what is Recommended Empiric Outpatient Treatment of Childhood CAP with 5 to 16 years of age?
Azithromycin (5 days)
90
what is the duration for each antibiotic giving empirically for Childhood CAP: Amoxicillin __________ Azithromycin___________ clarithromycin or erythromycin ____________
7-10 days 5 days 7-10 days
91
what is Recommended Empiric Inpatient Treatment of Childhood CAP with 60 days to 5 years of age?
- Cefuroxime for 10-14 days. - In critically ill patients: Cefuroxime + erythromycin 10-14 days, or cefotaxime + cloxacillin for 10-14 days
92
what is Recommended Empiric Inpatient Treatment of Childhood CAP with 5 to 16 years of age?
Cefuroxime + erythromycin 10-14 days, or azithromycin for 5 days.

Therapeutics Final (13 decks)

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