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M201 > W7 Respiratory Infections > Flashcards

W7 Respiratory Infections Flashcards

1
Q

What are some examples of respiratory infections?

A
  • Covid 19
  • Infective exacerbation of COPD
  • Tuberculosis (TB)
  • Empyema
  • Pleurisy
  • Influenza
  • Acute bronchitis Bronchiectasis
  • Pneumonia
  • Community acquired
  • Hospital acquired
  • Aspiration pneumonia
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2
Q

What is pneumonia by definition?
What are the 3 types

A

Definition:
* Inflammation of the lungs caused by a bacterial or viral infection, in which the air sacs fill with pus and can become solid.
* 2019 – affected 489 million people worldwide
* Most common population groups:
* Children <5 years
* Adults >70 - highest mortality
* Can affect either:
* BOTH lungs → double/bilateral pneumonia
* ONE lung → single / unilateral pneumonia
* Pneumonia can be split into three categories:
1) Community acquired pneumonia (CAP)
2) Hospital acquired pneumonia (HAP)
3) Aspiration pneumonia

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3
Q

What is community acquired pneumonia?

What are the risk factors?

What are the most and least causative organisms?

A
  • Caused by overgrowth of pathogenic bacteria in the upper respiratory tract leading to infection
  • The bacteria responsible for the infection will depend on local epidemiology
  • The severity of the infection will depend on:
  • The invading organism and its response to antimicrobial treatment
  • Patients underlying co-morbidities
  • Presence of risk factors
  • Age >65
  • PMHx of COPD
  • Exposure to cigarette smoke (active or passive smoker)
  • Housed in residential / care home
  • Alcohol abuse
  • Use of acid-reducing drugs - stomach acid, allows pathogens to colonise upper resp.
    tract more easily (GIS ISU)
  • Weaker risk factors: chronic renal disease, chronic kidney

Most common causative organisms
Streptococcus pneumoniae
Influenza viruses (viral CAP)

Less common causative organisms
Haemophilus influenzae
Staphylococcus aureus (inc MRSA)
Group A streptococci
Legionella spp **
** most common in immunocomprom pts

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4
Q

What are the symptoms of Influenza? (8)

A

Fatigue, low energy levels
Fever/chills
Severe coughing / sore throat – yellow/green sputum or bloody mucus
SOB / rapid breathing (High respiratory rate)
Chest pain
Nausea and vomiting
Muscle aches/ pains
Confusion

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5
Q

How can you diagnose CAP?
tests?
observations?

A

Diagnosis & Assessment:
* Thorough history from the patient – including HxPC / symptoms
Blood tests:
* CRP
* WCC

  • Patient observations:
  • Blood pressure
  • Heart rate
  • Respiratory rate
  • Temp
  • Oxygen saturation

Chest X-ray: shows new signs of consolidation
* Within 4 hours of presentation
* Within 1 hour if suspecting seps

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6
Q

What is the differential diagnosis of CAP? (7)

A
  • Covid 19 associate CAP – treatments differ
  • Acute bronchitis
  • Infective exacerbation of COPD
  • Tuberculosis
  • Empyema
  • Lung cancer
  • Pulmonary embolism (PE
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7
Q

CAP Treatment:
What is the criteria used to diagnose a patient?

A

C U R B - 6 5 (Hospital)
C R B – 6 5 (Primary care)

Confusion
Urea >7.0 mmol/L
Resps >30/min
Blood pressure *Low systolic <90 mmHg and <60mmHg
65- Age >65

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8
Q

CURB 65 0-1 low severity:
Treatment?

A

Amoxicillin PO 500mg TDS for 5 days
OR Pen allergic:
1. Doxycycline PO 200mg STAT, 100mg OD for 5 days
2. Clarithromycin PO 500mg BD x5days

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9
Q

CAP- Amoxicillin

A

Antibiotic class: Penicillin
* Side effects:
* Hypersensitivity; rash and anaphylaxis
* 1 – 10% of individuals exposed = reaction
* 0.05% of reactions = anaphylaxis
* Patients with atopic conditions more prone to anaphylactic reactions
* Cross sensitivity with cephalosporins
* Diarrhoea = Abx associated colitis
* Nausea and vomiting
* Contra indications: allergy (anaphylaxis)
* Cautions: Hx of allergy (inc. rash)
* Counselling:
* Can cause diarrhoea – seek advice if this becomes severe
* Diarrhoea is not an allergy – common s/e

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10
Q

CAP- Doxycycline

A
  • Antibiotic class: tetracycline
  • Side effects:
  • Angioedema (swelling –eyes, lips, tongue, hands)
  • Diarrhoea
  • Oesophageal irritation
  • Photosensitivity - skin
  • Teeth discolouration (avoided in children)
  • Hepatic disorders
  • inc intracranial hypertension: headache and visual disturbance
  • Contra indications: children <12 years
  • Cautions: myasthenia gravis ( muscle weakness)
  • Counselling:
  • Take with food
  • Swallow whole
  • inc skin sensitivity to sunlight – advise on SPF use, sunbed avoidance
  • Avoid calcium and aluminium containing products when taking = bind to the Abx rendering it ineffective. Take 2 hours before / 4 hours after
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11
Q

CAP- Clarithromycin:

A

Clarithromycin
* Antibiotic class: Macrolide
* Side effects:
*  appetite inc. altered taste
* GI discomfort – diarrhoea, nausea, vomiting,
burping
* Hearing impairment
* Dry mouth
* QT interval prolongation
* Cautions: when used with other QT prolonging drugs
!! REMINDER !!
Clarithromycin is an enzyme
INHIBITOR  interaction potential

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12
Q

CAP
What treatment is used for patients with Curb score 2 (moderate severity)?

A

Non-pen allergic
Amoxicillin (PO) 500mg – 1000mg TDS
5 days
PLUS Clarithromycin (PO) 500mg BD

Pen allergic: Doxycycline (PO) 200mg STAT, 100mg OD PLUS Clarithromycin (PO) 500mg BD x5 days

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13
Q

What treatment is used for patients with Curb score 3 or above (high severity)?

A

Non-pen allergic:
Co-amoxiclav (PO / IV) PO – 625mg TDS or I V – 1.2g TDS x5 days
Pen allergic:
Clarithromycin (PO / IV) 500mg BD
OR
Levofloxacin (PO / IV) 500mg BD
x5 days

  • Unlikely you will see the use of co-amoxiclav for CAP in hospital setting, unless advised by microbiology consultant or for
    very specific indications
  • Why?
  • High risk of clostridium difficile  infective diarrhoea often associated with the excess use of broad spectrum antibiotics
  • High resistance rates beginning to develop
  • Within SBUHB & HDUHB  1st line for CAP, CURB-3
  • Amoxacillin (IV) 1g TDS plus
  • Clarithromycin (PO/IV) 500mg BD
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14
Q

CAP- Co-amoxiclav

A
  • Antibiotic class: Penicillin (amoxicillin + clavulanic acid)
  • Side effects:
  • As per amoxicillin
  • Hepatic disorders: ALT, AST (liver enzymes)
  • Contra indications: Hx of jaundice due to co-amoxiclav
    administration
  • Monitoring:
  • Liver function (in pts with known liver disease)
  • Notes: allergy potential
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15
Q

CAP- Levofloxacin
Side effects?

A
  • Antibiotic class: Quinolone
  • Side effects:
  • GI upset - dec appetite, constipation, diarrhoea, N&V
  • QT prolongation
  • Affect glucose control
  • Photosensitivity reactions
  • Eye disorders / discomfort
  • Headache
  • Convulsions
  • Tendon damage
  • Serious musclo-skeletal and nervous system disorders
    Specific MHRA safety alerts released
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16
Q

CAP- Levofloxacin
What are the MHRA warnings?

A

1) Can induce convulsions (with/without Hx of seizures)
2) Tendon damage
* C/I in patients with Hx of quinolone induced tendon
damage
* Patients >60 at an increased risk
* Risk increased when used with corticosteroids
* Stop immediately is tendonitis suspected
1) INC risk of aortic aneurysm / dissection
2) INC risk of disabling, long lasting or irreversible adverse reactions affecting the musclo-skeletal and nervous system
* Patients should be provided with MHRA advice sheet outlining s/e to lookout for

17
Q

Levofloxacin:
Cautions?
C/I?
Counselling?
Monitoring?

A

Cautions:
* Patients with QT prolongation risk factors
* Use in children – arthritis in weight bearing joints
* Patients >60 – s/e risk
* Patients with renal impairment -  s/e risk
* Disorders that pre-dispose patient to seizures:
-Epilepsy
-Alcohol dependence

  • Contra indications:
  • Hx of quinolone induced tendon damage
  • Counselling:
  • Provide MHRA advice leaflet
  • Look out for signs / symptoms of tendonitis e.g. muscle or tendon pain, swelling
  • Monitoring:
  • Signs of s/e – discuss with the patient
  • Renal function
18
Q

CAP counselling?

A
  • Patient expectation in terms of symptom resolution should be addressed
  • Symptom should improve steadily but the rate of improvement will vary depending on the severity of the pneumonia
  • Symptoms resolution timeline:
  • 1 week: fever should have resolved
  • 4 weeks: chest pain and sputum production should have substantially reduced
  • 6 weeks: cough and breathlessness should have substantially reduced
  • 3 months: most symptoms should have resolved but fatigue may still be present
  • 6 months: most people will feel back to normal
19
Q

Hospital acquired pneumonia (HAP) -
BACTERIAL
What are the risk factors?

A
  • HAP vs CAP
  • Symptoms occur >48 hours after hospital admission
  • Symptoms differ slightly to CAP – less specific
  • Treatments differs as infection likely to be cause by different organisms (hospital acquired):
    -Pseudomonas aeruginosa
    -Escherichia coli
    -Klebsiella pneumoniae

Risk factors
* Poor infection control/hand hygiene – hence why this is so important in clinical settings
* Head of bed at <30° angle
* Intubation and mechanical ventilation
* Acid- medications (PPIs or H2 antagonists)

20
Q

HAP Symptoms?

A

Cough
Dyspnoea (shortness of breath)
Inc Resp rate
Confusion
Increase in lung secretions
Increased oxygen requirement
Fever/chills
Leukocytosis (high WCC) or Leukopenia (low WCC)

21
Q

How to diagnose HAP?
What symptoms can deem it as severe?

A

Chest X-Ray –signs of new significant lung
infiltration PLUS
Either…
* Fever >38°
* WCC >11
PLUS
Any of the following:
* Inc resp secretions
* SOB
* Cough
* resp rate
* impaired oxygenation
* New confusion

  • Unlike CAP – there isn’t a severity scoring tool that can be used to help guide treatment.
  • Severity of condition determined by patients clinical status e.g. deemed SEVERE if they have any of the following symptoms:
  • New confusion (other causes should also be considered)
  • Respiratory rate > 30/min
  • Bilateral or multiple infiltrates on Chest X-Ray
  • Severe sepsis and sepsis shock
  • Multi organ dysfunction
  • Acute (new) Respiratory failure (PaO2 < 8 kPa and/or PaCO2 > 6.0 kPa)
  • Requiring critical care support
22
Q

What are the non-severe treatments for HAP?

A

Non-pen allergy:
Co-amoxiclav (PO) 625mg TDS
5 days
Pen allergy: Doxycycline (PO) 200mg STAT, 100mg OD OR
Co-trimoxazole (PO) 960mg BD OR
Levofloxacin (PO) 500mg OD - BD

23
Q

Co-trimoxazole (BRAND: Septrin) in treating non-severe HAP:

A

Combination antibiotic: Sulfamethoxazole + trimethoprim
* Dosing:
* CrCL > 30 ml/min: 960mg BD
* CrCL < 30 ml /min: 480mg BD
* Side effects:
* Hypersensitivity; rash and anaphylaxis
* Diarrhoea = Abx associated colitis
* Blood disorders: Dec Hb, Dec PLT, Dec leucocytes

Contra indications: allergy to co-trimoxazole (or
trimethoprim or sulfonamides)
* Cautions:
* Blood disorders
* Risk of hyperkalaemia
* Elderly = increased risk of s/e
* Monitoring:
* Renal function – affects dosing, avoid if CrCL < 15
* Blood counts – especially in prolonged treatment

24
Q

What are the treatments for Severe HAP?

A

Non-pen allergy:
Tazocin (IV) 4.5g TDS x5 days
Pen allergy: (non-severe)
Meropenem (IV) 1g TDS
Pen allergy:
(severe) Levoflaxacin (IV) 500mg OD - BD

25
Q

Tazocin (Piperacillin & Tazobactam in treating severe HAP

A

Antibiotic class: Penicillin
* Dosing:
* CrCL > 20 ml/min: 4.5g TDS
* CrCL < 20 ml /min: 4.5g BD
* Side effects:
* Hypersensitivity; rash and anaphylaxis
* Diarrhoea  Abx associated colitis
* Nausea and vomiting
* Anaemia
* Contra indications: allergy (anaphylaxis)
* Cautions: Hx of allergy (inc. rash)
* Monitoring:
* Sodium levels – high levels of Na in each vial
* Renal function
* Bowel motions – broad spec Abx so C.Diff risk

26
Q

Meropenem (IV) in treating severe HAP

A

Antibiotic class: Carbapenems
Dose:
* CrCL >50 ml/min: 500mg – 1g TDS
* CrCL 26 – 50 ml/min: 500mg – 1g BD
* CrCL 10 – 25 ml/min: 250 – 500mg BD
Side effects:
* Diarrhoea
* Skin reactions  rash
* Contra indications:
* Severe penicillin allergy
* Monitoring:
* Liver function tests – risks of hepatotoxicity
* Allergy / cross sensitivity
* Cross sensitivity between carbapenems and penicillin’s
* Hence, contraindicated in patients with severe penicillin allergy (anaphylaxis, angioedema)

27
Q

What is COPD by definition?
What are the symptoms? (5)

A

Definition:
Chronic obstructive pulmonary disease is a progressive disease of the lungs
that is characterised by airflow limitation that are not fully reversible

Symptoms
* Increased shortness of breath – progressive & gets worse over time
* Chronic or recurrent cough
* Regular sputum production
* Wheeze
* Frequent chest infections

28
Q

What is an exacerbation?
What causes and exacerbation?

A

Sustained worsening of symptoms from the persons stable state (beyond their normal day-
to-day variation) which is acute in onset

  • There are certain triggers that can cause an exacerbation
  • These triggers may not always cause an infection and so antibiotics are not always needed. Triggers include:
  • Viral infections
  • Smoking
  • Environmental pollution
  • Bacteria ** - only trigger which will respond to antibiotics
29
Q

Exacerbation symptoms and diagnosis of COPD

A

Symptoms:
* Increase in the patients usual breathlessness or SOB
* Increased cough
* Changes to “normal” sputum production:
* Colour: green / yellow suggestive of infection
* Volume and viscosity (thickness) of mucus increased
* Less typical symptoms:
* Increased wheeze / chest tightness
* Reduced exercise tolerance
* Increased fatigue
* Acute confusion
Exacerbation symptoms and diagnosis

Diagnosis
* Thorough Hx from a patient to
establish whether they have a
PMHx of COPD
* Thorough Hx of their
symptoms have worsened
(with an acute onset)
* Trigger identification

30
Q

What is the differential diagnosis for HAP?

A
  • Pneumonia = consolidation on chest X-Ray
  • Pulmonary embolism = blood clot on the lung
  • Heart failure
  • Pneumothorax = collapsed lung
  • Pleural effusion = fluid in lung
31
Q

Treatment – infective exacerbation

A
  • For an infective exacerbation of COPD (IECOPD) – Antibiotics may need to be prescribed
  • Consider antibiotics for patients with an acute exacerbation of COPD but only after considering:
  • Symptom severity: are they worse / are there changes to the patients normal symptoms?
  • Sputum colour – green/yellow suggestive bacterial infection
  • Thickness and volume of sputum
  • Does the patient need hospitalisation?
  • Breathlessness severe
  • Significant co-morbidities
  • Oxygen saturation <90%
  • Confusion or conscious level affected
  • Previous exacerbation history and risk of the patient developing complications
  • Previous sputum cultures and the results  what antibiotics were the previous infecting bacteria susceptible to?
  • Antimicrobial resistance patterns within the area and previous antibiotic use
32
Q

What is the treatment choice for IECOPD?

A

1st and 2nd choice
- Amoxicillin (PO) 500mg TDS
- Doxycycline (PO) 200mg stat, then 100mg OD
- Clarithromycin (PO) 500mg BD
x 5 days

33
Q

What is the treatment choice for IECOPD?
Alternative choice – patients at risk of
treatment failure
What does this mean?

A

Co-amoxiclav (PO) 625mg TDS
5 days
Co-trimoxazole (PO) 960mg BD
Levofloxacin (PO) 500mg OD

M201 (81 decks)

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