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PHRM 865 > Exam 3 RTI > Flashcards

Exam 3 RTI Flashcards

1
Q

What are the three broad locations of host defense mechanisms

A
  1. Upper airways
  2. Conducting airways
  3. Lower respiratory tract
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2
Q

What is part of the upper airways (2)

A
  1. Nasopharynx

2. Oropharynx

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3
Q

Nasopharynx defense mechanism (5)

A
  1. Nasal hair
  2. Turbinates
  3. Anatomy of upper airways
  4. Mucociliary apparatus
  5. IgA secretion
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4
Q

Oropharynx defense mechanism (3)

A
  1. Saliva
  2. Sloughing of epithelial cells
  3. Complement production
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5
Q

What makes up the conducting airway (2)

A
  1. Trachea

2. Bronchi

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6
Q

Conducting airway host defense mechanism (5)

A
  1. Cough
  2. Epiglottic Reflexes
  3. Sharp, angled, branching airways
  4. Mucociliary apparatus
  5. IgG/M/A production
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7
Q

What makes up the lower respiratory tract (2)

A
  1. terminal airways

2. alveoli

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8
Q

Lower respiratory tract defense mechanisms (5)

A
  1. Alveolar lining fluid
  2. Cytokines
  3. Alveolar macrophages
  4. PMNs
  5. Cell-mediated immunity
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9
Q

What makes up alveolar lining fluid (4)

A
  1. surfactant
  2. fibronectin
  3. Complement
  4. immunoglobulin
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10
Q

What cytokines do we see in lower respiratory tract (3)

A
  1. TNF
  2. IL-1
  3. IL-8
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11
Q

Fibronectin mechanism

A

inhibits adherence of bacteria to cell surfaces –> prevents colonization

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12
Q

What happens when IgA gets degraded

A

colonization is promoted

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13
Q

Alveolar macrophages mechanism

A

eliminate organisms by phagocytosis and produce cytokines that recruit neutrophils into the lungs –> local area becomes acidic and hypoxic –> impairs phagocytic activity

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14
Q

Different types of pathogenesis for pneumonia (3)

A
  1. Aspiration
  2. Aerosolization
  3. Bloodborne
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15
Q

Most common pathogenesis for bacterial pneumonia

A

Aspiration that causes bacteria to colonize the oropharynx

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16
Q

Specific pathogens in CAP (7)

A
  1. Strep pneumoniae
  2. H. influenzae
  3. Mycoplama pneumoniae
  4. Legionella
  5. Chlamydophila
  6. Staph aureus
  7. Viral
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17
Q

Outpatient CAP pathogens (5)

A
  1. S. pneumoniae
  2. M. pneumoniae
  3. H. influenzae
  4. C. pneumoniae
  5. Respiratory viruses
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18
Q

Inpatient (non-ICU) CAP pathogens (7)

A
  1. S. pneumoniae
  2. M. pneumoniae
  3. C. pneumoniae
    4 H. influenzae
  4. Legionella species
  5. Aspiration
  6. Respiratory viruses
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19
Q

Inpatient ICU CAP pathogens (6)

A
  1. S. pneumoniae
  2. Legionella
  3. S. aureus
  4. GNB
  5. H. influenzae
  6. Influenza
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20
Q

most common species for bacteremic pneumonia cases

A

strep pneumoniae

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21
Q

Risk factors for DRSP

A
  1. extremes of age
  2. prior antibiotic therapy
  3. underlying illness/co-morbid
  4. Day care
  5. Recent or current hospitalization
  6. immunocompromised, HIV, nursing home, prison
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22
Q

symptoms of mycoplasma pneumoniae

A

gradual onset of fever, headache, and malaise; development of persistent, hacking, nonproductive cough after 3-5 days
sore throat, ear pain, and rhinorrhea usually present
non-pulmonary symptoms very common (N/V, diarrhea, myalgia, arthralgia)

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23
Q

mycoplasma timing

A

slow growth of 2-3 weeks

symptoms last up to 4 weeks

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24
Q

mycoplasma radiographic findings

A

patchy, interstitial infiltrates (not consolidation)

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25
Q

Legionella symptoms

A
  • gradual onset
  • presence of high fevers
  • relative bradycardia
  • Rapid progression on CXR and multilobar involvement
  • Mental status changes
  • Need for ICU care
  • Increased LFTs and SCr
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26
Q

What bacteria is more likely in patients post influenza

A

staph aureus

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27
Q

stap aureus symptoms

A

sudden onset of shaking chills, pleuritic chest pain, productive cough, increased WBC with left shift, consolidation

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28
Q

General symptoms of CAP

A 
sudden onset of fever
chills
pleuritic chest pain
dyspnea
productive cough
tachycardia
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29
Q

when is chest radiography needed in CAP

A

should be performed on all outpatients and inpatients with suspected CAP

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30
Q

chest radiography findings in CAP

A

dense lobar consolidation or segmental infiltrates suggestive of bacteria etiology

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31
Q

What should be seen on a gram stain

A

> 25 PMNs

<10 epithelial cells/LPFs

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32
Q

rust-colored sputum

A

s. pneumoniae

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33
Q

dark red, mucoid sputum

A

k. pneumoniae

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34
Q

foul smelling sputum

A

mixed anaerobic infection

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35
Q

In adults with CAP, should Gram stain and culture of lower respiratory secretions be obtained at time of diagnosis

A

Recommend NOT obtaining sputum gram stain and culture of respiratory secretions in adults with CAP managed in outpatient setting

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36
Q

When to do CAP gram stain

A
  • classified as severe CAP, esp if intubated
  • being treated for MRSA or p. aeruginosa
  • Previously infected with above
  • Were hospitalized and received parenteral antibiotics in the past 90 days
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37
Q

Initiation of CAP treatment and testing

A

Recommend initiation of empiric antibiotic therapy in adults with clinically suspected and radiographically confirmed CAP regardless of initial serum procalcitonin concentration

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38
Q

General treatment of CAP

A
  1. humidified oxygen if hypoxemic
  2. Bronchodilators
  3. Fluids
  4. Chest physiotherapy
  5. Appropriate antimicrobial therapy
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39
Q

Treatment of CAP for healthy outpatient adults without comorbidities or risk factors for antibiotic-resistant pathogens

A
  1. Amoxicillin

2. Doxycycline

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40
Q

Can you give macrolides for Treatment of CAP for healthy outpatient adults without comorbidities or risk factors for antibiotic-resistant pathogens

A

Yes where resistant is < 25%

Z-pack
Clarithromycin

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41
Q

Treatment of CAP for outpatient adults with co morbidities general

A

FQ monotherapy
beta lactam + macrolide
beta lactam + doxycycline

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42
Q

FQ Treatment of CAP for outpatient adults with co morbidities

A

levofloxacin
moxifloxacin
gemifloxacin

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43
Q

beta lactam Treatment of CAP for outpatient adults with co morbidities

A

Augmentin
Cefpodoxime
Cefuroxime

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44
Q

macrolide Treatment of CAP for outpatient adults with co morbidities

A

Z pack

Clarithromycin

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45
Q

doxycycline Treatment of CAP for outpatient adults with co morbidities

A

doxycycline 100 mg q 12h (? loading dose of 200 mg)

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46
Q

treatment of CAP in inpatient setting for empiric treatment of non-sever CAP in adults without risk factors for MRSA and P. aeruginosa general

A

beta lactam + macrolide
respiratory FQ
beta lactam + doxy if CI to FQs and macrolides

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47
Q

beta lactam treatment of CAP in inpatient setting for empiric treatment of non-sever CAP in adults without risk factors for MRSA and P. aeruginosa

A

Ampicillin/sulbactam
Cefotaxime
Ceftriaxone
ceftaroline

all IV

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48
Q

macrolide treatment of CAP in inpatient setting for empiric treatment of non-sever CAP in adults without risk factors for MRSA and P. aeruginosa

A

Azithromycin

Clarithromycin

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49
Q

respiratory FQ treatment of CAP in inpatient setting for empiric treatment of non-sever CAP in adults without risk factors for MRSA and P. aeruginosa

A

Levo

Moxi

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50
Q

doxycycline treatment of CAP in inpatient setting for empiric treatment of non-sever CAP in adults without risk factors for MRSA and P. aeruginosa

A

100 mg IV/PO q 12

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51
Q

treatment of CAP in inpatient setting for empiric treatment of severe CAP in adults without risk factors for MRSA and P. aeruginosa general

A

beta lactam + macrolide

beta lactam + FQ

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52
Q

beta lactam treatment of CAP in inpatient setting for empiric treatment of severe CAP in adults without risk factors for MRSA and P. aeruginosa

A

Ampicillin/sulbactam
Cefotaxime
Ceftriaxone
ceftaroline

all IV

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53
Q

macrolide treatment of CAP in inpatient setting for empiric treatment of severe CAP in adults without risk factors for MRSA and P. aeruginosa

A

Azithromycin

Clarithromycin

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54
Q

respiratory FQ treatment of CAP in inpatient setting for empiric treatment of severe CAP in adults without risk factors for MRSA and P. aeruginosa

A

Levo

Moxi

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55
Q

In inpatient setting, should patients with suspected aspiration pneumoniae receive additional anerobic coverage beyond standard empiric treatment for CAP

A

No

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56
Q

Treatment of CAP in inpatient, non-severe or severe CAP, prior respiratory isolation of MRSA

A

Add MRSA coverage:

vanc
linezolid

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57
Q

treatment of CAP in inpatient, non-severe or severe CAP, prior respiratory isolation of p. aeruginosa

A 
Pip/tazo 
cefepime 
ceftazidime 
aztreonam
meropenem 
imipenem
58
Q

In inpatient setting, should adults with CAP be treated with corticosteroids

A

No

59
Q

In adults with CAP who test positive for influenza, should the treatment regiment include antiviral therapy?

A

Yes

60
Q

In outpatient and inpatient adults with CAP who are improving, what is the appropriate duration of antibiotic therapy?

A

antibiotic therapy should be continued until the patient achieves clinical stability and for no less than a total of 5 days

61
Q

in adults with CAP who are improving, should follow-up chest imaging be obtained?

A

NO

62
Q

CAP strep pneumoniae MIC < 2 (pen sus) preferred therapy

A

pen g

amoxicillin

63
Q

CAP strep pneumoniae MIC < 2 (pen sus) alternative therapy

A

macrolide
cephalosporin
respiratory FQ
doxycyline

64
Q

CAP strep pneumoniae MIC > 2 (pen resistant) preferred therapy

A

respiratory FQ
ceftriaxone
cefotaxime

65
Q

CAP strep pneumoniae MIC > 2 (pen resistant) alternative therapy

A

vanc
linezolid
high-dose amoxicillin 3g/day

66
Q

CAP non beta lactamase producing h. influenzae preferred therapy

A

amoxicillin

67
Q

CAP non beta lactamase producing h. influenzae alternative therapy

A

fq
doxycycline
azithromycin
clarithromycin

68
Q

CAP beta lactamase producing h. influenzae preferred therapy

A

2/3 gen ceph

augmentin

69
Q

CAP beta lactamase producing h. influenzae alternative therapy

A

FQ
doxycyline
azithromycin
clarithromycin

70
Q

CAP mycoplasma/chlamydophila preferred therapy

A

macrolide

doxycycline

71
Q

CAP mycoplasma/chlamydophila alternative therapy

A

FQ

72
Q

CAP legionella preferred therapy

A

FQ

azithromycin

73
Q

CAP legionella alternative therapy

A

doxycyline

74
Q

CAP meth-sus s. aureus preferred therapy

A

nafcillin

oxacillin

75
Q

CAP meth-sus s. aureus alternative therapy

A

cefazolin

clindamycin

76
Q

CAP meth-res s. aureus preferred therapy

A

vanc

linezolid

77
Q

CAP meth-res s. aureus alternative therapy

A

bactrim

78
Q

CAP anaerobes preferred therapy

A

beta lactam/ase inhibitor

clindamycin

79
Q

CAP anaerobes alternative therapy

A

carbapenem

80
Q

CAP enterobacteriaceae preferred therapy

A

3/4 gen ceph

carbapenem

81
Q

CAP enterobacteriaceae alternative therapy

A

beta lactam/ase inhibitor

FQ

82
Q

HAP

A

pneumonia occuring > 48 hours after hospital admission

83
Q

VAP

A

pneumonia occurring > 48-72 hours after endotracheal intubation

84
Q

Outcomes in patients treated with guideline-adherent therapy

A

increased mortality noticed

85
Q

Pathogenesis of HAP, VAP

A
  • Microaspiration of oropharyngeal secretions colonized with pathogenic bacteria (gram negatives)
  • Aspiration of esophageal/gastric contents
  • hematogenous spread from distant site of infection
  • direct inoculation into airways of intubated patient by ICU personnel
  • mechanical ventilator- endotracheal tube bypasses host defenses and impairs lower respiratory tract defenses
86
Q

Diagnosis of HAP/VAP

A
  • no gold standard
  • time in relation to hospitalization and intubation
  • new lung infiltrate plus clinical evidence that the infiltrate is of an infectious origin
87
Q

common pathogen of HAP/VAP

A

aerobic gram-negative bacilli

88
Q

factors associated with increased risk of MDR VAP

A
  • prior antibiotic use in past 90 days
  • > 5 days of hospitalization prior to occurrence of VAP
  • septic shock at time of VAP
  • ARDS before VAP
  • Acute renal replacement therapy prior to VAP
89
Q

risk factors for MDR HAP

A

prior iv antibiotic use in last 90 days

90
Q

risk factors for MRSA HAP/VAP

A
  • prior iv antibiotic in past 90 days

- late onset hap/vap

91
Q

risk factors for MDR p. aeruginosa HAP/VAP

A

prior antibiotic use within 90 days (carbapenems, broad-spectrum cephalosporins, FQ)

92
Q

empiric treatment of clinically suspected VAP

A

provide coverage for:

  • s. aureus
  • p. aeruginosa
  • other GNB

Include agent active against MRSA (vanc or linezolid)

93
Q

when to use 2 antipseudomonal antibiotics from different classes

A
  • risk factors for resistance
  • In ICU where > 10% of Gram negative isolates are resistant to monotherapy agent
  • In ICU where local resistant rates unknown
94
Q

when to prescribe empiric monotherapy for p. aeruginosa

A
  • w/o risk factors for resistance

- In ICU where <10% of gram negative isolated are resistant to monotherapy agent

95
Q

VAP gram + antibiotics with MRSA acitivyt

A

vanc
or
linezolid

96
Q

VAP beta lactam antibiotics with antipseudomonal activity

A 
Pip-tazo 
or
cefepime 
ceftazidime
or
imipenem 
meropenem 
or
aztreonam
97
Q

VAP non beta lactam antibiotics with antipseudomonal activity

A 
cipro 400mg q 8
levo 750 mg q 24
or
amikacin 15-20mg/kg q 24
gentamicin 5-7 mg/kg q 24
tobramycin 5-7 mg/kg q 24
or
colistin
polymyxin B 1.5mg/kg q 12
98
Q

HAP empiric therapy: not at high risk of mortality and no risk factors increasing likelihood of MRSA

A
  • pip-tazo 4.5 g q 6
  • cefepime 2 g q 8
  • imipenem 500 mg q 6
  • meropenem 1g q 8
  • levo 750mg q 12
99
Q

HAP empiric therapy: not at high risk of mortality but with factors increasing likelihood of MRSA

A

all ors

  • pip-tazo
  • cefepime
  • ceftazidime
  • imipenem
  • meropenem
  • levo
  • cipro
  • aztreonam

PLUS

vanc
linezolid

100
Q

HAP empiric therapy: high risk of mortality or receipt of IV antibiotics during the prior 90 days

A

Two of the following:

  • pip-tazo
  • cefepime
  • ceftazidime
  • imipenem
  • meropenem
  • levo
  • cipro
  • aztreonam

PLUS
vanc
linezolid

101
Q

Should we use aminoglycosides with HAP

A

not recommended as monotherapy b/c of poor lung penetration, nephrotoxicity,, ototoxicity, associated with lower clinical response rates

102
Q

Should we use polymixins with HAP

A

avoid empiric use if alternatives available- reserve for patients with high prevalence of MDR pathogens

103
Q

Should we use tigecycline with HAP

A

avoid due to poor outcomes, increased mortality

104
Q

Treatment of MSSA in HAP and VAP

A

cefazolin
nafcillin
oxacillin

105
Q

Treatment of MRSA in HAP and VAP

A

vanc

linezolid

106
Q

Do you want to use daptomycin to treat pneumonia

A

No! inactivated by surfactant

107
Q

Treatment of enterobacterales in HAP and VAP

A

numerous options

108
Q

Treatment of EBSL producer in HAP and VAP

A

carbapenem

ceftazidime/avibactam

109
Q

Treatment of MBL producer in HAP and VAP

A

aztreonam + ceftazidime/avibactam empirically

aztreonam monotherapy if suscpetible

110
Q

Treatment of KPC producer in HAP and VAP

A

ceftazidime/avibactam
meropenem/vaborbactam
imipenem/cilastatin/relebactam

111
Q

Treatment of acinetobacter species in HAP and VAP

A

carbapenem or ampicillin/sulbactam if sus

cefiderocol if resistant

112
Q

treat of HAP and VAP if MDR to all other options

A

polymyxin plus inhaled colitisn if MDR to all other options

113
Q

duration of treatment for HAP and VAP

A

7 day course

114
Q

etiology of acute bronchitis

A

respiratory virus

115
Q

acute bronchitis clinical presentation

A 
cough (2-3 weeks)
coryza
sore throat
malaise
headache
fever
normal chest x ray
116
Q

acute bronchitis treatment

A

treat symptoms

117
Q

what to avoid in acute bronchitis treatment

A

corticosteroids

118
Q

do you use antibacterial therapy in acute bronchitis

A

NO

119
Q

pathogenesis of acute exacerbation of chronic bronchitis

A

bronchial wall becomes thickened due to irritants, number of mucus secreting goblet cells is markedly increased; hypertrophy of mucus glands –> further impairment of normal lung defenses; mucus plugging of smaller airways

120
Q

3 cardinal symptoms of ABECB

A
  1. increased cough or SOB
  2. increased sputum volume
  3. increased sputum purulence
121
Q

bacteria involved in ABECB

A
  • h. influenzae
  • s. pneumoniae
  • m. catarrhalis
  • p. aeruginosa
122
Q

treatment duration of ABECB

A

5-7 days

123
Q

Uncomplicated ABECB criteria

A 
Age < 65
FEV1 >50%
< 4 exacerbations/yr
no comorbid conditions
no risk factors
124
Q

uncomplicated ABECB initial treatment options

A 
2 gen macrolide
2/3 gen ceph
doxycyline
amoxicillin
bactrim
125
Q

complicated ABECB criteria

A

age >65
FEV < 50%
> 4 exacerbations
> 2 risk factors

126
Q

complicated ABECB initial treatment options

A

respiratory FQ

augmentin

127
Q

ABECB complicated with risk for infection with p. aeruginosa criteria

A

severe symptoms
constant purulent sputum
FEV < 35%
> 2 risk factors

128
Q

ABECB complicated with risk for infection with p. aeruginosa initial treatment options

A

FQ w/ antipseudomonal acitivity

pip/tazo

129
Q

pharyngitis microbes involved

A

viruses

group A, beta hemolytic strep

130
Q

pharyngitis symptoms

A

non-suppurative complications: acute rheumatic fever, acute glomerulonephritis, peritonsillar or retropharyngeal abscess, mastoiditis, otitis media, rhinosinusitits

131
Q

Group A strep pharyngitis treatment

A 
Pen V 
or
Amox 
or
2 gen cephs
132
Q

Group A strep pharyngitis treatment in penicllin allergic patients

A

1st gen ceph x10 if no anaphyl
Azithromycin x5
Clarithromycin x10
clindamycin x 10

133
Q

ARBS initial empiric therapy children first line no resis

A

Augmentin

134
Q

ARBS initial empiric therapy children second line risk for resis

A

Augmentin

135
Q

ARBS type 1 hypersensitivity second line children

A

levo

136
Q

ARBS second line children non-type 1 hypersensitivity

A

clinda + cefexime
or
cepodoxime

137
Q

ARBS severe infections requiring hospitalization

A

Amp-sul
ceftriaxone
cefotaxime
levo

138
Q

first line empiric therapy ARBS adults

A

Augmentin

Augmentin

139
Q

second line empiric therapy ARBS adults

A

Augmentin

140
Q

second line empiric therapy ARBS adults beta lactam allergy

A

doxy
levo
moxi

PHRM 865 (59 decks)

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