Lower respiratory tract infections

Question 1

Antibiotic of choice for acute pharyngotonsillitis

Answer 1

Penicillin VL
or
Amoxicillin (may result in rash)

Azithromycin if beta-lactam allergy

Question 2

Antibiotic choice for AOM

Answer 2

strep pneu, h. influ, moraxella

therefore:

1. Amoxicillin
   2.Coamoxiclav
2. allergy to beta-lactams: Azithromycin

Question 3

Non-viral causes acute bronchitis

Answer 3

Mycoplasma pneumoniae
Chlamydia pneumoniae
Bordetella pertussis

Suspect if local outbreak, longer incubation period, prolonged cough

Question 4

CAP definition

Answer 4

Clinical: acute illness and respiratory symptoms and systemic inflammation
PLUS
Radiological: new or progressive infiltrate on chest X-ray

Question 5

CURB-65

Answer 5

Confusion
Urea elevated (>7 mmol/L)
Respiratory rate >30
BP systolic <90 or diastolic ≤60
65 age ≥65

3 or more: CAP

Question 6

Commonest cause CAP

Answer 6

Strep pneu: other bacterial causes such as H.influ and K. pneu are more common in patients with comorbidities (HIV, diabetes, HF, COPD)
Viral infections

Question 7

Atypical bacteria causing CAP

Answer 7

Mycoplasma
Chlamydia
Legionella

Question 8

Acute illness, systemic symptoms, radiology: what to do next?

Answer 8

1. CURB-65 score: more than 3: severe. Less than 2 is not severe
2. Severe route: ADMIT. Ceftriaxone 1g iv daily or Coamoxiclav 1.2g iv TDS plus Azithromycin 500mg dly 3 days (Penicillin allergy: moxifloxacin). Try to start oral antibiotics ASAP
3. Not severe route: Outpatient treatment
   Elderly/comorbid: Coamoxiclav po
   Not older/comorbid: Amoxicillin po

HIV: consider empiric therapy for PCP

Question 9

No response to initial antibiotic therapy after 48 hrs

Answer 9

Consider COVID/influenza
Sputum GeneXpert
Exclude empyema/lung abscess
ADD MACROLIDE
Send blood and sputum cultures

Question 10

Acute exacerbation COPD definition

Answer 10

Acute increase in baseline dyspnoea, cough and/or sputum above the normal day-to-day variations, requiring a change in medication

80% infectious aetiology

Question 11

Common causes AE COPD

Answer 11

1. Viral (50%)
   Rhino
   Parainfluenza
   Corona
   Influenza
   RSV
2. Bacterial (40%)
   H. influ
   S. pneu
   M. catarr
   Enterobacteriaceae (frequent hospitalisation and antibiotic use)
   P. aeruginosa: recent hospitalisation, more than 4 courses antibiotics in past yr, severe, previous isolation of pseudomonas

Atypical bact not assoc. with AECOPD!

Question 12

Which class of antibiotics is indicated to reduce exacerbations of COPD

Answer 12

Macrolides

Question 13

Which class of antibiotics is indicated to reduce exacerbations of COPD

Answer 13

Macrolides

Question 14

Are antibiotics indicated in AE COPD?

Answer 14

Only if:
1. Increased sputum PURULENCE. increased dyspnoea, sputum volume

or

2. Requiring mechanical ventilation or admission to ICU

Question 15

Which antibiotics are indicated for AE COPD?

Answer 15

No comorbidities, GOLD stage 1 or 2, AECOPD less than 3/year, no antibiotics in last 3 mnths:

Oral: amoxicillin 500mg or doxycycline 100mg

Comorbidities, GOLD stage 3 or 4, AECOPD more than 3/year, antibiotics in last 3 mnths:

Oral coamoxiclav: 1g BD
IV Ceftriaxone: 1g daily

VACCINATE: pneumococcus, influenza, COVID-19

Question 16

What type of antibiotic do you start with when treating bronchiectasis?

Answer 16

NARROW spectrum: Amoxicillin

start broad spectrum (Coamoxiclav) after repeated courses of antibiotics

10 days

colonisation with resistant organisms occurs late (Pseudomonas0

Question 17

common presentation of aspiration pneumonia

Answer 17

After epileptic fit, drinking too much, bulbar weakness

Chemical pneumonitis first
Infection common: polymicrobial with oral aerobes and anaerobes

Lung abscess (need long course antibiotic), empyema

Question 18

Antibiotics that cover anaerobes:

Answer 18

Coamoxiclav or
Penicillin/amoxicillin plus metronidazole
Beta-lactam allergy: clindamycin or moxifloxacin

i think it’s a “sin” to have an allergy to beta-lactams