Pneumonia (CAP And HAP)

Question 1

Classification of pneumonia and definitions

Answer 1

CAP- pneumonia developing in patients with no contact to medical facility
HAP-pneumonia developing >48hours of hospital admission
Ventilation associated (VAP)-pneumonia developing >48 hours after intubation and mechanical ventilation

Question 2

Risk factors for CAP

Answer 2

Age >65years
DM
Asplenia
Smoking/alcohol use
Renal, cardiovascular, liver , pulmonary disease

Question 3

Risk factors for HAP

Answer 3

Aspirations
COPD, coma
Antacids, PPI, H2 antagonist
Supine position
>60years
Head trauma
MDR risk ie (MRSA, MDR pseudomonas) if IV use within 90 days

Question 4

Causative pathogens

Answer 4

S. Pneumonia, h. Influenza, legionella species, M. Pneumonia, C. Pneumonia

Question 5

Pathophysiology

Answer 5

Microorganisms gain access to lower respiratory tract by:
Inhalation of aerosols
Lungs via bloodstream from extra pulmonary site
Aspiration (anearobes)
Impaired mucociliary clearance, alveolar macrophage impaired

Question 6

Pathogens likely for paediatric group

Answer 6

Due to virus, adenovirus, parainfluenza,
Bacterial S.pneumonia, S. Aeureus, A streptococcus

Question 7

Clinical presentation Pneumonia

Answer 7

Pleuritic chest pain
Onset of fever,chills, productive cough, dyspnea
Hemoptysis or rust color sputum
Tachycardia
Crackles on lung expansion
Diminished breath sounds

Question 8

Give diagnostic measures pneumonia

Answer 8

Lab tests-cbc for leukocytosis
ABG- low oxygen saturation
Chest radiograph-denser lobar
Cultures and sensitivity
Renal -increased Creatinine, BUN
Blood cultures of concern of sepsis

Question 9

Non Pharmacological management

Answer 9

Humidified oxygen for hypoxemia
Bronchodilators is salbutamol when bronchospasm is present
Adequate hydration
IV fluids
Optimal nutrient support
Fever control ie tepid sponging and use of analgesics

Question 10

Give empiric therapy for previously healthy no risk factors ie comorbidities

Answer 10

Macrolide monotherapy- azithromycin 500mg q24hours 7-10 days
Or tetracycline doxycycline 100mg q12h

Question 11

Explain rationale for combination therapy for patients with comorbidities

Answer 11

Add beta lactam(to prevent superinfection by multiple pathogens in patients with comorbidities ) combination aids to cover resistant strains ie typical and atypical ie mycoplasma , legionella , chlamydia

Question 12

Give treatment for patients with comorbidities

Answer 12

Augmentin - 500mg q8h 7-10 days
Cefuroxime 500mg q8h IV/IM
Ceftazidime 1-2g q8-12h IV

Plus
Azithromycin 500mg day 1 , 250 mg day 2-4 (covers legionella)

Or monotherapy
Levofloxacin 500mg q24h 5-10days (covers legionella)

Question 13

Discuss CURB 65 score

Answer 13

RR >30 breaths /minute
BP systolic <90 mmHg diastolic <60 mmHg
Age >65 years
Uremia sign of AKI
0= low risk manage outpatient
1-2= consider hospitalization
3-4=high risk hospitalization

Question 14

Treatment for elderly with macrolide resistant S.pneumonia

Answer 14

Piperacillin/tazobactam 3.375g q6h
Ceftazidime 1-2g q8h

Question 15

Treatment of pneumonia
causative organism=MRSA

Answer 15

Vancomycin 15-20mg/kg q8-12h
Linezolid children 12 years and older 600mg oral/IV q12h for 10-14 days
Ceftaroline 600mg q12h IV

Question 16

Antibiotics for klebsiella pneumonia

Answer 16

Pipracillin-tazobactam- 3.375g q6h
FQs-levofloxacin 500mg OD 7-14 days
Or IV 250-500mg q24h
Carbapenem -imipem-cilastin 500mg -1g q6-8hour IV 2-14 days
Cephalosporins-ceftriaxone 1-2g q24h for 7-14 days

Question 17

What antibiotics do you use for pseudomonas

Answer 17

Pipiracillin-Tazo , levofloxacin, cefepime, ceftazidime, impineme with cilastin, aztreonem

Question 18

Compare regimen for inpatient vs outpatient

Answer 18

Outpatient no risk factors -macrolide/doxycycline
Inpatient suspect legionella-macrolide, FQs
Inpatient pseudomonas -levofloxacin,carbapenem,cefepine,Ceftazidime,imipenem with cilastin,pip-tazo,aztreonem
MRSA-linezolid, vancomycin
Klebsiella-FQ,ceph,carbapenems,pip-tazo

Question 19

Compare classes within (amoxicillin with amoxicillin/clavulanic acid

Answer 19

Resistance-amoxicillin prone
Utilization- amox/clav good for severe /complicated infections and where resistance likely
Spectrum -amox-broad while amox/clav broad but also cover b-lactamase producing
S/E- git effects increased in amox/clav
Composition -amox just penicillin type , amox-clav is combined with clavulonic acid

Question 20

Compare macrolide and tetracycline

Answer 20

Start with examples
MOA- tetracycline-30s ribosome subunit with macrolide 50s subunit
Utilization-tetracycline used as alternative but used where resistance is concern
Spectrum -both broad cover gram positive and negative but macrolide particularly effective against atypical ie Legionella
S/E -macrolide - QT prolongation,hepatotoxicity,c.difficile diarrhea,ototoxoxity
Tetracycline-git effects ie N/V , throat irritation (take lot of water), photosensitivity, children teeth discoloration and impact bone growth

Question 21

Compare within macrolide

Answer 21

Clarithromycin and Azithromycin have broader spectrum than erythromycin which is an older generation, and these other 2 are better tolerated and have a better safety profile. Erythromycin admin 2-4t ones ,clarithro x2 , azitho-x1

Question 22

Monitoring parameters

Answer 22

Amox-clav: allergic reaction, c.diff infection,git
Erythromycin-QT prolonging caution In pt with heart issues
Blood tests assses CBC due to thrombocytopenia of penicillins and hematologic toxicity of cephalosporins
ABG tests asses for oxygen
Chest X ray-signs of consolidation
Symptoms resolution