8.4 Pharmacological Management of Respiratory Infection

Question 1

What was the mortality rate of TB before anti-TB treatment

Answer 1

~50% (!)

Question 2

Did increased duration of antibiotic therapy decrease or increase relapse rates of TB?

Answer 2

Decrease

Question 3

Should you ever use a single antibiotic when treating tuberculosis?

Answer 3

No; this could lead to resistance

Question 4

Should you ever add a single antibiotic to a failing TB regimen?

Answer 4

No; this could lead to resistance

Question 5

Are tuberculosis drugs free in Australia?

Answer 5

Yes

Question 6

What is DOT in TB treatment? Why is it important?

Answer 6

• DOT (directed observed therapy) is when a trained healthcare worker or someone else (not family member) watches the patient swallow each dose of their drugs
• This prevents antibiotic resistance, relapse, and improves mortality rates

Question 7

What are the two phases of pharamcological TB treatment?

Answer 7

• Intensive phase (bactericidal)
• Continuation phase (sterilisation)

Question 8

What occurs during the intensive (bactericidal) phase of TB treatment? How long does it last?

Answer 8

• Kills of actively dividing TB population
• Lasts for at least 2 months

Question 9

What occurs during the continuation phase (sterilisation) of TB treatment? How long does it last?

Answer 9

• Semi-dormant/dormant persistor cells are formed during the intensive phase; this phase kills them
• Lasts for at least 4 months

Question 10

What is the most potent drug used during the bactericidal phase of TB treatment?

Answer 10

Isoniazid

Question 11

What is the most potent drug used during the sterilisation phase of TB treatment?

Answer 11

Rifampicin

Question 12

List some important ways of ensuring treatment completion during tuberculosis

Answer 12

• DOT
• Developing a partnership with the patient
• Monitoring for side effects
• Patient support measures

Question 13

Under what circumstances should we especially consider DOT for TB treatment?

Answer 13

• All infectious
• Drug resistant cases
• Cultural/language issues
• Elderly/mental health issues etc.

Question 14

Is TB treatment short or long in duration? How does this impact the probability of developing antibiotic resistance?

Answer 14

• Long in duration
• Provides many opportunities for interruption (acquired resistance)

Question 15

How can healthcare providers directly CAUSE antibiotic resistance to TB

Answer 15

By ‘breaking the rules’ (using/substituting one drug). Bad idea.

Question 16

What patient factors can cause drug resistant TB?

Answer 16

• Malabsorption
• Non-adherence

Question 17

What is the main source of drug-resistant TB?

Answer 17

Transmission from others

Question 18

Approach to treatment of drug-resistant TB

Answer 18

• Start with 4-5 drugs of proven susceptibility (that they haven’t been given before)
• Keep testing until it works

Question 19

How do the drugs used in drug-resistant TB differ from those in regular TB?

Answer 19

• More toxic
• More expensive ($100k vs $400)

Question 20

Does drug resistant TB require a mulidisciplinary approach of treatment?

Answer 20

Yes

Question 21

How many susceptible drugs should you use at once during TB treatment of regular, susceptible TB?

Answer 21

3-4

Question 22

Describe the radiological presentation of lobar pneumonia

Answer 22

Consolidation of a single lung lobe

Question 23

Describe the radiological presentation of bronchopneumonia

Answer 23

Patchy; involving one or several lobes

Question 24

Describe the radiological presentation of interstitial pneumonia

Answer 24

Interstitial inflammation histologically and radiologically

Question 25

Describe the radiological presentation of miliary pneumonia

Answer 25

Millet seed like opacities (Tb)

Question 26

Describe the investigations you could do in a patient with suspected pneumonia

Answer 26

- CXR +/- CT chest - Blood culture - Sputum microscopy and culture - Viral PCR - Pleural fluid aspirate and culture

Question 27

Why is it important to determine the aetiology of community acquired pneumnonia?

Answer 27

- Public health reporting/epidemiology - Providing directed therapy - Adjusting when initial empiric therapy is unsuccessful

Question 28

List some test findings that provide a definite aetiology of pneumonia

Answer 28

- Isolation of bacterial pathogens from blood or pleural fluid - Isolation of legionella from respiratory secretions (it's not usually there) - Legionella antigen in urine

Question 29

Can the aetiology of pneumonia be found in a majority of cases?

Answer 29

No, over half cannot.

Question 30

Should you delay antibiotic treatment in order to gather specimens for pneumonia diagnosis? Why not/why?

Answer 30

- No, you would not - This can have very bad outcomes

Question 31

A patient has no signs of lung consolidation on x-ray, but is coughing and spluttering. Do you give antibiotics? Why/why not?

Answer 31

- No you don't - They probably have a virus - Don't give antibiotics unnecessarily

Question 32

In pnuemonia treatment, do we generally prefer antibiotics with a wide or thin therapeutic window (initially)?

Answer 32

Wide

Question 33

In a patient with severe pneumonia, do we prefer bactericidal or bacteriostatic antibiotics?

Answer 33

Bactericidal

Question 34

If you know which bacteria is causing a patient's pneumonia, should you use broad spectrum or thinner spectrum antibiotics?

Answer 34

Thin; Charlie-Munger strategy

Question 35

How soon after clinical improvement of pneumonia should you switch to oral antibiotics?

Answer 35

ASAP

Question 36

Which has a broader spectrum: amoxycillin or penicillin?

Answer 36

Amoxycillin

Question 37

Is penicillin mostly able to kill gram-positive or gram-negative bacteria?

Answer 37

Gram positive

Question 38

What is a common antibiotic than can be used instead of penicillin if they are allergic?

Answer 38

Cephalosporins

Question 39

Is cephalosporin used as a first-line antibiotic? Why/why not?

Answer 39

- No - It can cause side effects including resistance and infection

Question 40

Macrolides suffix

Answer 40

-mycin

Question 41

What type of antibiotics could you use if you suspected that a patient had "atypical" tuberculosis?

Answer 41

- Macrolides - Tetracyclin

Question 42

Macrolides side effects

Answer 42

- GI side-effects - Hepatitis (erythomycin)

Question 43

Tetracycline suffix

Answer 43

-cycline

Question 44

What % of pneumonia-causing bacteria are fully penicillin susceptible? What % need a higher dose, and what % are fully resistant?

Answer 44

Fully susceptible: 80% Higher dose: 19% Fully resistant: 1%

Question 45

Are antibiotics more likely to negatively impact pregnant women in early or late pregnancy?

Answer 45

Late

Question 46

What immunisations should be considered for pneumonia patients?

Answer 46

- Influenza - COVID-19 - Pneumococcal

Question 47

What is pneumococcal disease?

Answer 47

Any disease caused by strep pneumoniae