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Flashcards in Adult Pulmonary Infections Deck (22):
1

CURB-65
Severity scores for CAP

Clinical Factors Points
confusion 1
BUN >19 mg/dL 1
(>7 mmol/L)
RR >=30 breaths/min 1
SBP <90 mmHg 1
DBP<=60 mmHg 1
Age >65 1

2

CAP most common pathogens

Strep pneumoniae
Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella
Haemophilus influenzae
Moraxella catarrhalis
virus & anaerobes

3

Most common pathogen in age 4mo-4yr (peak 2-7 months of age)

RSV

4

Most common pathogen in 5-18 yrs

Mycoplasma pneumoniae
Tx: macrolide

5

Outpatient treatment of CAP

If healthy:
newer macrolide (azithromycin, clarithromycin, erythromycin) or doxycycline (no QT prolongation)
With co-morbidities:
respiratory quinolone, or a beta-lactam + a macrolide (amoxicillin 1 gram TID, or amoxicillin with clavulanate 2 gram BID PREFERRED)

6

Inpatient treatment of CAP

non-ICU:
respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin), or a beta-lactam (cefotaxime, ceftriaxone, amp-sulbactam) + a macrolide
ICU:
beta lactam + aztreonam or fluoroquinolone
(if PCN allergy: fluoroquinolone or aztreonam

7

CAP diagnosis / work-up

CXR (false negative in dehydration and elderly patients. Repeat in 24-48 hours if suspect clinically)
CBC
Sputum for gram stain and culture
blood cultures x 2

8

Healthcare-associated pneumonia (HCAP)

treat differently from CAP
MRSA
DRSP
P. aeruginosa
H. influenzae

9

Pneumococcal Vaccine

PCV13
primary series: 2, 4, 6 months, booster 12-15 months
provide patients ages 14-59 months who have completed the full PCV7 series a supplemental dose of PCV13

10

Polyvalent Vaccine (PPSV) 23

age >=65 years (they do not need boosters)
children at risk >=2 years give at least 8 weeks after last PCV13
indications for single dose for 2-64 y/o:
chronic cardiac, chronic liver, alcoholism, DM, cochlear implants, CSF leak, chronic lung, asthma, smoker, residents of chronic care institutions
indications for 2 dose 3-5 years apart ages 2-64 y/o:
chronic renal, asplenia, sickle cell, immunocompromised

11

Modifying factors for drug-resistant streptococcus pneumoniae (DRSP)

age >65
beta lactam tx in last 3 months
ETOH abuse
immunosuppressive illness
multiple medical comorbidities
exposure to children in a day care center

12

BIRP criteria in HCAP (healthcare associated pneumonia)

B broad spectrum abx within past 3 months
I ICU admission
R resident of NH or poor functional status
P prior hospitalization within past 3 months

13

Catch-up immunization for pneumococcal vaccine

1st dose at 7-11 months: give 2 doses and booster 8 weeks later
1st dose at 12-23 months: 2 doses 8 weeks apart
1st dose at 2-5 years: one dose for healthy, unvaccinated children
1st dose at 2-5 years: 2 doses 8 weeks apart for at risk children

14

PCV13 and PPSV23

age>65: PCV13 followed my PPSV23 6-12 months later.
If PPSV23 was given first, wait at least one year to give PCV13.

15

Interferon-gamma release assays (IGRAs)

must be processed within 8-16 hours
cannot be used in children <5 y/o or immunocompromised persons
those who will be tested repeatedly (serial testing)

16

Treatment of active TB

INH (isoniazid), RIF (rifampin), PZA (pyrazinamide), EMB (ethambutol)

17

Two-step TB skin testing

initial TST negative, repeat test in 1-3 weeks
initial TST positive, consider them infected
initial TST negative, second TST negative - person not infected
initial TST negative, second TST positive - boosted reaction (infection most likely in the past and not recent)

18

Treatment of positive TST or QFT-G with negative CXR

INH daily or twice weekly x 6-9 months (9 months preferred).
rifampin daily x 4 months. consider adding pyridoxine
monthly exams for signs of hepatitis

19

HCAP treatment

Outpatient or Inpatient:
respirator quinolone or amp-sulbactam or ceftriaxone 2 gm daily or ertapenem
Inpatient ICU:
anti-pneumococcal/anti-pseudomonal beta-lactam + fluoroquinolone or aminoglycoside + anti-pseudomonal carbapenem. Consider anti-MRSA agent.

20

TB skin testing:
>5 mm is considered positive if:

HIV sero-positive
Recent TB direct contact
CXR shows prior inactive TB
immunosuppressed patients - prednisone >15 mg/day, TNF-a antagonists, organ transplant recipients

21

TB skin testing:
>10 mm is considered positive if:

long-term care facility - resident or employee
inmate
IV drug user
children <4 y/o
mycobacteriology lab personnel
diabetic
renal failure
cancer
recent immigrant (<5 years) from high risk country
high-prevalence area

22

TB skin testing:
>15 mm is considered positive if:

any person with no known risk factors - even if prior BCG vaccination