CAP guidelines 2020

Question 1

Sputum GS is highly specific for identifying the following: ____

Answer 1

1. S. pneumoniae
2. H. influenzae
3. S. aureus
4. Gram negative bacilli infection

Question 2

Sputum GSCS

Answer 2

Not recommended for LR
Recommended for MR & HR & Risk factor for MDR pathogen

Question 3

Predictors of Bacteremia

Answer 3

Systolic BP <90
Temp <35 or ≥ 40
PR ≥ 125
Liver disease
BUN ≥ 30
Serum Na <130
WBC <5,000 or >20,000

Question 4

4 variables significantly associated with positive blood culture

Answer 4

WBC <4,500
Serum creatinine >106 umol/L
Serum glucose <6.1 mmol/L
Temp >38.0 C

Question 5

Benefit of Blood CS is for __ (2)

Answer 5

Prognostication
Antimicrobial surveillance

Question 6

Blood CS

Answer 6

Moderate Risk CAP
High Risk CAP

Question 7

Indications for Influenza testing in patients with CAP

Answer 7

1. During periods of high influenza activity (July to January)
2. Age >60
3. Pregnant
4. Asthmatic
5. with Comorbidities

Question 8

Indications to get Urinary antigen test for Legionella

Answer 8

ICU admission
failure of outpatient therapy
Active alcohol abuse
Recent travel
Pleural effusion

Question 9

Legionella Urine Antigen test

Answer 9

May be considered for High Risk CAP

Question 10

Multiplex PCR

Answer 10

Not recommended

Question 11

Serious adverse effect of Azithromycin

Answer 11

Fatal arrhythmia

Question 12

Serious adverse effect of Fluoroquinolone

Answer 12

Tendonitis
Tendon rupture
CNS effects
Peripheral neuropathy
Myasthenia gravis exacerbation
QT prolongation
Torsades de pointes
Phototoxicity
Hypersensitivity

Question 13

CAP-LOW RISK: Management
No comorbidities

Answer 13

Amoxicillin 1g TID

OR

Clarithromycin 500 mg BId

OR

Azithromycin 500 mg OD

Question 14

CAP-LOW RISK: Management
with STABLE comorbidities

Answer 14

Co-Amoxiclav 625 mg TID or 1g BID

OR

Cefuroxime 500 mg BID

PLUS OR MINUS

Clarithromycin 500 mg BId

OR

Azithromycin 500 mg OD

OR

Doxycycline 100 mg BID

Question 15

The consensus panel voted against Monotherapy of ______ and _______, for treatment of CAP-LR, due to inferiority in coverage for S. pneumoniae and prevalence of Tuberculosis in the country, respectively.

Answer 15

Doxycycline
Levofloxacin

Question 16

Patients with MODERATE RISK CAP without MDRO infection

Answer 16

Non-pseudomonal Beta-lactam antibiotic
Ampicillin-sulbactam 1.5–3 g every 6 h

OR

Cefotaxime 1–2 g every 8 h

OR

Ceftriaxone 1–2 g daily

PLUS

Macrolide
Azithromycin 500 mg daily

OR

Clarithromycin 500 mg twice daily

Question 17

Patients with HIGH RISK CAP without
MDRO infection

FIRST-LINE

Answer 17

Non-pseudomonal Beta-lactam antibiotic
Ampicillin-sulbactam 1.5–3 g IV every 6 h

OR

Cefotaxime 1–2 g IV every 8 h

OR

Ceftriaxone 1–2 g IV daily

PLUS

Macrolide
Azithromycin 500 mg PO/IV daily

OR

Erythromycin 500 mg PO every 6 hours

OR

Clarithromycin 500 mg PO twice daily

Question 18

Patients with HIGH RISK CAP without
MDRO infection

ALTERNATIVE TREATMENT

Answer 18

Non-pseudomonal Beta-lactam antibiotic

PLUS

Respiratory fluoroquinolone
Levofloxacin 750 mg PO/IV daily

OR

Moxifloxacin 400 mg PO/IV daily

Question 19

Routine anaerobic coverage for suspected aspiration pneumonia is NOT
recommended, unless _____

Answer 19

lung abscess or empyema is suspected

Question 20

The most strongly and consistently associated risk factors for CAP due to MRSA
were _____

Answer 20

1. Previous MRSA colonization or infection, especially of the respiratory tract, within 1 year
2. Intravenous antibiotic therapy within 90 days

Question 21

Independent risk factors for
CAP due to P. aeruginosa

Answer 21

1. Previous P. aeruginosa colonization or infection of the respiratory tract
2. Severe bronchopulmonary disease
3. Bronchiectasis
4. Prior tracheostomy

Question 22

Independent risk factor for drug-resistant P. aeruginosa CAP

Answer 22

Intravenous antibiotic therapy within 90 days

Question 23

Risk factor for MDR Enterobacteriaceae

Answer 23

Prior colonization or infection with extended-spectrum beta-lactamase (ESBL)
producing organisms

Question 24

Risk for Methicillin Resistant Staphylococcus aureus (MRSA)

Answer 24

1. Prior colonization or infection with MRSA
   within 1 year
2. Intravenous antibiotic therapy within 90 days

Question 25

TREATMENT FOR CAP-MRSA

Answer 25

Non-pseudomonal Beta lactam antibiotic **PLUS** Macrolide OR Respiratory fluoroquinolone **PLUS** Vancomycin 15 mg/kg IV every 12 hours OR Linezolid 600 mg IV every 12 hours OR Clindamycin 600 mg IV every 8 hours

Question 26

Risk for ESBL

Answer 26

Prior colonization or infection with ESBL-producing organisms within 1 year

Question 27

TREATMENT FOR ESBL POSITIVE

Answer 27

Ertapenem 1g IV every 24 hours OR Meropenem 1 g IV every 8 hours (if Ertapenem is not available) **PLUS** Macrolide OR Respiratory fluoroquinolone **PLUS** Vancomycin 15 mg/kg IV every 12 hours OR Linezolid 600 mg IV every 12 hours OR Clindamycin 600 mg IV every 8 hours

Question 28

Risk for Pseudomonas aeruginosa

Answer 28

1. Prior colonization or infection with P aeruginosa within 1 year 2. Severe bronchopulmonary disease (severe COPD, bronchiectasis, prior tracheostomy)

Question 29

Treatment for Pseudomas aeruginosa

Answer 29

Piperacillin-Tazobactam 4.5g IV every 6 hours OR Cefepime 2 g IV every 8 hours OR Ceftazidime 2 g IV every 8 hours OR Aztreonam 2 g IV every 8 hours OR Meropenem 1 g IV every 8 hours (especially if with ESBL risk) **PLUS** Macrolide OR respiratory fluoroquinolone*

Question 30

Definition of **Clinical Failure**

Answer 30

1. Failure to reach clinical improvement within 7 days 2. Transfer to the intensive care unit after 24 hours in a ward 3. Need for re-hospitalization within 30 days

Question 31

Antiviral therapy recommended on the following patients:

Answer 31

1. Aged 60 years and above 2. Pregnant 3. Asthmatic 4. Other co-morbidities **who tests positive on Influenza virus test**

Question 32

Time of the first antimicrobial dose from arrival at the emergency department (ED) to the intravenous infusion of the antimicrobial should be within ____

Answer 32

within 4 hours of admission

Question 33

Definition of **Clinically stable** patient

Answer 33

1. Afebrile within 48 hours 2. Able to eat 3. Normal blood pressure 4. Normal heart rate 5. Normal respiratory rate 6. Normal oxygen saturation 7. Return to baseline sensorium

Question 34

Duration of treatment for Clinically Stable patients

Answer 34

5 days

Question 35

When to extend antibiotic therapy (>5 days)?

Answer 35

(1) pneumonia is not resolving (2) pneumonia complicated by sepsis, meningitis, endocarditis and other deep-seated infection (3) infection with less common pathogens (i.e. Burkholderia pseudomallei, Mycobacterium tuberculosis, endemic fungi, etc) (4) infection with a drug resistant pathogen

Question 36

When is it recommended to get post-treatment chest xray

Answer 36

After a minimum of **6 to 8 weeks** among patients with CAP to establish baseline and to exclude other conditions

Question 37

C-Reactive Protein

Answer 37

Not recommended

Question 38

Use of Procalcitonin **to monitor treatment response among patients with CAP**

Answer 38

Not recommended

Question 39

Use of Procalcitonin **to guide antibiotic discontinuation among patients with moderate or high risk CAP**

Answer 39

Conditional recommendation. May be used.

Question 40

________may cause slow resolution of pneumonia in the elderly

Answer 40

S. pneumoniae L. pneumophila

Question 41

Reasons for Non-improvement of condition after 72H of treatment

Answer 41

1.Incorrect diagnosis or presence of a complicating noninfectious condition 2. A resistant microorganism or an unexpected pathogen that is not covered by the antibiotic choice 3.Antibiotic is ineffective or causing an allergic reaction 4.Impaired local or systemic host defenses 5.Local or distant complications of pneumonia 6.Overwhelming infection 7.Slow response in the elderly patient 8.Exacerbation of comorbid illnesses 9.Nosocomial superinfection

Question 42

What should be done for patients who are not improving after 72 hours of empiric antibiotic therapy?

Answer 42

1. Repeat Chest Xray 2. Obtain additional specimen for microbiological testing

Question 43

Criteria for **De-escalation**

Answer 43

1. Resolution of fever for more than 24 hours 2. Improvement of cough and WBC counts 3. No respiratory distress 4. No bacteremia 5. No signs of unstable comorbid condition or any life threatening complication 6. No signs of organ dysfunction 7. Able to take oral fluids and oral medication with no malabsorption and etiologic agent is not a high risk pathogen.

Question 44

**CAP symptoms and resolution** Fever

Answer 44

1 week

Question 45

**CAP symptoms and resolution** Chest pain and Sputum production

Answer 45

4 weeks

Question 46

**CAP symptoms and resolution** Cough and Breathlessness

Answer 46

6 weeks

Question 47

**CAP symptoms and resolution** Most symptoms should have resolved, but fatigue may still be present

Answer 47

3 months

Question 48

**CAP symptoms and resolution** Back to normal

Answer 48

6 months