Community Acquired Pneumonia

Question 1

Causative organisms of outpatient or ambulatory pneumonia (<90 PSI)

Answer 1

S. pneumo
H. influenza
M. catarrhalis

Question 2

Causative organisms for hospital ward patients (>91 PSI)

Answer 2

S. pneumo + gram negative (E. coli),
P. aeruginosa
Legionella sp.

Question 3

Causative organisms for ICU

Answer 3

S. pneumo + S. aureus
or P. aeruginosa

Question 4

What are the vital signs of severe CAP?

Answer 4

Respiratory rate > 30 breaths/min (severe) in adults between 25-50 yrs old

O2 sat: 92%,
fever

Question 5

General symptoms of CAP?

Answer 5

cough, SOB, pleuritic chest pain, sputum production, fever, chills, myalgia, headache, arthralgia, confusion.

Question 6

Schedule for pneumovax 23 vaccine?

Answer 6

once only in a lifetime

Question 7

pneumovax 23 recommended age group

Answer 7

all ages

Question 8

prevnar 13 recommended age group

Answer 8

Ages 50+ (if immunocompromised), and those 65+ if not received pneumococcal vaccine in the past.
*can also be given to infants

Question 9

A patient had pneumovax 23 . He is high risk senior and wants to get the Prevnar 13. How long must he wait?

Answer 9

from 23 –> 13: wait atleast 1 year

Question 10

A patient got prevnar 13. He is high risk over age 50 and the only available vaccine will be Pneumovax-23. How long to wait?

Answer 10

8 week interval (for 13–>23)

Question 11

Why is it that a pathogen can cause pneumonia many times in the same individual?

Answer 11

Strep pneumo has 84 serotypes that differ in its structure of the polysaccharide capsule

Question 12

what are the 2 types of pneumococcal vaccines?

Answer 12

1. polysaccharide vaccine = Pneumovax 23
2. polysacch conjugated to a protein = enhanced immunogenicity = Prevnar 13

Question 13

when is pseudomonas likely suspcted?

Answer 13

hospital stay for > 7 days or icu
use of mechanical ventilator
IV catheter
pt with wound from surgery or burn

Community: cystic fibrosis, cirrhosis, repeated COPD exacerbation, recent abx use, infection from penetrating trauma

Question 14

who is at risk of resistance from abx ?

Answer 14

1. comorbidities - smoking, asthma, copd, cancer, CHD, CAD, diabetes, liver/kidney failure
2. malnutrition, acute wt loss (>5%)
3. immunosuppression, age > 65
4. alcoholics, attend daycare or exposed to child attending daycare
5. chronic corticosteroid use
6. recent use of abx in last 3 months, hospitalization in last 3 months

Question 15

empiric drug of choice in: outpatient, healthy adult, no risk of resistance?

Answer 15

amoxicillin 1000 mg TID OR
doxycycline 100 mg BID OR
azithromycin 500 mg day 1, then 250 mg daily

Question 16

empiric drug of choice in: outpatient + comorbidities (diabetes, cvd)

Answer 16

amoxi-clav + macrolide OR doxycycline OR FQs (levofloxacin 750 mg, or moxifloxacin 400 mg)

Question 17

empiric drug of choice in: inpatient setting, no risk factor for MRSA or P. aeruginosa

Answer 17

Beta lactams (ampicillin) + macrolides, or monotherapy FQs
If severe, B-lactam + macrolide, OR FQ + B-lactam

Question 18

empiric drug of choice in: Inpatient + MRSA or P. aeruginosa

Answer 18

MRSA coverage: vancomycin or linezolid

Pseudomonas - pip/tazo 4.5 g q6, cefipime, ceftazidime, aztreonam, meropenem, or imipenem

Question 19

DOC for specific pathogen: Strep pneumonia?

Answer 19

1st line: amoxicillin or amoxi-clav

2nd line: doxy or azithromycin

Question 20

DOC for specific pathogen: Chlamydia/Haemophilus/Mycoplasma Pneumonia

Answer 20

1st line - azithromycin, doxycycline

2nd line - levo or moxifloxacin

Question 21

DOC for specific pathogen: Legionella species

Answer 21

1st line: levo, moxi, azithro (21 days if severe)
2nd line: doxycycline

Question 22

DOC for specific pathogen: pseudomonas

Answer 22

1st line: antipseudomonal beta lactams such as imipenem/ceftazidime/cefepime + cipro x 21 days, OR pip-tazo

2nd line: aminoglycosides

Question 23

DOC for specific pathogen: H. influenza

Answer 23

outpatients - 1st line: azithro or clarithromycin

*avoid erythromycin if pt has COPD + pneumonia due to lower activity against H. influenza

Question 24

DOC for specific pathogen: MRSA

Answer 24

vancomycin or linezolid

Question 25

DOC for specific pathogen: MSSA

Answer 25

cloxacillin or cefazolin

Question 26

Treatment duration for home/ambulatory cases?

Answer 26

5 days

Question 27

Treatment duration for hospitalized patients and non-severe?

Answer 27

10 days

Question 28

Treatment duration for legionnaires

Answer 28

21 days (ICU)

Question 29

Tx durration for P. aeruginosa requiring hospital admission

Answer 29

21 days

Question 30

Tx duration for gram negative bacilli (E. coli) and klebsiella?

Answer 30

21 days

Question 31

If pt is in ICU and has Pseudomonas, what can we give?

Answer 31

1. to cover Psudo - cefepime, imipenem, meropenem pip/tazo 2. Aminoglycoside IV + macrolide IV OR 3. aminoglycoside IV + Cipro IV OR 4. cipro IV x 21 days

Question 32

Which antibiotic can cause serotonin syndrome with SSRIs?

Answer 32

Linezolid

Question 33

What are the metastatic infections in CAP ?

Answer 33

meningitis, purulent pericarditis, endocarditis, osteomyelitis

Question 34

patients with aspiration pneumonia + poor dental hygiene, putrid sputum or alcoholism (= risk for suspected anaerobic infxn) sould be treated with?

Answer 34

1. metronidazole 500 mg Q12h OR 2. pip-tazo or imipenem + FQ/ceftriaxone/cefotaxime

Question 35

What is the possible causative organism for CAP + HIV + neutropenia? Drug tx?

Answer 35

Pneumocystitis jirovcii -> treat with SMX/TMP for prophylaxis and treatment