Gremlin: CAP

Question 1

per CDC, 70% of hospitalized children with CAP were < years of age

Answer 1

< 5 yrs

Question 2

CAP risk factors

Answer 2

• Recent history of upper respiratory tract infections
• Lower socioeconomic status
• Crowded living environment
• Exposure to cigarette smoking
• Comorbidities:
  - asthma
  - Bronchopulmonary Dysplasia
  - Cystic fibrosis
  - Sickle cell disease
  - Congenital heart disease

Question 3

methods by which pathogens may enter the lungs leading to CAP

Answer 3

• inhaled aerosolized particles
• blood stream
• Aspiration

Question 4

CAP s/s

Answer 4

• Fever and cough must be present for dx
• Pleuritic chest pain
• Purulent expectorant
• Tachypnea [Infants > 70 breaths/min; Children > 50 breaths/min]
• Respiratory distress
  - Retractions (suprasternal, intercostal, subcostal)
  - Grunting
  - Nasal flaring
  - Apnea
• Wheezing
• Crackles or rales
• Pulse oximetry < 90% on room air
• Altered mental status

Question 5

CAP dx

Answer 5

gold standard = chest x ray
- looking for consildation (lobar or diffuse)

outpt dx may be made without chext xray if s/s STRONGLY suggest CAP

Question 6

who should be hospitalized for CAP

Answer 6

• Moderate to severe CAP
• Significant respiratory distress (SP02 < 90%)
• All infants < 3 months of age OR infants < 6 months of age with suspected bacterial CAP
• Suspicion/documentation of MRSA
• Concern for caretaker capabilities
• Underlying medical conditions

Question 7

what is the best predictor for the causative pathogen in CAP

Answer 7

age

Question 8

most common CAP pathogen in pts up to 15 yrs old

Answer 8

strep pneuomniae

appear as consolidate on chest xray

Question 9

which age group is most likely to have viral CAP and what are the suspected viruses

Answer 9

• 3 wks old - 5 yrs
• Influenza and RSV

Question 10

Whcih age group is most likely to have atypicals as the causative pathogen for CAP and what are the atypicals

Answer 10

• pts 5+ yrs
• M. pnemoniae, C. pneumoniae

appear hazy on a chest xray

Question 11

pt CAP treatment evaluation

Answer 11

• pt should be improving 2-3 days after abx iniation
• if pt not improving, evaluate abx choice and dosing
  
  • if correct agent adn corrrect dose is beign used: expnd coverage, evaluate need for macrolide
  • if incorrect: optimzie

Question 12

influenza virus treatment

Answer 12

• oseltamivir 5d
  
  • should be initiated iwthin 48 hrs

Question 13

outpt CAP treatment in pts < 5 years old

Answer 13

start with amoxicillin (alternatively augmentin) 90mg/kg/day divided BID or TID 10D

If atypical pneumonniae suspected: zitrho 10mg/kg/day on day 1 (MDD 500mg) then 5mg/kg/day on days 2-5 (MDD 250)

Question 14

why do we use high dose amoxicillin in CAP

Answer 14

to overcome resistance (s/ pneumoniae is resistant to penicillin B)

Question 15

amoxcicillin vs. augmentin coverage

Answer 15

clavulanate covers β lactamse producing organisms (H. influenzae, second most common pathogen)

Question 16

Why is the duration of zithro only 5 days

Answer 16

long half life

Question 17

outpt CAP treatment in pts > 5 years old

Answer 17

• amoxicillin (alternatively augmentin) 90mg/kg/day divded BID or TID 10D

zithro 5D if atypical suspected or provider unsure

Question 18

inpt treatment for CAP

Answer 18

• If pt fully immunized (flu Hib and strep PCV13) AND local strep resistnace is MIC < 2: ampicillin or pencillin G IV 10D
  
  • ampicillin: 200mg/kg/day IV divided Q6H
• If pt NOT fully immunized OR local strep resistance > MIC 2: ceftraixone or cefotaxime IV 10D
  
  • ceftraixone: 50mg/kg/day IV Q24H (preferred in unimmunized d/t H. influezae concerns)

Question 19

if a pt qualifies for ampicillin or penicillin use inpatient treatment of CAP BUT has a severe allergy to penicillin, what agents may be used instead

Answer 19

• Levofloxacin
• Linezolid
• Macrolide
• Clindamycin
• Bactrim
  The above options aren’t as good as penicillins, so relaly reserve switching for pts wiith anaphylaxis