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PR3151 Finals > IC16 LRTI > Flashcards

IC16 LRTI Flashcards

(47 cards)

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1
Q

S/S of acute bronchitis

A

acute cough (less than 3 weeks) due to inflammation of trachea and lower airways

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2
Q

diagnosis of acute bronchitis is …

A

clinical, exclude differential diagnosis (no pneumonia, acute asthma, COPD exacerbation)

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3
Q

is diagnostic testing needed for acute bronchitis?

A

no
unless presence of S/S of bacterial infection

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4
Q

how does acute bronchitis starts

A

starts from viral upper respiratory tract infection

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5
Q

any tx for acute bronchitis?

A

it is self limiting
(no abx, regardless of the duration of cough)

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6
Q

when is abx considered for acute bronchitis

A

when there is complication of bacterial infection
need further diagnosis to confirm
abx for the bacterial infection not acute bronchitis

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7
Q

advice for pt with acute bronchitits

A

cough may last for 3 weeks, abx will not hasten the resolution of cough
return to clinic if:
- develop fever, SOB, chest pain
- cough increases in extent or frequency
- significant cough persists beyond 3 weeks

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8
Q

Pneumonia definition

A

infection of lung parenchyma (alveoli, alveolar duct, bronchioles) -> proliferation of microbial pathogens in alveolar level

common: bacterial pneumonia
less common: fungal. viral (influenza)

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9
Q

Pathogenesis of pneumonia: mechanism of infection (exposure)

A
  • aspiration of bacteria in oropharyngeal secretions
  • inhalation of aerosols
  • hematogenous spread (through bloodstream) eg bacteremia
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10
Q

Pneumonia: RF

A
  • smoking
  • chronic lung disease (COPD, asthma, lung cancer)
  • immunosuppressed (HIV, GC use, chemo)
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11
Q

Pneumonia: clinical presentations

A

(pneumonia usually presents with systemic sx)
Systemic: Fever, chills, malaise, change in mental status (elderly), tachycardia, hypotension

Localised: Cough, chest pains, SOB, tachypnoea, hypoxia, increased sputum production

Physical examination: diminished breath sounds, inspiratory crackles on lung expansion

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12
Q

Pneumonia: radiographic finings (chest X-rays, lung CT, lung ultrasonogrpahy)

A

dx of pneumonia: requires evidence of a new infiltrate or dense consolidation (usually unilateral)

bilateral: fluid overload

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13
Q

Pneumonia: lab findings and urinary antigen tests (and their limitations)

A

signs of systemic infection (WBC, CRP, procalcitonin) - not specific for pneumonia

urinary antigen tests
- streptococcus pneumonia
- legionella pneumophilia
-> only indicate exposure to respective pathogens (may not be new), remain positive for days-weeks despite abx tx
-> recommended for severe CAP or hospitalised pt only (not for outpatient)

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14
Q

Pnenumonia: what are the possible cultures taken

A
  • sputum: low yield, highly contaminated
  • lower respiratory tract samples: invasive, less contamination, need trained HCP to do
  • blood cultures: to rule out bacteremia (esp for hospitalised pt)

(outpatient - no need culture, give empiric)

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15
Q

who needs to take pre treatment culture for pneumonia

A
  1. severe CAP
  2. RF for drug resistant pathogens (MRSA, pseudomonas)
    - empirically treated for MRSA/ pseudomonas
    - previously infected with MRSA/ pseudomonas in last 1 year
    - hospitalised or received parenteral abx in last 90 days
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16
Q

classification of pneumonia

A

CAP: <48hrs after hospital admission
HAP: >= 48hr after hospital admission
VAP: >= 48hr after mechanical ventilation

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17
Q

is CAP serious?

A

yes, may be admitted to ICU

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18
Q

RF for CAP

A

history of pneumonia
RF of pneumonia (smoking, chronic lung disease, immunosuppressed)

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19
Q

prevention of CAP

Study These Flashcards
A

smoking cessation
vaccination (influenza, pneumococcal)
- against influenza and strep pneumoniae

20
Q

CAP: pathogens (outpatient, inpt non severe, inpt severe)

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A

(outpt, inpt non severe)
- Strep pneumoniae
- Haemophilus influenzae
- Atypicals (Mycoplasma, Chlamydophila, Legionella pneumonia)
(for inpt based on RF) MRSA, pseudomonas

(inpt severe)
- all above +
- Staph aureus
- Gram negative bacilli (Klebsiella pneumonia, Burkholderia psudomallei)
(for inpt based on RF) MRSA, pseudomonas

21
Q

what other pathogens should be considered (CAP)

Study These Flashcards
A

influenza for all inpt during circulating season
Burkholderia pseudomallei usually from soil/ rain

22
Q

what are the risk stratification methods for CAP?

Study These Flashcards
A

pneumonia severity index (PSI)
CURB 65
IDSA/ATS criteria

23
Q

class in PSI

Study These Flashcards
A

class I and II: outpatient
class III: short hospitalisation or observation
class IV and V: inpatient

  • complex, limited use in clinical setting
24
Q

what are the factors in CURB 65

Study These Flashcards
A

Confusion (1 point)
Urea >7 mmol/L (1 point)
RR >= 30 (1 point)
SBP <90 OR DBP <=60 (1 point)
age >=65 (1 point)

0/1 point: outpatient
2 point: inpatient
>=3 point: inpatient, maybe ICU

25
IDSA/ATS criteria
major criteria: - mechanical ventilation - septic shock requiring vasoactive medication minor criteria: - RR> 30bpm - PaO2/FiO2 <= 250 - multilobar infiltrates - confusion/ disorientation - uremia (>7) - leukopenia (WBC <4) - hypothermia (<36) - hypotension requiring fluid resuscitation severe CAP >= 1 major OR >= 3 minor
26
CAP: abx for outpatient
Outpatient, no comorbidities Pathogen: strep pneumoniae - PO amoxicillin 1g q8h - PO levofloxacin (pen allergy) - PO moxifloxacin (pen allergy) Outpatient, comorbidities (CHD, lung, liver, CKD, DM) Pathogen: Strep pneumoniae, haemophilus influenzae, Atypicals Choice 1: - PO amoxicillin-clavulanate/ cefuroxime PLUS (to cover atypicals) - (macrolide) PO clarithromycin, azithromycin - PO doxycycline Choice 2: - PO levofloxacin - PO moxifloxacin
27
CAP: abx for inpatient, non-severe
Pathogens: Strep pneumoniae, Haemophilus influenzae, Atypicals Choice 1: - IV amoxicillin-clavulanate/ cefuroxime/ ceftriaxone PLUS (to cover atypicals) - (macrolide) IV clarithromycin, azithromycin - PO doxycycline Choice 2: - IV levofloxacin - IV moxifloxacin (MRSA RF) PLUS - IV vancomycin, linezolid (Pseudomonas RF) MODIFY tx: - IV piperacillin-tazobactam (add atypicals) - IV ceftazidime (add strep pneumoniae, atypicals) - IV cefepime (add atypicals) - IV meropenem (add atypicals) - IV levofloxacin (moxi does not cover pseudomonas) initial IV then step down to PO, can start PO if pt is well
28
MRSA & pseudomonas RF for inpatient non severe
- respiratory isolation of MRSA in last 1 year - hospitalisation or parenteral abx in last 90 days AND MRSA PCR screen positive - respiratory isolation of pseudomonas in last 1 year
29
CAP: abx for inpatient, severe
Pathogens: Strep penumoniae, Haemophilus influenzae, atypicals, Staph aureus, gram negative (Klebs, Burkolderia pseudomallei) Choice 1: - IV pen G/ amoxicillin-clavulanate PLUS (to cover Burkholderia) - ceftazidime PLUS (to cover atypicals) - (macrolide) IV clarithromycin, azithromycin Choice 2: - IV levofloxacin - IV moxifloxacin PLUS (to cover Burkholderia) - ceftazidime (MRSA RF) PLUS - IV vancomycin, linezolid (Pseudomonas RF) MODIFY tx: ceftazidime/ levofloxacin (cefta already in tx plan)
30
MRSA, pseudomonas RF for inpt severe
- resp isolation of MRSA/ pseudomonas in last 1 yr - hospitalisation or parenteral antibiotic use in last 90 days
31
add anaerobic cover when: what abx? For pneumonia
(shown by CT scan) lung abscess empyema - collection of pus in pleural cavity add IV/PO metronidazole, clindamycin if not using: amoxicillin-clavulanate, piptazo, meropenem, moxifloxacin
32
influenza management
add empiric oseltamivir x5d - initiate within 48hrs, up to 5 days - discontinue at 48-72hrs if no evidence of bacterial pathogen (negative culture, low procalcitonin level <0.25, early clinical stability)
33
why is respiratory FQ not first line for CAP (levo and moxi)
- increased AE (tendonitis, tendon rupture, neuropathy, QTc prolongation, CNS disturbances, hypoglycemia) - cross resistance to 3rd gen cephalosporins - preserve for gram negative infections (the only PO pseudomonas agent) - delay diagnosis of TB - undesirable monotherapy if TB
34
adjunctive corticosteroid therapy - for? - when is it used?
- decrease inflammation in lungs - not routinely added - add if shock refractory to fluid resuscitation and vasopressor support (in ICU) - no benefit in non severe CAP - conflicting data in severe CAP
35
CAP de-escalation (when and how)
when: - pt is hemodynamically stable (good BP, RR, vitals) - improving clinically - able to digest oral how: - positive cultures: use AST to narrow spectrum/ PO abx - no positive cultures: (deescalate) stop empiric cover for MRSA, Pseudomonas, Burkholderia in 48hrs - IV to PO either same abx or same class - still need cover Strep pneumoniae, Haemophilus influenzae, atypicals
36
CAP: tx duration
- minimum 5 days tx - 7 days if suspected MRSA, Pseudomonas - longer courses for: -> CAP complicated with deep-seated infections (eg meningitis, lung abscess) - 2-3 weeks -> infection with less common pathogens (Burkholderia, Mycobacterium tuberculosis, endemic fungi) - 3-6 weeks (TB 6mths)
37
CAP: step 4 monitor response
- achieve clinical stability within 48-72hrs (resolution of vital abnormalities, able to take oral, baseline mental status) - elderly, comorbidities pt take longer - first 72hrs do not escalate abx - no need repeat radiographic tests (unless clinical deterioration) or microbiological tests - ADR/ DDI
38
HAP/VAP: RF
1. pt related factors - elderly, smoking, COPD, cancer, immunosuppressive, prolong hospitalisation, coma, unconscious, malnutrition 2. infection control related factors - lack hand hygienes, contaminated respiratory care devices 3. healthcare related factors - prior abx use, sedatives, opioids analgesics, mechanical ventilation, supine position
39
HAP/VAP: prevention
- hand hygiene - appropriate use of abx and meds with sedative effects - VAP specific: - limit duration of mechanical ventilation - minimise sedation - elevate head of bed by 30 degrees
40
HAP/VAP: pathogens
Pseudomonas spp Acinetoabcter spp Enteric gram negative bacilli (enterobacter, Kleb, E coli) Staph aureus MUST empirically cover: - Pseudomonas aeruginosa - Staphylococcus aureus - Enterobacteriaceae
41
HAP/VAP: when to cover for MRSA
1. isolation of MRSA in last 1 year (not need respiratory isolation already, serious case!) 2. prior IV abx use in last 90 days 3. hospitalised in unit where >20% S.aureus are MRSA 4. high risk of mortality (eg ventilator support due to HAP/ septic shock)
42
HAP/VAP: when to use double antipseudomonal abx for empiric tx
any one of the following: 1. RF for antimicrobial resistance - isolation of pseudomonas in last 1 year (anywhere not respi only) - prior IV abx use within 90 days - acute renal replacement therapy prior to VAP onset 2. hospitalisation unit where >10% pseudomonas are resistant to monotherapy 3. high risk of mortality (eg ventilator support due to HAP/ septic shock) if not give one anti-pseudomonal agent - avoid use of AG as sole anti-pseudomonal agent
43
why is AG not good as monotherapy for pseudomonas in HAP/VAP
deep seated infection like pneumonia, AG not effective (need aerobic environment)
44
HAP/VAP: abx treatment
anti-pseudomonal agents: - IV piperacillin-tazobactam - IV cefepime - IV ceftazidime (avoid use if no MRSA coverage) - IV meropenem - IV imipenem AND/OR - IV levofloxacin - IV ciprofloxacin (dont use without MRSA coverage) OR - IV amikacin (avoid in monotherapy) (MRSA RF) PLUS IV vancomycin, IV/PO linezolid (PO linezolid has good oral F as IV, still can use)
45
HAP/VAP - deescalation/ IV to PO conversion
when: - pt is hemodynamically stable (good BP, RR, vitals) - improving clinically - able to digest oral how: - positive cultures: use AST to narrow spectrum/ PO abx, for pseudomonas use single (for culture directed tx, empiric can use 2) - no positive cultures: (deescalate) cover for pseudomonas, enteric GN, MSSA - IV to PO if possible
46
HAP/VAP: duration of tx
7 days regardless of pathogen for pt who achieved clinical stability - resolution of vitals - for HAP - baseline mental status longer tx for complicated HAP/VAP with deep seated infections (eg meningitis, lung abscess)
47
HAP/VAP: step 4 monitor repsonses
- clinical stability within first 48 - 72hrs - elderly pt with comorbidities take longer - dont escalate within the first 72hrs unless culture directed or severe deterioration - no need retest for radiographic/ microbiology unless clinical deterioration - ADR of abx

PR3151 Finals (7 decks)

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