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PR3151 Finals > IC16 LRTI > Flashcards

IC16 LRTI Flashcards

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

A

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

20
Q

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

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)

A

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

22
Q

what are the risk stratification methods for CAP?

A

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

23
Q

class in PSI

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

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
Q

IDSA/ATS criteria

A

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
Q

CAP: abx for outpatient

A

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
Q

CAP: abx for inpatient, non-severe

A

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
Q

MRSA & pseudomonas RF for inpatient non severe

A
  • 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
Q

CAP: abx for inpatient, severe

A

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
Q

MRSA, pseudomonas RF for inpt severe

A
  • resp isolation of MRSA/ pseudomonas in last 1 yr
  • hospitalisation or parenteral antibiotic use in last 90 days
31
Q

add anaerobic cover when:
what abx? For pneumonia

A

(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
Q

influenza management

A

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
Q

why is respiratory FQ not first line for CAP
(levo and moxi)

A
  • 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
Q

adjunctive corticosteroid therapy
- for?
- when is it used?

A
  • 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
Q

CAP de-escalation (when and how)

A

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
Q

CAP: tx duration

A
  • 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
Q

CAP: step 4 monitor response

A
  • 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
Q

HAP/VAP: RF

A
  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
Q

HAP/VAP: prevention

A
  • 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
Q

HAP/VAP: pathogens

A

Pseudomonas spp
Acinetoabcter spp
Enteric gram negative bacilli (enterobacter, Kleb, E coli)
Staph aureus

MUST empirically cover:
- Pseudomonas aeruginosa
- Staphylococcus aureus
- Enterobacteriaceae

41
Q

HAP/VAP: when to cover for MRSA

A
  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
Q

HAP/VAP: when to use double antipseudomonal abx for empiric tx

A

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

  1. hospitalisation unit where >10% pseudomonas are resistant to monotherapy
  2. 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
Q

why is AG not good as monotherapy for pseudomonas in HAP/VAP

A

deep seated infection like pneumonia, AG not effective (need aerobic environment)

44
Q

HAP/VAP: abx treatment

A

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
Q

HAP/VAP - deescalation/ IV to PO conversion

A

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
Q

HAP/VAP: duration of tx

A

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
Q

HAP/VAP: step 4 monitor repsonses

A
  • 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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