Infectious Disease: Respiratory Flashcards by Andrew Kreutzer

Acute Bacterial Rhinosinusitis
Major Symptoms include?

Purulent anterior nasal drainage
Purulent or discolored posterior nasal drainage
Nasal congestions or obstruction
Facial congestion or fullness
Facial pain or pressure
Hyposmia or anosmia
Fever

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Acute Bacterial Rhinosinusitis
Minor Symptoms

HA
Ear pain, pressure, or fullness
Halitosis
Dental pain
cough
Fever (for subacute or chronic sinusitis)
Fatigue

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Acute Bacterial Rhinosinusitis
Conventional criteria for diagnosis of ABRS?

At least 2 major symptoms OR
1 major and >/= 2 minor symptoms

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Acute Bacterial Rhinosinusitis
Microbiology (common bacteria)?

S. Pneumonia (GP) (30-40%)
H. influenzae (GN) (20-30%)
M. Catarrhalis (GN) (12-20%)

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Acute Bacterial Rhinosinusitis
Microbiology (common viruses)?

Rhinovirus
Influenza virus
Adenovirus

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Acute Bacterial Rhinosinusitis
First Line Therapy
Who gets it?
Duration?

Amoxacillin/Clavulanate (Augmentin) (Standard Dose)
Toxic, Fail topical decongestants, or w/ comorbid conditions, or sx for > 7d
5-7 days

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Acute Bacterial Rhinosinusitis
PCN Allergy

Levofloxacin
Doxycycline

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Acute Bacterial Rhinosinusitis
Risk For Abx Resistance or Failed Therapy

Amox/Clav (high dose)
Clindamycin + cefixime OR cefpodoxim
Levofloxacin

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Acute Bacterial Rhinosinusitis
When to Use High Dose of Amox/Clav:
What is the High dose?
Duration

2g q12 h
10-14d

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Acute Bacterial Rhinosinusitis
When to Use High Dose of Amox/Clav?

Regions where PNS SPNA is prevalent
Severe infection
Attendance at daycare
Age <2 or > 65
Recent hospitalization
Abx use w/n last mo
Immunocompromised

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CAP Pneumonia Criteria

Coming in from the community, doesn’t meet HC criteria

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Nosocomial Pneumonia Criteria: HAP

Occuring > 48 hrs after hospitalization

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Nosocomial VAP Criteria: VAP

Occring > 48 hrs after intubation

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CAP Pneumonia Probable Pathogens

Strep Pneumoniae
Mycoplasma pneumoniae
H. Influenzae
Chlamydophilia
Legionella spss.

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Nosocomial Pneumonia Probable Pathogens

Staphylococcus aureus
Pseudomonas aeruginosa
Enterobacter spss.
Klebsiella spss.
Acinetobacter
E. coli

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CAP Outpatient therapy
Previously Health
No recent abx use (w/n 90d)

Macrolide Or Doxycycline
Azithro 500mg POx1 then 250mg x 4d
Doxycycline 100mg PO BID x5-7d

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CAP Outpatient therapy comorbidities requiring higher treatment than Macrolide OR Doxycycline includes?

Chronic heart, lung, liver or renal dz
DM
Alcoholics
Malignancy/Immunosuppression
Previous abx (w/n 3mo)

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CAP Outpatient therapy
Comorbidities including
Chronic heart, lung, liver or renal dz
DM
Alcoholics
Malignancy/Immunosuppression
Previous abx w/n 3 mo

Respiratory FQ OR Beta-lactam + Macrolide (or doxycycline)

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CAP Outpatient therapy
Comorbidities including
Chronic heart, lung, liver or renal dz
DM
Alcoholics
Malignancy/Immunosuppression
Previous abx w/n 3 mo

Respiratory FQ’s for this are?

Moxifloxacin 400mg PO daily x 5-7days
Levofloxacin 750mg PO daily x 5-7days

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CAP Outpatient therapy
Comorbidities including
Chronic heart, lung, liver or renal dz
DM
Alcoholics
Malignancy/Immunosuppression
Previous abx w/n 3 mo

Beta Lactam + Macrolide (or Doxycycline)

Amoxicillin 1g PO TID x 5-7d
Amox/Clav 2g PO BID x5-7d
Cefpodoxime 200mg PO q12h x 5-7d
Cefuroxime 500mg PO q12 h x 5-7d
Ceftriaxone 1g IV daily x 5-7d
+
Azithro500mg PO x1 then 250mg x 4d
or doxycycline 100mg PO BID x 5-7d

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CAP Inpatient therapy
Non-severe, inpatient (Non-ICU patient)
Beta-Lactam + Macrolide (or doxycycline)

Beta-Lactam + Macrolide (or doxycycline)
Ceftriaxone 1g IV daily x 7-10d
Cefotaxime 1g IV q8h x 7-10d
Amp/Sulbactam 3g IV q6h x 7-10d
Ertapenem1g IV daily x 5-7d
+
Azithromycin 500mg PO/IV daily x 5d
Doxycycline 100mg PO/IV BID x 5-7d

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CAP Inpatient Therapy
Non-severe, inpatient (Non-ICU patient)
Respiratory FQ

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Moxifloxacin 400mg IV daily x 5-7d
Levofloxacin 750mg IV daily x 7-10d

CAP Inpatient therapy
Severe, inpatient (ICU patient)
Beta-lactam + Macrolide OR Respiratory FQ

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Ceftriaxone 1g IV daily x 7-10d
Cefotaxime 1g IV q8h x 7-10d
Amp/Sublactam 3g IV q6h x 7-10d
+
Azithromycin 500mg IV daily x 5d
Moxifloxacin 400mg IV daily x 5-7d
Levofloxacin 750mg IV daily x 5-7d

Empiric Treatment of VAP
Basic Empiric Therapy (No special circumstance)

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Piperacillin/tazobactam 4.5g IV q6h
Cefepime 1g IV q8h
Ceftazidime 2g IV q8h
Imipenem/cilastatin 500mg IV q6h
Meropenem 1g IV q8h
OR
Aztreonam 2g IV q8h

Empiric Treatment of VAP Additional Gram-Positive Coverage (if Unit MRSA rate is >10-20% or if unknown)

Vancomycin 15mg/kg q12h OR Linezolid 600mg IV q12h

Empiric Treatment of VAP Double-coverage of Pseudomonas (RF for resistance, unit where >10% of GN isolates are resistant to monotherapy, or GN resistance is unknown)

Ciprofloxacin 400mg IV q8h Levofloxacin 750mg IV daily Amikacin 15-20mg/kg IV daily Gentamicin 5-7 mg/kg IV daily Tobramycin 5-7 mg/kg IV daily OR Polymixin (colistin, polymixin B)

Empiric Treatment of HAP Not at High Risk for Mortality and No Factors Increasing the Likelihood of MRSA

Choose 1 Piperacillin/Tazobactam 4.5g IV q6h Cefepime 1g IV q8h Levofloxacin 750mg IV daily Imipenem/cilastatin 500mg IV q6h Meropenem 1g IV q8h

Empiric Treatment of HAP Not at High Risk for Mortality BUT w/ Factors Increasing the Likelihood of MRSA

Piperacillin/tazobactam 4.5g IV q6h Cefepime 1g IV q8h or Ceftazidime 2g IV q8h Levofloxacin 750mg IV daily or Ciprofloxacin 400mg IV q8h Imipenem/cilastatin 500mg IV q6h or Meropenem 1g IV q8h OR Aztreonam 2g IV q8h + Vancomycin 15 mg/kgq 12h Or Linezolid 600 mg IV q12h

Empiric Treatment of HAP High Risk of Mortality or Receipt of IV Abx w/n 90d

Piperacillin/tazobactam 4.5g IV6h Cefepime 1g IV q8h or Ceftazidime 2g IV q8h Imipenem/cilastatin 500mg IV q 6h or Meropenem 1g IV q8h + Levofloxacin 750mg IV daily or Ciprofloxacin 400mg IV q8h Amikacin 15-20mg/kg IV daily or Gentamicin 5-7 mg/kg IV daily or Tobramicin 5-7 mg/kg IV daily + Vancomycin 15mg/kg IV q12h OR Linezolid 600mg IV q12h

MRSA Risk Factors

Prior IV abx use w/n 90d Hospitalization in a unit where > 20% of S. aureus isolates are MRSA MRSA rates are unknown

High Risk for Mortality

Ventilator support d/t HAP Septic Shock

Pneumonia Treatment durations CAP= Nosocomial= Pseudomonal pneumonias=? MRSA pneumonia=?

5-7d 7d at least 14d (maybe???) often requires longer duration

When to switch IV to PO abx?

Hemodynamic Stability (SBP > 90mmHg) Tolerating PO Normally fxning GI tract Afebrile for ~48h

Empyema Classifications: Uncomplicated parapneumonic effusion

Exudative effusion Resolves w/ resolution of pneumonia

Empyema Classifications: Complicated parapneumonic effusion

Bacterial invasion of the pleural space Increased neutrophils and pleural fluid acidosis LDH > 1000 IU/L Cultures are often falsely negative Anaerobes

Empyema Classification: Thoracic Empyema

Evident bacterial infection of the pleural liquid Pus and/or presence of bacteria on gram-stain

Empyema Diagnosis: Pleural Fluid Laboratory Analysis orders includes

Microbiology Cell count (w/ diff) Chemistries (total protein, LDH, glucose) pH

Empyema Diagnosis: Light's Criteria includes

Total serum protein Pleural fluid protein Serum LDH Pleural fluid LDH

Empyema Diagnosis using Light's Criteria Transudative vs. Exudative Exudative effusion is present if?

1 of the following occurs LDH > 2/3 Upper Limit of Normal for serum Plueral Fluid: Serum Protein is > 0.5 Pleural Fluid: Serum LDH > 0.6

Empyema Microbiology

Typically the same pathogens that cause pneumonia Notable exception - anaerobes *Fusobacterium *Prevotella *Peptostreptococcus *Bacteroides

Empyema Treatment Abx Treatment

Treat Underlying Pneumonia BUT....add anaerobic coverage (if your primary regimen does not provide anaerobic coverage) *Clindamycin *Metronidazole

Empyema Treatment Duration of Treatment

Very pt specific Until clinical improvement Depends upon other interventions

Empyema Treatment Surgical Interventions: Chest tube placement/drainage if?

pH is < 7.2 Positive culture or gram-stain Purulent May need more than 1 tube placed if the collections are loculated Larger bore tubes are necessary for more purulent fluid Impact on treatment duration

Pulmonary Infections: Tuberculosis Diagnostics Induration >/= 5mm + is positive in which patients?

HIV infected-person Recent contact w/ TB infected person CXR changes c/w TB Organ transplant recipients Immunosuppression

Pulmonary Infections: Tuberculosis Diagnostics Induration >/= 10mm + is positive in which patients?

Recent immigrants from high-prevalence countries IV drug users Residents & employees of high-risk congregate settings Mycobacterial lab personel Persons w/ clinical conditions that place them at high risk Children < 4yo Infants, children & adolescents exposed to adults in high-risk categories

Pulmonary Infections: Tuberculosis Diagnostics Induration >/= 15mm + is positive in which patients?

In any person who does not meet any of the other criteria

Pulmonary Infections: Tuberculosis Treatment (Latent TB Infection) Drugs used to treat?

Isoniazid and Rifapentine Rifampin INH + Rifampin Isoniazid

Pulmonary Infections: Tuberculosis Treatment (Latent TB Infection) Isoniazid and Rifapentine Duration Interval Minimum Doses

3mo Once weekly 12

Pulmonary Infections: Tuberculosis Treatment (Latent TB Infection) Rifampin Duration Interval Minimum Doses

4mo Daily 120

Pulmonary Infections: Tuberculosis Treatment (Latent TB Infection) INH + Rifampin Duration Interval Minimum Doses

3mo Daily 90

Pulmonary Infections: Tuberculosis Treatment (Latent TB Infection) Isoniazid Duration Interval Minimum Doses

9mo Daily 270

Pulmonary Infections: Tuberculosis Treatment (Active TB - Non-HIV) Initial Treatment Phase Preferred Regimen Alternative Regimen 1 Alternative Regimen 2

INH, RIF, PZA, & EMB Daily 56 doses (8 weeks) INH, RIF, PZA & EMB Daily 14 doses (2 weeks) THEN Twice Weekly 12 doses (6 weeks) INH, RIF, PZA & EMB Thrice Weekly 24 doses (8 weeks)

Pulmonary Infections: Tuberculosis Treatment (Active TB - Non-HIV) Continuation Treatment Phase Preferred Regimen Alternative Regimen 1 Alternative Regimen 2

INH & RIF Daily 126 doses (18 weeks) OR INH & RIF Twice Weekly 36 doses (18 weeks) INH & RIF Twice Weekly 36 doses (18 weeks) INH & RIF Thrice Weekly 54 doses (18 weeks)

Infectious Disease: Respiratory Flashcards

(53 cards)