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CDM 3 Exam 1 > Lecture 6 - Respiratory 1 > Flashcards

Lecture 6 - Respiratory 1 Flashcards

1
Q

Most common causes of CAP? (viral)

A

Human rhinovirus
Influenza A/B

1/4 cases roughly

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2
Q

Most common causes of CAP (bacterial)

A

Strep. pneum
H. influenze
Atypicals

~ 1/7 cases

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3
Q

Pathogen mode of entry for CAP?

A

Aspiration = most common
Aerosolization
Bloodborne = uncommon

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4
Q

Risk factors for CAP?

A

65+
Smoking tobacco
Alcohol use disorder
Chronic medical conditions affecting immune system
Immunocompromised or on immunosuppressive agents
Acid-suppressing agents
Altered lvl of consciousness

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5
Q

CAP symptoms

A

cough, maybe productive
chest pain
shortness of breath/inc work of breathing
Fever/sweating/chills
fatigue
N/V/D

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6
Q

CAP diagnosis tests

A

Sputum gram stain/culture = gold standard

some invasive methods used in some cases
blood culture if severe disease or suspected Pseudomonas and MRSA
Rapid viral antigen test during flu test
Urine antigen tests
Multiplex PCR-based tests becoming more common**

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7
Q

Procalcitonin

A

responds rapidly, more specific to bacterial infection

can peak 6-12hrs after infection

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8
Q

Procalcitonin Guidelines

A

< .25 = less likely bacterial infection + maybe wait it out
> .25 = more likely bacterial infection + start ABX right away

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9
Q

Calculation of CURB-65 Score

A

Confusion = disorientation to person, place or time (A&O X 3 = not confused)
Uremia = BUN > 20mg/dL
Respiratory rate = > 30B/min
BP = SBP < 90 or DBP < 60
Age > 65

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10
Q

CURB < 1 =

A

Outpatient treatment

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11
Q

CURB 2 =

A

Inpatient vs observation

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12
Q

CURB > 3 =

A

Admission, possibly ICU

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13
Q

Outpatient treatment CAP, previously healthy and no antimicrobials within previous 3 months

A

Macrolides (azith = 500 1 PO, then 250mg QD)(Clarith = 500mg BID or 1000mg QD)
consider alternative if > 25% strep pneum macrolide resistant, usually not most appropriate

Doxy = 100 BID** Best option
Amox = 1000 TID

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14
Q

Outpatient treatment CAP, presence of comorbidities or antimicrobial use within previous 3 months

A

Levo = 750mg QD
Moxi = 400mg QD

B-lactam + macrolide(or doxy)
Amox/Clav 875/125 or 2000/125 BID
Cepodoxime 200mg BID
Cefuroxime 500mg BID

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15
Q

when should you worry about QTc with fluoroquinolone?

A

> 450 might be concerned, monitor carefully
500 probs wouldn’t add

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16
Q

Non-ICU inpatient treatment

A

Levo 750mg IV QD or Maxi 400mg IV QD

B-lactam + macrolide (or doxy) preferred**
Amp/sulbac 3g IV q6h
Ceftriaxone 1-2g IV q24hr
Ceftaroline 600mg IV q12h
Azimuth 500mg IV q24hr

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17
Q

ICU inpatient treatment

A

B lactam + macrolide or respiratory fluoroquinolone

if severe penicillin allergy, Aztreonam 2g IV q8h + fluoroquinolone

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18
Q

Criteria for clinical stability

A

Temp < 37.8C
HR < 100b/m
RR < 24
SBP > 90
O2 sat > 90%
Ability to maintain oral intake
Normal mental status

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19
Q

When can patients switch to oral therapy and stop Abx?

A

once hemodynamically stable can switch to oral of same class

Treat atleast 5 days, afebrile for 48-72hrs before stoping Abx

if no response or worsening = escalate or change in treatment

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20
Q

Adjunctive corticosteroid use in CAP

A

may benefit in severe and non-severe CAP, inc risk of hyperglycemia
May inc mortality in influenza pneumonia

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21
Q

Influenza A/B Txm

A

oseltamivir 75 BID X 5 days
Zanamivir (inh) 10mg Bid X 5 days (bronchospasm**)
Peramivir 600mg IV X 1 ($$$)

Start within 48hrs of symptoms

CAP-dep endonuclease inhib = Baloxavir 40mg or 80mg if > 80kg X 1 dose

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22
Q

Respiratory Syncytial virus

A

Ribavirin = immunocompromised w/ severe disease

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23
Q

Prophylaxis Influenza A/B Txm

A

Oseltamivir 75mg QD X 7 days
Zanamivir 10mg (inh) X 7 days

both after exposure

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24
Q

Respiratory syncytial virus prophylaxis

A

Palivizumab = prevention in high risk pediatric patients

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25
Most common & preferred antivirals for COVID-19 are...
Remdesivir = polymerase inhib Nirmatrelvir/ritonavir = Pro inhib
26
COVID management outpatient > 7 days of symptoms and/or low risk of progression (age/immunocompromised)
Symptomatic management alone
27
COVID management outpatient CrCL < 30 or sig drug interactions to other drugs
Remdesivir Bebtelovimab if no other options available
28
COVID management outpatient < 5 days of symptoms
Nirmatrevir/ritonavir = paxlovid Molnupiravir if no other options available
29
Inpatient COVID + No supplemental oxygen needed
No corticosteroids
30
Inpatient COVID + need supplemental Oxygen
Remdesivir w/ minimal oxygen req** Remdesivir + dexamethasone Dexamethasone Baricitinib or Tocilizumab if oxy demand rapidly inc**
31
Inpatient COVID + high flow oxygen or non invasive ventilation
Dexamethasone Dexamethasone + remdesivir Baricitinib or Tocilizumab if oxy demand rapidly inc
32
Inpatient COVID + Vent or ECMO
Dexamethasone if w/I 24hr of ICU admission then Dexamethasone + tocilizumab
33
CAP modifiable risk factors
Smoking Alcohol use disorder Acid-suppressant use Anti-psyh meds Immunizations**
34
Immunization recommendations > 65
PCV20 or PCV15+PPSV23
35
Immunization recommendations 2-64
Prevnar + Pneumovax for high risk groups Hib for high risk groups
36
Hospital acquired pneumonia (HAP)
occurs > 48hrs after admission and did not appear to be developing at time of admission most common cause of death among nosocomial infections
37
Ventilator-associated pneumonia (VAP)
a subset of HAP that occurs after > 48hrs of endotracheal intubation 90% of HAP cases in ICU
38
Sources of pathogens for HAP
Healthcare devices Environment Transfer of organisms between patients and staff Colonization w/ S.aureus and gram - bacilli
39
Nosocomial pneumonia Risk factors
Prior antibiotic exposure*** Endotracheal intubation/mechanical vent**** advanced age severity of underlying disease Acid-suppressing agents Supine position Altered mental status surgery Duration of hospitalization Enteral nutrition + nasogastric tubes
40
Sources of pathogens for VAP
Intubation and mechanical vent increase risk of pneumonia dramatically Leakage around ET tube cuff into lungs causes infections.
41
Diagnosis of VAP or HAP
New infiltrate on CXR Fever Inc O2 req Thick or inc respiratory secretions Blood cultures for suspected VAP
41
Diagnosis of VAP or HAP
New infiltrate on CXR Fever Inc O2 req Thick or inc respiratory secretions Blood cultures for suspected VAP non invasive sampling preferred for culture
42
Early onset HAP/VAP
2-4 days of hospitalization Better prognosis Less likely due to MDR pathogens
43
Late onset HAP/VAP
> 5 days of hospitalization Higher morbidity/mortality More likely due to MDR pathogens
44
Which coverage should always be included in HAP/VAP
coverage for S.aureus and P.aeruginosa
45
Healthcare Associated Pneumonia (HCAP) Definition
Hospitalized for 2+ days in last 90 days Live in LTC facility IV infusion in past 30 days Wound care in past 30 days Hemodialysis Contact w/ family member w/ MDR pathogen
46
Anti-MRSA ABX for HAP/VAP
Vanco 15-20 mg/kg IV q8-12h Linezolid 600mg IV q12h
47
Anti-Pseudomonal B-Lactam HAP/VAP
Pip/Tazo 4.5g q6 Cefepime 2g q8 Ceftazidime 2g q8 Meropenem 1g q8 Imipenem 500mg q6 Azretonam 2g q8
48
Non-B-Lactam Anti-Pseudomonal HAP/VAP
Levo 750 IV q24 Cipro 400 IV q8 Gentamicin/tobramycin 7mg/kg IV q24 Amikacin 15 mg/kg IV q24 Colistin/Polymixin B
49
Treatment for HAP
combo of agents to cover S.aureus (MRSA) and Pseudomonas
50
Treatment for VAP
combo of agent to cover S.aureus (MRSA) and Pseudomonas
51
When to use Dual Antipsuedomonals in HAP
Unlikely unless.... IV ABX in last 90 days Need vent Septic shock ARDS CF or Bronchiestasis
52
When to use Dual Antipsuedomonals in VAP
guidelines suggest in all cases unless resistance < 10% = unlikely
53
When is Inhaled ABX therapy used?
usually only recommended when pathogen is susceptible to only AG or polymyxins
54
Inhaled ABX therapy
Tobramycin 300mg nebulas inhaled BID Colistin 75-300mg inhaled BID
55
Recommended duration of ABx treatment?
7 days P.aeruginosa and Acinetobacter may have higher relapse with < 14 days txm
56
When to add MRSA coverage for HAP?
IV abx within 90 days MRSA prevalence > 20% or unknown Need vent support Septic shock
57
When do to dual anti-pseudomonal coverage for HAP?
IV bitoics w/ past 90 days need vent septic shock ARDS preceding VAP Cystic fibrosis Bronchiestasis
58
When to add MRSA coverage for VAP
IV abx within 90 days MRSA prevalence >10- 20% or unknown Need vent support Septic shock
59
When to do dual anti-pseudomonal coverage for VAP
IV bitoics w/ past 90 days unit resistant for mono agent > 10% or unknown late onset acute renal replacement therapy prior to VAP septic shock ARDS preceding VAP Cystic fibrosis Bronchiestasis
60
Guideliens dumbed down
HAP = everyone gets MRSA, most get single pseudomonal VAP = every gets MRSA, most get dual pseudomonal
61
VAT (Ventilator- Associated Tracheobronchitis)
No radiographic evidence of pneumonia ABx generally not recommended

CDM 3 Exam 1 (10 decks)

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