Lower Respiratory Tract Infections

Question 1

Community Acquired Pneumonia (CAP)

Answer 1

Onset outside of the hospital or < 48 hours from hospital admission

Question 2

CAP Outpatient Empiric Therapy if No Comorbidities and No Antimicrobial Use Within 90 Days

Answer 2

High-dose amoxicillin (preferred)
Doxycycline
Azithromycin (if pneumococcal resistance < 25%)

Question 3

CAP Outpatient Empiric Therapy if Comorbidities or Antimicrobial Use Within 90 Days

Answer 3

Combination Therapy:
Augmentin or 2nd Gen PO CEPH (cefpodoxime or cefuroxime) PLUS EITHER
Macrolide or Doxycycline

Monotherapy: respiratory FQ (levofloxacin or moxifloxacin)

Question 4

CAP Inpatient, Non-ICU Empiric Therapy No PCN Allergy

Answer 4

Ampicillin/sulbactam, cefotaxime, ceftriaxone, or ceftaroline PLUS EITHER
Macrolide or doxycycline

Question 5

CAP Inpatient, Non-ICU Empiric Therapy if PCN Allergy

Answer 5

Levofloxacin or moxifloxacin

Question 6

CAP Inpatient, ICU Empiric Therapy No PCN Allergy

Answer 6

Ampicillin/sulbactam, cefotaxime, ceftriaxone, or ceftaroline PLUS EITHER
Macrolide or fluoroquinolone

Question 7

CAP Inpatient, ICU Empiric Therapy if PCN Allergy

Answer 7

Aztreonam PLUS

Levofloxacin or moxifloxacin

Question 8

Risk Factors for MRSA

Answer 8

Antibiotic use within 90 days
ESRD
Prior influenza infection
Radiographic finding of cavitary/necrotizing lesions
Structural lung disease

Question 9

CAP MRSA Therapy

Answer 9

Add vancomycin or linezolid to regimen

Question 10

Risk Factors for Pseudomonas

Answer 10

Antibiotic use within 90 days
Alcoholism
COPD
Structural Lung Disease

Question 11

CAP Pseudomonas Therapy

Answer 11

Anti-pneumococcal, anti-pseudomonal beta-lactam (Zosyn, Cefepime, Meropenem) PLUS EITHER
Fluoroquinolone or Aminoglycoside PLUS
Azithromycin

Question 12

CAP Directed Therapy - S. pneumoniae (PCN-susceptible)

Answer 12

Amoxicillin or PCN G

Question 13

CAP Directed Therapy - S. pneumoniae (PCN-resistant)

Answer 13

Cefotaxime, ceftriaxone, levofloxacin, moxifloxacin

Question 14

CAP Directed Therapy - H. influenzae (non-beta-lactamase)

Answer 14

Amoxicillin

Question 15

CAP Directed Therapy - H. influenzae (beta-lactamase)

Answer 15

Cefotaxime or ceftriaxone

Question 16

CAP Directed Therapy - MSSA

Answer 16

Dicloxacillin, Oxacillin, Nafcillin

Question 17

CAP Directed Therapy - MRSA

Answer 17

Vanco or linezolid

Question 18

CAP Directed Therapy - Legionella

Answer 18

Fluoroquinolone or macrolide

Question 19

CAP Duration of Therapy

Answer 19

5 days

Question 20

Hospital-Acquired Pneumonia (HAP)

Answer 20

Occurring at least 48 hours from admission, with no prior sxs

Question 21

HAP High Mortality Risk

Answer 21

Need for ventilator support due to pneumonia

Septic shock

Question 22

HAP MRSA Coverage Needed

Answer 22

IV antibiotic use within 90 days

Unit where prevalence of MRSA > 20%

Question 23

HAP Double Pseudomonas Coverage Needed

Answer 23

IV antibiotic use within 90 days

Structural lung disease

Question 24

HAP Empiric Therapy if Low Risk for Mortality and MDR GNR and Local MRSA < 20%

Answer 24

Beta-lactam (Zosyn, Cefepime, Meropenem, Imipenem) OR

Levofloxacin

Question 25

HAP Empiric Therapy if Low Risk for Mortality and MDR GNR and Local MRSA > 20%

Answer 25

Beta-lactam (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam) OR Levofloxacin or ciprofloxacin PLUS Vanco or linezolid

Question 26

HAP Empiric Therapy if High Risk for Mortality or MDR GNR

Answer 26

Double Pseudomonas coverage from 2 separate classes: beta-lactams (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam), fluoroquinolones (Ciprofloxacin, Levofloxacin), aminoglycosides (amikacin, gentamycin, tobramycin) PLUS Vanco or linezolid

Question 27

HAP Duration of Therapy

Answer 27

7 days

Question 28

VAP MDR Risk Factors

Answer 28

IV antibiotics within 90 days Septic shock ARDS and renal replacement therapy prior to VAP Hospitalization at least 5 days prior to VAP

Question 29

VAP MRSA Coverage Needed

Answer 29

MDR VAP Risk Factors | Unit where prevalence of MRSA > 10%

Question 30

VAP Double Pseudomonas Coverage Needed

Answer 30

MDR VAP Risk Factors | Units where resistance to anti-pseudomonal agent > 10%

Question 31

VAP Empiric Therapy if No MDR VAP Risk Factors and Local MRSA and GNR Resistance < 10%

Answer 31

Beta-lactam (Zosyn, Cefepime, Meropenem, Imipenem) OR | Levofloxacin

Question 32

VAP Empiric Therapy if No MDR VAP Risk Factors, Local MRSA > 10%, and GNR Resistance < 10%

Answer 32

Beta-lactam (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam) OR Levofloxacin or ciprofloxacin PLUS Vanco or linezolid

Question 33

VAP Empiric Therapy if No MDR VAP Risk Factors, Local MRSA < 10%, and GNR Resistance > 10%

Answer 33

Double Pseudomonas coverage from 2 separate classes: beta-lactams (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam), fluoroquinolones (Ciprofloxacin, Levofloxacin), aminoglycosides (amikacin, gentamycin, tobramycin), polymyxins (colistin or polymyxin B) At least one agent active against S. aureus

Question 34

VAP Empiric Therapy if No MDR VAP Risk Factors and Local MRSA and GNR Resistance > 10%

Answer 34

Double Pseudomonas coverage from 2 separate classes: beta-lactams (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam), fluoroquinolones (Ciprofloxacin, Levofloxacin), aminoglycosides (amikacin, gentamycin, tobramycin), polymyxins (colistin or polymyxin B) PLUS Vanco or linezolid

Question 35

VAP Empiric Therapy if MDR VAP Risk Factors

Answer 35

Double Pseudomonas coverage from 2 separate classes: beta-lactams (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam), fluoroquinolones (Ciprofloxacin, Levofloxacin), aminoglycosides (amikacin, gentamycin, tobramycin), polymyxins (colistin or polymyxin B) PLUS Vanco or linezolid

Question 36

Duration of VAP Therapy

Answer 36

7 days

Question 37

HAP/VAP Directed Therapy - MRSA

Answer 37

Vancomycin or linezolid

Question 38

HAP/VAP Directed Therapy - Pseudomonas

Answer 38

Per antibiotic susceptibility results Continue combination therapy for septic shock/high mortality risk Monotherapy if septic shock resolves

Question 39

HAP/VAP Directed Therapy - Acinetobacter

Answer 39

Per antibiotic susceptibility results Carbapenem Ampicillin/sulbactam Polymyxin + inhaled colistin

Question 40

HAP/VAP Directed Therapy - ESBL GNR

Answer 40

Carbapenem treatment of choice

Question 41

HAP/VAP Directed Therapy - CRE

Answer 41

``` IV polymyxin + inhaled colistin Ceftolozane/tazobactam Ceftazidime/avibactam Imipenem/relebactam Cefidercol ```