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Infectious Diseases > Lower Respiratory Tract Infections > Flashcards

Lower Respiratory Tract Infections Flashcards

1
Q

What are the LRTIs?

A

Bronchitis, Pneumonia

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2
Q

What are the symptoms of bronchitis?

A

Acute cough (usually <3 weeks) due to inflamm of trachea and lower airways
Generally starts w viral URTI

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3
Q

When is antibiotics indicated in bronchitis?

A

Not indicated unless suscpected SECONDARY bacterial infection. Treat based on culture.

Adjunctive abx treats secondary bacterial infection NOT bronchitis

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4
Q

What are the symptoms of pneumonia?

A

Fever, chills, malaise
Alt mental status (elderly)
Tachycardia, hypotension
Cough
Increased sputum pdtn
SOB
Chest pain
Tachypnoea
Hypoxia

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5
Q

What are the signs of pneumonia?

A

WBC, CRP, procalcitonin
Urinary antigens
Lung auscultation, lung CT, lung ultrasonography: new infiltrates or dense consolidations, usually unilateral

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6
Q

What is the pathophysiology of pneumonia?

A

Aspiration or inhalation of bacteria containing respiratory secretions or aerosols.
Hematogenous spreading: Bacteremia extrapulmonary source to the lungs
Proliferation of pathogens in the lower airways and alveoli

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7
Q

What are the risk factors for general pneumonia?

A

Hx of pneumonia
Smoking
Chronic lung conditions (e.g. asthma, COPD, CF, lung cancer)
Immune suppression
Prone to aspiration
Elderly

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8
Q

What are the risk factors specific for HAP?

A

Prolonged hospitalisation
Coma, impaired consciousness
Mechanical ventilation
Supine position
Lack of hand hygiene compliance
Contaminated medical devices
Opioid analgesics
Sedatives
Prev abx use
Malnutrition

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9
Q

Define CAP.

A

Pneumonia onset in community or <48h after hospitalisation

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10
Q

Define HAP.

A

Pneumonia onset >=48h after hospitalisation

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11
Q

What are the treatment categories for pneumonia?

A

CAP:
Outpatient, no comorbidities
Outpatient w comorbidities
In patient, non-severe
In patient, severe

HAP,VAP

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12
Q

What bugs must we cover for outpatient, no comorbidities?

A

S. pneumoniae

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13
Q

What bugs must we cover for outpatient w comorbidities?

A

S. pneumoniae, H. influenzae, Atypicals

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14
Q

What bugs must we cover for inpatient, non-severe?

A

S. pneumoniae, H. influenzae, Atypicals

Based on risk factors: P. aeruginosa, MRSA

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15
Q

What bugs must we cover for inpatient, severe?

A

S. pneumoniae, H. influenzae, Atypicals, S. aureus, Gram -ve (K. pneumoniae), Burkholderia pseudomallei

Based on risk factors: P. aeruginosa, MRSA

If abscess present: anaerobes

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16
Q

What bugs must we cover for HAP, VAP?

A

P. aeruginosa, S. aureus, Enterobacterales, Gram -ve , Anaerobes

Based on risk factor: MRSA

17
Q

What is the recommended regimen for outpatient, no comorbidities?

A

Amoxicillin 1g Q8H
Penicillin allergy: Respi fluoroquinolones

18
Q

What is the recommended regimen for outpatient w comorbidities?

A

Amoxicillin-clavulanate or Cefuroxime AND
Azithromycin or clarithromycin or doxycycline

OR

Respi fluoroquinolones

19
Q

What is the recommended regimen for inpatient, non-severe?

A

Amoxicillin-clavulanate or cefuroxime or ceftriaxone AND
Azithromycin or clarithromycin or doxycycline

OR

Respi fluoroquinolones

If P. aeruginosa risk factors: modify regimen to include pseudomonal coverage (pip-tazo, ceftazidime, cefepime, meropenem, imipenem, ciprofloxacin, levofloxacin)

If MRSA risk factors: add Vancomycin, linezolid

Start IV, then de-esc to PO (but if well, start PO)

20
Q

What is the recommended regimen for inpatient, severe?

A

Amoxicillin-clavulanate or Pen G AND
Ceftazidime
(for Burkholderia pneumonallei, H. influenzae) AND
Azithromycin or clarithromycin

OR

Respi fluoroquinolone AND
Ceftazidime (for Burkholderia pneumonallei, H. influenzae)

If P. aeruginosa risk factor: Modify regimen to cover (pip-tazo, ceftazidime, cefepime, imipenem, meropenem, ciprofloxacin, levofloxacin)

If MRSA risk factor: add vancomycin or linezolid

If anaerobe cover req: PO/IV metronidazole. If metronidazole cannot be used, use PO/IV clindamycin

21
Q

What is CURB-65?

A

Confusion: 1
Urea >7.0 mmol/L: 1
RR >=30 bpm: 1
BP < 90/60 mm Hg: 1
>65y: 1

22
Q

What is the recommended regimen for HAP, VAP?

A

Antipseudomonal beta lactam: piperacillin-tazobactam, ceftazidime, cefepime, imipenem, meropenem AND

Antipseudomonal fluoroquinolones: Ciprofloxacin (if pt wants to be discharged, dont want to overlap gram +ve coverage) > Levofloxacin AND

Amikacin

If MRSA risk factors: add vancomycin or linezolid

23
Q

When do we give double anti-pseudomonal therapy for inpatient, severe?

A
  1. Risk of AMR (P. aeruginosa isolated in last 1y, IV abx in last 90d, RRT prior to VAP)
  2. Institution antibiogram shows >10% isolates resistant to agents considered for coverage of P. aeruginosa as monotherapy
  3. Prevalence but high risk of mortality

Do not use amikacin as monotherapy for pseudomonal coverage

24
Q

What are the MRSA risk factors?

A
  1. Respi isolation of MRSA in last 1y
  2. IV abx use or hospitalisation in last 90d
  3. MRSA PCR screen +ve
25
Q

Whar are the P. aeruginosa risk factors?

A
  1. Respi isolation of P. aeruginosa in last 1y
  2. IV abx use or hospitalisation in last 90d
26
Q

Describe the process in determining CAP stratification and treatment.

A
  1. Determine severity using CURB-65
  2. Based on IDSA to determine inpatient nonsevere or severe
27
Q

Define VAP.

A

Pneumonia onset >=48h after initiation of mechanical ventilation

28
Q

How do we de-escalate inpatient CAP?

A

De-escalate when hemodynamically stable (gd BP, RR, vitals), improving clinically, able to ingest oral meds.

If culture +ve: streamline to AST
If culture -ve: remove pseudomonal and MRSA coverage after 48h if not isolated and pt is improving

29
Q

How do we de-escalate HAP, VAP?

A

De-escalate when hemodynamically stable (gd BP, RR, vitals), improving clinically, able to ingest oral meds.

If culture +ve: streamline to AST
If culture -ve: remove only MRSA, gram -ve, anaerobe coverage after 48h if not isolated and pt is improving (MUST keep pseudomonal, enterobacterales, MSSA coverage)

30
Q

What is the treatment duration for CAP?

A

Min 5d
Provided pt achieved clinical stability: Resoln of vital sign abnormalities (HR, RR, BP, O2 sat, T), Ability to maintain PO intake, Baseline mental status

7d if suspected/proven MRSA or Pseudomonas:
Longer courses for abx therapy for
- CAP complicated with other deep-seated infections (e.g. meningitis, lung abscess) –> 2-3 weeks
- Infection w other , less common pathogens (e.g. Burkholderia pseudomallei, Mycobacterium tuberculosis or endemic fungi) –> 3-6 weeks Burkholderia, 3-6mo Mycobacterium

31
Q

What is the treatment duration for HAP/VAP?

A

7d regardless of pathogen
Provided pt achieved clinical stability: Resoln of vital sign abnormalities (HR, RR, BP, O2 sat, T), Baseline mental status

No evi that longer treatment duration reduces recurrence or mortality
Longer courses of abx for pneumonia complicated w other deep seated infections

32
Q

What is the IDSA criteria for severe CAP?

A

> = 1 major criteria OR >=3 minor criteria

Major criteria: mechanical ventilation, septic shock, use of vasoactive meds

Minor criteria: CURB, PaO2/FiOx2 <=250, multilobar infiltrates, leukopenia (wbc < 4x10^9), hypothermia (core T < 36 deg C)

Infectious Diseases (9 decks)

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