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Pharm I > Lower Respiratory Tract Infections > Flashcards

Lower Respiratory Tract Infections Flashcards

(123 cards)

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1
Q

Risk factors for bronchitis

A

Cold or damp climate
Cigarette smoke
Air pollution

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2
Q

Causative organisms of bronchitis

A 
Viral pathogens mcc
-Common cold virus
-Influenza
-Adenovirus
-RSV
Bacterial pathogens
-Chlamydophilia pneumonia
-Mycoplasma pneumonia
-Bordetella pertussis
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3
Q

Acute bronchitis tx

A

Symptomatic and supportive care

  • Antipyretics
  • Antitussives
  • Bronchodilators
  • Corticosteroids
  • -Medrol dose pack
  • -Prednisone dose pack
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4
Q

When are abx indicated for acute bronchitis?

A

High-risk pts

Persistent sx

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5
Q

Choice of abx for bronchitis

A

Similar to CAP
Macrolide or doxycycline
Respiratory FQ

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6
Q

ASA adult dose

A

325-650 mg q4h

Max: 4 gm/day

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7
Q

ASA pediatric dose

A

CI in children 2nd

Reye’s syndrome

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8
Q

ASA pearls/side effects

A

Inhibit prostaglandin synthesis (AKI)
Tinnitus
Upper GI events

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9
Q

Ibuprofen adult dosing

A

200-800 mg Q4-6H

Max: 3.2 gm/day

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10
Q

Ibuprofen pediatric dosing

A

10 mg/kg PO q4-6h

Max: 50 mg/kg/day

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11
Q

Ibuprofen pearls/side effects

A 
Use in age > 6 mos
Inhibit prostaglandin synthesis (AKI)
Epigastric pain/dyspepsia
GI ulcer/bleeding
Increased CV events
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12
Q

Acetaminophen adult dose

A

650 mg PO q4-6h

Max: 4 gm/day

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13
Q

Acetaminophen pediatric dose

A

10-15 mg/kg PO q4-6h

Max: 60 mg/kg/day

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14
Q

Acetamiophen pearls/side effects

A

Preferred in children
Caution in liver disease
Skin reactioAns

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15
Q

Influenza tx

A

Antivirals should be started within 48 hrs of symptom onset

-Reduces illness duration ~1.3 days

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16
Q

Amantadine

Rimantadine clinical pearls

A

Spectrum: Influenza A

Use not currently recommended due to resistance issues

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17
Q

Olsetamivir adult dose and influenza spectrum

A

Dose: 75 mg PO BID x 5 days
Spectrum: A and B

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18
Q

Zanamavir adult dose and influenza spectrum

A

Dose: 10 mg INH BID x 5 days
Spectrum: A and B

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19
Q

Olsetamivir pearls

A

Renally eliminated
Safe in children
Increased risk of neuropsychiatric events

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20
Q

Zanamivir pearls

A

Age >7
Increased risk of neuropsychiatric events
Bronchospasm

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21
Q

Azithromycin MOA

A

Inhibits protein synthesis (50s)

Bacteriostatic

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22
Q

Azithromycin typical adult dosing: pneumonia

A

Variable: 500 mg IV or PO daily on day 1, then 250 mg IV or PO daily on day 2-5

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23
Q

Azithromycin spectrum of activity

A

Some gram neg
Gram pos
ATYPICALS

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24
Q

Azithromycin pearls/ side effects

A

QT prolongation
Increased cardiac risk
D/N/V

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25
Doxycycline MOA
Inhibits protein synthesis (30s) | Bacteriostatic
26
Doxycycline typical adult dosing pneumonia
100 mg IV or PO q12h
27
Doxycycline spectrum of activity
Gram neg Gram pos ATYPICALS
28
Doxycycline pearls/side effects
``` Esophageal irritation (take with water) GI upset (N/V) -Take with food Decreased absorption with food Photosensitivity Tooth discoloration/hyperpigmentation -Caution in age < 8 yrs ```
29
Clinical presentation of pneumonia
``` Cough +/- sputum Fever/chills Pleuritic chest pain Dyspnea Crackles on chest exam Consolidation on chest radiography AMS ```
30
Microbiologic diagnosis of pneumonia
``` Sputum gram stain/culture - >25 PMN and < 5 epithelial cells Blood culture Broncho-alveolar lavage (BAL) - > 10 to the sixth CFU/mL Protected specimen brush (PSB) - > 10 to the third CFU/mL Urine antigen tests -Legionella and S. pneumo ```
31
Community Acquired Pneumonia (CAP)
New infection in pt residing in the community without a recent hx of antimicrobial use or exposure to health care environments
32
Hospital Acquired Pneumonia (HAP)
New infection occurring greater than or equal to 48 hrs after hospital admission
33
Ventilator Associated Pneumonia (VAP)
New infection occurring greater than or equal to 48 hours after endotracheal intubation
34
Atypical coverage of pneumonia
Macrolides Doxycycline Fluoroquinolones
35
MRSA pneumonia coverage
Vancomycin Linezolid Ceftaroline Telayancin
36
Anti-pseudomonal agents: other antimicrobials
``` FQs -Ciprofloxacin -Levofloxacin Aminoglycosides -Gentamicin -Amikacin -Tobramycin Colistin Polymyxin B ```
37
Side effects of PCNs
GI (N/V/D) Rash Hypersensitivity Seizure
38
Amoxicillin adult dose PNA
1 gm PO TID
39
Amoxicillin spectrum of activity
Gram pos | Gram neg
40
Amox-clav adult dose PNA
2 gm PO BID
41
Amox-clav spectrum of activity
Gram pos Gram neg Anaerobe
42
Amox-clav pearls and side effects
N/V/D | Hepatotoxic- reversible
43
Ampicillin/sulbactam spectrum of activity
Same as amox-clav
44
Ampicillin/sulbactam pearls and side effects
Hepatic impairment
45
Piperacillin/tazobactam adult dosing PNA
3.375 g IV q8h ext. inf. (4.5 g IV q6h)
46
Piperacillin/tazobactam spectrum of activity
Same as amox/clav + PSA
47
Piperacillin/tazobactam pearls and side effects
Thrombocytopenia Caution in CHF Dermatologic (+) Coombs
48
Cephalosporins side effects
GI (N/V/D) | Seizure
49
Drug interactions: cephalosporins
May increase INR
50
Cefuroxime adult dose PNA
750 mg IV q8h 500 mg PO q12h 2nd generation
51
Cefuroxime spectrum of activity
< Gm pos > Gm neg (not nosocomial) Anaerobes
52
Cefuroxime pearls and side effects
Only if PCN MIC less than or equal to 2
53
Cefpodoxime spectrum of activity
< Gm pos | > Gm neg (nosocomial)
54
Cefotaxime spectrum of activity
Same as cefpodoxime
55
Cefotaxime pearls and side effects
Not spec. indicated PNA
56
Ceftazadime spectrum of activity
Same as cefpodoxime and PSA
57
Ceftazadime pearls and side effects
Neurotoxic
58
Ceftriaxone adult dose PNA
1 gm q24h | 3rd gen
59
Ceftriazone spectrum of activity
Same as cefpodoxime
60
Ceftriaxone pearls and side effects
Pancreatitis Gallstones Avoid in neonates Avoid with Ca solutions
61
Cefepime spectrum of activity
Gram pos | Nosocomial gm neg including PSA
62
Cefepime pearls and side effects
Neurotoxic | (+) Coombs test
63
Carbapenems side effects
GI (N/V/D) | Seizure
64
Carbapenems drug interaction
Can decrease valproate concentrations
65
Imipenem/cilostatin spectrum of activity
``` Gram pos Gm neg Anaerobic PSA Enterococcus ```
66
Imipenem/cilostatin pearls and side effects
``` Seizures (highest risk) Hematologic effects (pediatrics) ```
67
Meropenem adult dose PNA
500 mg IV q6h or 1 gm IV q 8h
68
Meropenem spectrum of activity
Gm pos Gm neg Anaerobic PSA
69
Meropenem pearls and side effects
Extended infusion dosing
70
Doripenem
Not reliable in pna
71
Ertapenem spectrum of activity
Gm pos Gm neg Anaerobic NO PSA
72
Ertapenem pearls and side effects
Once daily product
73
Community acquired pneumonia most common pathogens
``` S. pneumoniae H. influenza M. catarrhalis Atypical -M. pneumoniae -C. pneumoniae -L. pneumonophilia Viral ```
74
How to select empiric antimicrobial therapy for pna
``` Cover the most likely pathogens -Assess pt risk factors Assess severity of illness Consider local resistance patterns Penetration to site of action Pt specific factors ```
75
Severity of illness assessment
Home vs hospital ICU vs non-ICU Pneumonia severity index (PSI) CURB- 65
76
CURB-65
``` One point each Confusion Urea (BUN) > 20 mg/dL Respiratory rate > 30 BP (SBP < 90 or DBP < 60) Age greater than or equal to 65 ```
77
CURB-65 score 0-1
Outpatient | Oral abx
78
CURB-65 score 2
Oupatient or inpatient | Oral or IV abx
79
CURB-65 score 3
Inpatient | IV abx
80
CURB-65 score 4-5
Inpatient +/- ICU | IV abx
81
CAP- outpatient tx
``` Otherwise healthy: Macrolide -Azithromycin, clarithromycin Doxycycline Outpatient comorbidities: respiratory fqs, -Moxifloxacin, levofloxacin B-lactam + macrolide ```
82
RF for P. aeruginosa
``` Structural lung disease -Bronchiectasis Corticosteroid therapy - > 10 mg prednisone/day Broad spectrum abx for > 7 days in past 30 days Malnutrition ```
83
RF for Drug-resistant S. pneumonia (DRSP)
``` Antibiotic in past 3 mos Alcoholism Immune-suppression -Disease or medications Multiple comorbidities -CHF, CKD, COPD, liver disease, diabetes Splenectomy High rate of macrolide-resistant S. pneumo in community ```
84
Side effects of FQs
``` QT prolongation CNS effects Hypoglycemia Peripheral neuropathy Photosensitivity Tendon rupture ```
85
Tx of CAP- inpatient (non-ICU)
Respiratory FQ -Moxifloxacin, levofloxacin Beta-lactam + macrolide (or doxycycline)
86
Tx of CAP- inpatient (ICU) | No MDR pathogens
Beta-lactam + azithromycin Beta-lactam + resp. FQ PCN allergy: resp. FQ + aztreonam
87
CAP- inpatient (ICU) | Risk for pseudomonas
Atipseudomonal beta-lactam + cipro/levofloxacin | Antipseudomonal beta-lactam + AMG + azithromycin
88
CAP- inpatient (ICU) | Risk for MRSA
``` Add coverage Vancomycin Linezolid Ceftaroline Telayancin ```
89
Aspiration pneumonia- oral contents pathogens
Anaerobes | Strep spp.
90
Aspiration pneumonia- oral contents tx
Pen G Ampicillin/sulbactam Clindamycin
91
Aspiration pneumonia- gastric contents pathogens
Enteric GN bacilli | S. aureus
92
Aspiration pneumonia- gastric contents tx
Ampicillin/sulbactam Amoxicillin/clavulanate Piperacillin/tazobactam Ticarcicillin/clavulanate
93
Criteria for clinical stability- IV to PO switch
Temperature less than or equal to 37.8 degrees Celsius HR less than or equal to 100 bpm RR less than or equal to 24 breaths/min SBP greater than or equal to 90 mm Hg SpO2 greater than or equal to 90% or pO2 greater than or equal to 60 mm Hg on room air Ability to maintain oral intake Nl mental status
94
Do not use in age <5
``` Ciprofloxacin Moxifloxacin Levofloxacin Tetracycline Doxycycline ```
95
CAP in pediatric pts
Most often viral | -Supportive therapy (antipyretics, hydration)
96
Outpatient CAP tx in peds
Amoxicillin +/- macrolide
97
Inpatient CAP tx in peds
Beta-lactam +/- azithromycin Fully immunized: Pen G IV or ampicillin IV Not immunized: Cefotaxime or ceftriaxone
98
Common gram-neg pathogens for HAP and VAP
``` P. aeruginosa E. coli (ESBL) Proteus spp. K. pneumonia (ESBL) Acinetobacter spp. ```
99
Common gram-pos pathogens for HAP and VAP
S. aureus | MRSA
100
VAP risk factors for MDR organisms
Prior IV abx in past 90 days Septic shock at time of VAP ARDS preceding VAP Greater than or equal to 5 days of hospitalization preceding VAP Acute renal replacement therapy prior to VAP
101
RR for MDR organisms- HAP
Prior IV abx in past 90 days
102
Empiric therapy: VAP
Anti-PSA broad spectrum beta-lactam + double coverage IF MDR risk factors present + MRSA coverage IF MRSA risk factors present
103
VAP anti-PSA broad spectrum beta-lactam
``` Cefepime Ceftazidime Imipenem Meropenem Piperacillin/tazobactam PCN allergy: aztreonam ```
104
VAP MDR risk-factors coverage drugs
``` Ciprofloxacin Levofloxacin (Aminoglycosides) (Colistin) (Polymyxin) ```
105
VAP MRSA coverage drugs
Vancomycin Linezolid (Telavancin) (Ceftaroline)
106
HAP group 1
Not at high mortality risk AND No MRSA risk factors
107
HAP group 2
Not at high mortality risk AND MRSA risk factors present
108
HAP group 3
High risk of mortality OR IV abx in last 90 days
109
Increased risk of mortality for HAP
Ventilatory support needed for pneumonia | Septic shock
110
MRSA risk factors for HAP
IV antibiotic tx in last 90 days > 20% isolates MRSA and not MSSA in unit MRSA prevalence in unit unknown
111
Empiric HAP therapy- group 1
``` Piperacillin/taxobactam Cefepime Levofloxacin (Imipenem) (Meropenem) ```
112
Empiric HAP therapy- group 2
``` One of the following: Piperacillin/tazobactam Cefepime Levofloxacin Ciprofloxacin Imipenem Meropenem Aztreonam One of the following: Vancomycin Linezolid ```
113
Empiric HAP therapy- group 3
``` One of the following: Piperacillin/tazobactam Cefepime Ceftazadime Imipenem Meropenem Aztreonam One of the following: Levofloxacin Ciprofloxacin Aminoglycoside One of the following: Vancomycin Linezolid ```
114
VAP/HAP Piperacillin/tazobactam dose
4.5 g IV q6h
115
VAP/HAP Cefepime dose
2 g IV q8h
116
VAP/HAP Meropenem dose
1 g IV q8h
117
VAP/HAP Ciprofloxacin dose
400 mg IV 18h
118
VAP/HAP Levofloxacin dose
750 mg IV q24h
119
Duration of CAP tx
Minimum 5 days therapy -Afebrile 48-72 hours -No more than 1 CAP-associated sign of clinical instability Longer duration may be indicated if -Initial antibiotic not active against identified pathogen -Clinical status resolving slowly
120
MOA of FQs
DNA gyrase and topoisomerase IV inhibitor | Bactericidal
121
MOA of aminoglycosides
Tobramycin, gentamycin, amikacin Gm-neg coverage only (including PSA) Inhibit protein synthesis (30s) Bactericidal
122
Adverse effects of aminoglycosides
Vestibular/ototoxicity (often irreversible) Nephrotoxicity (esp. in combination with Vancomycin) Neurotoxicity
123
Duration of tx- VAP/HAP
``` Short duration better -7 days for HAP and VAP MRSA -7 days (blood cultures negative) -14-21 days (blood cultures positive) Pseudomonas aeruginosa -7 days ```

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