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LRTI; CAP Flashcards

1
Q

What are 3 ways bacteria can enter the LRT through various mechanisms? (KIV, not in learning outcome)

A
  1. Aspiration of oropharyngeal secretions
  2. Inhalation of aerosols
  3. Haematogenous spreading
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2
Q

What is the S&S clinical presentation of pneumonia?

A
  • Cough, chest pains, SOB, hypoxia
  • Fever >38oC, chills
  • Tachypnoea, Tachycardia, Hypotension
  • Leukocytosis
  • Fatigue, anorexia, nausea, changes in mental status
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3
Q

What is the Physical Examination clinical presentation of pneumonia?

A
  • Diminished breath sounds over the affected area

- Inspiratory crackles during lung expansion

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4
Q

What is the Radiographic findings (clinical presentation and diagnosis) of pneumonia?

A
  • Chest XR (CXR) or CT

- New infiltrates or dense consolidation

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5
Q

What is the Lab findings (clinical presentation and diagnosis) of pneumonia?

A
  • CRP, procalcitonin
  • non-specific
  • limited discriminatory potential
  • not recommended for routine use to guide ABx initiation or discontinuation
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6
Q

What should we take note for respiratory cultures?

A
  • Sputum:
    ~ low yield; frequent contamination oropharyngeal secretions
    ~ Quality sample: >10 neutrophils and <25 epithelial cells per low-power field
  • Lower RT samples:
    ~ Less contamination
    ~ invasive sampling (e.g. bronchoalveolar lavage (BAL)
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7
Q

What should we take note for blood cultures?

A

Rule out bacteremia

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8
Q

What should we take note of urinary antigen tests?

A
  • Organisms that we are are looking for: Streptococcus pneumonia, Legionella pneumophilia
  • Limitations: indicate exposure to the respective pathogens, remain positive for days-weeks despite Abx treatment
  • NOT routinely used
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9
Q

What is the classification of CAP?

A

Onset in community or <48 hours after hospital admission

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10
Q

What are the risk factors for CAP?

A
  1. Age >/= 65yo
  2. Previous hospitalisation for CAP
  3. Smoking
  4. COPD, DM, HF, cancer, immunosuppression
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11
Q

What are some preventions for CAP?

A

Smoking cessation

immunisations (influenza, pneumococcal)

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12
Q

What are the risk stratification for major criteria?

A
  • Mechanical ventilation

- Septic shock requiring vasoactive medications

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13
Q

What are the risk stratification for minor criteria of CAP?

A
  • RR > or = 30 breaths/min
  • PaO2/FiO2 < or = 250
  • Multi-lobar infiltrates
  • Confusion/disorientation
  • Uremia (urea >7mmol/L)
  • Leukopenia (WBC <4 X 10^9/L)
  • Hypothermia (core temp <36oC)
  • Hypotension requiring aggressive fluid resuscitation
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14
Q

How many major/minor criteria to determine severe CAP?

A 
>/= 1 major criteria OR
>/= 3 minor criteria
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15
Q

What are the potential organisms for standard regimens in outpatient CAP?

A
  • Streptococcus pneumoniae
  • H. influenzae
  • Atypical organisms (MC)
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16
Q

What is the empiric therapy for patients who are generally healthy for outpatient standard regimen CAP?

A

b-lactam (amoxicillin)
OR
Resp FQ (levo/moxi) - for pen allergy

all PO

17
Q

What is the empiric therapy for patients with chronic heart, lung, liver or renal diseases, DM, alcoholism, malignancy or asplenia in OUTpatient CAP standard regimen?

A

b-lactam (Augmentin OR Cefuroxime) + Macrolide (Clarithro/Azithro) OR Doxy

OR

Resp FQ (levo/moxi)

all PO

18
Q

What are the organism present in inpatient non-severe CAP?

A
  • Streptococcus pneumoniae
  • H. influenzae
  • Atypical organisms (MCL)
19
Q

What is empiric therapy for inpatient non-severe CAP?

A

b-lactam (augmentin OR ceftriaxone) + Macrolide (clarithro/azithro) OR Doxy

OR

Resp FQ (levo/moxi)

b-lactam and FQs adm IV (step down to PO later)
Macrolide and doxy adm PO (if there is no N/V, can tolerate)

20
Q

What are the organisms present in inpatient severe CAP?

A
  • Streptococcus pneumoniae
  • H. influenzae
  • Atypical organisms (MCL)
  • S. aureus
  • Other gram-ve bacilli (e.g. K. pneumoniae, BURKHOLDERIA PSEUDOMALLEI) B.P.
21
Q

What is empiric therapy for inpatient severe CAP?

A

b-lactam (augmentin + CEFTAZIDIME) + Macrolide (clarithro/azithro) OR Doxy

OR

Resp FQ (levo/moxi) + CEFTAZIDIME

b-lactam and FQs adm IV (step down to PO later)
Macrolide and doxy adm PO (if possible)

22
Q

What if pt has pen allergy? What if allergy to Ceftazidime?

A

Evaluate the severity of penicillin allergy
E.g. Simple rash, most can tolerate; 3rd gen, low cross reactivity
E.g. If anaphylaxis, omit ceftazidime and other b-lactams and just give resp FQs; we know that it doesnt cover B.P. but no choice. Monitor and see if need to cover B.P.

23
Q

What is the indications for anaerobic coverage and what anaerobes are present (inpatient only) ?

A
  • any one of them: Lung abscess and/or empyema

- common species: Bacteriodes fragilis, Prevotella spp, Porphyromonas spp, Fusobacterium spp.

24
Q

Which Abx to add for anaerobic activity? (except for which situations?)

A
  • Clindamycin (IV/PO) OR Metronidazole (IV/PO)

Augmentin and moxifloxacin in standard regimen have already anaerobic coverage, so don’t need to add Clinda/Metro if augmentin/ moxi is given
(pip-tazo as well)

25
Q

What are the indications for MRSA and what Abx would be provided to cover MRSA?

A
  • Any one of these: Prior respiratory isolation of MRSA in the last 1 year and/or Severe CAP only: hospitalisation and received IV ABx within last 90days (and locally validated risk factors)

Abx added to standard regimenP

  • Vancomycin IV
  • Linezolid (PO/IV)
26
Q

What is the indication for pseudomonal coverage and what are the Abx covered for Pseudomonas?

A

Prior respiratory isolation of Pseudomonas in the last 1 year

Modify standard regimen, add:

  • Pip/Tazo (IV)
  • Ceftazidime IV (alr in standard regimen for inpatient severe)
  • Cefepime IV
  • Meropenem IV (reserve for ESBL)
  • Levo (IV/PO) (alr in standard regimen outpt and inpt)
27
Q

Why FQs are not 1st line therapy?

A
  • inc adv effects
  • collateral damage
  • preserve activity for other gram-ve infections
  • FQs only PO options covering P. aeruginosa
  • Delay diagnosis of TB
28
Q

Is adjunctive corticosteroid therapy recommended?

A

NO

29
Q

What is the safety and efficacy for monitoring CAP?

A

Safety: adv effects of Abx (diarrhoea, rash), renal fn

Efficacy:

  • clinical improvement expected in 48-72 hours (dec cough, chest pain, SOB, fever, WBC, tachypnoea, etc.; elderly w multiple comorbidities may take longer)
  • Should not escalate Abx therapy in 1st 72 hours (unless culture-directed or sig clinical deterioration)
  • Radiographic improvement lags behind, up to 4-6wks for resolution (repeat only if clinical deterioration)
30
Q

When to modify treatment for empiric coverage for MRSA/ P. aerugionsa?

A

STOP coverage in 48hrs if no MRSA/P. aeruginosa is found on culture and pt is improving

31
Q

When to step down to PO?

A

ALL criteria must be met:

  • Haemodynamically stable
  • Clinically improved/improving
  • Afebrile >/= 24hrs
  • Normal GIT function
  • Able to ingest PO med

if there are positive cultures: use susceptibility results to guide selection of PO abx

if no +Ve cultures: use same Abx or another ABx of same class; empiric coverage with PO step-down therapy for MRSA/P. aeruginosa/B. pseudomallei usually irrelevant

32
Q

e.g. if ceftriaxone + clarithromycin was given at first for inpatient non-severe IV, how do we step down to PO?

A

Ceftriaxone (IV) –> cefuroxime (PO)

clarithro was alr in PO

33
Q

How long is the treatment? exceptions?

A
  • at least 5 days (until clinical stability is achieved, i.e., afebrile, able to take PO, normal vital signs, O2 saturation and mental status)
  • most achieve stability within 48-72 hrs
  • Exceptions:
  • MRSA, P. aeruginosa ~ 7 days
  • B.P. ~ 3-6 months

PT (19 decks)

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