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CPR Exam 2 > Pharm: CAP, HAP, VAP > Flashcards

Pharm: CAP, HAP, VAP Flashcards

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1
Q

What does the prevnar vaccine offer protection from?

Who is recommended to get the vacceine?

A

Protection from 13 S. pneumonae strains

Recommended for:

All children < 2 yo

Immunocompromised adults

Adults 65+

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2
Q

What does Pneumovax offer protection from?

Who is recommended to get the vacceine?

A

Protects from 23 strains of S. pneumoniae

Recommended for:

All adults 65+

Immunocompromised people age 2-64

Adults 19-64 who smoke cigarettes

Readminister every 5 years once started

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3
Q

How do you treat viral pneumonia?

A

Get your flu shot!

Oseltamivir, sanamivir (only effective if started within 48 hrs of symptom onset)

No effective drugs for adenovirus, parainfluenza, RSV

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4
Q

What are patients with viral pneumonia at risk of developing?

A

Secondary bacterial “superinfections” caused by S. pneumoniae, S. aureus, or H. influenzae

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5
Q

What is first line treatment for patients without risk factors for severe cases of CAP without a penicillin allergy?

A

Amoxicilline plus a macrolide or doxycycline

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6
Q

What is the first line treatment for patients without risk factors for severe case of CAP with a penicillin allergy?

What if they can’t tolerate cephalosporins?

A

Third generation of cephalosporin plus a macrolide or doxycycline

If can’t tolerate cephalosportins, give respiratory fluoroquinolone or lefamulin

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7
Q

What is the first line treatment for patients with risk factors for a sever course of CAP with a penicillin allergy?

What if they can’t tolerate cephalosporins?

A

Third generation cephalosporin plus a macrolide or doxycycline

If unable to tolerate cephalosporins and no structural lung dz, give respiratory fluoroquinolone or lefamulin

If unable to tolerate cephalosporins and has structural lung dz, give respiratory fluoroquinolone only

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8
Q

What is the first line treatment for patients with risk factors for a severe course of CAP without a penicillin allergy?

A

Amoxicillin-clavulanate plus a macrolide (preferred) or doxycycline

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9
Q

What drug class can’t you combine with penicilins in same IV solution?

A

Aminoglycosides

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10
Q

What drugs do you use agains penicillinase-producing strains of S. aureus?

A

Penicillinase-resistant penicillins (ex. nafcillin)

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11
Q

What penicillins have the greatest activity agains gram negative bacteria?

A

Broad spectrum penicillins (ex. ampicillin, amoxicillin)

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12
Q

What penicillins are useful agains P. aeruginosa?

A

extended spectrum penicillins (ex. piperacillin)

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13
Q

What can you combine penicillins with to increase activity?

A

beta-lactamase inhibitors (ex. clavulanate, tazobactam, sulbactam)

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14
Q

When would you use amoxicillin + clavulanate?

A

CAP if no penicillin allergy

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15
Q

What are some toxicities associated with amoxicillin + clavulanate?

A

Hypersensitivity reactions

superinfections, fungal or bacterial, including c. diff

Don’t use in patient’s with mononucleosis –> rash

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16
Q

What is the MOA of piperacillin + tazobactam?

A

Piperacillin inhibits bacterial wall synthesis

Tazobactam inhibits many beta lactamases

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17
Q

What types of organisms does piperacillin + tazobactam protect against?

A

broad spectrum

most gram positive & gram negative aerobes & anaerobes

Active against pseudomonas

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18
Q

What can you use piperacillin + tazobactam for?

A

CAP, HAP & VAP

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19
Q

What are the third generation cephalosporins?

What group of bacteria are they active against?

A

ceftriaxone, cefpodoxime, cefditoren

Have improved penetration through gram negative outer membrane

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20
Q

What are the fourth generation cephalosporins?

What group of bacteria are they active against?

A

cefepime

Has improved penetration through gram negative outer membrane with improved activity against gram positive

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21
Q

Why is ceftriaxone noteworthy?

A

not eliminated by the kidney so dose adjustment not needed for renal impairment

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22
Q

What important cefalosporin has bleeding tendancies?

A

ceftriaxone

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23
Q

What are the parenteral cephalosporins?

A

ceftriaxone (3rd gen)

cefepime (4th gen)

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24
Q

What are the oral cephalosporins?

A

cefditoren (3rd gen)

cefpodoxime-proxetil (3rd gen)

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25
What organisms can you use cefpodoxime and cefditoren agains?
wide spectrum of gram positive and gram negative
26
What do you have to be careful with when giving cefpodoxime and cefditoren to patients with decreased renal function?
Longer 1/2 life of medication Potential nephrotoxic effects if mixed with other nephrotoxic drugs (ex. aminoglycosides, warfarin)
27
What are some toxicities associated with cefpodoxime and cefditoren?
Beta lactam allergy Superinfection (c. diff) Cefditoren increases INR
28
What is the MOA of tetracyclines?
Inhibits 30S subunit & interferes with tRNA delivery thereby slowing growth of bacterial peptide chains ## Footnote **Kills bacterial lacking cell walls!**
29
What is the tetracycline drug of choice (in combination) for CAP?
Doxycycline
30
Can tetracyclines be used in kids?
They shouldn't, lead to permanent teeth staining
31
What are some other adverse effects of tetracyclines?
Impaired absorption (esp if taking antacids, Ca or Mg supplements) Esophageal irritation and ulceration Photosensitivity Not recommended in combo with bactericidal drugs (ex. penicillins)
32
What are some examples of macrolides?
Ezithromycin Clarithromycin Azithromycin Clindamycin
33
What is the MOA of macrolides?
Bind 50S subunit and block peptide chain elongation
34
What are some indications for macrolide use? What drugs are commonly used?
Drug of choice (in combo) for CAP (azithromycin or clarithromycin) Coverage of aerobic and anaerobic gram-positive organisms (effective against most) Generally not effective against gram negative bacteria **EXCEPT pasteurella, haemophilus, & neisseria spp.** Effective against Legionella, mycoplasma, mycobacteria, some rickettsia, and chlamydia Generally ot active against fungi or protozoa
35
What are some adverse effects of clarithromycin?
Less GI upset CYP450 inhibitor
36
What are some advantages of azithromycin?
Does not disrupt CYP450 function Has different ring structure tha other macrolides (better for allergies?) Concentrates in phagocytes and slowly release bacteriostatic levels of drug from single dose with t1/2 of 2-4 days
37
What are some examples of respiratory fluoroquinolones?
levofloxacin (3rd gen) gemifloxacin (4th gen) moxifloxacin (4th gen)
38
What do respiratory fluoroquinolones cover? How are they administered?
broad spectrum agains both gram positive and gram negative Some adminstered orally
39
Should you use fluoroquinolones in CAP?
Use is discoraged unless: - comorbid conditions - recent antimicrobial use - high prevalence of high-level macrolide resistant S. pneumonae in the local community
40
What are some adverse reactions of fluoroquinolones?
Achille's tendon rupture (esp. in children, elderly, and those who stress tendon) GI upset photosensitivity
41
What are some indications for vancomycin?
Given IV for MRSA and MRSE individuals with penicillin allergies (anytime can't give penicillins)
42
What happens if you infuse vancomycin too fast?
Red Man Syndrome
43
What is linezolid active against? When do you use it?
Most gram positive bacteria Use in CAP (S. pneumonae including concurrent infection with s. aureus) and HAP (S. aureus or S. pneumonae)
44
Can you give linezolid orally?
Yes
45
What organisms does aztreonam cover?
Wide spectrum of gram neg aerobes including pseudomonas No activity agains gram pos or anaerobes
46
What is the MOA of imipenem?
Binds \>1 PBPs Inhibits bacterial wall synthesis
47
What organisims does imipenem cover?
Wide spectrum of activity agains gram neg and gram pos aerobic and anaerobic bacteria ## Footnote **Active against many MDR strains!**
48
What are some adverse effects of gentamicin?
Nephrotoxicity (generally reversible) Neurotoxicity Ototoxicity
49
What are usually the drugs of choice for aspiration pneumonia? Why did we switch to these drugs?
Ampicillin-sulbactam or amoxicillin-clavulanate Used to use clindamycin but switched because of strong association with c. difficile colitis
50
What are some c. diff colitis causing antibiotics?
clindamycin fluoroquinolones broad spectrum cephalosporins penicillin macrolides (occasionally) trimethoprim-sulfamethoxazole (occasionally)
51
What are your "nasty bugs"? Why are these so bad?
ESKAPE E. coli Staphlococcus (S. aureus) Klebsiella pneumoniae Acinetobacter Baumannii Pseudomonas aeruginosa Enterococcus faecalis All have post-translational modifications that give rise to abx resistance
52
What should you give a CAP pt at increased risk of both MRSA and Pseudomonas infection?
Anti-MRSA agent (Vancomycin or linezolid) Levofloxacin Aztreonam An aminoglycoside (gentamycin)
53
What should you give a CAP pt with a severe beta lactam allergy with pseudomonas risk factors only?
levofloxacin aztreonam an aminoglycoside (gentamycin)
54
What should you give a CAP pt with a severe beta lactam allergy with MRSA risk factors only?
Anti-MRSA agent (vancomycin or linezolid) A respiratory flurorquinolone (levofloxacin, moxifloxacin, gemifloxacin)
55
What should you give a CAP patient **without** a severe beta lactam allergy with an increased risk of MRSA and pseudomonas infection?
Anti-MRSA agent (vancomycin or linezolid) Antipseudomonal/antipneumococcal beta lactam (piperacillin-tazobactam, cefepime, ceftazidime, imipenem or meropenem) Antipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin)
56
What is the prefered treatment for a CAP pt **without** a severe beta lactam allergy with an increased risk of MRSA infection only?
**Combination beta lactam based regimen** **If no macrolide contraindication: Anti-MRSA agent** (vancomycin or linezolid) **+ antipneumococcal beta lactam** (ceftriaxone, cefotaxime, ceftaroline, ertapenem, ampicillin-sulbactam) **+ a macrolide** (azithromycin or clarythromycin) **If pt has macrolide contraindication: same regimen as above but swap macrolide for doxycycline**
57
What is the alternative treatment for a CAP pt without a severe beta lactam allergy with an increased risk of MRSA infection only?
Fluoroquinolone based regimen Respiratory fluoroquinolone (levofloxacin, moxifloxacin, or gemifloxacin) Anti-MRSA agent (vancomycin or linezolid)
58
What should you give a CAP patient without a beta lactam allergy with a risk of pseudomonas infection only?
Antipseudomonal/antipneumococcal beta lactam (piperacillin-tazobactam, cefepime, ceftazidime, imipenem, meropenem) Antipseudomonal fluoroquinolone (levofloxacin, ciprofloxacin)
59
What is the prefered treatment for a CAP patient with no beta lactam allergy and no MRSA or pseudomonas risk factors?
If no macrolide contraindication: An antipneumococcal beta lactam (ceftriaxone, cefotaxime, ceftaroline, ertapenem, ampicillin-sulbactam) + a macrolide (azithromycin or clarithromycin) If macrolide contraindication: same as above but swap macrolide for doxycycline
60
What is an alternative treatment for a CAP patient with no beta lactam allergy and no MRSA or pseudomonas risk factors?
Respiratory fluoroquinolone monotherapy (levofloxacin, moxifloxacin or gemifloxacin)
61
What are risk factors for MDR pseudomonas and other gram negative bacilli in VAP?
Tx in ICU in which \>10% of gram neg isolates are resistant to agent being considered for monotherapy Tx in ICU in which local antimicrobial susceptibility rates are not known Colonization with or prior isiolation of MDR pseudomonas or other gram neg bacilli
62
What are MRSA risk factors in VAP?
treatment in a unit in which \>10 to 20 percent of Staphylococcus aureus isolates are methicillin resistant treatment in a unit in which the prevalence of MRSA is not known colonization with OR prior isolation of MRSA
63
What are general risk factors for MDR colonization in VAP?
* IV antibiotic use within the previous 90 days * septic shock at the time of VAP * ARDS preceding VAP * ≥ 5 days of hospitalization prior to the occurrence of VAP * acute renal replacement therapy prior to VAP onset

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