Pneumonia

Question 1

T or F: Pneumonia is the #1 cause of death from ID

Answer 1

true

Question 2

types of pneumonia (3)

Answer 2

Community aquired
Hospital acquired (nosocomial)
Aspiration pneumonia

Question 3

Two types of hospital acquired pneumonia

Answer 3

health care associated

ventilator associated

Question 4

What type of pneumonia do we see most often?

Answer 4

community acquired

Question 5

CURB-65 scoring system defined

Answer 5

C - confusion
U - uremia or BUN > 20 mg/dL
R - resp rate at least 30
B - blood pressure systolic < 90 or diastolic < 60
65 - Age at least 65

Each is worth one point
0-1: tx at home
2: consider inpt
>3: potential ICU

Question 6

Organisms for community acquired pneumonia

Answer 6

strep pneumonia 
h inluenza
legionella spp*
mycoplasma pneumoniae*
chlamoydophila pneumonia*

Less common: 
M Cat
Klebsiella pneumoniae
Staph aureus 
Viruses

*“atypical” organisms

Question 7

DRSP

Answer 7

drug resistant strep pneumonia

Question 8

Risk factors for drug resistant strep pneumonia (DRSP)

6

Answer 8

Age <2 or >65
abx within the last 3 months
alcoholism
medical comorbidities
immunosuppressive illness or therapy
exposure to child at day care

Question 9

Guidelines from Infectious disease society of America/American thoracic society
(3)

Answer 9

• sputum and blood cultures are recommended for all community acquired pneumonia patients, not just those with severe CAP.
• especially for those receiving empirics for MRSA or pseudomonas
• recommending against steroids for pneumonia unless they are in refractory septic shock
• recommending against follow up routine chest imaging

Question 10

IDSA/ATS therapy updates

Answer 10

• recommending against macrolide mono therapy bc of resistance
• beta lactam/macrolide and beta lactam/fluoroquinolone are both still acceptable for severe CAP but the evidence is stronger for beta lactam/macrolide

Question 11

IDSA/ATA guidelines for initial treatment in outpatient CAP pts include

Answer 11

high dose amoxicillin- best

doxycycline* save for those with Qtc or allergy to amoxicillin
amoxicillin/clavulanate*
various cephalosporins
FQs
macrolides (at the bottom of the list bc of resistance)

Question 12

high dose amoxicillin is

Answer 12

1g TID

outpatient regimen

Question 13

most often tx for inpatient CAP

Answer 13

B lactam macrolide

Question 14

it’s not likely to see staph aureus in CAP but if you do expect it

Answer 14

vanco

Question 15

2 common options for empiric therapy in the non icu patient

Answer 15

macrolide plus beta lactam

FQ alone

Question 16

macrolide plus beta lactam for empiric, non ICU CAP.

examples (3)

Answer 16

ceftriaxone
ampicillin
ertapenem

Question 17

Fluroquinolone empiric therapy for the non ICU pt c CAP

example

Answer 17

levo or moxi

Question 18

empiric therapy options for ICU patients with CAP
2
plus 1 if PCN allergic

Answer 18

ceftriaxone or cefotaxime
ampicillin sulbatam PLUS FQ
if PCN allergic: moxi or levo PLUS aztreonam

Question 19

modifying factors of CAP treatment

Answer 19

structural lung disease
beta lactam allergy
community acquired MRSA

Question 20

structural lung disease as a modifying factor for CAP tx

Answer 20

use an anti pseudomonal agent (like cefepime, pip/tazo, imipenem, or meropenem) PLUS macrolide or levo or cipro.

Question 21

beta lactam allergy as a modifying factor for CAP

Answer 21

use FQ with or without vanco

Question 22

Community acquired MRSA as a modifying factor for CAP tx

Answer 22

Vanco plus linezolid plus FQ

Question 23

Hospital acquired pneumonia

Answer 23

developed at least 48 hours after admission, with no mechanical ventilation involved

Question 24

ventilator associated pneumonia

Answer 24

pneumonia occurring 48 hours after intubation

can take place on top of existing hospital acquired.

Question 25

how many HAPs per 1000 admissions

Answer 25

5 - 15

Question 26

how much does being on a ventilator increase risk of HAP?

Answer 26

6 - 20 x

Question 27

how many days does HAP increase a hospital stay?

Answer 27

7 - 9

Question 28

Routes of entry for HAP | 5

Answer 28

micro aspiration of oropharyngeal secretions aspiration of gastric/esophageal contents inhalation of infectious aerosol hematogenous spread direct inoculation from staff

Question 29

organisms of HAP

Answer 29

``` enterobacteria like e coli and klebsiella staph aureus psuedomonas aeruginosa acinetobacter anaerobes due to aspiration ```

Question 30

what do you need to watch for with HAP?

Answer 30

multi drug resistant organisms

Question 31

risk factors for multi drug resistant pathogens (MDRO) | 6

Answer 31

- abx in last 90 days - current hospitalization > 5 days - inc freq of community resistance - immunosuppression - ICU - days on mech ventilation

Question 32

risk factors for having increased frequency of community resistance (5)

Answer 32

``` hospitalized for longer than 2 days in the last 90 days home care dialysis nursing home family member with MDRO ```

Question 33

if you use a drug that covers MRSA, chances are

Answer 33

it'll also cover MSSA. | Does not work the other way around.

Question 34

HAP Empiric Treatment if pt is not at high risk of mortality and no inc likelihood of MRSA

Answer 34

``` need single agent for psuedomonas *piper/tazo OR cefepime OR levo OR imipenem OR meropenem ```

Question 35

HAP empiric treatment if not at high risk of mortality but at risk for MRSA

Answer 35

add vanco or linezolid

Question 36

HAP empiric treatment if at high risk of mortality or received abx in the past 90 days and concern for MRSA

Answer 36

Two of the following (but not 2 beta lactams) - pip/tazo, cefepime, ceftazidime, levo, cipro, imipenem, meropenem, amikacin, gentamicin, tobramycin, aztreonam PLUS vanco or linezolid

Question 37

HAP empiric treatment if at high risk of mortality or received abx in the past 90 days without concern for MRSA

Answer 37

2 of the following: pip/tazo, cefepime, levo, imipenem, meropenem for MSSA empiric coverage save naf/ox/diclox for proven MSSA

Question 38

VAP empiric treatment want MRSA covered want psuedomonas covered

Answer 38

One of each: MRSA: Vanco*, linezolid Pseudomonas - Beta Lactam: pip/tazo* OR cefepime or ceftazidime OR imipenem or meropenem OR aztreonam pseudomonas - non beta lactam: cipro or levo* OR amikacin or gentamycin or tobramycin

Question 39

VAP empiric treatment | cover pseudomonas

Answer 39

beta

Question 40

de escalation of antibiotics as culture info comes available: if cultures do not grow S aureus

Answer 40

stop vanco / linezolid

Question 41

de escalation of antibiotics as culture info comes available: if cultures grow MSSA

Answer 41

use an anti staph penicillin

Question 42

de escalation of antibiotics as culture info comes available: if cultures grow one/more of the enterobacteriaceae

Answer 42

try to use a more narrow apectrum agent based on susceptibility

Question 43

de escalation of antibiotics as culture info comes available: when susceptibility of GNR is available:

Answer 43

narrow and discontinue second agent like amino glycoside or FQ

Question 44

Duration of therapy for HAP and VAP

Answer 44

7 days

Question 45

Aspiration pneumonia occurs

Answer 45

typically as a result of altered consciousness or anatomic abnormalities

Question 46

Asp Pneumonia, comm acquired is primarily ____ also may see ____, _____, ______

Answer 46

primarily anaerobic in nature may also see S aureus, strep, or gram neg bacilli.

Question 47

Therapy for asp pneumonia is directed at

Answer 47

mouth flora

Question 48

Asp pneumonia, community acquired | regimens

Answer 48

clindamycin plus moxi or levo or cipro * ampicillin/sulbactam IV or amox/clavulanate PO imipenem

Question 49

if CAP with question of aspiration

Answer 49

moxi or amp/sulb or amox/clav

Question 50

treatment duration for aspiration pneumonia, community acquired

Answer 50

7-10 days

Question 51

Asp pneumonia, hospital acquired | treatment is geared towards

Answer 51

covering nosocomial pathogens and anaerobes

Question 52

Regimens for asp pneumonia, hospital acquired

Answer 52

add metronidazole to PCN or ceph add clinda to FQ or aztreonam or use drugs that already have anaerobic coverage: - b lactam/b lactase inhibitors (pip/tazo) - carbapenems (imipenem, meropenem) - some FQs like moxi