Pneumonia Flashcards
(23 cards)
CAP (Community Acquired Pneumo)
Who gets it?
E,C,I,S,A,C,V,I,H
- Elderly >= 65 yrs old
- Children <5yrs old
- immunocomp
- smokers
- alcoholism
- chronic med conditions - COPD, asthma, diabetes, CHF, cAD
- Viral respiratory tract infection
- impaired airway protection - stroke, seizure, anesthesia, drug use, dysphagia
- healthy individuals
CAP - Clin Presentation
- What are respiratory sx’s?
Non specific sx’s?
- -Cough
– Wheezing/dyspnea
– Tachypnea
– Increased sputum production
– Pleuretic chest pain
– Signs of pulmonary consolidation - Fever and chills
– Increased WBCs
– Tachycardia
– Fatigue, diarrhea, N/V
Diagnosis and ADmission :
What 3 diagnostic tests to use and what do they tell u?
- Pneumonia severity index (PSI)
-preferred over CURB, identifies pt as low risk and better in predicting mortality - SMART-COP : Identifies need for vasopressor and or mechanical ventilation
- CURB -65
-easy to use, score of >=2 usually requires hospitalization
Severity Assessment w/possible ICU Admission :
1) Major criteria (need 1)
2) Minor criteria (at least 3)
(9)
- Respir failure requiring mechanical ventilation
- septic shock with need for vasopressors - Confusion/disorientation
– Blood urea nitrogen ≥20 mg/dL
– Respiratory rate ≥30 breaths/min
– Hypotension requiring aggressive fluid resuscitation
– WBC <4000 cells/mm
– Platelet count <100,000 cells/mm
– Core temperature <36oC
– PaO2/FiO2 ratio ≤250
– Multilobar infiltrates
Diagnosis of CAP :
1) Clinical presentation (4)
2) Chest ray showing?
3) Gold standard for incr accuracy?
4) Microbio?
- Fever, cough, SOB and pleuritic chest pain
- Infiltrates or consolidation
- CT
- Sputum grain stain and culture
CAP : Biomarkers
1) CRP ?
2) Procalcitonin?
- what does a high level suggest?
-State the levels and whether or not u should stop abx
1) > 40 mg/L
2) Bacterial infection
If >=0.25 continue abx,
-if stable pts and < 0.25 or <0.1 initially, or critically - ill pt’s delcining to < 0.5 -discont abx (suspected alternative diagnosis )
CAP Pathogens :
1) Typical 3 ?
2) Atypical 3?
- S.pneumo, h.influenzae, m.catarrhalis
- Legionella, chlamydia, mycoplasma pneumoniae
RF for Pseudomonas : CO2BAMS
?
COPD : Severe cases w/repeated exacerbations
Corticosteroid therapy >10 mg/day
Bronchiectasis or structural lung disease
Recent broad spectrum Abx (within 3 months)
Malnutrition
Smoker (maybe)
CAP : OUTpatient tx
1) healthy adults w/no comorbidities or rf? (3)
2) adults w/comorb or rf
state combo vs monotherapy
- Amoxi, doxycycline or macrolide
- Combo ther : Augmentin or cephalosporin AND macrolide (clarithro or azithro) or doxycycline
Monother : Respiratory fluoro (Moxi, levo or gemifloxacin)
- Risk factors for Outpt tx (2)
- Comorbidities ?
- Prior respiratory isolation of MRSA or Pseudo, or recent hospitalization
AND receipt of parenteral abx (in last 90 days) - Chronic heart (CHF), lung (COPD), liver and renal diseases
▪ Diabetes
▪ Alcoholism
▪ Asplenia
▪ Malignancy
▪ > 65 Years Old
InPT Tx for CAP
1) Non severe in ward?
2) Severe (ICU) w/ no mrsa or pseudomonal risk
3) What about for icu pt’s with PCN allergies?
4) If suspsected CA MRSA?
- Beta lactam + Macrolide OR
ANti-pneumococc fluoro (levo or moxi) - Beta lactam (cefotaxime, ceftriaxone, or Amp/Sulb) PLUS Macrolide (preferred) OR anti-pneumo fq (levo, moxi)
- FQ + aztreonam
- add on vanco or linezolid
Inpatient ABX therapy for pt’s with prior MRSA or PSeudo isolation OR recent hospitalization with IV Abx
see chart
Community Associated MRSA
TX options?
Linezolid
Vanco?? (not rlly bc we dont know how well it penetrates lung)
Non severe : Clindamycin, bactrim, doxy, fluoroquinolone
Duration of IV/PO Abx Therapy :
Most Mild to Moderate?
MRSA?
5-7 days
7-14 days
CAP Prevention :
1) Vaccinations such as ??
2) WHat should be offered?
- Pneumococcal - Elder >= 65 and at risk adults 19-64 yrs
-Influenza , and TDAP –> Recc for adults 19-64 yrs - Smoking cessation
HAP : When does it occur?
Whats the empiric coverage?
Other coverage?
VAP : When does it occur ?
Empiric coverage?
Other coverage?
- > = 48 hrs after hospital admission
-Pseudo, S.aureus MRSA or MSSA, enteric gram neg
Other :
-ESBL-producing enteric gram neg
-Acinetobacter - > = 48 hrs after endotrach intubation
-Pseudomonas , S.aureus MRSA or MSSA, enteric gram neg
Other :
-Acinetobacter spp, anaerobes !
Risk factors for ABX resistance
1) in VAP caused by MDR Organism?
2) In HAP caused by MDR Organism?
3) Risk factors for HAP and VAP for Pseudomonas?
4) Risk factors for HAP and VAP for MRSA?
- Use of IV antibiotics in the past
90 days
▪ > 5 days of hospitalization prior
to occurrence of VAP
▪ Septic shock at the time of VAP
▪ Acute Respiratory Distress
Syndrome before VAP
▪ Acute renal replacement
therapy prior to onset of VAP - USe of IV ANX in past 90 days
- -Use of IV antibiotics in the
past 90 days
▪ Mechanical ventilation
▪ History of COPD
▪ Cystic fibrosis and bronchiestasis
▪ Colonization or prior isolation of MDR
Pseudomonas - Use of IV antibiotics
in the past 90 days
▪ Colonization or prior
isolation of MRSA
▪ Treatment in a unit
in which
▪ >20% MRSA
▪ MRSA unknown
Diagnosis of HAP :
1) Presence of ?
2) New onset ?
-L
-Respiratory sx’s such as ?
3) Sputum gram stain and culture obtained prior to ?
4) Cultures of __ or __ as appropriate
- -New lung infiltrate on Chest X-ray plus
✓Clinical evidence infiltrate is of infectious origin - Fever
-leukocytosis
-Cough, purulent sputum, decline in oxygenatiom, SOB, Pleuritic chest pain - ABX
- blood, CSF
empiric tx for HAP : See charts for 2 options
and VAP
Duration of therapy should be 7 days
Pneumonia Prevention :
1) Which annual vaccine?
age ?
2) ___ vaccine for those how old?
- Influenza
- >= 50 yrs of age - Pneumococcal
-> 65 yrs of age
Bacterial Pneumonitis :
1) Clindamycin dosing
-Duration
AE’s ?
- Monitoring ?
- 150-450 mg PO q6hrs
MRSA : 600 mg po q8hrs or 300 mg IV q6,8,12
-7-21 days
- diarrhea, drug induced cdiff
-Liver and renal function tests, stool culture
Metronidazole :
1. Dosing
2.Need another ___ due to high failure rates of using mono therapy
3. AE’s ?
4. Monitoring ?
- 500 mg IV/PO q6hrs x 7 days
max of 4g/day - anaerobic agent
- GI (N/V/D/F/C)
- Metallic taste
-Neuro (Sz, dz, vertigo, confusion, ataxia) - CBC with differential
