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68 Cards in this Set

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Most common pathogen in community acquired pneumonia:

S. pneumoniae
What are "atypical pathogens" that cause CAP?
M. pneumoniae
C. pneumoniae
Are cephalosporins stable in the presence of beta-lactamase?
Yes.
What drugs treat CAP caused by S. pneumoniae?
Macrolides (azithro-, clarithro-, erythromycin)

Standard dose amoxicillin

Cephalosporins (ceftriaxone, cefuroxime, cefpodoxime)

Tetracyclines (doxycycline)
Antimicrobials that treat CAP caused by DRSP.
High Dose (4 g/day) amoxicillin

Respiratory fluroquinolones (levo-, moxi-, gemifloxacin).

Telithromycin
About telithromycin.
It is a macrolide derivative that is currently approved only for PNA. Other uses were discontinued because of liver toxicity. LFT function monitoring is required.
What is the primary indication for using a respiratory fluroquinolone for CAP?
To treat DRSP.
What are the risk factors for CAP caused by DRSP? Note that they are more extensive than the risk factors for DRSP-associated sinusitis.
Antimicrobial use in last 3 months

Exposure to child in daycare

Age >=65

Medical comorbidities (asplenia, COPD, etc.)

Alcohol abuse

Immunosuppression
How are atypical pathogens spread in CAP?
Cough.
What populations are at risk for CAP with atypical pathogens?
Anyone who spends time in close quarters with crowds: people in college dormitories, prisons, long-term care.
Which antibiotics will treat CAP caused by atypical pathogens?
Macrolides

Respiratory fluroquinolones

Tetracyclines (doxycycline)
Why are penicillins and cephalosporins not effective against atypical pathogens in CAP?

M. pneumo and C. pneumo do no have a cell wall, so they have 'natural resistance" to beta-lactam antibiotics, which inhibit cell wall synthesis.

What is the national rate of resistance of H. influenzae via beta lactamase production?
30%
What are risks for CAP with H. influenzae as the causative organism?
tobacco-related lung disease

current or significant history of tobacco use
What antimicrobials are effective against CAP caused by H. influenzae?
Cephalosporins

Amox/clavulanate

macrolides

fluroquinolones

tetracyclines
What antimicrobials are effective against CAP caused by Legionella?
Macrolides

fluroquinolones

tetracyclines
How is Legionella transmitted?
By aspirating mist from a contaminated water source. Common sources include shower heads, hot tubs, fountains.
Can legionella be transmitted person-to-person?
No.
What is one contraindication to doxycycline?
Pregnancy. It may cause tooth staining in the unborn child.
Is a sputum culture required to diagnose CAP?
No. Cultures rarely isolate the infective organism and are often contaminated with oral flora, etc.
Which macrolides are CYP inhibitors?
erythromycin and clarithromycin
What bodies publish consensus guidelines for treatment of CAP?
Infectious Disease Society of America/American Thoracic Society (IDSA/ATS)
What are the two IDSA/ATS classifications of CAP?
Previously health with no abx use in last 3 months.

OR

Comorbidities: COPD, diabetes, renal failure, heart failure, asplenia, alcoholism, immunosuppression, malignancy, OR recent use of antimicrobials.
What are the likely organisms causing CAP in previously healthy individuals with no abx in the last 3 months?
susceptible S. pneumo

Atypicals (M. and C. pneumo)

Viruses including influenza, RSV, adenovirus, parainfluenza.
What are the likely organisms causing complicated CAP (comorbidities, immunosuppression, recent abx)?
S. pneumo with DRSP risk

H. influenzae

Atypicals (M. and C. pneumo)

Respiratory viruses.
Differences in causative organisms in CAP for the two IDSA/ATS classifications:
In complicated CAP, there is risk of infection with H. influenzae and greater risk for DRSP.
First-line treatment (strong recommendation) for CAP in previously healthy people:
A macrolide
Second-line treatment (weak recommendation) for CAP in previously health people:
doxycycline
Treatment for CAP complicated by recent antibiotic use (3 mos) or comorbidity:
Respiratory floroquinolone (levo-, moxi-, and gemifloxacin)

OR

Azithro- or clarithromycin (better gram negative coverage than erythro-)
AND
beta lactam (HD amoxicillin, HD augmentin, cetriaxone, cefpodoxime, cefuroxime)

Note: doxy can be substituted for the macrolide.
About asplenia and pneumococcal infection:
Asplenia entails significant risk for pneumococcal infection with DRSP. Always give pneumovax.
Nausea and vomiting with CAP indicates:
Possible need for admission
4 common symptoms of PNA
Cough (90%)
Dyspnea (66%)
Sputum production (66%)
Pleuritic chest pain (50%)
Characteristics of pleuritic chest pain:
Pain is elicited by deep breathing, is localized, and is sharp and stabbing in quality. A pleural friction rub may be auscultated over the location of the pain.
Is a follow-up CXR required to confirm resolution of CAP?
No, however smokers should have a CXR in 7-12 weeks to check for lung cancer.
What patient characteristics should cause the NP to consider hospitalization for CAP?
Age >65

Abnormal electrolytes or CBC

Renal disease, DM, CHF, immunosuppression, airway disease.

Abnormal vital signs.
What are risk factors for CAP caused by pseudomonas?
Lung disease

corticosteroid use of prednisone >10mg/day or higher

Broad spectrum antibiotic use in last one month

malnutrition
Do macrolides and tetracyclines have activity against DRSP?
No.
What percentage of CAP is caused by S. pneumo?
Nearly 2/3
Best medication to treat CAP in a previously healthy, 38 year old woman with an IUD:
a) doxycycline
b) moxifloxacin
c) amoxicillin
d) TMP/SMX
a) doxycycline.

Amoxicillin alone and TMP/SMX are never adequate for CAP. Moxifloxacin is too strong for this previously healthy woman.
Chest exam findings with CAP:
Dullness to percussion with egophony, whispered pectoriloquy and increased tactile fremitus over any consolidation.

Bronchial or bronchovesicular breath sounds over lung fields.

Late inspiratory crackles or a pleural rub.
Best antibiotic to treat CAP in a 55 year old man with no chronic health conditions.
a) azithromycin
b) levofloxacin
c) TMP/SMX
d) cefprozil
a) azithromycin

TMP/SMX is not recommended for CAP. Levofloxacin is stronger than needed. Cefprozil is recommended in conjunction with a macrolide for complicated CAP, but is never used alone as it really only covers S. pneumo.
Best antibiotic to treat CAP in a 70 year old man with 50 pack-year history of smoking
a) doxycycline
b) levofloxacin
c) amox/clavulanate
d) cefdinir
b) levofloxacin.

This is CAP complicated by smoking. Doxycycline is recommended for uncomplicated CAP. Amox/clavulanate and cefdinir are never used alone for CAP.
T/F: Fluroquinolones are photosensitizing
T
T/F: Fluroquinolones are renally metabolized.
F
Which of the following characteristics apply to the macrolides
a) consistent activity against DRSP
b) contraindicated in pregnancy
c) effective against atypical pathogens
d) unstable in the presence of beta-lactamase
c) effective against atypical pathogens.
What is the duration of abx therapy for CAP recommended by ATC?
5-7 days.
Modifying factors for P. aruginosa infectinon in CAP include all of the following except
a) corticosteroid use
b) structural lung disease
c) malnutrition
d) day care attendance
d) day care attendance. This is a risk factor for DRSP infection.
How can the NP determine the adequacy of a sputum sample for grams staining and evaluation of CAP?
Adequate samples have few epithelial cells and many WBCs.
When seeing a 62-year old hospitalized with CAP
a) pneumococcal vaccine should be given at the end of antimicrobial therapy
b) pneumococcal vaccine can be given today and influenza vaccine in 2 weeks
c) influenza vaccine today and pneumococcal in two weeks.
d) both vaccines should be given today.
d) current antibiotic therapy and past infection with CAP are not contraindications for pneumovax or influenza vaccine
Two nicknames for neutrophils.
Polys and segs (these refer to mature nutrophils).
What are "bands" and what do they mean?
They are immature neutrophils, and an increase in their relative presence indicates response to a bacterial infection.
Action of neutrophils:
Bacteria
Action of Lymphocytes:
Virus
Action of monocytes:
Debris
Action of eosinophils:
allergens and parasites
Action of basophils:
unknown
Approximate normal % of CBC of each cell types.
Neutrophils - 60%
Lymphocytes - 30%
Monocytes - 6%
Eosinophils - 3%
Basophils - 1%

(Mnemonic for order: Noboby Likes My Educational Background).
Normal lab values: bands.
0-4% of Leukocytes
Normal lab values: WBC count
6 - 10 x 10^3 /mm^3
Three components of the WBC "left shift"
1. Leukocytosis (WBC>10,000)
2. Neutrophilia (Neutrophils >70%)
3. Bandemia (Bands >4%)
What does a WBC "left shift" indicate?
Bacterial infection.
Typical findings in a CBC indicating viral infection:
Neutrophils: 35% (decreased due to relative increase in Lymphocytes)
Lymphocytes: 55% (increased)
Bands: 3% (still within normal range)
What is the most common causative organism in acute bronchitis?
Respiratory viruses - 90%
Bacteria comprise just 10% of pathogens in acute bronchitis. What are the three most common bacteria?
M. and C. pneumoniae
B. pertussis
Symptomatic therapy for viral bronchitis:
Anticholinergic bronchodilator such as ipatropium bromide INH (Atrovent)

Short course of oral corticosteroids for protracted cough.
What causes cough in acute bronchitis?
Cough is the response to swelling of the airways caused by inflammation.
What antimicrobials are active against B. pertussis?
Macrolides

Tetracyclines
What type of bacteria is B. pertussis?
Gram negative.