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70 Cards in this Set
- Front
- Back
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CAP occurence
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CAP occurs throughout the year
Great variability in relative incidence within certain populations or caused by certain pathogens Most common and severe in very young, elderly, and patients with chronic underlying diseases Mortality rates vary from <1% in outpatients to 30-40% in severely ill hospitalized patients |
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pathogenesis of CAP
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Pathogens gain entry to lower airways through:
Aspiration of oropharyngeal secretions Inhalation of aerosolized particles Hematogenous spread Infections involve alveolar spaces, inflammation and destruction of alveolar membranes and terminal bronchioles |
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most common way to aquire CAP
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microaspirations of oropharyngeal secretions
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complications of CAP
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abscess, empyema, sepsis, ARDS, metastatic spread to other organs
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alveolar spaces normal vs. CAP
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normal: spongy, spacey
CAP: spaces are packed with WBCs, fluids, etc...obliterates gas exchange |
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normal host defenses of the respiratory tract
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Gag reflex
Antimicrobial substances on mucosal surfaces Lysozyme Lactoferrin Secretory IgA Mucous production Ciliary “sweeping” actions Coughing & sneezing Alveolar macrophages Lung surfactant |
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risk factors for CAP
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Risk factors for infection are those that result in compromised host defense mechanisms of the respiratory tract and/or increased risk of aspiration:
advanced age chronic pulmonary disease neurologic disorders CHF chronic liver dx chronic renal dx neoplastic dx DM immunosuppression neutropenia cigarrete smoking alcoholism |
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pathologic etiology of CAP
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Causative pathogen identified in only 30-50% of CAP cases
Most bacterial CAP caused by single pathogen, although polymicrobial infection can occur Atypical pathogens cause approximately 20% of all cases of CAP, but greatly increased in outpatient infections Commonly referred to as “walking pneumonia” May occur concomitantly with “typical” infections |
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is most CAP mono or polymicrobial?
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mono
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most common microbial pathogens in CAP
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The "Big three"
Streptococcus pneumoniae 20-60% Haemophilus influenzae 3-10% Moraxella catarrhalis |
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mortality rates associated with CAP pathogens
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Pseudomonas 61%
Klebsiella 36% Staph. aureus 32% Not common, but significant mortality |
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CAP: aspiration pneumonia
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Occurs in patients who aspirate large volumes of oropharyngeal secretions
Alcoholism, seizure disorders, general surgery, CVA, drug intoxication, head injury, severe illness with obtundation, neurologic disorders, esophageal dysfunction, nasogastric feedings, tracheotomy, endotracheal tubes, periodontal disease Commonly associated with, and treated as, anaerobic infection Commonly involve mixed aerobic/anaerobic infections |
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what additional microbes do you need to treat with aspiration risk?
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anaerobes
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clincal presentaiton: CAP
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Typically includes fever, chills, dyspnea, productive cough, tachycardia, tachypnea, chest radiograph abnormalities
Signs and symptoms do NOT easily differentiate between specific causative pathogens Most “typical” bacterial pneumonias are unilateral and involve single lobe of lung |
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what pathogens cause "atypical" CAP
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legionella
chlamidophila pneumoniae mycoplastma peneumoniae |
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clinical presentation of typical CAP
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sudden onset
toxic, ill appearance high fever >39C elevated WBC with left shift, sometimes leukopenia possible chills, rigors productive, prululent cough bacteria, WBCs on gram stain cyanotic, increased RR, chest pain, pleural pain dense lobar infiltrates, consolidation on chest radiograph |
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clinical presentaiton of atypical CAP
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insidious onset
maliaise, fatigue, diarrhea, muscle aches low grade fever <39C normal, slight WBC elevation chills, rigors absent nonproductive cough, mucus mixed oral flora or no bacteria on gram stain unremarkable RR status patchy, diffuse infiltrates on chest radiograph |
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T.J. is a 23 y.o. female previously in good health. She begins a new semester of graduate school and three weeks later starts complaining of headache, fatigue, lethargy, a nagging cough productive of thin, clear sputum, and a fever of 100oF. Her clinical findings are most consistent with:
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acute atypical pneumonia
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Pathogens most likely associated with T.J.’s infection include:
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mycoplasma pneumonia, and chlamydia pneumoniae
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B.K. is a 68 y.o. male with a history of alcoholism. He is brought to the Emergency Department by his wife after “acting funny” and running a fever. Clinical findings in the ED include fever to 41oC, tachycardia, tachypnea, hypotension, cough productive of thick greenish sputum, and altered mental status. He smells of alcohol and his wife states that he has “been on a binge”. Organisms suspected to be involved in this infection include:
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Streptococcus pneumoniae and oral anaerobes
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outpatient sputum cultures?
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Sputum cultures not universally recommended in outpatients
Usefulness controversial (b/c typically atypicals that dont show up well on gram stain) |
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hospitalized patient sputum cultures/blood cultures?
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In most hospitalized patients: blood cultures x 2, sputum gram stain and culture
Specimens should include >25 PMNs and <10 epithelial cells on high-power microscopic field Gram stains and cultures should usually show a single predominant pathogen Remember that many patients will have no pathogen identified |
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A sputum culture from a woman with suspected pneumonia shows the following on a high-power field: 10-15 PMNs, 30-40 epithelial cells, and many Gram-positive cocci, Gram-negative bacilli, and Grm-negative cocci. This sputum specimen would be considered to be:
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contaminated specimen (mixed oganisms)
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goals of CAP tx therapy
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Goals of therapy
Complete eradication of causative pathogen Complete clinical cure of the infection |
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inpatient vs outpatient CAP tx decision
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Decision to treat patient as outpatient vs. inpatient often regarded as single most important treatment decision
Severity of infection Risk of complications and/or mortality Ability of patients to successfully complete therapy |
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what is PORT/PSI?
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pneumonia severity index
tool for clinician to help make thearpy decision put patients in a Risk Class I-V and mortality rate |
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PSI outpatient risk class
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I-II
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PSI hospital risk class
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IV-V
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PSI clinical judgement class?
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III, short hospital, finish at home?
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non pharm treatment of CAP
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Bed rest
Adequate hydration Humidifier or vaporizer Adequate nutrition Chest physiotherapy Supplemental oxygen Mechanical ventilation |
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pharmacologic treatment of CAP
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Antipyretics
Antitussives (dextromethorphan, codeine) Bronchodilators Antibiotics |
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what is empiric AB CAP tx based on?
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Severity of illness
Risk factors for more resistant pathogens Risk of complicated course, increased mortality |
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Blue sclera
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Osteogenesis imperfecta (collagen defect, usually type 1)
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erythromycin non-susceptible strep. pneumoniae high vs low level resistance
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high level: ribosomal methylation
low level: efflux |
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risk factors for drug resistant S. pneumoniae (DRSP)q
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Risk factors for drug-resistant S. pneumoniae (DRSP)
***Recent antibiotic exposure Older patients (age >65 y) ***Multiple medical comorbidities (including COPD, diabetes, renal failure, CHF, or malignancy) Recent stay in hospital of long-term care facility Children in day care + parents, siblings & other close contacts Alcoholism Immunosuppressive illness, drugs |
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Empiric Therapy of Suspected Bacterial CAP in Outpatients: Previously healthy with no recent AB therapy
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»No Recent Antibiotic Therapy:
–Macrolide –Doxycycline both cover atypicals |
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what are the most common bacteria in CAP in healthy patients with no previous AB therapy
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atypicals
this group of people do not have very resistant bigs |
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describe a previously healthy patient that gets CAP (no prior AB exposure)
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no comorbidities
bacteria are not very resistant mainly atypicals |
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why are FQ not used in previously healthy patients that get CAP (no AB exposure)
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they are too broad specturm
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Empiric Therapy of Suspected Bacterial CAP in Outpatients: Recent Antibiotic Therapy (within 3 months):
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–Respiratory fluoroquinolone (levofloxacin 750 mg, moxifloxacin, or gemifloxacin)
–Advanced Macrolide + high-dose Amoxicillin (3 gm/d) –Advanced Macrolide + high-dose Amoxicillin/clavulanate (4 gm/d) these patients have increased resistance therefore higher MIC so need higher doses |
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in previously healthy patients with AB exposure what are the typical bigs ass. with CAP
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strep
h. flu moraxella atypicals s. auerus |
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what is used in prevoius healty patients with AB exposure that get CAP as an advanced macrolide
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clarithromycin
azithromycin |
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in a previously healty patient that has had AB exposure do you use the same AB
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no do not use the AB that they were previously exposed to
side note: it does not matter what they were treated for any AB exposure counts in the past 3 months |
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Antibiotics with Useful Activity AgainstStreptococcus pneumoniaein CAP PCN Susceptible
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PCN G or PCN V
Ampicillin/amoxicillin 1stgen. cephs “True" 2ndgeneration cephs Azithromycin Clarithromycin Doxycycline |
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remember the atypicals
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Mycoplasma pneumoniae
Chlamydophila pneumoniae Legionella pneumophila |
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AB used to treat the atypicals
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Erythromycin
Clarithromycin Azithromycin Telithromycin Fluoroquinolones (all) Tetracyclines (all) |
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High-Dose, Short-Course Fluoroquinolone Therapy
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Rationale for high-dose therapy
»Maximize and exploit concentration-dependent killing (killing much more rapidly) »Achieve higher Cmax/MIC and AUC/MIC values –Increased penetration in various tissues and fluids –More rapid eradication –Prevents the development of resistance »Enables use of shorter durations of therapy –Minimizes potential for resistance –May help reduce adverse event rates –More convenient for patients |
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750-mg, Short-Course Levofloxacin for CAP: Protocol
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»Multicenter, randomized, double-blind, noninferiority study
»Comparison of 500-mg levofloxacin QD 10 days vs. 750-mg levofloxacin QD 5 days »Patients stratified according to Pneumonia Severity Index (PSI) –PSI 70: Patients treated as inpatients or outpatients –PSI 70 but 130: Patients treated as inpatients for at least 24 hours |
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duration of CAP treatmenat (know)
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10 days or 5 days if doing 750 mg of FQ
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is cipro effective when treating CAP
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no it sucks, but all other FQ are good
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Empiric Therapy of Suspected Bacterial CAP in Outpatients with comorbidities with no recent AB exposure
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–Respiratory fluoroquinolone
any FQ besides cipro remember it does not work against CAP still worried about atypicals and everything mentioned on other CAP slide just more at risk for gram (-) and resistant bugs |
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Empiric Therapy of Suspected Bacterial CAP in Outpatients with comorbidities and recent AB exposure
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–Respiratory fluoroquinolone
–Advanced Macrolide + -Lactam (high-dose amoxicillin or amoxicillin/clavulanate, cefuroxime, cefpodoxime, cefprozil, or other advanced-generation cephalosporins) choose whatever they were not previously expossed too |
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Empiric Therapy of Suspected Bacterial CAP in Outpatients with comorbidities and suspected aspirations
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Amoxicillin/clavulanate or Clindamycin
»Moxifloxacin would also be appropriate covering for anaerobes |
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Antibiotics with Useful Activity AgainstS. pneumoniaein CAP: PCN intermediate
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Intermediate1st, "true" 2nd gen. cephs
Ceftriaxone Cefotaxime Levofloxacin Moxifloxacin Gemifloxacin Vancomycin Azithromycin Clarithromycin Telithromycin |
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Antibiotics with Useful Activity AgainstS. pneumoniaein CAP: PCN resistant
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Levofloxacin
Moxifloxacin Gemifloxacin Telithromycin Vancomycin Telavancin Quinupristin/dalfopristin Linezolid Daptomycin Tigecycline |
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Empiric Therapy of Suspected Bacterial CAP in Inpatients (non-ICU)
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Medical Ward
»-Lactam + Macrolide (still treating for atypicals) –Ceftriaxone, cefotaxime, ampicillin/sulbactam, ertapenem –Azithromycin »Respiratory fluoroquinolone –Levofloxacin 750 mg or Moxifloxacin (gemifloxicin is not here because does not have an IV formulation) treat for 10 days, if using Levo 750 mg treat for 5 |
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Appropriate Drug Selection for Inpatient CAP -Lactam+ Macrolide
OR Fluoroquinolone? |
Appropriate drug selection probably consists of balanced mix of drugs rather than exclusive use of any one regimen
»Long-term resistance concerns »“Collateral damage” »No one regimen is appropriate for every patient »Cost pick based on patient |
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what is the most sig. MOR for b-latams
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PBP alterations
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Empiric Therapy of Suspected Bacterial CAP in Inpatients (ICU) Critically ill patients in the ICU: (NOT ON QUIZ)
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»Preferred therapy:
parenteral cephalosporin + either macrolide or fluoroquinolone parenteral -lactam/ -lactamase inhibitor + either macrolide or fluoroquinolone) »Alternative therapy in PCN-allergic patients:fluoroquinolone + aztreonam »Suspected aspiration:fluoroquinolone + clindamycinparenteral -lactam/ -lactamase inhibitor + either macrolide or fluoroquinolone |
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Treatment of CAP duration
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Usual duration of therapy = 7-10 days
Patients should show clinical improvement within 48-72 hours »Patients with more severe infection or underlying illnesses may show delayed response Switching from IV PO therapy should be treatment priority in hospitalized patients »Clinical improvement while on IV therapy »No contraindications to PO intake »Ability to take oral nutrition/medications |
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Discharge criteria for CAP
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during the 24 hours prior to discharge to home, patients should have no more than 1 of the following:
»Temperature >37.8 oC »Pulse >100 beats/min »Respiratory rate >24 breaths/min »Systolic BP <90 mm Hg »O2saturation <90% »Inability to maintain oral intake Criteria must be supplemented with good clinical judgment Is the patient stable?????? |
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prevention of CAP
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Vaccination of high-risk patients:
»Pneumococcal vaccine »Haemophilus influenzaetype b vaccine »Influenza vaccine |
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T.J., the patient with atypical pneumonia in the previous questions, would most appropriately be treated as: (he is a previously healthy patient with no exposure to AB)
1.An outpatient for the full course of therapy. 2.An inpatient for the full course of therapy. 3.An inpatient for the first several days, then complete therapy as an outpatient. |
1.An outpatient for the full course of therapy.
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T.J., the patient with atypical pneumonia in the previous questions, would most appropriately be treated as: (he is a previously healthy patient with no exposure to AB)Which of the following would be the most appropriate antibiotic regimen for T.J.? Assume that she has no drug allergies.
1.Oral cefuroxime alone. 2.Oral azithromycin alone. 3.Oral cefuroxime plus oral azithromycin. 4.Oral levofloxacin. |
2.Oral azithromycin alone.
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do b-lactams alone cover atypicals
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nope
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B.K., the alcoholic patient in the previous question, would most appropriately be treated as:
1.An outpatient for the full course of therapy. 2.An inpatient for the full course of therapy. 3. An inpatient for the first several days, then completion of therapy as an outpatient. |
3. An inpatient for the first several days, then completion of therapy as an outpatient.
he is too sick to treat at home the majority of patients don't need to be in the hosptial for the full course of treatment, unless they have complications |
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Which of the following would be the most appropriate antibiotic regimen for B.K.? Assume that he has no drug allergies.(the alcoholic, inpatient treatment)
1.IV ceftriaxone alone. 2.IV azithromycin alone. 3.IV levofloxacin alone. 4.IV ceftriaxone plus IV azithromycin. 5.IV ceftriaxone plus IV clindamycin plus IV azithromycin. |
5. IV ceftriaxone plus IV clindamycin plus IV azithromycin.
need to cover for anaerobes |
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Assume that B.K. has a severe penicillin allergy. Which of the following would be the most appropriate antibiotic regimen? (this is the sick alcoholic again)
1.IV levofloxacin alone. 2.IV azithromycin plus IV clindamycin. 3.IV moxifloxacin alone. 4.IV ceftriaxone plus IV clindamycin. 5.IV levofloxacin plus clindamycin. |
3.IV moxifloxacin alone.
or 5.IV levofloxacin plus clindamycin. |
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how could you simplify this regimen and still cover anaerobes
IV ceftriaxone plus IV clindamycin plus IV azithromycin. |
levo + clinda
moxifloxicin alone unasyn + ertapenem or azithromycin |
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does unasyn (ampicillin/sublactame) cover atypicals
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nope, it covers anaerobes very well though
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