835 > CAP > Flashcards

CAP Flashcards

(44 cards)

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1
Q

CAP

A
  • Community-acquired pneumonia

- Acute infection of pulmonary parenchyma and has been acquired in the community

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2
Q

Pneumonia

A
  • Leading cause of death by infection
  • Affects the very young and elderly
  • Challenges: diagnoses, wide microbe etiology, resistance
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3
Q

Pathogenesis - Entry

A
  • Inhalation
  • Direct spread from upper respiratory tract
  • Aspiration
  • Hematogenous seeding (less likely)
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4
Q

Pathogenesis - Other

A
  • Impaired defense mechs contribute to risk: smoking, alcohol, stroke
  • Altered host function: age, COPD, AIDS, imumunosuppressive agents, malnutrition
  • Prior viral infection (flu)
  • Site of care varies by microbe infecting patient
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5
Q

Smoking Risks

A
  • Impairs ciliary function

- Contributes to CAP risk

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6
Q

Alcohol/Smoke Risks

A
  • Impairs cough and epiglottic reflex

- Contributes to CAP risk

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7
Q

Risk Factors + Pathogens

A
  • COPD - H. influenzae, M. catarrhalis (B-lactamase producers)
  • Alcoholism: S. pneumoniae, aspiration
  • Injection drug use: S. aureus
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8
Q

S. Pneumoniae

A
  • Most common pathogen in CAP
  • Colonizes upper respiratory tract in ~10% of healthy adults
  • Polysaccharide capsules: >90 serotypes, target for vaccines
  • Resistance is an issue
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9
Q

S. Pneumoniae Abx Resistance

A

Resistance to following:

  • PCN
  • Macrolides
  • Fluoroquinolones
  • Cephalosporins
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10
Q

Risk for S. Pneumoniae

A
  • Age >= 65 years old
  • Comorbidities: asthma, diabetes, COPD, malignancy, chronic heart/lung/liver/kidney disease
  • Alcoholism
  • Immunosuppression
  • Exposure to child in daycare
  • Beta-lactam, macrolide, or fluoroquinolone use in last 3 months
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11
Q

H. Influenzae

A
  • Gram “-“ coccobacillus
  • Colonizer of URT
  • Indistinguishable clinical features from S. pneumoniae
  • ~30% produce beta-lactamases
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12
Q

Atypical Bacteria

A
  • M. pneumoniae, C. pneumoniae, Legionella spp
  • Symtoms: non-productive cough, absence of leukocytes
  • Abnormal X-ray
  • Hard to identify/isolate in lab
  • Abx options: FQN, azithromycin, doxy
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13
Q

M. Pneumoniae

A
  • Mycoplasma pneumoniae
  • Short rod-shaped bacteria w/o cell wall
  • Not detectable on gram stain
  • Responsible for ~10-20% of cases
  • Transmission high in close congregate settings (dorms)
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14
Q

C. pneumoniae

A
  • Chlamydophilia pneumoniae
  • Gram “-“ obligate intracellular bacteria
  • Responsible for ~5-10% of cases
  • Mild symptoms, usually worse in elderly
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15
Q

L. pneumophila

A
  • Legionella pneumophila
  • Naturally occurring aquatic bacteria (intracellular)
  • Accounts for 1-5% of CAP, rare
  • Causes severe disease
  • Increased risk: recent travel (2 weeks), contaminated water, elderly, smoking, immunocompromised
  • Urine antigen test available
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16
Q

Clinical Symptoms

A
  • Cough
  • Sputum production
  • Fever
  • Chills
  • Dyspnea
  • Pleuritic chest pain
  • N/V
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17
Q

Physical Exam Findings

A
  • Tachycardia
  • Tachypnea
  • Diminished breath sounds
  • Egophony
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18
Q

Diagnosis

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A
  • Chest X-ray showing infiltrate is “gold standard” and should always be obtained when pneumonia is suspected
  • Additional diagnostic testing is optional in outpatient and recommended in some hospitalized patients
19
Q

CAP Risk Assessment

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A
  • Treat either outpatient, inpatient medical floor, or ICU
  • Treatment depends on severity and mortality risks
  • Risks are determined from vital signs/stability, physical exam, lab tests, and need for IV therapy
20
Q

CAP Scoring Systems

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A
  • PSI (Pneumonia severity index) is preferred, larger proportion assessed for OP treatment
  • Assessess risk for mortality (hospitalization required)
  • Not designed to select level of care needed for hospitalized patients
21
Q

PSI Risk Class I

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A
  • Absence of risk factors
  • 0.4% 30 day mortality risk
  • Recommended Tx Site: Outpatient
22
Q

PSI Risk Class II

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A
  • =<70 points
  • 0.7% 30 day mortality risk
  • Recommended Tx Site: Outpatient
23
Q

PSI Risk Class III

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A
  • 71-90 points
  • 2.8% 30 day mortality risk
  • Recommended Tx Site: Outpatient or brief inpatient
24
Q

PSI Risk Class IV

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A
  • 91-130 points
  • 8.5% 30 day mortality risk
  • Recommended Tx Site: Inpatient
25
PSI Risk Class V
- >130 points - 31.1% 30 day mortality risk - Recommended Tx Site: Inpatient
26
CURB-65
- Requires no labratory data | - Doesn't consider outpatient treatment as much as PSI
27
Admitting CAP to ICU
- Major criterion: need for vasopressors, need for mechanical ventilation - At least 3 of the minor criteria for severe CAP
28
Minor Criteria
- RR >= 30 breaths/min - Multilobar infiltrates - Confusion/disorientation - Uremia - Leukopenia - Thrombocytopenia - Hypothermia - Hypotension - PaO2/FiO2 ratio =< 250
29
Etiology Identification
- Organism identified in only ~30% of CAP cases | - Start empiric abx from procalcitonin diagnostic tests AND additional tests/labs
30
Additional Tests/Labs for Empiric Treatment
- Pretreatment sputum/bronchoalveolar lavage gram stain and culture - Pretreatment blood gram stain and culture - Urine legionella antigen test - Urine pneumococcal antigen test
31
Empiric Outpatient Therapy + NO Comorbidities/Risk Factors for Drug-Resistance
-Strong Recommendation: Amoxicillin 1g PO TID Conditional Recommendations: -Doxy 100 mg PO BID Macrolide (If resistance <25%): -Azith 500 mg PO day 1, then 250 mg PO daily x 4days -Clarithromycin 1000 mg ER PO QD or 500 mg BID **Don't use FQN**
32
Empiric Outpatient Therapy + Comorbidities/Risk Factors for Drug-Resistance
B-Lactam + Macrolide - Augmentin 875/125 or 2000/125 PO BID - Cefpodoxime 200 mg PO BID - Cefuroxime 500 mg PO BID ``` OR Respiratory FQN -Moxifloxacin 400 mg PO QD -Levofloxacin 750 mg PO QD -Gemifloxacin 320 mg PO QD ```
33
Empiric Inpatient Therapy + Non-ICU
``` B-Lactam -Ceftriaxone 2g IV q24h -Cefotaxime 2g IV q8h -Unasyn 3g IV q6h -Ceftaroline 600 mg IV q12h PLUS Macrolide -Azithromycin 500 mg IV/PO QD -Clarithromycin 500 mg PO daily ``` OR Respiratory FQN: -Moxifloxacin 500 mg IV/PO q24h -Levofloxacin 750 mg IV/PO q24h **DON'T use corticosteroids**
34
MRSA + CAP
- Low prevalence - Results in severe disease - Empiric coverage recommended for patients with history of respiratory isolation within year, severe CAP with history of hospitalization or locally validated risk factors - Treatment: Vanco 15 mg/kg IV q12h OR Linezolid 600 mg IV/PO q12h - De-escalate treatment if PCR is negative or doesn't grow in culture
35
P. aeruginosa + CAP
- Low prevalence - Risk factors: lung disease, immunosuppression, ventilation - Empiric coverage recommended for patients with history of respiratory isolation within year, severe CAP with history of hospitalization or locally validated risk factors - De-escalate treatment if doesn't grow in cultures
36
-P. aeruginosa + Treatment Options
- Zosyn: 4.5g IV q6h - Cefepime 2g IV q8h - Ceftazidime 2g IV q8h - Primaxin: 500 mg IV q6h - Meropenem 1g IV q8h - Aztreonam 2g IV q8h
37
Aspiration
- May result in pneumonitis - Many patients have symptom resolution in 24-48 hours without treatment - Anaerobic bacteria don't play a major role - Anaerobic coverage rarely indicated unless lung abscess or empyema suspected
38
Empiric Inpatient Treatment + ICU
- B-Lactam PLUS Macrolide or Respiratory FQN | - Can also add empiric coverage for P. aeruginosa and MRSA if necessary
39
Duration of Therapy
- Continue treatment until patient is stable, minimal 5 days of Tx - Hemodynamically stable and improving clinically with PE - Cavitary or extrapulmonary disease may require longer therapy - Other considerations: narrow therapy if possible, consider switching IV=>PO if able to and normal GI tract
40
Viral Influenza
- Symptoms: fever, chills, cough, sore throat, runny nose, muscle aches, HA, fatigue, N/V, diarrhea - Rapid testing recommended during influenza season
41
Severe Viral Influenza Risks
- <5 y.o. or >= 65 y.o. - Preggo or postpartum (2 wks post-delivery) - Patients with certain comorbidities - American Indian or Alaskan natives - Long-term aspirin therapy - Patients in long-term care facilities
42
Influenza Treatment Indications/Benefits
- Indicated for patients at risk of serious complications and positive PCV/symptoms, hospitalized or severely ill patients with positive PCR/symptoms - Best benefits when starting within 48 hours - Shown to decrease severity of symptoms and time of illness by 1-2 days
43
Influenza Treatment Options
- Oseltamivir (Tamiflu): 75 mg PO BID x5d - Zanamavir (Relenza): two 5mg inhalations BID x5d - Peramivir (Rapivab): 600mg IV once - Baloxavir marboxil (Xofluza): 40 mg PO once
44
General Prevention
- Vaccine for 6+ mo - Pneumococcal vaccines for 65+ y.o. and high-risk comorbidities - Smoking cessation
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