LRTIs

Question 1

what are common causes for pneumonia?

Answer 1

• aspiration of upper airway microbiota
• inhalation of aerosolized material
• metastatic seeding from the blood to the lung (rare; surgery, trauma, catheterization)

Question 2

what are some clinical signs of pneumonia?

Answer 2

RR > 30
HR > 100
temp > 100
also
purulent sputum, leukocytosis, decrease O2

Question 3

signs and symptoms of pneumonia?

Answer 3

• cough
• sputum production
• dyspnea
• fever and chills
• hemoptysis (blood in sputum)
• pleuritic chest pain
• tachypnea
• tachycardia
• diminished breath sounds
• egophony (E sounds like A)
• increased WBC

Question 4

pneumonia on a CXR?

Answer 4

uni=lobe and middle lung infection with lower lobe infiltrates (most common)

Question 5

gram stain

Answer 5

• used for severe cases
• gram + diplococci = strep. pneumoniae
• cluster of gram + cocci = staph. aureus
• gram - coccobacilli = H. influenzae
• gram - dipplococci = M. catarrhalis
• plump gram - rods = Klebsiella pneumoniae
• thin gram - rods = pseudomonas aeruginosa

Question 6

what color is the gram stain for gram NEGATIVE bacteria?

Answer 6

PINK (gram positive = PURPLE)

Question 7

sputum culture

Answer 7

• generally expectorated sputum
• reserved for severe cases (hospitalized)
• try to obtain BEFORE ABX so still get high yield of gram stain and culture
• will present with normal flora a lot of the time

Question 8

what are some other diagnostic tests?

Answer 8

• BAL (bronchoalveolar lavage)
• blood cultures (admitted and severe)
• procalcitonin (only in severe/sepsis)
• O2 saturation
• urinary antigen testing (pneumococcal and legionella)
• viral panel

Question 9

CURB-65

Answer 9

another test, get a certain score

Question 10

community-acquired pneumonia

Answer 10

no exposure to the healthcare system

Question 11

hospital-acquired pneumonia

Answer 11

pneumonia not incubating at time of hospital admission and occurring ≥ 48 hours AFTER admission
- can also include patients coming from the community who have received IB ABXs within 90 days of admission

Question 12

ventilator=associated pneumonia

Answer 12

pneumonia occurring > 48 hours after endotracheal intubation

Question 13

what is the most common pathogen for pneumonia regardless of CAP, HAP, or VAP?

Answer 13

Streptococcus pneumoniae

Question 14

atypical pathogens

Answer 14

• legionella pneumophila
• mycoplasma penumoniae
• chlamydophila pneumoniae

Question 15

what are some characteristics of pneumonia caused by legionella pneumophila?

Answer 15

mild to rapidly progressing pneumonia
- water exposure
- males > females
- smokers

Question 16

how to treat pneumonia caused by legionella pneumophila?

Answer 16

• fluoroquinolone
• azithromycin

Question 17

typical pneumonia

Answer 17

• abrupt onset
• unilateral well-defined infiltrate
• significant fever, chills, sweats, dyspnea
• purulent sputum production
• primary pulmonary symptoms: pleuritic chest pain

Question 18

atypical pneumonia

Answer 18

• gradual onset
• diffuse infiltrates, ground-glass appearance
• mild fever, mild dyspnea
• dry cough
• extrapulmonary symptoms common: myalgias, diarrhea, abdominal pain

Question 19

outpatient treatment of CAP for someone who was previously healthy with no risk factors for drug resistance

Answer 19

• PO amoxicillin
• PO doxycycline (alternative)
• PO macrolide (azithro and clarithromycin ONLY)

Question 20

comorbidities

Answer 20

• age < 2 or > 65
• beta-lactam within prior 3 months
• alcohol abuse
• immunosuppression
• exposure to daycare
• cancer
• chronic respiratory disease

Question 21

outpatient treatment of CAP for someone with comorbidities

Answer 21

• PO amoxicillin/clavulanate OR cephalosporin (cefpodox, cefdinirm cefurox) PLUS macrolide (azithro or clarithro)
• PO respiratory quinolone (levo, moxifloxacin) IF ALLERGY or RESISTANCE HX

Question 22

inpatient treatment of NON-SEVERE CAP

Answer 22

• IV Beta-Lactam (ampicillin/sulbactam, ceftriaxone) PLUS macrolide OR respiratory fluoroquinolone

Question 23

inpatient treatment of SEVERE CAP

Answer 23

• IV Beta-lActam PLUS Macrolide OR
• IV Beta-Lactam PLUS respiratory fluoroquinolone
• give anti-MRSA or anti-pseudomonal IF prior respiratory cultures

Question 24

duration of ABXs for CAP

Answer 24

treat for a MINIMUM of 5 days (generally 7 days/1 week)
- patients should be afebrile for 48-72 hours

Question 25

what are some pretreatment tests

Answer 25

- blood cultures and expectorated sputum samples for gram stains and culture should be sent for all patients with anti-MRSA or anti-pseudomonal ABX orders - patients with SEVERE CAP should have urinary antigen test for legionella and strep pneumoniae

Question 26

antibiotic assessments

Answer 26

- check for allergies!! - check for QTc prolongation (quinolones and azithromycin can both prolong the ATc)

Question 27

what are some signs and symptoms of HAP

Answer 27

- same as CAP but more SEVERE - respiratory complications more common - SIRS(systemic inflammatory response syndrome)/Sepsis more common

Question 28

how should we treat patients if HAP or VAP are suspected (all disease severity)

Answer 28

if there is late onset (≥5 days) OR risk factors for MDR pathogens, prior ABX, colonization, hospitalization, or chronic care, immunosuppression/therapy -> use BROAD spectrum initial ABX therapy for MDR pathogens if not, just use limited-spectrum initial ABX therapy

Question 29

what are some potential pathogens for VAP and what are some recommended ABXs?

Answer 29

- streptococcus pneumoniae - H. influenzae - MSSA -> ceftriaxone OR levofloxacin, moxifloxacin, OR ampicillin/sulbactam, OR ertapenem

Question 30

recommended ABX therapy for VAP?

Answer 30

- ceftriaxone OR - levo, moxi OR - amp/sul OR - ertapenem

Question 31

when should we empirically cover for pseudomonas?

Answer 31

- prior IV ABX use within previous 90 days - severe presentation (septic shock, need for ventilator support) - previous infection/colonization - immunosuppression

Question 32

how should we empirically cover for pseudomonas?

Answer 32

- ONE anti-pseudomonal ABX

Question 33

pseudomonas ABX recommendations

Answer 33

- piperacillin/tazobactam - cefepime - ceftazidime - imipenem, meropenem (reserved due to potency) - aztreonam (reserved for alternate combinations - ciprofloxacin (reserve for PO availability, renal considerations) - levofloxacin (limited data; reserve for only moderate infections or less) - aminoglycosides - colistin, polymixin B (last resort)

Question 34

what are some targeted treatments?

Answer 34

CULTURES - HAP: patients treated should have a sputum sample obtained noninvasively, then BAL if possible - VAP: noninvasive sampling of semi-quantitative cultures preferred over invasive sampling of quantitative cultures

Question 35

noninvasive sampling

Answer 35

endotracheal aspiration

Question 36

invasive sampling

Answer 36

BAL

Question 37

duration of ABX therapy

Answer 37

7 day duration for both HAP and VAP regardless of pathogen!

Question 38

CAP treatment for healthy patients

Answer 38

oral monotherapy with amoxicillin (or macrolide or doxycycline)

Question 39

CAP treatment for patients with comorbidities

Answer 39

oral combo therapy with beta-lactam (only amox/clav) + macrolide -> OR respiratory quinolone (levo, moxi if allergy or resistance hx)

Question 40

inpatient CAP treatment

Answer 40

IV therapy; combo (BL + MAC or BL + FQ)

Question 41

treatment for HAP/VAP

Answer 41

combo therapy -> anti-MRSA or pseudomonal agent (1 BL - cefepime, pip/tazo, most carbapendems) - duration 7 days