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ID Exam 4 A
Beck CAP
| Question | Answer |
|---|---|
| Risk Stratification: Pneumonia Severity Index: PSI interpretation: Death (<0.5%) = what class? and point of care? | Class I; Outpatient |
| Risk Stratification: Pneumonia Severity Index: PSI interpretation: Score: </= 70; death: <1% = what class? and point of care? | Class II; Outpatient or Inpatient |
| Risk Stratification: Pneumonia Severity Index: PSI interpretation: Score: 71-90; death: 1-3% = what class? and point of care? | Class III; Outpatient or Inpatient |
| Risk Stratification: Pneumonia Severity Index: PSI interpretation: Score: 91-130; death: 9% = what class? and point of care? | Class IV; Inpatient |
| Risk Stratification: Pneumonia Severity Index: PSI interpretation: Score: >130; death: 27% = what class? and point of care? | Class V; Inpatient |
| Patient in Risk Class I include: | -Age < 50yo; -No PSI comorbidities; -No altered mental status or qualifying HR, RR, SBP, or temperature |
| Guidelines prefer PSI over _________ | CURB-65 |
| What is your CURB-65? **each is worth 1 point | Confusion; Uremia (BUN >/= 20); Respiratory Rate >/= 30; Blood Pressure (<90/60 mmHg); Age >/= 65yo |
| Does CURB-65 determine if a pt has pneumonia? | No |
| CURB-65 Score interpretation: If a pt has a score of 0-1 or death risk of 0.7-2.1%, this pt will be: | treated outpatient |
| CURB-65 Score interpretation: If a pt has a score of 2 or death risk of 9.2%, this pt will be: | Inpatient |
| CURB-65 Score interpretation: If a pt has a score of >/= 3 or death risk of 14.5-57%, this pt will be: | Inpatient, assess for ICU |
| Why do the guidelines prefer PSI over CURB-65 for assessing Pneumonia risk? | Because PSI is better at predicting mortality than CURB-65. Its more accurate |
| Beck: If BUN is not given, can a CURB-65 score still be done? | Yes, it can be done w/o BUN, as CRB-65 |
| Differences b/w Pneumonia: What are s/sx of "Standard" Pneumonia? | Fever, cough, Purulent Sputum, Dyspnea, Pleuritic chest pain |
| Differences b/w Pneumonia: What are s/sx of "Atypical" Pneumonia? | Typically < 50 yo; Persistent cough that does not resolve with time (common); Dry cough (uncommon); Prolonged onset of symptoms (uncommon); Low grade fever |
| Some examples of atypical Pneumonias would be? | M. Pneumoniae, C. Pneumoniae, Legionella |
| With M. Pneumoniae and C. Pnumoniae, what are some symptoms a pt could expect with these offending pathogens? | Pharyngitis, Hoarseness, Heachace |
| With Legionella, what is a symptom a pt would expect with this offending agent? | Diarrhea (GI issues associated with outbreak |
| Diagnostic tools for CAP may include cultures, what kind of testing on these cultures? | Respiratory cultures, blood cultures, Urinary antigen tests for SEVERE CAP, and PCR testing |
| Respiratory cultures for CAP include? | (***increase in invasiveness --->) Sputum culture--> Tracheal aspirate---> Bronchoalveolar lavage (BAL)---> Protected specimen brush |
| (Beck) Guidelines state that in outpatient we do not recommend ____ ______ because it doesn't give us useful information | Sputum cultures |
| Blood cultures are NEVER outpatient. In CAP blood cultures are only if pt is _________ or if starting MRSA or PsA (Pseudomonas) tx of CAP | SEVERE |
| All patients diagnosed with ____ and _____ will get Blood cultures | HAP; VAP |
| A Urinary antigen test is used for SEVERE CAP seen with which bacteria? | Streptococcus pneumoniae and Legionella pneumoniae |
| PCR testing is done in which cases? | respiratory viruses, including influenza, respiratory syncytial virus, and SARS-CoV-2; Mycoplasma pneumoniae and Chalmydophila pneumoniae; Methicillin-resistant Staph Aureus (MRSA) |
| MEMORIZE: What are the expected CAP pathogen distribution seen in Outpatient cases? | Streptococcus pneumoniae; Mycoplasma pneumoniae; Haemophilus Influenzae; Chlamydophila pneumoniae; Respiratory viruses |
| MEMORIZE: What are the expected CAP pathogen distribution seen in Inpatient, NON-ICU cases? | S. pneumoniae; M. pneumoniae, C. pneumoniael H. influenzae, Legionella spp, Respiratory viruses |
| MEMORIZE: What are the expected CAP pathogen distribution seen in ICU Inaptient? | S. pneumoniae, staphylococcus aureas, Legionella spp, H. influenzae, Gram - negative bacilli (i.e. E.coli., Pseudomonas, Klebsiella, and Enterococcus) |
| What is my Empiric Treatment for CAP in Outpatient (No comorbidities or risk factors for MRSA or Pseudomonas)? | Amoxicillin OR Doxycycline OR Macrolide (if < 25% local resistance) Azithromycin/ Clarithromycin |
| What is my Empiric Treatment for CAP in Outpatient (Presence of comorbidities, use of an abx in last 3 months, risk factors for DRSP)? | Antipneumococcal FQ (Moxifloxacin; Levofloxacin 750 mg) OR Beta-lactam + Macrolide* (amox-clav; cefpodaxime; cefuroxime) |
| What is our problem with macrolides? | Azithromycin is "given out like water" Should not be used as mono-therapy for CAP |
| What are my risk factors for Drug-resistant S. Pneumoniae? | Age <2 or >65 yo; Alcoholism; Immuosuppresive therapy or illness; Previous antibiotic therapy (last 3 months); Multiple medical comorbidities; Exposure to child in day care center |
| What are examples of comorbidities that would put me at more risk for Pneumonia? | chronic heart, lung, liver or renal disease, Diabetes, alcoholism, malignancies, asplenia; (**not HTN) ***Remember that comorbidities determine if your first or 2nd column for outpatient Empiric treatment |
| So for outpatient w/ presence of comorbidities, use of abx in last 3 months, or risk factors for DRSP, what do the guidelines prefer? | Beta lactam + macrolide (gives coverage for S. pneumo as well as atypicals; remember that macrolides are not added on for extra S. pneumo coverage; Beta lactams added on can bne amox-clav; cefpodaxime, cefuroxime. |
| If Macrolides aren’t available what can we use instead to add on to B-lactam therapy for outpatient w/ risk factors CAP? | Doxycycline |
| When determining Duration of therapy for CAP its all dependent on? | Clinical stability |
| What is the criteria for clinical stability for CAP? | Temperature < or = to 37 C; HR </= 100 bpm; RR </= 24 bpm; SBP >/= 90 mmHg; Arterial O2 saturation >/= 90% or pO2 >/= 60 mmHg on room air; ability to maintain oral intake; normal mental status |
| Duration of therapy for CAP is no less than _____ days | 5 |
| Lets say we added on Moxifloxacin as monotherapy for a pt, what monitoring for efficacy and safety is recommended? | improvement of symptoms; safety: watch for SCr, remember BB warnings: aortic dissection, peripheral neurotoxicity, malignant exacerbations, tendon ruptures, QTc prolongation, CNS effects |
| What is the QTc contraindication level? | > 500 |
| What is the MAJOR criteria for ICU admission | 1. Invasive mechanical ventilation 2. Septic Shock |
| What is the MINOR criteria for ICU admission | RR >/= 30 bpm; PaO2/FiO2 </= 250; Multilobar INFILTRATES; Confusion; BUN >/= 20 mg/dL; Leukopenia (WBC < 4); Thrmobocytopenia (<100K); Hypothermia (<96.8 F); Hypotension (SBP < 90mmHg) |
| What is the OTHER criteria for ICU admission | Lactic acid >/= 4 mmol/L; pH < 7.30-7.35; Albumin <3.5 g/dL; Na < 130 mEq/L; WBC > 20; HR >/= 125 bpm; Older age (>80 yo) |
| If my major criteria is greater than or equal to 1 pt is admitted to the: | ICU |
| If my minor criteria is greater than or equal to 3 pt is admitted to the: | ICU |
| The risk of CAP increases proportionately with the presence of how many criteria? | greater than 3 |
| Which atypical pathogen can stay on in the ICU? | Legionella |
| ⭐️ When do we add on MRSA coverage empirically? AKA risk factors for MRSA | ⭐️ Prior MRSA colonization or infection in last year; Recent hospitalization in last 90 days AND parenteral abx |
| Questionable Add-on empirical MRSA coverage include? | Long-term hemodialysis; IV drug abuse; Recent influenza |
| What is my Empiric Treatment for CAP Inpatient (NON-ICU general ward)? | Antipneumococcal FQ (Moxifloxacin; Levofloxacin 750 mg) OR B-lactam + Macrolide (Cefotaxime, Ceftriaxone, Ceftaroline, ampicillin-sulbactam) |
| Ceftaroline covers what that no other Cephalosporin covers? | MRSA |
| If you decide that you met the risk factor for MRSA in CAP what drug are we going to add on? | Vanco or Linezolid |
| If pt meets the criteria for PsA for inpatient CAP? | Cefepime or Pip-tazo |
| What is my Empiric Treatment for CAP Inpatient ICU? | Beta lactam (Cefotaxime, Ceftriaxone, Ceftaroline, Ampicillin-Sulbactam) PLUS Macrolide (Azithro or Clarithro) OR Antipneumococcal FQ **remember the guidelines prefer a Beta lactam + macrolide in the ICU over the B-lactam + FQ combo |
| How would your empiric regimen change if the pt also tested positive for influenza inpatient? | Add oseltamivir (** doesn't matter on duration of symptoms--> start your antiviral on top of your abx if you think theres a bacterial component to the infection |
| Which drug adds MRSA coverage but should never be used for any type of lung infection? | Daptomycin--> Gets deactivated by surfactants in our lungs |
| What is the MRSA coverage agents to use for CAP according to Beck? | Vanco or Linezolid |
| What medications do we avoid in pts with the flu? | steroids because they are associated with increased death |
| Let's say we started MRSA coverage in the Inpatient setting (Vanco)--> we recommend to order _____ _____ aka MRSA nares | MRSA PCR |
| When the MRSA nares reports a high negative predictive value, what does this mean? | If negative, pt is most likely NOT colonized with MRSA in the respiratory tract and MRSA is much less likely to be the pathogen causing the infection |
| So if MRSA nares are _______, de-escalate MRSA treatment (d/c Vanco/Linezolid) and choose a _________ spectrum abx that cover your other pathogens you are concerned about that is not MRSA | Negative; narrower **other pathogens (MSSA, S. Pneumo, and S. aureus) |
| If MRSA nares come back positive then? | Questionable but more than likely continue MRSA therapy |
| How would your management change if a pt's QTc interval was 564 msec? | cannot go with guideline preferred B-lactam + macrolide or combo with FQ; would have to go with B-lactam + Doxycycline since it does not increase QTc |
| Duration of therapy changes from 5 days to __ days when dealing with MRSA or Pseudomonas | 7 |
| When is it appropriate to switch from IV to PO therapy? | When pt is hemodynamically stable; clinically improving; able to ingest medications; normally functioning GI tract BecL "If the gut works, use it" Pt is stable and clincally improving--> anticipating discharge from the hospital very shortly |
| What is Aspiration Pneumonia? | Oropharyngeal or gastric contents enter the lung *Beck: "bugs we worry about fro GIT tract are different than what we worry about for respiratory tract" |
| In the 1970s they thought _________ may be a predominant pathogen causing aspiration pneumonia | anaerobes *Current shift--> anaerobes are less likely to be source of infection |
| 2019 IDSA CAP guidelines--> there is no need to add anaerobic coverage unless there is evidence of __________ OR __________ on radiograph | ABSCESS; EMPHYEMA |
| What is emphyema? | collection of fluid usually outside of lungs that is a "juicy breeding ground" for bacteria *This is when we add anaerobic coverage |
| Recap map: Pt is inpatient and is considered non-severe, what agents do I use? | beta lactam + macrolide OR Respiratory FQ (monotherapy) Duration is for no less than 5 days |
| Recap map: Pt is inpatient and is considered severe, what agents do I use? | Beta-lactam + macrolide (Preferred) OR Beta-lactam + respiratory FQ (acceptable but 2nd line Duration is 5-7 days (7 for serious MRSA or Pseudomonas) |
| CAP: Adding Pseudomonas Coverage empirically (AKA risk factors for Pseudomonas) include? | Prior Pseudomonas colonization in last year; Recent hospitalization in last 90 days AND parenteral antibiotics |
Created by:
Xander635
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