front 1 Pulmonary defense mechanisms | back 1 • Mechanical barriers lower Airway |
front 2 What is Pneumonia? | back 2 Lower respiratory tract infection |
front 3 Pneumonia | back 3 - By Organism: Typical vs. Atypical |
front 4 Pneumonia | back 4 CAP, HAP, VAP |
front 5 Pneumonia | back 5 - By Morphology: Lobar pneumonia vs. Bronchopneumonia |
front 6 CAP | back 6 pneumonia acquired outside the hospital setting (or within 48 hours
of hospital |
front 7 HAP | back 7 Hospital-acquired pneumonia (HAP) |
front 8 VAP | back 8 Ventilator-associated pneumonia (VAP) |
front 9 Atypical Pneumonia | back 9 Pneumonia due to “atypical” bacterial pathogens |
front 10 Atypical Pneumonia | back 10 Atypical symptoms or imaging findings |
front 11 Pneumonia By Morphology | back 11 • Bronchopneumonia-in the bronchials |
front 12 Aspiration pneumonia | back 12 Aspiration of oropharyngeal or gastric contents into the lung
resulting |
front 13 Aspiration pneumonitis | back 13 - Chemical injury caused by aspiration of acidic gastric
contents |
front 14 Epidemiology | back 14 Influenza and Pneumonia |
front 15 CAP: Diagnostic Recommendations | back 15 Required for Diagnosis |
front 16 is Routine micro and laboratory assessment of ambulatory/outpatients
| back 16 NO |
front 17 in admitted patients with severe CAP or those | back 17 attempt to obtain blood and sputum cultures |
front 18 pneumonia-HPI-symptoms(pt work up) | back 18 Fever, fatigue, weakness, decreased exercise tolerance, light headedness, cough, sputum production, shortness of breath, chest pain, confusion. |
front 19 pt medical Hx-pt work up for pneumonia look out for the following | back 19 Asthma, COPD, cardiovascular disease, cerebrovascular disease |
front 20 pt- work up. causes of pneumonia | back 20 Causes of pneumonia |
front 21 pt-work up- consider drugs pt taking. | back 21 - Previous antimicrobials |
front 22 pt workup review of systems what would the vitals look like in someone with pneumonia? | back 22 Febrile, BP may be up or down, tachycardic, increased RR, decreased O2 sats. CNS-dec level of consciousness, confusion, not orientated. CVS: Chest discomfort or pain
Resp: |
front 23 what do labs look like in someone with pneumonia? | back 23 WBC elevation (other acute phase reaction) |
front 24 what other labs for pneumonia? | back 24 Additional diagnostic testing to detect influenza and other viruses,
including SARS-CoV-2 |
front 25 diagnostics for pneumonia | back 25 CXR: infiltrates (new or progressive) a patchy infiltrate represents broncopneumonia in a pt with streptococcus pneumonia infection. |
front 26 goals of therapy | back 26 1. Prevent mortality |
front 27 labs-what cultures are done for pneumonia? | back 27 Cultures: |
front 28 BUG | back 28 Inherent Susceptibility |
front 29 DRUG considerations | back 29 Efficacy |
front 30 HOST | back 30 Age/Weight |
front 31 CAP: Empirical Antimicrobial Therapy | back 31 1. Generate list of most likely pathogens |
front 32 Clinical Prediction Rules | back 32 In addition to clinical judgement, we recommend that clinicians use
a |
front 33 pneumonia severity index includes: | back 33 demographics, co-morbidities, physical exam/vital signs, lab/imaging. |
front 34 CURB-65 | back 34 confusion, uremia, respiratory rate, BP, age ≥ 65
Scores ≥2: hospitalization recommended |
front 35 no data | back 35
Number of
factors Mortality Rate
Recommended Site
Of Care |
front 36 if the risk of mortality is <2 % where shud the pt be managed? any pt with scores of 1-2 -consider hospital assessment/ admission | back 36 outpatient if score eq or > 3 =hospital admission |
front 37 ..................... required for pts with septic shock requiring intubation and mechanical ventilation | back 37 direct admission to ICU |
front 38 gram positive organisms | back 38 cocci(staphylococcus-clustered and steptococcus and enterococcus -pairs/chains) bacilli 1. aerobic- (corynebact, bacillus, listeria) 2.anaerobic- clostridium actinomyces |
front 39 gram negative bacilli (aerobic) simple growth | back 39 1. lactose fermenters: e.coli, klebsiella sp , citrobacter sp. 2. non lactose fermenters: pseudomonas sp, burkholderia sp, acinetobacter sp, morganella sp, proteus sp, serratia sp, stenotrophomonas sp. |
front 40 fastidious growth | back 40 legionella, haemophilus, bordetella, camylobacter |
front 41 Outpatient | back 41 Respiratory viruses |
front 42 Inpatient | back 42 Respiratory viruses |
front 43 Inpatient (ICU) etiology | back 43 Respiratory viruses |
front 44 Atypical coverage | back 44 Mortality |
front 45 CAP: Outpatients (Nova Scotia guidance) standard regimen | back 45 amoxicillin 500-1000mg TID(renal adjust required) -cefuroxime 500mg BID, Doxy 100mg BID or levo 750mg DAILY IF PENICILLIN ALLERGY |
front 46 .....is unnecessarily broad for most CAP in previously healthy | back 46 amoxi-clav |
front 47 CAP: Outpatients (IDSA 2019) initial treatment strategies for outpatients with CAP | back 47 if no comorbidities or risk factors for MRSA or pSuedomonas aeruginosa- amoxil or doxy or macrolide if local resistance is < 25% |
front 48 what do u give to CAP pts with comorbidities? | back 48 combo therapy with amoxi-clav or cephalosporin AND macrolide or doxy |
front 49 it is not recomended locally to add a ....... for atypical bacteria coverage. | back 49 macrolide or doxy |
front 50 IDSA 2019: Considerations for outpatients | back 50 Comorbidities |
front 51 Risk factors for MRSA or P. aeruginosa | back 51 • Prior respiratory isolation of MRSA or P. aeruginosa OR |
front 52 CAP: Inpatient-Hospital (Non-ICU) NS guidance what is the standard therapy for CAP in-patient (non-ICU) | back 52 amoxil 500-1g TID OR ampicillin 2g IV q6h levo 750mg PO/IV daily. cefuroxime 500mg PO BID or 750mg IV q8h cefrotriaxone 1g IV q24h |
front 53 how is atypical coverage handled for CAP inpatients (non-ICU)? | back 53 routine coverage has not been proven to be of benefit in this setting. consider risk factors-i.e prior resp isolation of MRSa or P-aeroginosa or recent hospitalization/ receipt of parenteral antibiotics in the last 90 days. if strong suspicion of atypical pathogens and not on fluoroquinolone, -azithro 500mg x3 days -doxy 100mg BID preffered (if prolonged QTC) |
front 54 CAP in Inpatients-Severe (ICU) NS guidance (ICU regimen for for in patients with CAP) | back 54 cefriaxone 1 g IV q24h plus azithromycin 500mg PO /IV daily. OR Levo 750mg PO/IV daily (preffered if legionella is isolated) |
front 55 in the case of risk factors in ICU pts with CAP | back 55 consider risk factors-i.e prior resp isolation of Pseudomonas or recent hospitalization/ receipt of parenteral antibiotics in the last 90 days- give pip/tazo 4.5 g IV q6h in the case of prior resp isolation of MRSa- Add vancomycin to standard regimen. |
front 56 oseltamivir 75 mg BID X5 days(dose adjust in renal dyfunction) | back 56 is recommended empiric therapy in hospitalized patients with suspicion of influenza, regardless of timing of symptom onset. |
front 57 CAP: Inpatients IDSA 2019 wat is the standard regimen for nonsevere inpatient pneumonia | back 57 beta-lactam(clavulin) + macrolide(e.g erythro) OR respiratory fluoroquinolone. |
front 58 wat is the standard regimen for severe inpatient pneumonia | back 58 beta lactam plus macrolide OR beta- lactam + fluoroquinolone. |
front 59 what is the recomended antimicrobial therapy for streptococcus pneumoniae if it is nonpenicillin resistant (MIC <2MCG/mL) | back 59 Penicillin G, amoxicillin alternatives-macrolide, cephalosporin, cefpodoxime, cefprozil,cefuroxime,ceftriaxone, cefotaxime, clindamycin,doxy, resp-fluoroquinolone |
front 60 what is the recomended antimicrobial therapy for streptococcus pneumoniae if it is penicillin resistant (MIC =/>2MCG/mL) | back 60 -vanco, linezoid, high-dose amoxil (3g/day with penicillin MIC <=4mcg/ml) preferred agents chosen on the basis of susceptibility, including cefotaxime, ceftriaxone, fluoroquinolone |
front 61 what is the recomended antimicrobial therapy for haemophilus influenzae Non-b-lactamase producing | back 61 amoxil preferred alternatives fluoroquinolone, doxycycline, azithromycin, clarithromycin. |
front 62 what is the recomended antimicrobial therapy for haemophilus influenzae b-lactamase producing | back 62 preferred= 2nd or 3rd gen cephalosporin, amoxil-clav Alternatives= alternatives fluoroquinolone, doxycycline, azithromycin, clarithromycin. |
front 63 what is the recomended antimicrobial therapy for mycoplasma pneumoniae/chlamydophila pneumoniae | back 63 preferred= macrolide, a tetracycline alternative= fluoroquinolone |
front 64 what is the recomended antimicrobial therapy for legionella species | back 64 preferred = fluoroquinolone, azithromycin alternative= doxycycline |
front 65 what are the options for CAP | back 65 Penicillins (i.e., amoxicillin) |
front 66 Ceftriaxone (3rd generation cephalosporin) Spectrum | back 66 Streptococci pneumoniae, Group A, B, C and G streptococcus PK/PD -Time above MIC |
front 67 IV to PO step down criteria for clinical stability must meet all criteria | back 67 temp <= 37.8 deg c hrt rate <=100beats/min respiratory rate <=24 24 breaths/min systolic blood pressure >=90% or PO2 >=60mmHg on room air Ability to maintain oral intake normal mental status |
front 68 Treatment Duration | back 68 Treatment Duration Afebrile (T ≤ 37.8 x 48-72 h) AND |
front 69 Treatment Failure | back 69 Drug factors |
front 70 Treatment Approach | back 70 • Establish diagnosis |
front 71 HAP | back 71 Hospital-acquired pneumonia (HAP) |
front 72 VAP-arises .48-72 hours after endotracheal intubation. In a Canadian cohort study of ventilated for ≥48 h (17.4%) developed | back 72 Pneumonia – Classification |
front 73 Generally, approximately 30% of HAP occurs in ............... | back 73 critical care settings |
front 74 ...accounts for 15% of all nosocomial infections | back 74 HAP |
front 75 sources of microorganisms causing HAP and VAP endogenous | back 75 endogenous -oropharynx trachea nasal carriage sinusitis gastric fluids |
front 76 sources of microorganisms causing HAP and VAP exogenous | back 76 health care workers ventilatory circuits nebulizers biofilms |
front 77 mechanism of pneumonia | back 77 it occurs when colonized secretions are inhaled into the lungs through the endotracheal tube |
front 78 Diagnosis | back 78
2 of the following |
front 79 Empiric Therapy | back 79 1. Presence of risk factors for MDRO |
front 80 Risk factors for MDR organisms | back 80 = If prior IV antibiotic use within the preceding 90 days, patient is
at |
front 81 Resistance patterns & Prevalence | back 81 Consider vancomycin if: |
front 82 Classification of Severity | back 82 The following risk factors for mortality = severe illness requiring
ICU |
front 83 HAP: no risk factors for mdro non-icu empiric trtment | back 83 ceftriaxone 1 g IV q 24h or amox-clav 875/125 mg BID or levo 750mg IV/po Q24h |
front 84 HAP: no risk factors for MDRO +NON-ICU what are the core pathogens | back 84 strep pneumonia H. influenzae staph. aureus enteric gram-neg bacilli(klebsiella, E. coli, Enterobacter, proteus) |
front 85 HAP: Risk factors for MDRO or requiring ICU what are the core pathogens? | back 85 staph aureus(and MRSA), Enteric gram-neg bacilli(incr resistance) klebsiella, E. coli, enterobacter, proteus. serratia, pseudomonas, acinetobacter |
front 86 HAP: Risk factors for MDRO or requiring ICU what is the empiric trtment ? | back 86 Piperacillin-tazobactam* 4.5 g IV q6h meropenem if IGE-Mediated penicillin allergy |
front 87 Staph. aureus (and MRSA) Pathogens | back 87 Staph. aureus (and MRSA) |
front 88 VAP empiric trtment | back 88 Piperacillin-tazobactam* 4.5 g IV q6h Meropenem if IgE-mediated penicillin allergy |
front 89 HAP/VAP: antibiotic Options | back 89 Cephalosporins (i.e., ceftriaxone) |
front 90 Piperacillin-tazobactam | back 90 Antipseudomonal penicillin+ beta-lactamase inhibitor |
front 91 pip-tazo spectrum | back 91 Streptococci pneumoniae, Group A, B, C and G
streptococcus, Staphylococcus aureus (MSSA), |
front 92 what is the pk/pd of pip-taz? protein binding? vd elimination t1/2 | back 92 time above MIC 30% 0.25L/kg 70 to 80% renally eliminated 1h |
front 93 pip-taz dosing | back 93 Pseudomonas 4.5 g IV q6h, other indications 3.375g IV q6h interval depends on renal function, prolonged infusions used to optimize PK/PD. |
front 94 Adverse effects | back 94 Platelet dysfunction, thrombocytopenia, allergy, serum sickness,
cytopenias, nausea vomiting, |
front 95 what are some drug interactions with pip-taz | back 95 Avoid concomitant administration with methotrexate (increased methotrexate levels) |
front 96 Meropenem & Imipenem-Cilastatin (Carbapenems) spectrum | back 96 Streptococci pneumoniae, Streptococcus spp., Staphylococcus aureus
(MSSA), Enterococcus Faecalis |
front 97 Meropenem & Imipenem-Cilastatin (Carbapenems) PK/PD | back 97 Time above MIC |
front 98 Meropenem & Imipenem-Cilastatin (Carbapenems) protein binding | back 98 2% (meropenem), 20% (imipenem) |
front 99 Meropenem & Imipenem-Cilastatin (Carbapenems) Vd Elimination T1/2 | back 99 0.25 L/kg 70 % renally eliminated |
front 100 Meropenem & Imipenem-Cilastatin (Carbapenems) Dosing Adverse effects Drug interactions | back 100 500 mg IV q6h (local strategy) |
front 101 Aminoglycosides Spectrum | back 101 (not comprehensive) |
front 102 Aminoglycosides | back 102
PD
Concentration dependent killing |
front 103 Aminoglycosides: dosing options | back 103 • Lower dose given |
front 104 Extended interval | back 104 Extended interval |
front 105 what is the Extended dosing interval exclusion criteria | back 105 Ascites |
front 106 Aminoglycosides: what are Adverse Effects | back 106
Ototoxicity (not reversible)
|
front 107 Aminoglycosides Follow up and monitoring | back 107 • Duration > 7days |
front 108 Antipseudomonal Therapy | back 108 Antipseudomonal cephalosporin (ceftazidime, cefepime, ceftolozane-tazobactam) |
front 109 double coverage : for pts with HAP who are being treated empirically what is the recommendation? | back 109 antibiotics with activity against p. aeruginosa and other gram-negative bacilli |
front 110 Double Coverage? | back 110 Double Coverage? |
front 111 MRSA Pneumonia | back 111 Vancomycin is still the agent of choice for MRSA pneumonia |
front 112 Summary: Empiric Therapy | back 112 -Establish diagnosis |
front 113 Treatment Duration (empiric therapy) | back 113 For patients with HAP and VAP we recommend a 7-day Exclusions: complicated, abscess, empyema, immunocompromised |
front 114 Treatment Principles | back 114 -Initiate broad spectrum antibiotics based on most likely organisms
and patient specific factors |
front 115 empiric trtment nova scotia NS HEALTH (HAP)-which regimen is used with the following risk factors? no rapid clinical deterioration not admitted to ICU No IV antibiotic WITHIN preceding 90 days | back 115 ceftriaxone 1 g IV q24h OR amoxi-clav 875mg bid. OR levo 750mg PO/IV q24h |
front 116 what is recommended for for any of the following? HAP requiring ICU management : septic shock and/or intubation. colonization or prior infection with pseudomonas or other resistant gram-negative bacilli (e.g extended spectrum beta-lactamase producing e. coli, klebsiella) prolonged hospitalization(>2wks) IV antibiotic use within 90 days | back 116 pip-taz 4.5g IV q6h OR meropenem 500mg IV q6h -preffered if colonized/infected with pip-taz resistant microorganism OR IgE mediatd penicillin allergy |
front 117 empiric trtment if MRSA suspected -known MRSA colonization previous MRSA INFECTION | back 117 add vancomycin IV |