interview prep

Community acquired pneumonia (CAP)

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What 3 things do you need for a diagnosis?

1. New pulmonary infiltrates

2. 1 respiratory symptom

3. 1 other symptom or a sign

Respiratory symptom: (4)

Other symptoms: (4)

1. New or increased cough

2. New or increased sputum

3. Dyspnea

4. Pleuritic chest pain

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1. Abnormal lung sounds

2. Fever (>100.4 F)

3. Leukocytosis

4. Hypoxia (<90)

To classify as severe or non-severe you need one major criterion or three minor criterion

Major:

1. Septic shock requiring vasopressors

2. Mech vent

Minor:

1. RR >30

2. Confusion disorientation (look up the rest)

Standard regimen (Recent hospitalization within 90 days w/ IV abx but NOT SEVERE)

B-lactam + Atypical coverage

or

FQ

What are Pseudomonas risk factors? What do you do if one is present?

History of PSA colonization or infection at any site within 1 year OR advanced structural lung disease OR severe CAP + recent abx

Use a beta-lactam that covers PSA

MRSA risk factors

1. Recent Abx hospitalization w/ IV abx within 90 days

2. History of MRSA colonization or infection within 1 year

3. MRSA nasal PCR pos

Ampicillin/sulbactam

1.5-3g IV q6h

Ceftriaxone

1-2g IV q24h (2g if >80kg)

Cefotaxime

1-2g IV q8h

Azithromycin

500mg IV/PO q24h*

(Azithromycin 500mg q24 hours x 3 doses for 1500mg total to treat atypical pneumonia)

Clarithromycin

500mg IV/PO BID

Doxycycline

100mg IV/PO BID (for macrolide intolerance or QtC prolongation)

Levofloxacin

750mg IV/PO q24h

Moxifloxacin

400mg IV/PO q24h

Vancomycin

Vancomycin 15 mg/kg IV q 8-12h (trough 15-20 ug/mL), consider loading dose of 25-30 mg/kg x 1 dose for severe illness

Linezolid

600 mg IV/PO BID

Piperacillin/tazobactam

4.5g IV q6h

Cefepime

2g IV q8h

Ceftazidime

2g IV q8h

Imipenem

500mg IV q6h

Meropenem

1000mg IV q8h

Severe CAP with allergy to β-lactams

Consider levofloxacin 750mg IV/PO q24h ± aztreonam 2g IV q8h +/- MRSA coverage

Should be treated for 5 days of clinical stability (7 if MRSA). To be clinically stable you need to meet 5 criteria

1. Tmax ≤38ºC (100.4 F)

2. HR ≤100

3. RR ≤24

4. Arterial O2 saturation ≥90% or pO2 >60mmHg

5. Baseline mental status

6. SBP ≥90 mmHg

VAP

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High risk of MDR: Cover for MRSA if a risk factor for antimicrobial resistance (Table 2), patients being treated in units where >10%–20% of S. aureus isolates are methicillin resistant, and patients in units where the prevalence of MRSA is not known

High risk of MDR: Double cover for PSA if ______ of _____ are resistant to an agent being considered for monotherapy in hospital antibiogram. Can achieve double coverage with a ____ ____

10% ; (-) isolates ; Resp FQ

High risk of MDR: General treatment

Antipseudomonal beta-lactams +  another antipseudomonal agent + gram positive coverage for MRSA

HAP/VAP

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Risk factors for MDR in HAP

IV Abx within 90 days

Risk factors for MDR in VAP

1. IV Abx within 90 days

2. Septic shock @ time of dx

3. ARDS b4 dx

4. Hospitalization >5 days prior to VAP onset

5. Acute renal replacement therapy prior to VAP onset

HAP - Antibiotic escalation

Cover for MRSA if

1. MDR risk factor

2. High mortality risk (septic shock or vent)

3. Unit prevalence of MRSA is >20%

Double cover for PSA if

1. MDR risk factor

2. High risk of mortality

3. Structural lung disease

VAP - Antibiotic escalation

Cover for MRSA if

1. MDR risk factor

2. Unit prevalence of MRSA is >10%

Double cover for PSA if

1. MDR risk factor

2. Resistance to monotherapy >10% (or unknown)

MRSA nasal swab: If negative, ____

discontinue MRSA coverage (>95% negative predictive value in CAP)

LDL goal for primary prevention of ASCVD