Anti-Infectives - Pneumonia

Pneumonia

Acute respiratory infection of the lungs primarily affecting the alveoli resulting in fluid/pus accumulation

infiltrate, sputum, pleuritic, leukocytosis

Pneumonia Clinical Presentation

• Newly recongized pulmonary ___________ PLUS at least 2 of the following

  • New/increased ______ production

  • shortness of breath

  • ________ chest pain

  • Confusion

  • Fever

  • Rales

  • ____________ (or leukopenia with increased band formation)

Community Acquired Pneumonia (CAP)

Common Pathogens

• Streptococcus pneumoniae

• Haemophilus influenzae

• Mycoplasma pneumoniae

• Chlamydophila pneumoniae

• Legonella pneumophila

• Respiratory viruses

Hospital acquired pneumonia, ventilator-associated pneumonia, CAP with MDR risk factors

Common pathogens

• Staphylococcus aureus

• Pseudomonas aeruginosa

• Enteric gram negatives

• Acinetobacter baumannii

low, home, 65, comorbidities, viral, aspiration, environmental

Community-Acquired Pneumonia

• Lack of healthcare exposure = ___ risk for MDR pathogens

• Most patients can be treated at ____

• Risk factors

  • Age > __ years

  • Chronic ___________ (COPD, asthma, CHF, DM)

  • _____ respiratory tract infections

  • Impaired airway protection (__________)

  • Smoking/alcohol overuse

  • Crowded living conditions

  • Low-income residence

  • _____________ toxin exposure (solvents, paints, gasoline)

Pneumonia Severity Index (PSI), CURB-65

What two tools can be used to determine if a patient with CAP should be admitted?

ICU

Direct ___ admission for CAP patients with the following criteria

• hypotension requiring vasopressors

• Respiratory failure requiring mechanical intubation

• > 3 IDSA/ATS 2007 minor severity criteria

90, pneumonia, MRSA, influenza, negative

MRSA risk factors - CAP

• Hospitalization + receipt of parenteral antibiotics within __ days

• Necrotizing __________

• Recurrent ____ infections

• Septic shock

• Post-_________ infection

• Failure while on broad-spectrum gram-________ coverage

• Immunocompromised

90, nursing, structural, history

Pseudomonas risk factors - CAP

• Hospitalization + receipt of parenteral antibiotics within __ days

• _______ home resident

• Immunocompromised

• Chronic _________ lung disease

• Previous _______ of MDRO

aspiration, gastric, anaerobic, anti-anaerobic, empyema

Aspiration Pneumonia

• Estimated 5-15% of pneumonia hospitalization are secondary to __________

• Aspiration pneumonitis - aspiration of _______ contents (typically resolves within 24-48 hrs without treatment)

• Unlikely _________ bacteria are causative pathogens

• ____-_________ antibacterial coverage is NOT recommended in aspiration pneumonia

  • Exceptions: lung abscess or _______

5, stability, resolution, vital, mentation

Duration of Therapy - CAP

• No less than _ days

• Duration may be extended based on clinical __________

  • _________ of vital signs

  • Ability to eat

  • Normal ________

multi-drug resistant, blood, definitive, nasal, procalcitonin

Hospital-Acquired Pneumonia

• Develops >48 hours after hospital admission = risk for _____-____ _________ (MDR) pathogens

• Respiratory and _____ cultures should be obtained to determine _________ therapy

• MRSA _____ Swab PCR may be helpful to de-escalate anti-MRSA coverage

• IDSA/ATS Guidelines recommend AGAINST routine use of _____________ to withhold initiation of antibiotics in patients with HAP

parenteral, 20, prevalence

MRSA Risk Factors - HAP

• Receipt of _________ antibiotics within 90 days

• Hospitalization in a unit with >__% S. aureus isolates being methacillin-resistant

• _________ of MRSA unknown

antibiotics, structural

Pseudomonas Risk Factors - HAP

• Receipt of parenteral ___________ within 90 days

• Presence of _________ lung disease (bronchiectasis, cystic fibrosis)

7, extended, vital, eat

Duration of Therapy - HAP

• NO less than _ days

• Duration may be ________ based on clinical stability

  • Resolution of _____ signs

  • Ability to ___

  • Normal mentation

intubation, blood, nasal, procalcitonin

Ventilator-Associated Pneumonia (VAP)

• Develops >48 hours after endotracheal _________ = risk for MDR pathogens

• Respiratory and _____ cultures should be obtained to determine definitive therapy

• MRSA _____ Swab PCR may be helpful to de-escalate anti-MRSA coverage

• IDSA/ATS Guidelines recommend AGAINST routine use of ______________ to withhold initiation of antibiotics in patients with VAP

90, shock, ARDS, 5, renal, 10-20

MRSA Risk Factors - VAP

• Receipt of parenteral antibiotics within __ days

• Septic _____ at time of VAP onset

• _____ preceding VAP onset

• Hospitalization for >_ days prior to VAP onset

• Acute _____ replacement therapy prior to VAP onset

• Hospitalization in a unit with >__-__% S. aureus isolates being methacillin-resistant

• Prevalence of MRSA unknown

90, shock, ARDS, 5, renal, 10, structural

Pseudomonas/MDR Gram Negative Risk Factors - VAP

• Receipt of parenteral antibiotics within __ days

• Septic _____ at time of VAP onset

• ____ preceding VAP onset

• Hospitalization for >_ days prior to VAP onset

• Acute _____ replacement therapy prior to VAP onset

• Hospitalization in a unit with >__% gram negative isolates being resistant to monotherapy agent

• Prevalence of resistance is unknown

• Presence of _________ lung disease (bronchiectasis, cystic fibrosis)

7, extended

Duration of Therapy - VAP (same as HAP)

• NO less than _ days

• Duration may be _________ based on clinical stability

  • Resolution of vital signs

  • Ability to eat

  • Normal mentation

malignancies, pancreatitis, surgery, nutrition, critical

Fungal Pneumonia Risk Factors

• Immunocompromised

• Hematologic ____________

• Broad-spectrum antibiotics

• Hemodialysis

• Central line

• DM

• Necrotizing ____________

• Recent major _______

• Parenteral ________

• ________ illness

nonproductive, pleuritic, dyspnea, infiltrates

Fungal Pneumonia Clinical Presentation

• Fever

• ____________ cough

• _________ chest pain

• Progressive _______

• Mediastinal lymphadenopathy

• Hemoptysis

• Pulmonary __________, nodules, consolidation, cavitation, or pleural effusion