Patho PCT II Exam 2 CAP/HAP/Endocarditis

Outside, 48

CAP is classified as pneumonia onset ____ of the hospital or within ____ hours of hospital admission.

65, DM, smoking

Risk factors for CAP include age > ____ years, ____, asplenia, chronic comorbidities, ____ and/or alcohol abuse.

Lower, sepsis

Pneumonia is a (lower/upper) RTI and is a common cause of severe ____.

Inhalation, aspiration, spread, cleared

Pneumonia pathogens usually gain access to the lungs by direct ____, ____ of oropharyngeal contents, or hematogenous ____ from another infection site. Organisms are normally ____ with intact immune system/defenses.

Impairment, colonization, aspiration, pulmonary

Pneumonia pathogenesis:

1. ____ of host defenses

2. ____ of upper respiratory tract

3. ____ of oropharyngeal secretions

4. ____ infections

Sepsis, mortality

Pneumonia patients with tachypnea, hypotension, hypothermia, and leukopenia have signs of ____ and have an increased risk of ____.

Empirically

Pneumonia is usually treated ____ because the causative pathogen is only identified in 40-60% of cases.

Strep pneumo, H. flu, M. cat

What is the most commonly identified organism in CAP? Second most common? What organism is common in immunocompromised and hospitalization?

Mycoplasma, chlamydia, legionella

What are the three atypicals that can cause CAP listed from most frequent to least frequent?

Aspirating, oral, gut

Anaerobic pathogens can be seen in CAP potentially from ____. GP anaerobes (pepto) live in the ____ cavity and GN anaerobes live in the ____ (bacteroides, fusobacterium).

Lung disease, b-lactams, colonization, immunocompromised

Risk factors for Pseudomonas CAP:

1. Patients with underlying ____ ____ (Interstitial, CF)

2. Prior use of ____-____ within 30 days

3. Prior airway ____ within last 12 months

4. Severely ____

Viruses, co-infections

(Bacterial/viruses) account for most CAP cases in children and many cases in adults. Bacterial/viral ____-____ are common.

Abrupt, productive, sputum, tachy, decreased

CAP signs and sx:

1. Onset is (gradual/abrupt) or subacute

2. Fever, chills, dyspnea, (productive/non-productive) cough

3. ____ production (sometimes hemoptysis)

4. (Brady/tachy)-pnea & -cardia, retractions, grunting respirations, (increased/decreased) or abnormal breath sounds

PE, infiltrate, vitals, gram stain, urinary

Diagnosis of PNA includes ____ and history, chest x-ray with lower lobe ____, ____ (fever, BP, HR, RR), respiratory ____ ____, ____ antigens, and other lab tests (cultures, CBC, blood gas).

Difficult, pathogen

Adequate specimens for sputum Gram stains are (easy/difficult) to obtain. They allow for ____-directed therapy.

Biomarkers

Patients being treated inpatient for PNA can under diagnostic ____ tests (c-reactive protein, procalcitonin).

Oral, adherence, follow-up

CAP patients should be treated inpatient if they are unable to take ____ medications, have unreliable patient ____, no home care or ability to get to outpatient ____-____.

Respiratory, ventilation, vasopressors

CAP patients should be considered for ICU admission if they are in ____ distress, need mechanical ____ due to respiratory failure, are in shock, need ____ due to hypotension, or have low urine output/AKI.

Resistant, narrow, adjust, lower

Sputum and blood cultures obtained at the time of CAP diagnosis are good because they identify ____ pathogens, (widen/narrow) therapy, help ____ therapy if failed initial, and lower ____ for hospitalized patients.

Yield, change, false positives, stay, abx

Sputum and blood cultures obtained at time of CAP diagnosis have cons including poor ____ of sputum cultures and blood cultures, blood cultures rarely result in therapy ____, ____ ____ leading to unnecessary broad spectrum abx, and blood cultures increase the length of ____ in hospital and duration of ____.

Severe, MRSA, Pseudomonas

Based on the IDSA CAP guidelines, patients with ____ disease (so all inpatients), patients being empirically treated for ____ or ____, or those with risk factors for them should get a sputum and blood culture.

1, 3, need of vasopressors or mechanical ventilation

Severe disease is classified as ____ major or at least ____ minor criteria. What are the major criteria?

RTI, IV abx, 90

Risk factors for MRSA/PSA CAP include previous _____ infection with MRSA or PSA. It also includes patients who were hospitalized and received ____ ____ within the last ____ days.

Narrow, mortality, relapse

Legionella and pneumococcal urinary antigen tests have pros and cons. Pros include (widen/narrow) therapy and decrease ____. Cons include concern for ____ therapy too much in response to positive tests and increase the risk of clinical ____ (miss a bug).

Should not, severe, are

Based on the new IDSA CAP guidelines, legionella and pneumococcal urinary antigens (should/should not) be routinely checked except for patients with ____ CAP. In clinical practice, if a patient is in the inpatient setting, they (are/are not) most likely going to test it.

Influenza

In CAP patients, respiratory sample should be tested for ____ on high activity months.

Is not

Based on the IDSA CAP guidelines, procalcitonin (is/is not) recommended to determine need for initial ABX.

0-1, 2, 3-5

CURB-65 scores of ____-____ are low risk and should consider home treatment. Scores of ____ are probable admissions or close outpatient management. Scores of ____-____ suggest admission.

70, outpatient, 71-90, 91-130, 130, inpatient

PSI scores ____ are V. IV and V should be treated (inpatient/outpatient).

Low, higher

PSI is more accurate in identifying and defines a greater proportion of patients at (low/high) risk. There is (lower/higher) discriminatory power for 30-day mortality.

Overemphasis, improvement

The prediction rule (CURB-65 and PSI) has limitation including an (underemphasis/overemphasis) on age and not accounting for continuing patient ____ (one point in time).

Ease, underestimate, PSI

CURB-65 is simpler than PSI, has potential for greater ____ of use in clinical settings, and has almost identical predictive values. The PSI may (underestimate/overestimate) severity among younger patients. However, the (CURB-65/PSI) is recommended by the guidelines.

No just inpatient vs. outpatient

Does the PSI tell us where in the hospital the patient should be admitted (general floor vs. ICU)?

Higher, direct admit to the ICU

Patients transferred to ICU after general ward admission have (lower/higher) mortality than those directly admitted to ICU. If patients are that sick at admission, what should you do?

Amoxicillin 1g TID OR doxycycline 100mg BID

What are the two options for outpatient treatment of CAP for patients without comorbidities or risk factors for resistant pathogens?

B-lactam AND macrolide or doxycycline, levo 750mg QD or moxi 400mg QD

What are the two options for outpatient treatment of CAP for patients with comorbidities?

Combo therapy with ____-____ AND ____ or ____.

Monotherapy with what two drugs and doses?

Resistance, atypical, oral, monotherapy

Fluoroquinolones are good CAP outpatient monotherapy because there are very low ____ rates, cover both typical and ____ organisms, have good ____ BA, convenience of ____, and relative rarity of serious adverse effects.

AE, C. diff, ESBL

Fluoroquinolones are cons for CAP outpatient monotherapy are increasing reports of ____, increase risk of ____ ____ infections, and risk of colonization with FQ-resistant ____ bacteria.

B-lactam, macrolide, fluoroquinolone

For nonsevere CAP patients treated inpatient without MRSA/PSA risk factors, use either combo therapy of ____-____ and ____ or monotherapy of ____.

Ceftriaxone 1-2g QD, azithromycin 500 mg QD

What b-lactam is usually used and dose for CAP treatment? What macrolide and dose?

B-lactam and doxycycline 100 mg BID

For nonsevere CAP patients treated inpatient without MRSA/PSA risk factors that have CI to macrolide and FQ, what combo would you use instead?

B-lactam + macrolide or B-lactam + FQ

For severe CAP patients treated inpatient without MRSA/PSA risk factors, what two combo therapies are your options?

Hemodynamically, oral, high

Inpatient CAP treatment can be switched from IV to PO once patient is improving clinically, ____ stable, able to take ____ meds. (Low/high) BA agents are recommended.

No unless lung abscess or empyema

Is anaerobic coverage routinely added for suspected aspiration pneumonia in CAP? When would it be?

Vanc 15mg/kg q12h or linezolid 600mg q12h

What two drugs and doses could you consider when treating CAP inpatient with MRSA/PSA risk factors to cover the MRSA part?

Pip-tazo, cefepime, aztreonam, carbapenems

What drugs could you consider when treating CAP inpatient with MRSA/PSA risk factors to cover the PSA part?

Add coverage

For CAP patients who have had prior respiratory isolation of MRSA or PSA, do you add coverage or wait for cultures?

Wait for cultures, add coverage

For nonsevere CAP patients who have had recent hospitalization and IV abx and locally validated risk factors for MRSA or PSA, do you add coverage or wait for cultures? If patient is severe?

No

Are corticosteroids recommended for use in CAP patients?

Yes

For patients with CAP who also test positive for the flu, do you give antivirals with the ABX?

5, 7, 14

In CAP, ABX therapy should be continued until the patient achieves stability AND for at least ____ days. Is the CAP is due to MRSA or PSA, treat for at least ____ days. If it is a less common pathogen like Legionella, treat for ____ days.

No

Is routine follow-up chest imaging needed in adults whose sx resolve within 5-7 days?

Chelation, tendon, neuropathy, CNS

Fluoroquinolone monitoring and sx:

____ with cations

____ rupture

Peripheral ____

____ SE

GI, blood, anaphylaxis

Penicillin monitoring and sx:

____ sx

____ dyscrasias

____ hypersensitivity rxn

Chelation, water, pregnancy, photosensitivity

Tetracyclines monitoring and sx:

____ with cations

Give with full glass of ____

____ concern

____ (sunburn)

GI, QTc prolongation

Macrolides monitoring and sx:

____ SE (N/V/D)

Possible ____ ____ (heart)

GN bacilli (pseudomonas, klebsiella, e. coli, acinetobacter) and staph aureus

What are the two most common groups of organisms responsible for HAP?

HAP

(CAP/HAP) is more likely to be MDR.

48

HAP is pneumonia not incubating at time of admission and occurring at least ____ hours after admission.

48

VAP (ventilator) is pneumonia occurring more than ____ hours after endotracheal intubation.

Sedatives, steroids, immunosuppressants, antacids, H2RA, abx

What are 6 drugs that increase the risk of HAP?

Increase pH in stomach allowing bacteria to come in

Why do antacids and H2RAs increase the risk of HAP?

Bacteremia, organs, ICU, resistant, initial

Risk factors for increased risk of mortality in HAP patients includes ____, dysfunction of other ____, severe underlying disease, transfer from another ____, late onset PNA with ____ pathogens, inappropriate ____ ABX.

Strep pneumo, H. flu, staph aureus, and GN bacilli

In early onset HAP (2-5 days after admission), what are the four main organism?

Pseudomonas, acinetobacter, stenotrophomonas, MRSA

Late onset HAP includes the same organisms as early onset but are more likely to include which four organisms?

MRSA and Pseudomonas, IC, gastric acid suppressants and ABX

Most MDRO pathogens are what two bugs? What patient group is at an increased risk? What two drugs puts patients at an increased risk?

90, septic shock, ARDS, 5

VAP patients are at higher risk for MDRO if they've had prior ABX use within ____ days, ____ ____ at time of VAP, ____ preceding VAP, more than ____ days of hospitalization prior to VAP onset, and acute respiratory therapy prior to onset.

Masked

HAP sx are similar to CAP sx, but they may be ____ by comorbid illnesses.

Fever, WBC, sputum, respiratory, infiltrates

HAP diagnosis:

Unexplained new or worsening ____

New or unexplained increased ____

Change in quantity or quality of ____

Worsening ____ function

New or worsening ____ on CXR

48-72, age, severity

Some improvement is expected within ____-____ hours when treating HAP. There may be delayed resolution with increasing ____, multiple underlying illnesses, and increasing ____ of infection.

7 days, Pseudomonas

What is the usual duration of tx for HAP and VAP? It is longer with severe infections with difficult to treat organisms like what?

Before

Cultures should be obtained (before/after) starting empiric therapy.

Zosyn, cefepime, cipro/levo, carbapenems, Pseudomonas

For HAP treatment, if patients are not at a high risk of mortality or MRSA, what 4 drugs/classes would be appropriate for empiric therapy (GN coverage)? What do you need to make sure your choice covers (why we wouldn't choose ceftriaxone)?

Vancomycin, linezolid

For HAP treatment, if patients are not at a high risk of mortality but MRSA is more likely, use the same ABX as before (GN coverage) PLUS ____ or ____.

2 broad spectrum GN coverage abx PLUS vanc or linezolid

For HAP treatment, if patients are at a high risk of mortality or received IV ABX within 90 days, what combo would you use?

Interstitial, 30, Pseudomonas, immunocompromised, 5

Risk factors for antipseudomonal b-lactams susceptibility (APBL-S) include ____ lung disease, prior non-APBL use within ____ days, prior airway colonization with ____, severely ____, prolonged hospitalization >____ days at sx onset.

CF, 48, 30, resistant, 12

Risk factors for APBL-R for PSA are ____ or bronchiectasis, prior APBL use of at least ____ hours within last ____ days, and prior airway colonization with Pseudomonas ____ to APBL within last ____ months.

Vanc, linezolid, GN, cipro/levo

Empiric therapy for VAP is ____ or ____ PLUS ____ coverage drugs (Zosyn, cefepime, imipenem, carbapenem, aztreonam) PLUS ____/____ or aminoglycoside or polymyxin.

Inhaled

____ ABX are suggested in combo with systemic ABX for CF patients or VAP due to GN bacilli only susceptible to aminoglycosides or polymyxin.

Double coverage, MOA

When treating HAP or VAP due to Pseudomonas, you want ____ ____ from different classes. This allows for two ____.

Broaden, resistance, septic shock

Combo therapy for HAP or VAP due to PSA can ____ the spectrum and reduce ____. This is used for patients in ____ ____/at high risk of death with unknown susceptibilities.

20, vanc or linezolid

If the institutional rate of MRSA is >____% in HAP and VAP, add MRSA coverage. What are the two DOC?

Fever, 100, 24, 90, 90, oral

During 24 hours prior to discharge after HAP or VAP, patients should not have more than one of the following:

1. ____ (>37.8C)

2. Pulse > ____ beats/min

3. RR > ____ breaths/min

4. SBP < ____ mmHg

5. O2 sats < ____

6. Inability to maintain ____ intake

Sinusitis, widen, MRSA, antiviral, antifungal

If HAP or VAP therapy fails, rule out nosocomial ____, (widen/narrow) antibacterial spectrum, cover ____, anaerobes, and GNs, add ____ and ____.

Infection control, pulmonary, gastric pH

HAP prevention:

1. ____ ____ procedures (handwashing, isolation)

2. Maintenance/restoration of good ____ mechanics

3. Avoidance of drugs increasing ____ ____

Heart valves, prosthetic

Endocarditis is an infection of the endocardial surface of the heart, most often involving ____ ____, especially ____ ones.

Tricuspid, right

IV drug use-associated endocarditis frequently occurs in the ____ valve and is called "(right/left)-sided" endocarditis.

Staph and strep, GN, Candida

What are the two most common organisms causing endocarditis? It can also be caused by non-HACEK (GP/GN) bacilli or fungal infections like ____.

Staph aureus, viridans group strep and enteroccocus

Native valve acute endocarditis is most commonly caused by what organism? Native valve subacute endocarditis is commonly caused by what two organism?

Staph aureus, GP

Prosthetic valve endocarditis is most commonly caused by what organisms? Other organisms causing it are (GP/GN).

Platelet, trauma, bacteremia

Endocarditis pathogenesis could start with ____ deposits that cause nonbacterial thrombotic endocarditis or ____ to mucous membranes/colonized tissue that causes ____.

Adherence, colonization, vegetation

No matter the beginning of the pathogenesis of endocarditis (nonbacterial thrombotic vs. bacteremia), it will lead to ____, ____, and a mature ____.

High, rapid, death

Acute infective endocarditis has (low/high) virulence. Damage to cardiac structures is very (rapid/gradual). If untreated, ____ may occur within days to weeks.

Less, low, gradual, pre-existing

Subacute infective endocarditis, is a (less/more) invasive organism with (low/high) virulence. Damage is very (rapid/gradual) and usually occurs in those with ____-____ valvular heart disease.

Hypo, septic

Acute clinical presentation of endocarditis includes (hypo/hyper)tension, leukocytosis, altered mental status, and ____ picture.

Fever, Roth, murmur, splenomegaly

Endocarditis physical exam findings:

____ is present in about 90% of endocarditis cases.

HEENT: assess for ____ spots (from septic emboli) and conjunctival hemorrhage

Cardiac: new or worsening ____

Abdomen: assess for ____

Splinter, Janeway, Osler, clubbing, stroke

Endocarditis physical exam findings:

Extremities: assess for ____ hemorrhages, ____ lesions, ____ nodes, and ____ of the fingers

Neuro: cerebral complications - ____-like sx

TTE, TEE

Echocardiograms are one of the diagnostic tests for endocarditis. (TTE/TEE) is less invasive and usually what is done first. (TTE/TEE) is more invasive but also more specific and sensitive.

ABX, 3, different, 2, 24-48

When doing blood tests for endocarditis, you should avoid giving ____ prior to blood cultures when possible. >/= ____ sets of blood cultures from (the same/different) venipuncture sites. >/= ____ sets of samples from blood cultures at ____-____ hours intervals until negative culture obtained.

2, 1 3, 5

For a definite diagnosis of endocarditis, patients must have ____ major criteria or ____ major and ____ minor or ____ minor.