Therapeutics - LRTI 2
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What CURB 65 score indicates severe pneumonia, hospitalization and consideration of ICU admission?
The presence of any one of what S/S indicates severe pneumonia?
- RR >30/minute
- R failure by ABG
- Mechanical ventilation
- Multi-lobular involvement
- Increased radiograph opacity by 50% w/in 48 hours of admission
- >4 hours of vasopressors needed
- Urine output < 20 mL/min or <80 mL/min over 4 hours or ARF requiring dialysis
What are the risk factors for drug resistance in pneumonia?
- >65 years
- Beta-lactam therapy w/in 3 months
- Immunosuppressive therapy/disease
- Multiple medical co-morbidities
- Exposure to a child in day care
What specific pathogens should be considered in the very elderly, due to predisposing conditions to aspiration?
G- and anerobes
What specific pathogens should be considered in the very young (< 1 months)?
Listeria monocytogenes or Chlamydia
What specific pathogens should be considered in the late teens to middle age?
What specific pneumonia causing pathogens should be considered in AIDS?
Pneumocystis jiroveci (formerly carinii), Mycobacterium avium complex (MAC)
What specific pneumonia causing pathogens should be considered in Alcoholism?
Gram negative bacilli & anaerobes
What specific pneumonia causing pathogens should be considered in COPD?
What specific pneumonia causing pathogens should be considered in Cystic fibrosis
- Pseudomonas aeruginosa
- Necessitates prophylaxis
What specific pneumonia causing pathogens should be considered in Sickle cell anemia?
What specific pneumonia causing pathogens should be considered in Viral influenza?
What is the normal recommended treatment for CAP in an otherwise healthy adult?
- Azithromycin (Zithromax) 500 mg PO QD x 7-10D
- Clarithromycin (BIAXIN) 500 mg PO BID x 10-14D
- Doxycycline 100 mg PO BID for 10-14 days
Who should not receive Doxycycline for pneumonia?
Don’t use in pregnant or kids
What are the alternative treatments for CAP in otherwise healthy adults?
- 2nd gen cephalosporin (Cefuroxime, axetil, Cefprozil) + or – a macrolide
- Flouroquinolone (Levo, Moxi or Gemi…NOT CIPRO)
Why are macrolides often used with cephalosporins for CAP?
Macrolides add Mycoplasma coverage that cephalosporins don’t offer
What is a normal treatment regimen for patients with Cardiopulmonary (COPD, Asthma, HF, etc.) comorbidities and CAP?
- Beta-lactam and a Macrolide:
- cefpodoxime 400 mg PO BID x 10-14D
- cefuroxime axetil 500 mg PO BID x 10-14D
- amoxicillin +/- clavulanate 1 gm PO Q8H
- ceftriaxone 1gm once followed by cefpodox
- Azithromycin or clarithromycin or doxycycline
What are the alternative treatments for patients with Cardiopulmonary (COPD, Asthma, HF, etc.) comorbidities and CAP?
What are the recommended treatments for adult patients w/o severe CAP, but are being treated as inpatients?
- azithromycin 500 mg IV QD + beta lactam* IV
- doxycycline 100 mg IV BID + beta lactam* IV
- Respiratory fluroquinalone (moxifloxacin (Avelox), gemifloxacin (Factive), levofloxacin (Levaquin)
- * = ampicillin/sulbactam, ceftriaxone or cefotaxime
What treatment regimen is indicated for a patient with severe disease, no risk factors for pseudomonas and inpatient treatment for pneumonia?
- Ceftriaxone or cefotaxime (3rd gen)
- Azithromycin IV or Flouroquinolone IV
What are the most common pathogens associated with bronchiolitis?
- Respiritory syncytial virus (RSV) – Most common
- Parainfluenza virus
What are the clinical manifestations of Bronchiolitis?
- URI symptoms
- Respiratory distress
How is Bronchiolitis diagnosed?
- Absence of leukocytosis
- Negative CXR
- Nasal secretions with positive viral agents
What are the usual treatments for Bronchiolitis?
- Beta 2 agonists (don’t work very well)
- Corticosteroids (no real benefit)
- Ribavirin (Not FDA approved to be given by small participle generator but that is how it is administered)
What drugs are often given in the ER and confuse the diagnosis of Bronchiolitis because they cause falsely elevated WBCs?
Epinephrine and Solumedrol
What are the indications for Ribavirin in the treatment of Bronchiolitis?
- PAO2 < or = to 65 or rising PCO2
- < 6 weeks in age
- Significant co-morbidities
bronchiolitis occurs in kids less than ______years of age.
Bronchiolitis is seasonal, appearing from ____________ to ______________.
Bronchiolitis can be prevented with ___________agents in specific criteria driven instances.
What is the bronchilotis prophylactic and what is it’s dose?
- Palivzumab (Synagis)
- 15 mg/kg IM monthly from Nov to April
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