ID - Pneumonia Influenza Sinusitis UTI

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Snooze
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298539
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ID - Pneumonia Influenza Sinusitis UTI
Updated:
2015-03-18 17:47:50
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Pneumonia
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Pneumonia, Influenza, Sinusitis, UTI
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  1. Which of the following has the highest mortality rate among the others:
    -CAP w/o hospitalization
    -CAP with hospitalization
    -Nosocomial
    Nosocomial (33-50%)
  2. In order to qualify to be considered CAP, what 4 factors must be considered?
    • Pt must not have...
    • 1. Hosp for 2 or more days w/in 90days

    2. Live in LTC facility

    3. In the past 30d, received either: IV Abx, chemo, or wound care

    4. Attendance at a hosp or HD clinic
  3. Sx's of CAP include fever, rigors, sweats, fatigue but also has a common unique sx of what in elderly? What 3 sx's are the MOST common n unique to CAP?
    Elderly: Mental status changes

    • New cough w/or w/o sputum
    • Onset of SOB
    • Chest discomfort
  4. Hospitalization should be based on CURB-65 for pt w/CAP. What does it represent?
    • Confusion
    • Urea>=20mg/dl (BUN)
    • RR>30 breaths/min
    • BP: SBP<90 or DBP<60
    • -65: Age 65 and older
  5. CURB-65 reps which pt should b hospitalized. Based on the points 0-5, where should pts be treated? Outpt, inpt, ICU?
    • 0: Outpt
    • 1: Outpt

    2: Outpt or Inpt

    3: Inpt

    • 4: Inpt +/- ICU
    • 5: Inpt +/- ICU
  6. Wuts the diff in definition of these 3 nosocomial pneumonia:
    -HAP (hosp acquired)
    -VAP
    -Health care asso'd pneumonia
    HAP: Pneumonia that occurs 48hrs or more after admission (is not incubating at time of admission)

    VAP: Pneumonia that arises more than 48-72hrs after endotracheal intubation

    Health care asso'd pneumonia: Pneumonia that develops in pt hosp for 2 or more days w/in 90d; who lives in LTC facility; who had tx of either IV Abx, chemo, or wound care w/in past 30 days; or who attended hosp or HD clinic
  7. Wut r the top 3 bugs with highest incidence to CAP? Top 2 bugs for HAP?
    • CAP:
    • Unidentified (40-60%)
    • Mycoplasma pneumo (atypical bug)
    • Strep pneumo (9-20%)

    • HAP:
    • Unidentified (50%)
    • S. aureus (10%)
  8. Wut r the 3 drug classes available that can treat atypical bugs (i.e. Legionella, Mycobacterium, Mycoplasma, Chlamydia)?
    • 1. TCNs
    • 2. Macrolides
    • 3. FQ's (levo, moxi, gemi)
  9. Besides the common pathogens found in CAP, which common bugs can be found in the following specific populations:
    -Alcoholics
    -Poor oral hygiene
    -COPD
    -Exposure to water
    -HIV infx
    • -Alcoholics: Oral anaerobes
    • -Poor oral hygiene: Oral anaerobes

    -COPD: M. catarrhalis

    -Exposure to water: Legionella

    -HIV infx: Pneumocystis jiroveci
  10. For CAP tx in the outpt setting (0-1 points with CURB-65), in the previously healthy and no Abx tx in past 3 months, what are the treatment choices? (3)
    • Use macrolide first-line
    • 1. Azithromycin 500mg x1, then 250mg po days 2-5
    • 2. Clarithromycin 1000mg po qd x7d

    3. Doxycycline 100mg PO BID (use only if allergic to macrolides)
  11. For CAP tx in the outpt setting (0-1 points with CURB-65), with certain comorbidities (COPD, CHF, DM, renal or liver dz, cancer, asplena, immunosuppression) and/or recent Abx tx in past 3 months, what are the treatment choices? [HINT: What can be used as monotherapy and combo therapy... 3 monotherapies and 5 diff combos]
    • Monotherapy: FQ's
    • 1. Levofloxacin 750mg po qd
    • 2. Moxifloxacin 400mg po qd
    • 3. Gemifloxacin 320mg po qd

    • Combo therapy: Macrolide (or doxy) PLUS beta-lactam
    • 1. Macrolide PLUS Amoxicillin 1g PO TID
    • 2. Macrolide PLUS Amox/Clav 2g PO BID
    • 3. Macrolide PLUS Ceftriaxone IV 1g q12 or 2g q24 followed by cefpodoxime PO
    • 4. Macrolide PLUS cefpodoxime 200mg PO BID
    • 5. Macrolide PLUS cefuroxime 500mg PO BID
  12. For CAP tx in inpt setting (2+ pts in CURB-65), whats empiric tx in pt w/moderately severe pneumonia not requiring ICU? [HINT: 2 Monotherapies and 3 combo therapies]
    • Monotherapy: FQ's
    • 1. Levofloxacin 750mg IV qd
    • 2. Moxifloxacin 400mg IV qd

    • Combo therapies: Macrolide (or doxy) PLUS beta-lactam
    • 1. Macrolide PLUS Ampicillin 1-2g IV q8hrs
    • 2. Macrolide PLUS Ceftriaxone 1g IV q12hrs or 2g IV q24hrs
    • 3. Macrolide PLUS cefotaxime 1-2g IV q8hrs
  13. For CAP tx in inpt setting (4+ pts in CURB-65), whats empiric tx in pt w/ severe pneumonia requiring ICU? [HINT: 3 combos]
    • IV FQ/Azithromycin PLUS beta-lactam:
    • 1. IV FQ/Azithromycin PLUS ampicillin/sulbactam (Unasyn) 1.5-3.0g IV q6hrs
    • 2. IV FQ/Azithromycin PLUS Ceftriaxone 1g IV q12hrs or 2g IV q24hrs
    • 3. IV FQ/Azithromycin PLUS Cefotaxime 1-2g IV q8hrs
  14. When evaluating for antibiotics to use for nosocomial pneumonia, one must evaluate risk for MDR organisms, like PA, MRSA, etc. What are the 5 risk factors for MDR organisms?
    • 1. Abx tx w/in past 90d
    • 2. Hosp of 5 days or more
    • 3. High resistance in community or hosp unit
    • 4. RF for health-care asso'd pneumonia
    • 5. Immunosuppressive dz and/or therapy
  15. Nosocomial pneumonia tx is separated into 2 components: Early onset (<5 days) and late onset (5 days or more)/RF for MDR organisms.

    What are the 4 tx choices for early onset hosp-acquired pneumonia? [HINT: All monotherapy]
    1. Ceftriaxone 1g IV q12hr or 2g IV q24hrs

    2. Levofloxacin 750mg IV q24hrs or ciprofloxacin 400mg IV q8hrs

    3. Ampicillin/sulbactam (Unasyn) 1.5-3.0g IV q6hrs

    4. Ertapenem 1g IV q24hrs
  16. Nosocomial pneumonia tx is separated into 2 components: Early onset (<5 days) and late onset (5 days or more)/RF for MDR organisms.

    What are the 4 tx choices for late onset/RF for MDR organisms for hosp-acquired pneumonia? [HINT: All combos]
    All AMG/FQ + another anti-PA +/- Vanco/Linezolid (MRSA)

    1. AMG/FQ + ceftazidime/cefepime 2g IV q8hrs

    2. AMG/FQ + Imi/Mero/Dori-penem 1g IV q8hrs (fyi ertapenem has NO PA coverage)

    3. AMG/FQ + Piperacillin/Tazobactam (Zosyn) 3.375gIV q4hrs or 4.5g IV q6hrs

    • 4. To all above, if MRSA risk, add either:
    • -Vancomycin 45-60mg/kg/day q8-12hrs (max 2000mg/dose), trough 15-20mg/L
    • OR
    • -Linezolid 600mg IV q12hrs
  17. When evaluating for MRSA coverage in nosocomial pneumonia, what are the 5 RF's for MRSA to help consider using vanco/linezolid?
    1. Hx of MRSA infx/colonization

    2. Recent hosp

    3. Recent Abx use

    4. Presence of invasive health care devices

    5. High local incidence >10%
  18. Influenza occurs almost exclusively in months ranging ___________ and pts should be vaccinated in months _______________.
    Influenza occurs almost exclusively in months ranging Dec-April and pts should be vaccinated in months Sep - Oct.
  19. Mortality from influenza is greater in which population? However, flu vaccine can prevent >___% of illnesses, hospitalizations, and deaths in this popl'n.
    Mortality: >65 yo (esp w/heart or lung dz), fyi 80% of deaths in this age grp.

    Can prevent >50% of M&M in >65yo (fyi prevents >70-90% in <65yo healthy ppl)
  20. Wut r 8 differences in influenza and Cold sx's? [HINT: 5 more prominent sx in influenza, 3 more prominent in Cold]
    • Influenza:
    • 1. Onset is sudden
    • 2. High T >101 deg F is characteristic
    • 3. HA is prominent
    • 4. Myalgia (can be severe)
    • 5. Exhaustion (not seen in Cold)

    • Cold:
    • 1. Stuffy nose common
    • 2. Sneezing is usual
    • 3. Sore throat common
  21. Which 3 pt groups should be treated w/neuraminidase inhibitors w/in 48hrs of confirmed/suspected influenza?
    • 1. Hospitalized pts
    • 2. Severe, complicated, or progressive illness
    • 3. High risk of influenza complications (<2yo, >65yo, chronic dz states, immunosuppressed, pregnant, live in LTC, etc)
  22. Which of the following are neuraminidase inhibitors? Which are not rec'd for tx nor Px d/t univeral resistance in influenza A?
    -Amantadine (Symmetrel)
    -Rimantadine (Flumadine)
    -Oseltamivir (Tamiflu)
    -Zanamivir (Relenza)
    • Neuraminidase inhibitors
    • -Oseltamivir (Tamiflu)
    • -Zanamivir (Relenza)

    • Not rec'd:
    • -Amantadine (Symmetrel)
    • -Rimantadine (Flumadine)
    • -FYI these only effective against influenza A virus
  23. What is the Px dose and Tx dose for influenza of oseltamivir? Zanamivir? (Must be initiated w/in 48hrs of confirmed/exposed)
    • Px: (fyi use in severely immunosupp'd)
    • 1. Oseltamivir 75mg once daily x10d
    • 2. Zanamivir 10mg (2 inhalations) daily x4 wks

    • Tx:
    • 1. Oseltamivir 75mg BID x5d (fyi 75mg daily for CrCl<30)
    • 2. Zanamivir 10mg (2 inhalations) BID x5d
  24. What is one common ADR of oseltamivir? Zanamivir?
    Oseltamivir: GI (N/V)

    Zanamivir: Bronchospasms or cough (not rec in pt w/asthma or COPD)
  25. Pneumococcal vaccine (Pneumovax 23, Prevnar 13) recommendation groups will be separated into immunocompetent and immunosuppressed patients.

    Describe the 3 immunocompetent groups and their pneumococcal vaccine recommendations.
    • Immunocompetent:
    • 1. Age 65 and older: PCV13, then PPSV23 (8 wks after PCV13, at least 5yrs after 1st PPSV23 if given. If PPSV23 given <65, ensure PCV13 given at least 1yr after 1st PPSV23)

    2. 19-64yo with chronic dz (CV, Pulm, DM, alcoholism, liver) or are adult asthmatics/smokers: SINGLE dose of PPSV23

    3. Ppl w/cochlear implants or CSF leaks: PCV13, then PPSV23 (8 wks later)
  26. Pneumococcal vaccine (Pneumovax 23, Prevnar 13) recommendation groups will be separated into immunocompetent and immunosuppressed patients.

    Describe the immunosuppressed group and their pneumococcal vaccine recommendations.
    • Immunocompromised:
    • 1. Ages 19 and older with HIV, leukemia, lymphoma, Hodgkin dz, MM, malignancy, chronic renal failure (or nephrotic syndrome); recieving chemo (including corticosteroids); those who have recieved organ or bone marrow txplant; those with functional or anatomic asplenia: PCV13, then PPSV23 (8 wks later, AND 5yrs after 1st PPSV23, if given. Wait 1 yr after 1st PPSV23 to give PCV13, if applies)
  27. This answers why patients need both Prevnar 13 and Pneumovax 23... whats the difference and similarity in serotype coverage in each vaccine?
    Both cover same 12 serotypes

    Prevnar covers 1 more than PPSV23

    Pneumovax covers 11 more than PCV13
  28. When should children start getting influenza vaccine? At what age should patients get 2 vaccinations on their 1st season (and how many months apart from 1st shot)?

    In which patients is there a dramatic decreased antibody response?
    Everyone 6 months or older should get vaccine

    1st season: <9yo should receive TWO doses, at least 1 month apart

    Decreased response: HIV pt have <60% adequate response (but should still get it!)
  29. Which pt's r indicated for the following flu vaccines:
    1. Inactivated trivalent/quadrivalent (Fluzone, Fluarix)
    2. LAIV intranasal (FluMist)
    3. High dose trivalent (Fluzone HD)
    4. Inactivated intradermal (Fluzone intradermal)
    5. Inactivated cell culture based (Flucelvax)
    6. Recombinant inactivated (Flublok)
    1. Inactivated trivalent/quadrivalent (Fluzone, Fluarix): 6 months and older (includes pregnant, healthcare workers, close contact w/immunocompromised ppl)

    2. LAIV intranasal (FluMist): Healthy 2-49yo

    3. High dose trivalent (Fluzone HD): 65 and older (fyi CDC has no pref over this or reg)

    4. Inactivated intradermal (Fluzone intradermal): 18-64yo

    5. Inactivated cell culture based (Flucelvax): 18 and older (still has egg allergy caution)

    6. Recombinant inactivated (Flublok): 18-49yo, safe for egg allergy
  30. Sinusitis can be caused by viruses, bacteria or fungi. ________ accounts for >90% cases while ___________ accounts for <10% of cases.
    Viruses accounts for >90% cases while bacteria accounts for <10% of cases.
  31. To dx sinusitis, pt must have ___ major symptoms. Alternatively, pt can be dx'ed if they have ___ major sx and ____ minor sx's. What are 4 major sx's and 5 minor sx's?
    Dx sinusitis: pt must haveĀ 2 major symptoms. Alternatively, 1 major sx and 2+ minor sx's.

    • Major:
    • 1. Purulent nasal discharge
    • 2. Nasal/facial congestion
    • 3. Facial pn or pressure
    • 4. Fever (acute sinusitis only)

    • Minor:
    • 1. HA
    • 2. Ear pain (pressure or fullness)
    • 3. Halitosis
    • 4. Dental pn
    • 5. Fever (subacute or chronic sinusitis)
  32. Although similarities in viral and bacterial sinusitis include having nasal discharge/congestion, scratchy throat, facial pn and HA, they also have distinguishing differences. What are their differences in the following:
    1. Nasal discharge
    2. Fever
    3. When sx's peak
    4. Duration
    1. Nasal discharge: Viral is clear to purulent to clear (bacterial is always purulent)

    2. Fever: Viral seldom has fever (if +, resolve w/in 48hrs)

    3. When sx's peak: Viral peaks on d3-6; Bacteria can be either persistent >10d, early and severe, or improved sx's that worsen on d5-6

    4. Duration: Viral is 5-10d; Bacterial is >10d
  33. Wuts 1st line therapy for bacterial sinusitis?
    Augmentin 2g PO BID or 90mg/kg/d divided twice daily
  34. Wuts 2nd line therapy for bacterial sinusitis? [HINT: 3 drug classes, 2 suggestions for PCN-allergic kids]

    What are 2 adjunctive therapies?
    • 2nd line:
    • 1. Doxycycline 100mg PO BID
    • 2. FQ's - Cipro 500mg BID x10d (kids w/type I hypersensitivity to PCN's)
    • 3. Cefpodoxime 200mg PO BID with clindamycin (150mg q6-8hrs?) (kids w/non-type I hypersensitivity to PCN's)

    • Adjunct therapies:
    • 1. Intranasal saline
    • 2. Intranasal corticosteroids (for pt w/allergic rhinitis)

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