Term
|
Definition
| infection/inflammation of alveoli, distal airways, & interstitium of lung |
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Term
| Community-Acquired Pneumonia (CAP) |
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Definition
non-hospitalized pt;
inflammation of parenchyma in lungs;
caused by ACUTE infection;
Routes of Pathogen Access:
- inhaled aerosolized particles
- entry into lungs via blood stream
- aspiration of oropharyngeal contents
Overcome Host Defenses:
- saliva, sloughing epithelial cells;
- mucociliary activity, cough reflex;
- alveolar macrophages, neutrophils |
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Term
| Risk Factors/Common Comorbidities for CAP |
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Definition
advanced age;
HIV;
recent Abx therapy;
cigarette smoking;
EtOH/narcotic abuse;
asplenia;
chronic pulmonary disease;
CHF, asthma, CVD, chronic renal disease, DM, liver dx, neoplastic dx |
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Term
| Common Bacterial Pathogens for CAP |
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Definition
| Strep. pneumoniae, Mycoplasma pneumoniae, Haemophilus influenzae, Chlamydophilia pneumoniae, Legionella, Gram-Neg bacteria, Staph. aureus |
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Term
| Clinical Presentation of CAP |
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Definition
S/Sx:
- abrupt onset of fever/chills, dyspnea, productive cough, rust-colored sputum/hemoptysis, pleuritic chest pain, myalgia, malaise/fatigue;
PhEX:
- tachypnea, tachycardia, dullness to percussion, bronchial breath sounds, inspiratory crackles, rales, rhonchi, wheezing;
Labs:
- leukocytosis (esp. neutrophils)
- elevated bands = "left shift"
- low O2 sat
CXR:
- infiltrates in single or both lobes
- lower lobe = most bacterial forms
- pleural effusions |
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Term
| Sputum Samples (Gram-Stain, culture) |
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Definition
ideally done before starting Abx;
- not routinely recommended for outpatient
- recommended for inpatients |
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Term
|
Definition
| indicated for severe CAP in intubated pts |
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Term
| Bronchoscopy/Brochial alveolar lavage (BAL) |
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Definition
| recommended if immunocompromised pts or if failed previous therapy |
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Term
|
Definition
available for Strep. pneumoniae & Legionella pneumophilia;
- rapid turnaround time;
- maintains high sensitivity after initiation of Abx;
- costly & does NOT provide susceptibilities |
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Term
|
Definition
Confusion, Uremia, Respiratory Rate, low Blood pressure, age 65 or >;
Score: 0-1 --> Group 1 Low Mortality --> Suitable for home (PO) therapy;
Score = 2 --> Group 2, Intermediate Mortality --> consider hospital tx (short stay or hospital supervised outpt);
Score = 3 or more --> Group 3 High Mortality --> manage in hospital as severe pneumonia, assess for ICU, Admission ESPECIALLY if score >4-5 |
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Term
|
Definition
Severe = 1 major criterion OR >3 minor criterion;
Minor:
- RR >30 breaths/min, PaO2/FiO2 ratio <250, multilobar infiltrates, confusion/disorientation, uremia (BUN >20), leukopenia (WBC <4000), thrombocytopenia (Plt <100,000), hypothermia, hypotension;
Major:
- invasive mechanical ventilation
- septic shock w/ need for vasopressors |
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Term
| Empiric Outpatient Tx of CAP in pts who are PREVIOUSLY HEALTHY/NO RISK FACTORS for RESISTANCE |
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Definition
Macrolide (azithromycin, erythromycin, clarithromycin)
OR
doxycycline (weak)
**If high rates of macrolide-resistant S. pneumoniae --> consider using alternative agents if no comorbidities |
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Term
| Empiric Outpatient Tx of CAP in pts who have COMORBIDITIES, ABX IN LAST 3 MONTHS, OTHER RISK FACTORS for RESISTANCE |
|
Definition
Respiratory FQN - moxifloxacin, gemifloxacin, levofloxacin
OR
Beta-lactam PLUS macrolide
OR
Beta-lactam PLUS doxycycline |
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Term
| Non-ICU Empiric Therapy for INPATIENT CAP |
|
Definition
respiratory FQN - moxifloxacin, gemifloxacin, levofloxacin --> *preferred in PCN allergy;
OR
Beta-lactam PLUS macrolide;
**Preferred initial therapy is IV |
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Term
| ICU (severe) Empiric Therapy for CAP |
|
Definition
beta-lactam (cefotaxime, ceftriaxone, ampicillin/sulbactam)
PLUS
respiratory FQN OR azithromycin
**If PCN Allergy:
- respiratory FQN PLUS aztreonam
**IV initial therapy preferred |
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Term
| Empiric Therapy for CAP involving Pseudomonas |
|
Definition
antipneumococcal + antipseudomonal Beta-Lactam (piperacillin/tazobactam, cefepime, meropenem) - *if PCN allergic, substitute w/ Aztreonam
PLUS
1) ciprofloxacin OR levofloxacin
Or
2) azithromycin AND aminoglycoside (gentamicin, tobramycin, amikacin)
OR
3) aminoglycoside (gentamicin, tobramycin, amikacin) AND antipneumococcal FQN (moxifloxacin, levaquin, NOT ciprofloxacin) |
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Term
| If CA-MRSA is suspected in Empiric Tx of CAP |
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Definition
| add vancomycin OR linezolid to current stadard empiric therapy |
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Term
| Duration of Therapy for CAP |
|
Definition
minimum of 5 days;
pt must be afebrile for 48-72 hrs;
pt must not have more than 1 CAP-associated sign of clinical instability |
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Term
| Criteria for Clinical Stability |
|
Definition
Temp <37 C;
HR <100 bpm;
RR <24 breaths/min;
SBP >90 mmHg;
O2 sat >90% or PO2 >60 mmHg on room air;
Ability to maintain oral intake;
Normal mental status |
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Term
| Hospital-Acquired Pneumonia (HAP |
|
Definition
>= 48 hrs after admission to hospital, not incubating before admission;
- manage in hospital ward or ICU per severity of illness |
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Term
| Ventilator-associated Pneumonia |
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Definition
| >= 48-72 hrs after endotracheal intubation |
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Term
| HealthCare Associated Pneumonia (HCAP) |
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Definition
| any pt hospitalized within 90 days of infection; resided in nursing home, LTCF; received recent IV Abx therapy, chemotherapy or wound care w/in last 30 days of infection; or attended a hospital or hemodialysis (HD) clinic |
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Term
| Risk Factors for Nosocomial Pneumonia |
|
Definition
severe illness (acute or chronic - including chronic lung dx);
advanced age (>70 yrs old);
prolonged hospitalization;
coma;
reintubation;
malnutrition;
chest surgery;
antacid therapy (H2RA, PPIs);
increased aspiration risk (NG tubes, ET tubes, & enteral feedings) |
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Term
| Risk Factors (ICU) for VAP/HAP |
|
Definition
mechanical ventilation;
endotracheal intubation;
longer duration of mechanical ventilation;
depressed level of consciousness (sedation);
pre-existing lung dx;
immunosuppression from dx or medications;
malnutrition |
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Term
|
Definition
Gram-Neg (resistant):
- PSA, E. coli, Klebsiella, other Enterobactericeae (Enterobacter, Serratia, Citrobacter), Proteus, Acinetobacter, Stenotrophomonas;
Gram-Pos:
- Staph. aureus (MSSA, MRSA), Strep. pneumoniae, H. influenzae, Coag. neg Staph, Corynebacterium, Viridans Grp Strep.;
Anaerobes: from aspiration events |
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Term
|
Definition
occurs w/in 4 days of hospitalization;
-likely caused by Abx-sensitive bacteria
- better prognosis |
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Term
|
Definition
develops after 5+ days of hospitalization;
- more likely to be caused by Abx-resistant bacteria;
- associated w/ increased pt mortality/morbidity |
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Term
| Risk Factors for Multi-Drug Resistant (MDR) HAP |
|
Definition
current hospitalization >= 5 days;
duration of mechanical ventilation (>= 7 days);
Abx therapy within 90 days;
prior use of broad spectrum antibiotics |
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Term
| Risk Factors for MDR HCAP |
|
Definition
residence in nursing home or LTCF;
home wound/infusion therapy;
chronic dialysis within 30 days;
family member with MDR pathogen/known exposure;
>= 2 days in hospital within last 90 days;
immunosuppressive dx &/or therapy |
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Term
| Pts at High Risk for Fungal HAP |
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Definition
organ transplant;
immunocompromised;
neutropenic pts |
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Term
| Principles of Management of HAP/VAP/HCAP |
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Definition
Avoid untreated or inadequately treated HAP;
Recognize variability of bacteriology;
Avoid overuse of Abx;
Apply prevention strategies aimed at modifiable risk facots |
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Term
| Differential Diagnosis of HAP |
|
Definition
acute respiratory distress syndrome (ARDS);
thromboembolic dx (pulmonary embolism);
aspiration pneumonitis (chemical pneumonitis);
metastatic processes (effusion);
sepsis;
CHF;
atelectasis |
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Term
|
Definition
Presence of new or worsening pulmonary infiltrates on CXR
PLUS 2 of following:
- unexplained new or worsening of fever;
- new or unexplained leukocytosis or leukopenia;
- change in qty & quality of pulmonary secretions;
- worsening respiratory status |
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Term
| Empiric Therapy of Early-Onset HAP if NO KNOWN RFs for MDRs, EARLY ONSET, ANY DX SEVERITY |
|
Definition
ceftriaxone
OR
levofloxacin/moxifloxacin/ciprofloxacin
OR
ampicillin/sulbactam
OR
ertapenem |
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Term
| Empiric Therapy for LATE ONSET HAP in pts WITH RFs for MDRs or LATE ONSET, & ALL DX SEVERITIES |
|
Definition
antipseudomonal cephalosporin (cefepime, ceftazidime)
OR
antipseudomonal carbapenem (imipenem/cilastatin, meropenem, doripenem)
OR
Beta-Lactam/Beta-Lactamase Inhibitor (piperacillin/tazobactam)
PLUS EITHER:
respiratory FQNs (levofloxacin, ciprofloxacin)
OR
aminoglycoside (amikacin, gentamicin, tobramycin)
PLUS EITHER:
vancomycin
OR
linezolid |
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Term
| AVOID overtreating HAP/VAP/HCAP - Streamlining Antibiotics |
|
Definition
tailor therapy once culture results/susceptibilities known;
change therapy to most narrow-spectrum agent that covers pathogen;
save combo therapy for MDR organisms;
limit AMG therapy to avoid toxicity; |
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Term
| Duration of Therapy for HAP |
|
Definition
Avoid over-treating;
Recommended: 7-14 days
- may depend on culture results
- longer tx (14-21 days) for PSA |
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Term
|
Definition
| brochodilator that improves oxygenation in bronchospastic pts w/ HAP |
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Term
|
Definition
| dries excessive respiratory secretions in pts w/ HAP |
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Term
| Non-Pharm Therapies for Tx of HAP |
|
Definition
supplemental O2;
adequate hydration/diuresis, monitoring fluid status;
nutritional support;
chest physical therapy;
manual suctioning of secretions;
smoking cessation; |
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Term
|
Definition
Influenza vaccine;
Pneumococcal vaccine |
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Term
| Pneumococcal Polysaccharide Vaccine (Prevnar-13, Pneumovax-23) |
|
Definition
Recommended for:
- all persons >65 yrs;
- high-risk persons 2-64 yrs;
- current smokers;
Revaccination Schedule:
ONE TIME REVACCINATION
- after 5 yrs for adults >= 65 yrs old, if 1st dose given before 65 yrs old;
- persons w/ asplenia;
- immunocompromised pts; |
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Term
| Inactivated Influenza Vaccine |
|
Definition
IM, killed virus;
Recommended Groups:
- all persons >50 yrs old;
- high-risk pts 6 months-49 yrs old;
- household contacts of high-risk pts;
- healthcare providers;
- children 6-23 months old;
Revaccination Schedule:
- annual |
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Term
| Live Attenuated Influenza Vaccine |
|
Definition
Intranasal, LIVE;
Recommended Groups:
- healthy persons 5-49 yrs old including HealthCare professionals, household contacts of high risk pts;
Recommended Revaccination:
- annual |
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Term
| Antibiotics w/ PSA coverage |
|
Definition
AMGs:
- gentamicin, tobramycin, amikacin;
Quinolones:
- levofloxacin;
Beta-Lactams:
- Cephalosporins: ceftazidime, cefepime;
- Carbapenems: imipenem/cilastatin, meropene, doripenem;
- Combinations: piperacillin/tazobactam (Zosyn), ticarcillin/clavulanate (Timentin) |
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Term
| Adjunctive Measures for HAP/VAP |
|
Definition
Blood glucose control:
- reduces risk of nosocomial blood stream infections
- reduces duration of mechanical ventilation
- reduces ICU stay, morbidity/mortality;
GI Stress Ulcer Prophylaxis
- decreasing acidity in stomch may be bad;
- may increase risk of aspiration, bacterial translocation;
During Enteral Feedings, Place Pt in Semi-Recumbent Position:
- reduce risk of aspiraiton |
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Term
|
Definition
| inactivated by lung surfactant, DO NOT use in tx of pneumonia |
|
|
Term
|
Definition
DO NOT use as monotherapy for pneumonia!!!
- only 20% of [serum] penetrates lung/alveoli |
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