CPAP APDIP Tbe Tbh Dd i y LOWER RESPIRATORY INFECTIONS Pulmonary/Critical Care Community- | Within 72 hours of hospitalization | - S. pneumoniae Acquired -H. influenzae - Moraxella -S. aureus - Atypicals (see below) - MSSA/MRSA/Strep - Pseudomonas - E.Coli, Klebsiella, Enterobacter Hospital- Acquired > 72 hours after hospitalization Ventilator- Acquired > 48 hours after ventilation Etiology: [orem Coli Group B Strep ‘Mycoplasma Chlamydia Virus (RSV) IV Drug Use MSSA/MRSA Pseudomonas Alcohol Use Klebsiella Anaerobes Pneumococcus MSSA/MRSA Cystic Fibro: MRSA/MSSA Pneumococcus Pseudomonas Clinical: - Acute onset fever/chills, productive cough, dyspnea, pleuritic chest pain - Hypoxemiia, rales, dullness to percussion, increased tactile fremitus <4 weeks old 4 weeks-18 y/o Postviral Diagnosis: - Chest X-ray (Gold standard, infiltrates are classic) - Sputum Culture, Blood Culture, Pneumococcal/Legionella urine antigen test - These are indicated in certain circumstances (ICU admissions, certain underlying comorbidities/past medical history) COT es Etiology: - Mycoplasma pneumoniae, Chlamydia pneumoniae, Chlamydia psittaci, Coxiella burnetii (Q fever), Legionella - Viruses: Influenza, adenoviruses, RSV Clinical: - Insidious onset (headache, sore throat, fatigue), dry cough, fever - Diffuse wheezing, rhonchi, or rales - CXR (Diffuse reticulonodular infiltrates)LOWER RESPIRATORY INFECTIONS Gu euseu caus Curb-65 (aid for disposition) - Confusion 0-1— Outpatient - Urea (BUN) > 19 mg/dL. = 2— Inpatient -RR>30 - BP < 90/60 mmHg ~ Age > 65 Subgroup Outpatient Intervention - Empiric Antibiotic: Macrolide or Doxycycline. - If high rate of resistance to above, or antibiotic use within the last 3 months — B-lactam (ie Amox) PLUS Azithromycin or Levofloxacin - 5 day course. Must be afebrile for > 48 hours upon termination of antibiotics. HAP or VAP Inpatient CAP - Beta-lactam (Ceftriaxone, Ampicillin-Sulbactam) PLUS macrolide (Azithromycin) - OR respiratory fluoroquinolone (Levo/Moxifloxacin) ICU CAP - Empiric Antibiotics: Beta-lactam (Ceftriaxone, Ampicillin-Sulbactam) PLUS Macrolide (Azithromycin) or respiratory fluoroquinolone (Levo/Moxifloxacin) - MRSA Coverage (Vancomycin or Linezolid) IF: Septic shock/mechanically ventilated, known MRSA colonization or risk factors for colonization - Pseudomonas coverage (Piperacillin-Tazobactam, Cefepime, Meropenem) IF: Structural lung disease (bronchiectasis), gram negative rods on gram stain, frequent COPD exacerbations - MRSA Coverage (Vancomycin or Linezolid) PLUS - Pseudomonas coverage: Pip-Tazo, Cefepime, Gentamicin Follow-up: - Narrow therapy based on culture results, change to oral meds when stable - X-ray will not improve for 4-6 weeks after treatment Pulm26 - High risk individuals should receive follow up X-ray in ~ 7 weeks - For example, male smokers, age > 50 y/o Yay PARRAAR S @ oan ay) IP DMM MM G ¢ | PE Da PPPP PT