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68 Cards in this Set
- Front
- Back
Most common pathogen in community acquired pneumonia: |
S. pneumoniae
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What are "atypical pathogens" that cause CAP?
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M. pneumoniae
C. pneumoniae |
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Are cephalosporins stable in the presence of beta-lactamase?
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Yes.
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What drugs treat CAP caused by S. pneumoniae?
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Macrolides (azithro-, clarithro-, erythromycin)
Standard dose amoxicillin Cephalosporins (ceftriaxone, cefuroxime, cefpodoxime) Tetracyclines (doxycycline) |
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Antimicrobials that treat CAP caused by DRSP.
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High Dose (4 g/day) amoxicillin
Respiratory fluroquinolones (levo-, moxi-, gemifloxacin). Telithromycin |
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About telithromycin.
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It is a macrolide derivative that is currently approved only for PNA. Other uses were discontinued because of liver toxicity. LFT function monitoring is required.
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What is the primary indication for using a respiratory fluroquinolone for CAP?
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To treat DRSP.
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What are the risk factors for CAP caused by DRSP? Note that they are more extensive than the risk factors for DRSP-associated sinusitis.
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Antimicrobial use in last 3 months
Exposure to child in daycare Age >=65 Medical comorbidities (asplenia, COPD, etc.) Alcohol abuse Immunosuppression |
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How are atypical pathogens spread in CAP?
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Cough.
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What populations are at risk for CAP with atypical pathogens?
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Anyone who spends time in close quarters with crowds: people in college dormitories, prisons, long-term care.
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Which antibiotics will treat CAP caused by atypical pathogens?
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Macrolides
Respiratory fluroquinolones Tetracyclines (doxycycline) |
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Why are penicillins and cephalosporins not effective against atypical pathogens in CAP?
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M. pneumo and C. pneumo do no have a cell wall, so they have 'natural resistance" to beta-lactam antibiotics, which inhibit cell wall synthesis.
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What is the national rate of resistance of H. influenzae via beta lactamase production?
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30%
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What are risks for CAP with H. influenzae as the causative organism?
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tobacco-related lung disease
current or significant history of tobacco use |
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What antimicrobials are effective against CAP caused by H. influenzae?
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Cephalosporins
Amox/clavulanate macrolides fluroquinolones tetracyclines |
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What antimicrobials are effective against CAP caused by Legionella?
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Macrolides
fluroquinolones tetracyclines |
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How is Legionella transmitted?
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By aspirating mist from a contaminated water source. Common sources include shower heads, hot tubs, fountains.
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Can legionella be transmitted person-to-person?
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No.
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What is one contraindication to doxycycline?
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Pregnancy. It may cause tooth staining in the unborn child.
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Is a sputum culture required to diagnose CAP?
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No. Cultures rarely isolate the infective organism and are often contaminated with oral flora, etc.
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Which macrolides are CYP inhibitors?
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erythromycin and clarithromycin
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What bodies publish consensus guidelines for treatment of CAP?
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Infectious Disease Society of America/American Thoracic Society (IDSA/ATS)
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What are the two IDSA/ATS classifications of CAP? |
Previously health with no abx use in last 3 months.
OR Comorbidities: COPD, diabetes, renal failure, heart failure, asplenia, alcoholism, immunosuppression, malignancy, OR recent use of antimicrobials. |
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What are the likely organisms causing CAP in previously healthy individuals with no abx in the last 3 months?
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susceptible S. pneumo
Atypicals (M. and C. pneumo) Viruses including influenza, RSV, adenovirus, parainfluenza. |
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What are the likely organisms causing complicated CAP (comorbidities, immunosuppression, recent abx)?
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S. pneumo with DRSP risk
H. influenzae Atypicals (M. and C. pneumo) Respiratory viruses. |
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Differences in causative organisms in CAP for the two IDSA/ATS classifications:
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In complicated CAP, there is risk of infection with H. influenzae and greater risk for DRSP.
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First-line treatment (strong recommendation) for CAP in previously healthy people:
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A macrolide
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Second-line treatment (weak recommendation) for CAP in previously health people:
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doxycycline
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Treatment for CAP complicated by recent antibiotic use (3 mos) or comorbidity: |
Respiratory floroquinolone (levo-, moxi-, and gemifloxacin)
OR Azithro- or clarithromycin (better gram negative coverage than erythro-) AND beta lactam (HD amoxicillin, HD augmentin, cetriaxone, cefpodoxime, cefuroxime) Note: doxy can be substituted for the macrolide. |
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About asplenia and pneumococcal infection:
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Asplenia entails significant risk for pneumococcal infection with DRSP. Always give pneumovax.
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Nausea and vomiting with CAP indicates:
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Possible need for admission
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4 common symptoms of PNA
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Cough (90%)
Dyspnea (66%) Sputum production (66%) Pleuritic chest pain (50%) |
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Characteristics of pleuritic chest pain:
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Pain is elicited by deep breathing, is localized, and is sharp and stabbing in quality. A pleural friction rub may be auscultated over the location of the pain.
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Is a follow-up CXR required to confirm resolution of CAP?
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No, however smokers should have a CXR in 7-12 weeks to check for lung cancer.
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What patient characteristics should cause the NP to consider hospitalization for CAP? |
Age >65
Abnormal electrolytes or CBC Renal disease, DM, CHF, immunosuppression, airway disease. Abnormal vital signs. |
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What are risk factors for CAP caused by pseudomonas?
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Lung disease
corticosteroid use of prednisone >10mg/day or higher Broad spectrum antibiotic use in last one month malnutrition |
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Do macrolides and tetracyclines have activity against DRSP?
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No.
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What percentage of CAP is caused by S. pneumo?
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Nearly 2/3
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Best medication to treat CAP in a previously healthy, 38 year old woman with an IUD: |
a) doxycycline.
Amoxicillin alone and TMP/SMX are never adequate for CAP. Moxifloxacin is too strong for this previously healthy woman. |
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Chest exam findings with CAP:
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Dullness to percussion with egophony, whispered pectoriloquy and increased tactile fremitus over any consolidation.
Bronchial or bronchovesicular breath sounds over lung fields. Late inspiratory crackles or a pleural rub. |
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Best antibiotic to treat CAP in a 55 year old man with no chronic health conditions.
a) azithromycin b) levofloxacin c) TMP/SMX d) cefprozil |
a) azithromycin
TMP/SMX is not recommended for CAP. Levofloxacin is stronger than needed. Cefprozil is recommended in conjunction with a macrolide for complicated CAP, but is never used alone as it really only covers S. pneumo. |
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Best antibiotic to treat CAP in a 70 year old man with 50 pack-year history of smoking
a) doxycycline b) levofloxacin c) amox/clavulanate d) cefdinir |
b) levofloxacin.
This is CAP complicated by smoking. Doxycycline is recommended for uncomplicated CAP. Amox/clavulanate and cefdinir are never used alone for CAP. |
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T/F: Fluroquinolones are photosensitizing
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T
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T/F: Fluroquinolones are renally metabolized.
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F
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Which of the following characteristics apply to the macrolides
a) consistent activity against DRSP b) contraindicated in pregnancy c) effective against atypical pathogens d) unstable in the presence of beta-lactamase |
c) effective against atypical pathogens.
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What is the duration of abx therapy for CAP recommended by ATC?
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5-7 days.
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Modifying factors for P. aruginosa infectinon in CAP include all of the following except
a) corticosteroid use b) structural lung disease c) malnutrition d) day care attendance |
d) day care attendance. This is a risk factor for DRSP infection.
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How can the NP determine the adequacy of a sputum sample for grams staining and evaluation of CAP?
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Adequate samples have few epithelial cells and many WBCs.
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When seeing a 62-year old hospitalized with CAP
a) pneumococcal vaccine should be given at the end of antimicrobial therapy b) pneumococcal vaccine can be given today and influenza vaccine in 2 weeks c) influenza vaccine today and pneumococcal in two weeks. d) both vaccines should be given today. |
d) current antibiotic therapy and past infection with CAP are not contraindications for pneumovax or influenza vaccine
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Two nicknames for neutrophils.
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Polys and segs (these refer to mature nutrophils).
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What are "bands" and what do they mean?
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They are immature neutrophils, and an increase in their relative presence indicates response to a bacterial infection.
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Action of neutrophils:
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Bacteria
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Action of Lymphocytes:
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Virus
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Action of monocytes:
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Debris
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Action of eosinophils:
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allergens and parasites
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Action of basophils:
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unknown
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Approximate normal % of CBC of each cell types.
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Neutrophils - 60%
Lymphocytes - 30% Monocytes - 6% Eosinophils - 3% Basophils - 1% (Mnemonic for order: Noboby Likes My Educational Background). |
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Normal lab values: bands.
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0-4% of Leukocytes
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Normal lab values: WBC count
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6 - 10 x 10^3 /mm^3
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Three components of the WBC "left shift"
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1. Leukocytosis (WBC>10,000)
2. Neutrophilia (Neutrophils >70%) 3. Bandemia (Bands >4%) |
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What does a WBC "left shift" indicate?
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Bacterial infection.
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Typical findings in a CBC indicating viral infection:
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Neutrophils: 35% (decreased due to relative increase in Lymphocytes)
Lymphocytes: 55% (increased) Bands: 3% (still within normal range) |
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What is the most common causative organism in acute bronchitis?
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Respiratory viruses - 90%
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Bacteria comprise just 10% of pathogens in acute bronchitis. What are the three most common bacteria?
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M. and C. pneumoniae
B. pertussis |
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Symptomatic therapy for viral bronchitis:
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Anticholinergic bronchodilator such as ipatropium bromide INH (Atrovent)
Short course of oral corticosteroids for protracted cough. |
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What causes cough in acute bronchitis?
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Cough is the response to swelling of the airways caused by inflammation.
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What antimicrobials are active against B. pertussis?
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Macrolides
Tetracyclines |
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What type of bacteria is B. pertussis?
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Gram negative.
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