pulmonary inf./TB/sarcoidosis Flashcards
questions to ask
sick contacts
travel hx
testing to do
CXR
sputum sample (40% can’t)
-may need bronchoscopy
sodium levels may be
low
CAP org
Strep pneumo
cough mechanism prevents
URI from becoming LRTI
S. pneumo presentation
fever, hypothermia, tachypnea, cough +/- sputum (typically), dyspnea, chills/rigors/sweats -ha, lack of appetite -clammy, bluish skin -N/V, joint pain -fatigue -inspiratory crackles, bronchial breath sounds -may have hemoptysis (non-hosp. pts, not chemo pt)
S. pneumo CXR
-+ CXR w/ infiltrate or consolidation
S. pneumo compensatory mechs
- low BP
- inc. HR
dx testing necessary?
not always; empirically tx for S.pneumo
S.pneumo tx
augmentin, levoquin, PCN, clindamycin
other dx
Cx, Gs, urine antigen testing
other orgs
Legionella pneumophilia
Group A, C, G strep
Staph aureus (inc. CA-MRSA)
complication with S. aureus (CA-MRSA)
fall months, get influenza–>secondary bac. pneumo
consider HIV testing
hypoxemic, bacteremic, young, otherwise sev. pts
HIV+ pts w/ CD4 count >200 more likely
to have CAP vs. OI
flu season
(sept-march)
if flu pt. 5 days oral Tamiflu again has high fevers, purulent sputum
S. aureus
S. aureus tx
vancomycin, zyvox (linezolid)$, PCN, augmentin
MRSA
bactrin, clindamycin, doxycyclin
- fever 101.5
- ha, chills, body ache, malaise
- “foggy”
- hyponatremic (121)
- WBC count low (4.2K)
- heating/cooling repair, produce section, etc
Legionella pneumonia
“Legionnaire’s disease”
fogginess, altered may be due to
hyponatremia
Legionella on sputum Cx
very rarely
do urine antigen
Legionella symps begin
2-14 days post-exposure
Leg.: transmitted?
cannot be transmitted person-person
Leg tx 1st line
macrolide(clarithromycin, azithromycin)
doxycycline
Leg tx rec. abx, comorb.
resp. FQs
macrolide + B lactam (cefuroxime, amoxicillin, augmentin)
inpt. management
resp. FQ: moxifloxacin, levofloxacin, IV moxifloxacin, levaquin*
macrolide + beta lactam: azithromycin + ceftriaxone*
inpt ICU management
azithromycin or resp. FQ + antipneumococcal B lactam (cef, amp)
inpt. ICU tx for pts allergic to B lactams
FQ + aztreonam, tigecycline
inpt. ICU tx for high risk pseudomonas
piperacillin-tazobactam, cefepime, carbapenem, ciprofloxacine or levofloxacin
-poss. B lactam + aminoglycoside (gentamicin, tobramycin, amikacin)* rarely used
inpt. ICU tx for high MRSA risk
influenza, DM, HAP
(make sure covers pseudomonas and MRSA)
add vancomycin or linezolid
old, bed bound, nursing home: cause of pneumonia?
aspiration on own secretions
-don’t cough
HCAP orgs
pseudomonas, MRSA
HCAP risks
- Antibiotic therapy in the past 90 days
- Acute hospital stay for at least 2 days in the past 90 days
- Residence in an extended care facility or recent prolonged rehab stay
- Need for infusion therapy (chemotherapy) or hemodialysis
- Home wound care
- Family member with infections involving multidrug resistant organisms
- Immunosuppressed patient
HAP develops
> 48 hrs AFTER admission to hospital
VAP occurs in
a mech. vent. pt >48 hrs after intubation
what to do with intubation pts
-keep head of bed 30 degrees
-do mouth care (suction)
CULTURE!
HAP orgs
- S. aureus (MRSA)
- S. pneumo (DR)
- G- orgs
- ESBL prod. orgs (E. coli, Kleb, enterobacter)
- resistant to PCN, cephalosporins, use carbapenems
- CRE prod. orgs in enterobacter family: move to aminoglycosides (tigasil, tobramycin, etc)
- acinetobacter spp. (chron. ventilated, trachs): unasyn, tigacil (otherwise resist.)
HAP empiric tx
S. aureus/MRSA/pseudomonas coverage
- antipseudomonals (cefepime, ceftazidime, imipenem, meropenem, piperacillin-tazobactam, aztreonam)
- 2nd antipseudomonal (Levofloxacin, Cipro, aminoglycoside)
- MRSA coverage (Vancomycin, Linezolid, also tigacil, cefteraline?)
- known ESBL carrier? (carbapenem)* right away!*
aminoglycoside
gentamicin
tobramycin
amikacin
(can give inhaled gentamicin!)
15 lb weight loss, 101 F 3 weeks gen. malaise coughing up thick green phlegm, foul smell etOH, bad teeth
aspirated inf. sputum–>purulence in lungs–>cough up from bronchus
CXR: obvious lung abscess
-weight loss from anaerobic process
w/ lung abscess pt.
more…
may need to decorticate
(keep malignancy in ddx)
lung abscess pt. dx
probable anaerobic pneumonia w. lung abscess
probable anaerobic pneumonia w. lung abscess risks
aspiration risk : etOH, nursing home
-indolent symps w/ fever, weight loss
MORE
probable anaerobic pneumonia w. lung abscess tx
clindamycin
amoxicillin-clavulanate (augmentin (for anaerobes))
amoxicillin (not usually)
moxifloxacin (anaer. cov)
IV zosyn, IV carbapenems, IV clindamycin (for hosp. pts)
pulm. infiltrates in immuncomp pts
consider opportunistic orgs, viruses, protozoa, fungi
-
pulm infilt. in HIV pt w/. high CD4 >200 more likely to be
Strep pneumo vs. pneumocystis jiroveci or other OI
fungal etiology of pulm. infiltrates
aspergillus, histplasmosis, blastomycosis, coccidiodomycosis
reality with aspergillus
infects people who are SEVERELY immune compromised (not everyday ppl to avoid rent due to mold)
- pts will dev. fungal ball (not nec. causes sickness)
- causes UR allergy sympts (chronic dry cough, irritation)
coccidiodomycosis
valley fever
histplasmosis, blastomycosis
may be in immunocompetent ppl
viral etiologies of pulm. infiltrates
HSV, CMV pneumonia
other causes of pulm. infilt.
atypical mycobacterial infections
(pts with sticky airways, high Ig levels, floppy airways)
(40-80 yo tiny women)
no good tx (Tb drugs)
TB stats
In 2013 a total of 9,588 new TB cases were reported in the US
Incidence of 3.0 cases per 100,000 people
Decrease from incidence of 4.2% in 2012
Incidence among foreign-born is 13x greater
64.6% of all TB cases
Half of all cases of TB in 2013 occurred in California, Texas, New York, and Florida
4,917 total cases
86 total cases of MDR TB were identified in 2012
TB greatest country
MEXICO
+ tuberculin skin test
induration*
>15 mm in gen pop
>10 mm in HC workers, inc. risk
>5 mm in HIV+
TB blood testing
INterferon Gamma Release Assay (IGRA)
- QuantiFERON TB gold in-tube test (vs. T-spot TB test?)
- reduces tester error, can be used on BCG vaccinated pts
IGRA advantages
Requires a single patient visit to draw a blood sample.
Results can be available within 24 hours.
Does not boost responses measured by subsequent tests, which can happen with tuberculin skin tests (TST).
Is not subject to reader bias that can occur with TST.
Is not affected by prior BCG vaccination.
IGRA disadvantages
Blood samples must be processed within ~24 hours after collection while white blood cells are still viable.
There is limited data on the use of QFT-GIT in children younger than 17 years of age, among persons recently exposed to M. tuberculosis, and in immunocompromised patients.
Errors in collecting or transporting blood specimens or in running and interpreting the assay can decrease the accuracy and potentially lead to indeterminate results.
False positive results can occur with Mycobacterium szulgai, Mycobacterium kansasii, and Mycobacterium marinum.
if skin is - and quantiferon is +
it is POSITIVE
get CXR
if skin is + and quantiferon is -
interminate, consider factors (case by case)
get CXR
if pt. are on anti-inflammatory tx (anti-TNF)
MORE
drop chances of getting TB down to general population
TB seen where in lungs
top, oxygen rich, aerated
+ CXR
get 3 sputum samples, bronchoscopy if unable
if active TB
public health for MDRTB therapy
if 3 sputum samples neg
scarring on CXR
once latent TB established
discontinue tx
who should be tx?
everyone, esp. immuncomps, HIV+, those about to start immunosuppressive meds
what are risks if no LTBI tx taken?
lifetim
MORE
LTBI tx (6-9 mos)
isoniazid, rifampin
+follow liver function
this med does not play well with other
rifampin (for young ppl, not on many other meds) (used back up for BC) (fine for etOH)
active TB tx
RIPE: rifampin, isoniazid, pyrazinamide, ethambutol (streptomycin) core
active TB always send..
susceptibility Cx
1st 2 mos…
then 4 mos…
all 4 drugs
isoniazid, rifampin
never tx active TB with
single agent
isolate active causes?
no longer infectious after 2 wks tx
MDR-TB
resist. to INH and RIF
XDR-TB
less common INF, RIF, others, FQ
INH resistance
&&
Rifampin resistance
INH + Rifampin resistance
III
XDR-TB tx
admin 4-6 drugs in combo (SUSCEPTIBLE) : mult. 2nd line drugs, should include all avail. 1st line drugs
- newer agents, trial agents
- 18-24 mos (2 yrs!)
sarcoidosis CXR
bilat perihilar finding, may have parenchymal involvement
biopsy of hilar nodes (sarcoidosis)
noncaseating granulomas (excl. lymphoma)
serum ACE in sarcoid.
elevated in 40-80% pts
sarcoid. multisyst. presentation
skin, eye, joint involvement
sarcoid. tx
oral prednisone (mos-yrs)
