6. Community Acquired Pneumonias Flashcards
Alphabet Soup for Pneumonia
• HAP: Hospital-acquired pneumonia – ≥ ____ h from admission
• VAP: Ventilator-associated pneumonia – ≥ ____ h from endotracheal intubation
• HCAP: ____
– Long-term care facility (NH), hemodialysis, ____, wound care, etc.
• CAP: Community-acquired pneumonia – ____
48 48 healthcare-associated pneumoni outpatient chemo outside of hospital or extended-care facility
Body surfaces and their normal microbial flora
TAKE A LOOK
yah
Defective pulmonary defense mechanisms and disease
So what makes someone develop pneumonia?
• Will see if look at who gets pneumonia - its really a breakdown of these things
◦ If patient comes into hospital he doesn’t go through each of these unless it comes up a lot
Mechanical:
• Impair gag/cough: if intubated - placed on mechanical ventilation then bypass your coughing or gag
reflex - why ____ is important b/c you bypass those defenses
Reads slide for nasal hairs turbinates (both the pathological condition and manifestations)
Immune system: innate and adaptive (can’t forget it after 1st year, always comes back)
Innate:
• neutrophils - patients on chemo or neutropenic
◦ Invasive aspergillosis = very serious ____ infection
• Phagocytes, complement, and defenses caused by many different conditions
Adaptive:
• CD4 cells is the big one - for ____.
◦ Helper cell so orchestrates entire immune system
‣ so not just CD4, CD8, and antibodies - rather everything gets impacted here
More and more we are now treating diseases with immune modulators
◦ Will see people on rituximab and monoclonal antibodies - will see more and more of that
VAP
fungal
HIV
The likelihood of infection is determined by the balance of these factors:
____: ability to damage tissue
____:
Host defenses
____: integrity of barriers ease of drainage
____
____
organism virulence inoculum size anatomic innate immunity acquired immunity
What exactly is pneumonia?
- inflammation of the ____, in this case caused by infection
- ____/diffuse
- ____/interstitial
- +/- n____ or abscess formation
- when the inflammation is alveolar, it results in ____ (“solidification”) of the pulmonary parenchyma
- resolution with or without scarring
- associated with
- infection of ____ (empyema) • infection of ____
- ____ syndrome
- infection of ____
pulmonary parenchyma focal alveolar necrosis consolidation pleural fluid bloodstream sepsis distant sites
Pneumonia
defined: inflammation of the lung with ____ and ____.
• We’ll only speak about infectious causes of pneumonia today.
Community Acquired Pneumonia (CAP) best defined by what it’s not:
– Nosocomial (hospital-acquired) pneumonia: >____ hours after admission to a hospital (not developing at admission)
• ventilator-associated pneumonia (VAP); develops >____ hours after endotracheal intubation
– healthcare-associated pneumonia (HCAP): develops in a ____ pt with extensive healthcare contact (eg, in- ____; dialysis; residence in a nursing home or other long-term care facilities; recent >____ hour hospitalization within past ____ days)
– chronic pneumonia: symptoms > ____ weeks (no relation to ____)
CAP ≡ \_\_\_\_ pneumonia (ie, none of the above)
consolidation
exudation
48 48-72 non-hospitalized home nursing care 48 90 2 hospital/home setting
acute
CAP – Pathogenesis
• ____ are the 3 main mechanisms by which bacteria reaches the lungs
inhalation
aspiration
hematogenous spread
Pathogenesis
• Primary inhalation: when organisms bypass normal ____ mechanisms or when the Pt inhales ____ organisms that colonize the ____ or respiratory support equipment
• Aspiration: occurs when the Pt aspirates ____ upper respiratory tract secretions
• Hematogenous: originate from a ____ source and reach the lungs via the ____
– ____
respiratoyr defense aerobic organisms upper respiratory tract colonized distant blood stream endocarditis
Pneumonia is common and deadly.
____ million cases of pneumonia occur yearly in the US. Almost ____% will be hospitalized.
____% of those hospitalized will die.
5
20
15
Epidemiology
Conditions predisposed to pneumonia:
- ____
- HIV
- ____
- diabetes
- ____
- liver disease
- ____
- transplant
- ____
- neurologic disease
lung disease heart disease elderly chemotherapy renal failure
Section summary
• Even though the lungs are sterile, precariously perched above them is a veritable cesspool of potential pathogens, the ____ and the potential ____ of which determining the likelihood and the expression of pneumonia. Vive la toux!
• The fact that pneumonia remains so common and deadly is a testament to the unrelenting success of our medical interventions: it is a shining surrogate for non-pneumonia mortality averted….
virulence
inoculum size
Clinical Presentation
____, cough, ____, pleuritic ____
Sudden ____
exceptions exist ….
for example: the ____ may present with fever and altered mental status alone
(many other exceptions; clinical experience will guide)
fever dyspnea chest pain onset elderly
Clinical Presentation
sputum production
productive:
“green,gray;
yellow, white”
tends to be ____ or ____
Productive: clear
or
non-productive
tends to be ____
lobar
bronchopneumonia
interstitial
Clinical Presentation
physical exam: ____
____
____
consolidation
tachypnea
tachycardia
How typical is the “typical presentation”?
• 80% have the “____” symptoms
• cough seen in 80%; ____ of sputum in 60-80%
– attenuated by pain, ____
• frequent presence of non-respiratory (nonspecific) symptoms:
– ____, anorexia, ____, diarrhea
• who doesn’t have classic symptoms?
– elderly more likely to have only ____ symptoms,
• failure to ____, decompensation of underlying disease, ____
– those with altered ____, underlying liver disease, ____ failure, CHF, ____ disease (ie, organ decompensation)
• PE - ____, tachycardia common
– ____in 80%
– signs of consolidation (____, dullness to percussion) in only ____%
classic
productive
splinting
fatigue
diarrhea
nonrespiratory thrive confusion mental status renal lung
tachypnea
rales
egophony
30
Establishing the diagnosis
Establishing the presence of pneumonia requires both:
____
____ = infiltrate
• A clinical picture of pneumonia, without an infiltrate on CXR, should be considered ____ (though the patient’s overall ____ should be considered)
compatible clinical picture
chest radiograph
bronchitis
what is the radiographic finding diagnostic for bronchitis?
TAKE A LOOK
yah
Infiltrate Patterns
Lobar
Possible diagnosis:
____, Kleb, ____,
Patchy
Possible diagnosis:
____, viral, ____
Interstitial
Possible diagnosis:
____, PCP, ____
Cavitary (gas filled space within a zone of pulmonary consolidation or within a mass or nodule)
Possible diagnosis:
____, Kleb, ____, S. aureus, ____
Large effusion
Possible diagnosis:
____, anaerobes, ____
s. pneumo
h. flu
atypicals
legionella
viral
legionella
anaerobes
TB
fungi
staph
kleb
Acute Bronchitis: self-limited inflammation of the bronchi due to ____ airway infection
- Presentation: 5 days of ____, usually with sputum production; ____ occasionally present
- Bronchitis is one of the ____ reasons for patients to visit their physician, accounting for 10 million visits per year (~twice the prevalence of ____); ~____% of the population in any given year will be diagnosed with acute bronchitis
- Inappropriate prescription of antibiotics for bronchitis are a major contributor to the development of ____, as well as increasing the risk of drug- associated ____, and increasing ____
upper
cough
fever
top 10
CAP
5
drug resistance
adverse effects
health care costs
Acute Bronchitis
• there is ____ (in extensive literature) for treating bronchitis with antibiotics
– about 2/3 of people who seek care for bronchitis are given ____, which contributes to rising levels of ____ in the community
• exceptions:
– ____ (whooping cough, ____) is the only agent for which evidence supports antibiotic treatment (specifically to decrease transmission)
• Considerations: ____, influenza
• microbiology: ____; and the same bacteria that can cause ____
no support
antibiotics
antibiotic resistance
pertussis bordetella pertussis COPD respiratory viruses pneumonia
Establishing the microbiologic diagnosis of pneumonia
• The yield of methods to identify a specific organism is ____: ____% in clinical practice,
and only ____% in clinical studies.
• Sputum cultures have a yield of ____%.
• Blood cultures have a yield of ____%.
low 20 60 20-50 10-20
Microbiologic Diagnosis
____ is prepared and examined under the microscope»_space;> specimen is also ____ to appropriate media for ____
expectorated sputum (\_\_\_\_ cough only) induced sputum (\_\_\_\_)
sputum smear plated growth deep nebulized saline
Interpretation of sputum specimens
assessment of quality of specimen: proportion of ____ cells
interpretation of gram stain
gram ____, gram ____, etc.
wait for culture (____ hours)
wbc’s to epithelial
positive cocci
negative rods
24-48
Section summary
- There is a typical appearance of CAP, but one must have a ____ of suspicion in some cases
- Making the correct distinction between CAP and bronchitis is a critical step in reducing unnecessary ____ and cost
- The ____ diagnosis of CAP is difficult (but pays dividends if it’s made); testing requires shrewd interpretation
high index
antibiotic exposure
microbiologic
