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
Time and the Microbiology Lab
admission: 0 \_\_\_\_: 1 hour \_\_\_\_: 6 hours \_\_\_\_: 24 hours \_\_\_\_: 48 hours
CXR
gram stain
organism identification
antimicrobial susceptibility
Pathogens of Acute Pneumonia
…even simpler (?)
Bacterial \_\_\_\_ Legionella pneumophila \_\_\_\_ Chlamydia pneumoniae
____
Enterobacteriaceae
____
(Pseudomonas)
step pneumoniae
mycoplasma pneumoniae
drug resistant strep pneumoniae (DRSP)
(staph aureus)
Pathogens
• Typical versus atypical bacteria
– Typical- ____, Haemophilus influenzae, ____, group A streptococci, ____, anaerobes, and ____ bacteria.
– Atypical- ____, M pneumoniae, ____, and C. psittaci
s. pneumoniae
staphylococcus aureus
moraxella catarrhalis
aeorbic gram negative
legionella spp
c pneumoniae
Staph aureus
• S aureus pneumonia that is community acquired is usually seen in ____ adults and in younger patient recovering from ____ (post influenza pneumonia).
– The ____ remains the most frequent pathogen post influenza
older
influenza
pneumococcus
Causes of CAP in ambulatory patients
If looking at causes of CAP in ambulatory patients (this is someone who is outpatient):
• ____, respiratory viruses, and ____ account for a lot
◦ ____ a lot b/c don’t make diagnosis always in ambulatory situation
• ____ very low!
Causes of CAP in hospitalized, non-ICU patients
Hospitalized, non-ICU
• Notice ____, respiratory virus, ____ (and a lot of ____n)
Causes of CAP in ICU patients
When you are really sick in ICU - legionella and strep pneumonia account for a large percent
• So when someone is in ICU (and get echmo) - you’re not looking for mycoplasma pneumonia, rather
looking for ____
◦ Go into details to then determine if have legionella and ____
So very helpful to know the ____ patient is at
mycoplasma pneumoniae
strep pneumoniae
unknown
legionella
strep pneumonia
mycoplasma
unknown
legionella
strep pneumonia
setting
Approach to Pneumonia
• First, classify the clinical situation based roughly on ____, in order to manage the patient and to pick an appropriate empiric regimen:
– ____ (outpatient)
– ____
– ____
• Second, look for epidemiologic clues to suggest ____ causes of pneumonia, that might either require additional antibiotic treatment, or other specific interventions (respiratory isolation). Consider whether ____ means (eg, bronchoscopy) would be helpful to establish diagnosis.
severity
ambulatory
hospitalized (non-ICU)
ICU
unusual
invasive
Epidemiologic conditions and/or risk factors related to specific pathogens in community-acquired pneumonia
These are also some clues (similar to the bird with chlamydia psittaci)
• If someone isn’t fitting the picture - 30 yr old comes in says I woke up today felt like crap, X-ray shows etc.
◦ If can’t find reasons these are some of the things he would start asking
‣ Are they ____ (may be these bacteria), lung abscess, exposure to ____
‣ 9 times out of 10 don’t have to do this, just for the case that can’t figure out whats going on
• May find out they’ve been exposed to (ex:) bat or bird droppings - its ____
• These are some of the exceptions
alcohol
bird
histoplasmosis
Pneumonia Severity Index
How do you know who gets admitted to the hospital and who doesn’t?
Couple ways: pneumonia severity index (PSI) came out a really long time ago (developed from database in Philadelphia)
◦ The orange box in back
◦ No1 actually gauges in ____
That translates into blue box
◦ Determines where you are going to give them their care and the mortality rate
◦ See mortality rate starts low but an grow pretty high
Categories:
1. ____ (+10 if nursing home resident)
2. ____
3. ____
4. ____
Add all the points up and go to blue box
◦ If <51 then would have very low ____ and treat them as an ____. Comes with that what set of antibiotics
◦ If class V some things determine if go to ICU
Can see that for someone who is around 50 years old, if has a couple of these can quickly rise up to being over 91 and being ____
People don’t really use this exactly, but gauge it when someone comes into ER and determine if get ____ or not.
Gets handy in an office. Ex: 30 year old woman with very little of risk factors - she has very low mortality rate and can treat her as an outpatient
head age coexisting illness physical exam findings lab or radiographic findings
mortality rate
outpatient
admitted
Pneumonia Severity Index
I
Points: ____
Mortality: ____
Site of care: ____
II
Points: ____
Mortality: ____
Site of care: ____
III
Points: ____
Mortality: ____
Site of care: ____
IV
Points: ____
Mortality: ____
Site of care: ____
V
Points: ____
Mortality: ____
Site of care: ____
<51
0.1%
outpatient
51-70
0.6%
outpatient
71-90
2.8%
in or outpatient
91-130
9.5%
inpatient
> 130
26.7%
inpatient
Treatment
• Outpatient treatment-previously healthy
– ____ (____, Clarithromycin, or ____) OR
– ____
macrolide
azithromycin
erythromycin
doxycycline
Treatment
• Outpatient treatment-presence of comorbidities such as heart, lung, liver, or renal disease. Diabetes, alcoholism, malignancy, asplenia, or use of antibiotics in the past ____ months.
– A respiratory ____ (____, Gemifloxacin, or ____ (750mg)) OR
– A ____ (high dose ____, amoxicillin/Clavulanate, cefuroxime) plus a ____ (Azithromycin, Clarithromycin, or Erythromycin)
3 quinolone moxifloxacin levofloxacin beta lactam amoxicillin macrolide
Treatment
• Inpatient, non-ICU treatment
– A respiratory ____ (____,
Gemifloxacin, or ____ 750mg) OR
– A ____ (Ceftriaxone) PLUS a ____ (Azithromycin, Clarithromycin, or Erythromycin)
quinolone
moxifloxacin
levofloxacin
beta lactam
macrolide
Treatment
• Inpatient, ICU treatment
– A ____ PLUS ____ OR
– A ____ plus a respiratory ____ OR
– A respiratory ____ PLUS ____ (penicillin ____ patients)
beta-lactam azithromycin beta lactam quinolone quinolone aztreonam allergic
Special Concerns
• MRSA
– ____ OR
– ____
vancomycin
linezolid
Section summary
- Treatment of CAP must be initiated ____, prior to the availability of a firm ____ diagnosis
- Choice of treatment regimen for CAP is dependent upon ____ of illness, which correlates (roughly) with the ____
- Rare agents of CAP should be considered under the proper epidemiologic exposure
right away
microbiologic
severity of illness
pathogen
Case 1
This is why his X-ray looks like • Whats abnormal? ◦ Looks like \_\_\_\_ - can't see that angle ‣ Don't know if there is an infiltrate hiding there
Case 1, Question 1. Should this patient be treated at home, on the floor, or in the ICU?
a. Home, on oral antibiotics
b. In the hospital, on a regular medical floor, on IV antibiotics
c. In the ICU
On the floor meaning on the hospital floor
Answer: ____. there are a couple of things that worry him that would go into ICU
c
Case 1, Question 2. Name three likely causative agents, based upon the information in this lecture.
a. Bordetella pertussis, E. coli, Lactobacillus
b. Mycobacterium tuberculosis, Legionella pneumophila, Haemophilus influenzae
c. Legionella pneumophila, Streptococcus pneumoniae, Mycoplasma pneumoniae
d. Legionella pneumophila, Streptococcus pneumoniae, Staph aureus
This is important!!! Go back to that severity slide
• What would make people really sick? What was the one pathogen that was different from the outpatient and the floor? Answer: ____
◦ also ____ is for very sick, so c or d
◦ And then mycoplasma pneumonia is often in ____
◦ So answer is “d” - these 3 would really make you sick enough to warrant an ICU
admission (____ is not)
I WOULD KNOW THESE 3 - ____
Walking pneumonia - people who look better than their x-ray shows
• Not going to be people with these 3
◦ people with these 3 will be ____, tachycardic, ____
d
c
outpatient
mycoplasma pneumoniae
legionella, streptococcus, staph aureus
hypertensive
tachypneic
Case 1, Question 3. After stabilizing him and starting empiric antibiotics, what else can be done?
a. Nothing
b. Ceaseless worry
c. Try to establish a diagnosis
d. Put him in respiratory isolation
Answer: ____
Key is to try, will probably come up with nothing, but just try
• Isolation only needed for the ____ or ____
c
flu
TB
Case 1, Question 4. This is a gram stain from expectorated sputum. What diagnosis does it suggest?
a. Streptococcus pneumoniae
b. Klebsiella pneumoniae
c. Staph aureus
d. No diagnosis is suggested from this specimen
This picture has a squamous cell - so answer is:
____ from this specimen
• This is all saliva
d. no diagnosis is suggested from this specimen
Case 2
Looks normal. No infiltrate. Looks more like ____, more like a ____ infection
interstitial
viral
Case 2: question 1: What is the most likely cause of his presentation?
a. Pneumococcal pneumonia (Streptococcus pneumoniae)
b. Haemophilus influenzae pneumonia
c. Influenza virus infection
d. Acute bronchitis
Answer: c. ____
influenza
Case 2,
continued
Oseltamavir = drug given for flu
Last paragraph indicates: he got ____ (most likely)
• So flu, gets better, then new syndrome = ____
◦ 2 bugs post flu = ____
secondary pneumonia
superinfection
strep pneumonia
staph aureus
Case 2a
a. The influenza is resistant to oseltamavir.
b. There is a superinfection (superimposed infection)
with a bacterial pathogen, with resultant bacterial
pneumonia.
c. This is ARDS (adult respiratory distress syndrome).
d. This is a case of oseltamavir - associated primary effusion lymphoma.
Answer: ____
B
Case 3
No specific lobe with infiltrate
• Hazy all over, maybe ____
interstitial
Case 3, question: which of the following is the most helpful in establishing the diagnosis?
a. Knowing his hobbies and interests
b. Examination of the gram stained expectorated sputum
c. The height of his WBC
d. Knowing whether he has a history of diabetes
Answer: ____
remember that long list? This is a case that’s sort of not making sense to most people
• What would you do for him
◦ He’s 55 and was fine, then gets sick
◦ Would treat him for CAP
‣ But if isn’t getting better then would have to start going into his ____
• try to find out about weird ____ he may of had
• But still will treat him the same
◦ Take away if someone comes in with syndrome compatible with CAP - treat
them, and if doesn’t get better then call someone in to help make diagnosis
knowing his hobbies and interests
hobbies and interests
exposures
Conclusions
Acute pneumonia is ____ and deadly. It remains a significant ____ despite advances of modern medicine.
Etiologic (microbiologic) diagnosis is ____, but pays dividends.
Selection of antibiotics is dependent upon the ____ (____ of illness, primarily), not the microbiologic culture data. ____ exist to minimize the likelihood that an organism will be missed.
Epidemiologic clues suggest a microbiologic etiology other than the ones covered by the recommendations in a ____ proportion of cases. Being aware of the clues that suggest the presence of these organisms can allow for more successful outcomes of the “____” cases.
common
problem
low-yield
clinical scenario
severity
recommendations
small
outlier
Question 3: What easily ascertained information can predict the etiology of pneumonia, in an evidence-based way? a. Socioeconomic background. b. Color and consistency of the sputum. c. Severity of illness. d. Duration of illness. e. Pattern of infiltrate on CXR.
Trying to figure out which bacteria is causing the pneumonia
• Reads each answer
• Hopefully after everything gone through wouldn’t say “E”
◦ Specifically if pointed to cavity on chest x-ray doesn’t tell you one diagnosis
Answer = ____
C (severity of illness)
Pneumococcal pneumonia: virulence
• Every single organism has key virulence factors that are very important in its pathogenesis
• Amazes him that these little guys can do such powerful things
◦ Not even going to get into genetics, and how they get resistent
‣ In hospital now - there are isolation carts everywhere in hallway - now any room you go into are wearing a gown and gloves (didn’t use to be that way). Done b/c these bacteria have evolved over time and become ____ (something to think about now), problem is that the
production of antibiotics isn’t keeping up with the ____
So here is a pneumacacul (?) which is most common cause of ____
• Around it is it’s ____ - this is it’s big virulence factor - keeps it from being ____. And see
same thing with a Group A strep.
resistant
resistant mechanisms
pneumonia
capsule
phagocytosed
