6 - Pneumonia

Question 1

Pneumonia is:

Answer 1

An infection of the alveoli

Could be bacteria, virus, fungi, etc

Question 2

Community-acquired pneumonia

Answer 2

Acute pulmonary infection in a patient who is NOT hospitalized or residing in a nursing home 14 days or more before presentation

Question 3

Hospital-acquired pneumonia

Answer 3

New infection occurring 48 hrs or more after hospital admission

Question 4

Ventilator-acquired pneumonia

Answer 4

New infection occurring 48 or more hours after starting mechanical ventilation

Question 5

Healthcare-associated pneumonia:

Answer 5

Patients hospitalized for 2 or more days within the past 90 days

Nursing home / long term care residents

Patients receiving home IV antibiotic therapy

Dialysis patients

Patients receiving chronic wound care

Patients receiving chemotherapy

Immunocompromised patients

Question 6

Productive cough?

Answer 6

Think bacterial

Question 7

Nonproductive cough?

Answer 7

Think viral or atypical

Question 8

MC organism for CAP?

Answer 8

Pneumococcus

Question 9

Most patients with severe CAP who were otherwise healthy have:

Answer 9

S. Pneumoniae

Or

Legionella

Question 10

What kind of patient may have pneumonia with more than one organism?

Answer 10

Nursing home patients
Drunks
HIV with low CD4 counts

Question 11

Common sxs of pneumonia

Answer 11

Cough
Fatigue
Fever
Dyspnea
Sputum production
Pleuritic CP

Question 12

Rust-colored sputum?

Answer 12

Steptococcus pneumoniae

Question 13

Purulent sputum?

Answer 13

Staphylococcus aureus

Question 14

Currant jelly sputum?

Answer 14

Klebsiella pneumonia

Question 15

Patchy infiltrates with frequent abscess formation?

Answer 15

Pseudomonas aeruginosa

Recently hospitalized
Immunocompromised
Hot tubs

Question 16

Gradual onset pneumonia?

Answer 16

Haemophilus influenzae

Question 17

Pneumonia type more common in COPD’ers?

Answer 17

Moraxella catarrhalis

Question 18

Gradual onset with putrid sputum?

Answer 18

Anaerobes

Think drunks

Question 19

Slide 13-14

Answer 19

More detail on species-specific sxs

Question 20

Classic presentation of pneumococcal pneumonia?

Answer 20

Sudden onset
Rigors
Bloody sputum
High fever
CP
Lobar infiltrates

Question 21

At risk for pneumococcal pneumonia?

Answer 21

Elderly
Kids under 2yrs
Minorities 
Children who attend day-care
Immunosuppressed

Question 22

Consider s. aureus pneumonia in what kind of patients?

Answer 22

Chronic lung dz
Laryngeal CA
Immunosuppressed
NH patients 
Others at risk for aspiration pneumonia

Question 23

How will staphylococcal pneumonia look on CXR?

Answer 23

Extensive infiltration and effusion or empyema

Question 24

Staph vs klebsiella?

Answer 24

Staph insidious

Klebsiella rapid onset

Question 25

Describe pseudomonas pneumonia

Answer 25

Severe - cyanosis, confusion Bilateral lower-lobe infiltrates with occasional empyema Think prolonged hospitalization, nursing homes, steroid therapy, broad spectrum ABX use

Question 26

The atypical bacteria are:

Answer 26

Legionella, chlamydia, mycoplasma They lack a cell wall, so they do NOT respond to beta-lactam ABX They DO respond to macrolides OR a respiratory fluoroquinolone (levo, moxi)

Question 27

At risk for legionella?

Answer 27

Smokers Chronic lung dz Transplant patients Immunosuppressed

Question 28

Legionella pneumonia is commonly complicated by:

Answer 28

GI sxs, including ABD pain, vomiting, and diarrhea

Question 29

Mycoplasma pneumonia is frequently associated with:

Answer 29

Retrosternal chest pain Also, unlike legionella, mycoplasma does NOT have GI symptoms

Question 30

What extrapulmonary sxs can mycoplasma show?

Answer 30

``` Rash Neuro Arthralgia Heme Kidney ```

Question 31

MC cause of viral pneumonia?

Answer 31

Influenza

Question 32

If your clinical findings suggest pneumonia but our CXR is neg:

Answer 32

Treat empirically anyway

Question 33

In the suspected pneumonia patient, an SpO2 < 91 is associated with:

Answer 33

More complications, and may warrant treatment beyond meds and discharge

Question 34

MCC of acquired immunodeficiency syndrome-related death in pregnant women in the United States?

Answer 34

Pneumocystis jiroveci pneumonia

Question 35

Common atypical pneumonia agent in the elderly?

Answer 35

Legionella

Question 36

MCC of bacterial pneumonia in patients with HIV?

Answer 36

S. Pneumoniae

Question 37

Common first choice for outpatient txt for CAP?

Answer 37

Single-drug therapy Marcolide or a respiratory fluoroquinoline Doxy as an alternative Erythromycin is cost-effective but causes GI side effects in 25% of patients Clarithromycin - metallic taste Azithromycin - once daily dosing = better compliance

Question 38

CDC recommendations re: use of fluoroquinolones:

Answer 38

Reserved for pts who cannot tolerate other agents Or Have documented pneumococcal resistance Or Have failed other therapies

Question 39

Don’t use fluoroquinolones in patients with:

Answer 39

Myasthenia gravis

Question 40

Patients admitted to the ICU with healthcare-associated pneumonia should have coverage for:

Answer 40

Methicillin resistant s. aureus with drugs such as vanc or linezolid

Question 41

Do most patients with CAP require hospitalization?

Answer 41

Nope Use the CURB-65 rule to aid in disposition decision-making

Question 42

Criteria for ICU admission

Answer 42

``` Septic shock Needing a vent Markedly elevated RR Partial pressure of arterial oxygen / fraction of inspired oxygen ratio <250 Multilobar infiltrates Confusion Uremia with a BUN > 20mg/dL Leukopenia, thrombocytopenia, hypothermia, hyponatremia, lactic acidosis, asplenia ```

Question 43

What did the homeless man get for Christmas?

Answer 43

Pneumonia