6 - Pneumonia And TB Flashcards
1
Q
Types of pneumonia
A
CAP
Nosocomial
2
Q
What are the 3 types of nosocomial pneumonia?
A
- Hospital acquired
- Health care associated
- Ventilator associated
3
Q
What are the pathways of pneumonia spread?
A
2 major:
- Inhalation: via droplets
- Aspiration: via oropharyngeal secretions
1 minor:
- blood borne pathogens
4
Q
What is the MC type of pneumonia pathogens?
A
Bacterial»_space; Viral
Usually S. Pneumoniae
5
Q
Common bacterial pneumonia pathogens (list)
A
S. Pneumoniae (MC) S. Aureus H. Influenzae Klebsiella pneumonia Pseudomonas sp Legionella sp Chlamydia pneumonia Mycoplasma pneumoniae
6
Q
How do patients get s. Aureus in their lungs to cause pneumonia?
A
Usually after influenza infection or hematogenous spread
7
Q
Who usually gets h. Influenzae pneumonia?
A
COPD patients
8
Q
Who usually gets klebsiella pneumonia?
A
Alcoholics
9
Q
What is the definition of CAP?
A
Occurring outside hospital
Ambulatory patients
Not in nursing home
w/in 48hrs of admission
10
Q
Prevalence of pneumonia?
A
4-5 million in US per year
11
Q
Is pneumonia a big problem?
A
Yes 25% of cases require hospitalization
It is the most deadly infectious disease in the U.S.
12
Q
What are the risk factors for CAP?
A
Increasing age ETOH Tobacco use Comorbitites (asthma, COPD, etc) Immunosuppression
13
Q
What are some normal defenses that prevent CAP in most healthy people?
A
Cough reflex
Immunity
Mucociliary clearance
14
Q
Do viruses cause CAP?
A
Yes but not usually (1/3)
Influenza
RSV
Adenovirus
Parainfluenza
15
Q
SS of CAP?
A
Acute onset of: fever, cough (+/- sputum) and dyspnea
Maybe:
- sweats
- chills
- chest discomfort
- rigors
- pleurisy
- hemoptysis
16
Q
What is usually seen on PE for CAP?
A
Acutely ill appearing
- fever
- tachypnea
- tachycardia
- desaturation of arterial O2
17
Q
What will the chest exam show with CAP?
A
Inspiratory crackles, bronchial breath sounds
Dullness on percussion/egophony if lobar or effusion present
18
Q
Can chest exam diagnose CAP?
A
No its only 50% sensitive
19
Q
What usually causes atypical pneumonia?
A
Mycoplasma pneumonia
20
Q
S/S of atypical pneumonia?
A
Gradual onset Dry cough HA Malaise N/V
May not appear sick
21
Q
CXR for atypical pneumonia?
A
Usually worse than pt apperiance
22
Q
Should i culture my CAP pt?
A
No, empiric tx usually works
Maybe if hx of travel
23
Q
What will pulmonary opacity on CXR or CT?
A
Patchy airspace disease Lobar consolidation w air bronchiogram Diffuse alveolar/interstitial opacities Pleural effusion Cavitations
24
Q
How long will it take pneumonia to clear on CXR?
A
6+ weeks
- image “lags” behind clinical improvment
25
When do pneumonia pts need to return to the clinic?
Not necessary if clinical response is present
26
Who needs a follow up x ray?
High risk pts need another CXR at 7-10 weeks
Sometimes we find malignancy post tx
27
What special exams can be done for CAP?
Thoracentesis
Bronchoscopy
Procalcitonin
28
If i suspect P. Jirovecii or M. Tuberculosis what is the best way to get a sample?
Bronchoscopy
29
What do procalcitonin levels tell me?
It is released in response to bacterial toxins and inhibited by viral infections
30
How quickly should i initiate tx for CAP?
Dont delay > 6hrs
31
Which CAP etiologies generally dont need hospitalization?
S. Pneumo
Mycoplasma pneumo
Chlamydia pneumo
Influenza
32
My patient has not had abx w/in 90 days, what abx do they need?
Macrolide (clarithromycin or azithromycin)
Or
Docycycline
33
My patient has one or more of the following:
had abx in last 90 days age is >65,
comorbidity
Immunosuppressed
Works in daycare
What meds does he need?
Respiratory FQ
-moxi/gemi/levofloxacin
Or
Macrolicde + beta-lactam (amox-clavulante)
34
Which CAP etiologies usually get hospitalized?
```
S. Pneumo
Mycoplasma pneumo
Chlamydia pneumo
H. Influenzae
Legionella sp
Viral
Aspiration pneumonia
```
35
Do CAP pts need IV abx?
They are often used but not superior to oral
36
Inpatient abx for CAP?
First line:
Respiratory FQ
Or
Marcolide (azithromycin or clarithromycin)
+
Cefotaxime or ceftriaxone or ampicillin
37
What are the MC CAP etiologies that get admitted to ICU?
```
S. Pneumo
H. Influenzae
Legionella
Enterobacteriaceae
S. Aureus
Pseudomonas sp
```
38
Abx for ICU treatment?
Respiratory FQ or azithromycin
+
Cefotaxime or ceftriaxone or ampicillin
(Antipseudomona beta-lactams)
39
What is the pneumonia vaccine called?
Polyvalent pneumococcal vaccine
40
What are PSI and CURB-65?
Methods to determine when to admit pts
PSI - Pneumonia severity index
Curb-65 - simpler estimate
41
What does CURB-65 stand for?
```
C - confusion
U - urea >20mg/dL
R - respiratory rate >30
B - BP <90 systolic / <60 diastolic
65 - 65 yrs or older
```
Each is worth 1 point
42
CURB 65 points scale?
0-1: low death (3%)
2: moderate risk (9%)
3-5: high risk (15-40%)
- hospital
4-5 pts gets ICU
43
Do you treat nosocomial pneumonias the same as CAP?
Nope hospital flora is super strong
44
What is HAP?
Hospital acquired pneumona
>48hrs after admission
45
What is HCAP?
Healthcare associate pneumonia
| - non-hospitalalized pt w/ extensive healthcare contacts
46
What is VAP?
Ventilator associated pneumonia
Developed >48hrs after intubation
47
What are some factors that contribute to the pathogenis of nosocomial pneumonias?
Things that change the respiratory tract flora:
```
Intubation
Dirty hands
Aerosols
Abx-resistance
Malnutrition
Increased age
Change in consciousness
Swallowing disorder
Underlying disease
```
48
How fast does respiratory tract flora change?
75% colonization in the first 48hrs of hospitalization
49
What is normally protective from changes in respiratory tract flora?
Gastric acid
| - many hospitalized pts are on pH lowering meds
50
What are the MC nosocomial pneumonia pathogens?
```
S. Aureus (MRSA and MSSA)
Pseudomonas aeruginosa
Gram neg rods
- enterobacter
- klebsiella
- e coli
```
51
What are the common s/s of nosocomial pneumonia?
Nonspecific, 2+ of:
- fever
- leukocytosis
- purulent sputum
52
DDX for hospital acquired pneumonia?
```
CHF
Ateletasis
Aspiration
ARDS
PE
Med rxn
```
53
What labs should i order for nosocomial pneumonias?
```
Blood cultures x 2
CBC w differential
CMP
ABG/SpO2
Thoracentesis/pleural fluid
```
54
Do people aspirate oropharyngeal secretions?
Its normal to aspirate small amounts during sleep
Amount goes up with anaerobic respiratory infections
55
Who is at an increased risk for aspiration?
```
ETOH
Seizures,
Anesthesia
Tracheal/NG tubes
Central nervous system dz
Dirty mouth people
```
56
What is different about anaerobic pneumonia?
They like to make abscesses which leads to:
Fever
Wt loss
Malaise
foul smelling purulent sputum
57
What lab is required for anaerobic pneumonia
They need an aspirate, thorocentesis, bronchoscopy culture
Remember its anaerobic so you need to go get it
58
What will anaerobic pneumonia look like on images?
Lung abscess
Necrotizing pneumonia
Empyema
59
What is a lung abscess?
Thick walled solitary cavity w surrounding consolidation
Same as outside lungs but inside...
60
What is necrotizing pneumonia?
Multiple areas of cavitation w surrounding consolidation
61
What is empyema?
Purulent pleural fluid
Hard to treat b/c they are little pockets
62
Tx for anaerobic pneumonia?
Clindamycin
Amox-clav
Amox/PCN + metronidazol
Empyema and abscess may require incision and drainage
63
TB
Tuberculosis - nuff said
Jk there are a bunch more cards coming
64
TB is one of the worlds most widespread and deadly illnesses but what about the US?
It is the 2nd MC infectious cause of death in adults
65
What bacteria causes TB?
mycobacterium tuberculosis and 1/3 of the world has it
66
How is TB spread?
Person inhales airborne droplet nuclei of TB
Tubercle bacilli reaches the alveoli
Bacilli ingested by alveolar macrophages
Then the magic happens
67
What are the possible outcomes of the TB inhalation?
1. Immediate clearance (not likely)
2. Primary disease: infection escapes alveolar macrophage and wrecks shit
3. Latent infection: TB is contained, cant spread and dont have active disease
4. Reactivation disease: latent period ends and primary happens
68
What does primary tuberculosis and Miley cyris have in common?
“They came in like a wrecking ball!!!”
69
What can cause latent TB infection to become active?
HIV/AIDS
ESRD, DM, Lymphoma
Corticosteroids
Smoking
(Gaspar triangle)
70
What is it called when TB becomes hematogenously disseminated active TBf?
Miliary TB
71
S/S of active TB?
```
Slowly progressive constitutional sxs
Chronic cough (MC)
Dypsnea (rare)
```
72
What will a PE find for TB?
Chronically ill and malnourished pt
Non-specific chest exam
- apical crackles are possible
73
What are some labs to diagnose M. Tuberculosis
3 consecutive a.m. sputum spp.
Blood cultures
Needle bx of pleura (culture)
74
What will a CXR tell me about TB?
It cannot distinguish from primary, latent or reactivated disease
But it does show the disease is there
75
What can CXR of TB be mistaken for?
Lower lobe disease may masquerade as a malignancy or pneumonia
76
How do we test for TB?
PPD (purified protein derivative)
77% sensitive
97% specific
77
What can cause a false negative for PPD?
```
Poor technique
Current infection
Advanced age
Corticosteroids
Malnutrition
```
78
What is the TB blood test called?
Interferon gamma release assay (quantiFERON gold/Tspot)
79
Is interferon gamma release assay a good test?
Advantages: fewer false pos and no f/u required
Disadvantages: the monies
80
We get a pos test. Now what?
Report to local and state public health
81
What is tx for active TB?
Isoniazid (INH)
Rifampin
Pyrazinamide
Ethambutol
X 9 months
82
What is the tx for resistant active TB?
18-24 months of 3+ drug regimen
Direct observed treatment
83
What is direct observed treatment?
Nonadhearance is often why tx fales so we want keep a closer eye on them
84
Baseline labs for active TB?
```
CBC
CMP
Visual acuity/color test
Audiogram
Serum uric acid
```
85
PPD allowable size before its considered pos?
5+ mm = high risk/sick pts
10+ mm = hospital workers/jail staff/homeless
15+ mm = healthy normal people
86
What are the treatment regimens for latent TB?
INH x 9 months (preferred)
Rifampin + Pyrazinamide x 2 mo
Rifampin x 4 mo
