77. Pneumonia Flashcards
In a patient with signs and symptoms of pneumonia, do not rule out the diagnosis on the basis of a normal chest X-ray film. Name example.
- Consider dehydration
- Neutropenia
- VIH
Après avoir posé le diagnostic de pneumonie, évaluez les risques d’avoir contracté un agent pathogène atypique.
Nommez les risques (5)
- ATCD tuberculose
- exposition aux oiseaux
- voyages
- infection par le VIH
- aspiration
C’est quoi l’interaction médicamenteuse entre Warfarin (Coumadin) et les antibiotiques ?
Plusieurs antibiotiques peuvent interagir avec elle et modifier son effet anticoagulant, augmentant ainsi le risque de saignement ou, plus rarement, diminuant son efficacité.
(Ex : Azithro, clarithro)
Par le biais de l’anamnèse, de l’examen physique et des tests de laboratoire, identifiez les patients qui sont à risque élevé de développer des complications de leur pneumonie et qui bénéficieraient d’une hospitalisation, même si leur état peut sembler cliniquement stable.
Nommez un outil clinique pour aider à la décision
CURB-65 Score for Pneumonia Severity
0 - 1 = Consider outpatient
2 = Consider inpatient treatment or outpatient with close followup.
3 - 5 = Inpatient
In a patient who is receiving treatment for pneumonia and is not responding, do what? (3)
- Revise the diagnosis (e.g., identify other or contributing causes, such as cancer, chronic obstructive pulmonary disease, or bronchospasm)
- consider atypical pathogens (e.g., Pneumocystis carinii, TB)
- diagnose complications (e.g., empyema, pneumothorax).
- Modify the therapy appropriately (e.g., change antibiotics).
Which patient would benefit from immunization or other treatments to reduce the incidence of pneumonia ?
- the elderly
- nursing home residents
- debilitated patients
Identify patients (e.g., the elderly, nursing home residents, debilitated patients) who would benefit from immunization or other treatments.
Name vaccines.
- flu vaccine
- Pneumovax
- ribavarine
Name TYPICAL pathogens : Pneumonia (3)
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
Name ATYPICAL pathogens : Pneumonia (3)
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Legionella spp
Name ASPIRATION pathogen for pneumonia (1)
Bacteroides (anaerobes)
Describe : Community-Acquired pneumonia (2)
- No hospitalization within 14d of onset
- OR <4d prior to onset
Describe dx : Pneumonia (3)
- Two symptoms (fever, rigors, cough change, pleuritic chest pain, SOB)
- AND auscultatory findings (localized crackles, bronchial breath sounds)
- AND X-ray opacity
Name symptoms : Pneumonia (6)
- Fever/chills
- New or change in cough
- Pleuritic chest pain
- N/V
- Urine/Stools
- Fatigue, Myalgias
Name risk factors : Pneumonia (2)
- Smoker, comorbid
- Antibiotics or hospitalization in past 3 months
Adults with an acute respiratory infection and normal vital signs/pulmonary exam are likely/unlikely to have pneumonia
unlikely (~0.4%)
Describe investigations : Pneumonia
- Chest X-ray (PA and lateral) required for diagnosis according to IDSA. Highly suggested in children as well according to CPS
- Labs : CRP (most accurate), procalcitonin, leukocytosis (was only modestly, if at all, accurate)
If severe pneumonia, what labs to consider (4)
- Ag urinaire contre les légionelles et les pneumocoques. Positif même après des jours d’ATB
- Coloration de Gram et culture des crachats (r/o Staphylococcus aureus résistant à la méthicilline, P. aeruginosa). Culture de légionelles
- PCR virale sur écouvillon nasopharyngé (influenza, coronavirus, etc…)
- S’il n’y a pas d’amélioration, vous pouvez surveiller la CRP/Procalcitonine.
____ more evidence than CURB-65 to determine outpatient vs inpatient treatment of pneumonia
Pneumonia Severity Index (PSI)
Describe tx : Pneumonia (2)
- Oxygen
- Drainer les épanchements pleuraux importants ou en cas de suspicion d’empyème
- Antibiotics
Describe ATB for pneumonia (4)
If no antibiotics in past three months
- Clarithromycin 500mg PO BID x7d or Azithromycin or Doxycycline. Promote less resistance to macrolides by using clarithromycin
- Amoxicillin 1g PO TID x7d (less emphasis on covering atypicals)
- Pediatrics - Amoxicillin 90 mg/kg/d PO divided TID x7-10d (consider atypical coverage in children ≥5 years old)
- May consider shorter courses in children with community-acquired pneumonia (3d or 5d) as per recent studies CAP-IT, SAFER, SCOUT-CAP.
Describe ATB if comorbidities or recent antibodies (3)
- Amoxicillin with atypical coverage (Clarithromycin or Azithromycin or Doxycycline)
- If non-anaphylactic penicillin allergy = Cefuroxime or Cefadroxil + atypical coverage (consider monitor in office 1-2h)
- Anaphylactic penicillin allergy = Levofloxacin or Moxifloxacin as below
Describe second-line tx : Pneumonia (2)
(after failed 72-96h)
Levofloxacin PO DIE x 5 days or Moxifloxacin PO DIE x 7d
Describe tx pneumonia if hospitalized and intensive care
Cefotaxime IV q8h or Ceftriaxone IV q12-24h AND Levofloxacin or Moxifloxacin or Azithromycin
Note: Ceftriaxone superior to Pip/Tazo (as 15% Strep pneumo resistant to Pip/Tazo in community-acquired pneumonia)
Consider covering for legionella if risk factors. Name ris factors (7)
- Elderly, immunosuppression, smoker, lung disease
- T>39ºC
- Neurological (Confusion/Weakness/Gen det)
- GI (diarrhea)
- Electrolytes (Hyponatremia. hypophosphatemia, renal/hepatic dysfunction, thrombocytopenia, leukococytosis)
- Hematuria
- Hotel, cruise ships, residence (water reservoir contamination)
Describe follow-up : Pneumonia ()
- Return if no improvements after 72h of treatment (fever should not return after 3d)
- IDSA recommends not routinely obtaining follow-up imaging if symptoms resolve within 7 days (low quality evidence)
Repeat CXR in 6w (r/o underlying disease) if
* >50yo or immunosuppressed, lung disease, alcohol, smoker, >5% weight loss in past month
* Extensive/necrotizing pneumonia
Describe prevention : Pneumonia (3)
- Smoking cessation
- Hygiene (handwashing)
Vaccination
* Influenza
* Pneumococcal >65yo or comorbidity. Prevents invasive pneumococcal disease (bacteremia)
