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MS2 Respiratory > 9/11- Pulmonary Infections > Flashcards

9/11- Pulmonary Infections Flashcards

1
Q

What are the various routes of infection to the lungs?

A
  • Inhalation of contaminated droplets/aerosols
  • Aspiration
  • Hematogenous
  • Direct extension
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2
Q

What are host defenses to lung infections?

A

Mechanical

  • Anatomical (nasal turbinates, nasal hairs, glottis, branching airways)
  • Cough reflex
  • Mucociliary escalator

Immune-based responses: alveolar macrophages and surfactant proteins

  • Engulf, opsonize and kill bacteria and viruses
  • Release inflammatory mediators to defend the lung =>syndrome of pneumonia
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3
Q

What are risk factors for community acquired pneumonia?

A
  • Alcoholism
  • Asthma
  • Immunosuppression
  • Institutionalization
  • Age > 70
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4
Q

Clinical manifestations of CAP?

A

Onset/prodrome: insidious, acute or fulminant

Severity: mild to fatal

Symptoms:

  • Fever, cough (dry or productive), pleuritic chest pain, chills or rigors, shortness of breath
  • Associated symptoms: HA, nausea, vomiting, diarrhea, myalgia, fatigue
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5
Q

What is found on the physical exam of pt with pneumonia?

A
  • Tachypnea
  • Fremitus – increased or decreased
  • Percussion – dull or flat
  • Crackles
  • Pleural friction rub
  • Whispered pectoriloquy (increased clarity of whispered words; same connotation as bronchopony)
  • Egophony – E to A (extreme bronchophony)
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6
Q

What are the typical etiologic agents of community acquired pneumonia? Atypical?

A

Typical:

  • Strep pneumoniae
  • Hemophilus influenzae
  • Staph aureus
  • CA-MRSA
  • Klebsiella pneumoniae

Atypical:

  • Mycoplasma pneumoniae
  • Chlamydia pneumoniae
  • Legionella spp
  • Respiratory viruses
  • Fungi

Vary according to geographic areas, patient population, season, age group

(Only find etiologic agent in 1/2 of outpts or 2/3 of inpts.. in everyday practice, 70% of cases are not identified)

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7
Q

What common pathogens are associated with alcoholism?

A
  • S pneumoniae
  • Oral anaerobes

Gram negative bacilli:

  • Klebsiella
  • Acinetobacter
  • M TB
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8
Q

What common pathogens are associated with bronchiectasis, cystic fibrosis?

A
  • Pseudomonas
  • Burkholderia cepacia
  • Staph aureus
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9
Q

What common pathogens are associated with COPD?

A
  • H influenzae
  • Pseudomonas
  • Legionella
  • S pneumoniae
  • Moraxella catarrhalis
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10
Q

What common pathogens are associated with Flu season?

A
  • Influenza virus
  • S pneumoniae
  • Staph aureus
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11
Q

What common pathogens are associated with exposure to water?

A

Legionella spp

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12
Q

What common pathogens are associated with poor dental hygiene?

A

Oral anaerobes

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13
Q

What common pathogens are associated with HIV?

A
  • Pneumocystis jirovecii
  • Strep pneumoniae
  • Mycobaterium tuberculosis
  • H influenzae
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14
Q

How is a CXR useful in pneumonia?

A

Helpful in diagnosis

  • Presence/extent of infiltrate
  • Presence of pleural effusion
  • Follow clearing of infiltrate
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15
Q

When would you order a CT chest?

A
  • Complicating factor
  • Negative CXR with strong suspicion for pneumonia
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16
Q

What are other tests that can be used in diagnosis/management of pneumonia?

A

WBC count: indicate need for hospitalization (very high or very low)

Sputum Gram stain:

  • Adequate lower respiratory tract specimen: fewer than 10 squamous epithelial cells and >25 PMNs per LPF
  • Can identify organisms by characteristic appearance

Sputum culture

Blood culture (if admitted to hospital), low yield: 5-14%

Antigen tests: uine strep and legionella

PCR tests: Rapid flu, M TB, Legionella, Mycoplasma

Serology: mycoplasma, viruses, fungi

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17
Q

What is the pneumonia severity index (PSI)?

A

20 variables with points assigned

Severity classes I-V for point ranges with associated mortality rates

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18
Q

What is the CURB 65 criteria?

A
  • Confusion
  • Urea > 7 mmol/L
  • Respiratory rate > 30
  • Blood pressure: SBP under 90 or DBP under 60
  • Age > 65

Mortality rate:

1- 1.5%

2- 9.2%

3- 22%

19
Q

How do you select antibiotics for CAP?

A

Strep pneumoniae: cephalosporin

Atypical pathogens: macrolide

  • Evaluate risk factors for drug resistance (risk factors for community-acquired MRSA)
  • Treatment should start as soon as possible
20
Q

What is nosocomial pneumonia?

A

HAP, VAP

  • Pneumonia development at least 48 hours after hospital admission
21
Q

What is healthcare associated pneumonia?

A
  • Transition between nosocomial and community acquired pneumonia
  • Up to three months after health care episode (admitted for at least 2 days)
  • Residence in NH
  • IV antibiotics, chemo or wound care within 30 days
  • Attended hemodialysis in hospital or clinic
22
Q

What are common etiologies for healthcare associated pneumonia?

A

(Similar to nosocomial pneumonia)

Gram negative bacilli: 64%

  • E coli
  • Pseudomonas (21%)
  • Klebsiella
  • Enterobacter

Gram positives

  • Staph aureus- most common single pathogen! (MRSA > 50%)
23
Q

Complications of pneumonia?

A
  • Pleural effusion – parapneumonic or empyema
  • Lung abscess
  • Metastatic infection
  • Respiratory failure
  • Septic shock
  • Multiple organ failure
24
Q

What immunocompromised patients/situations should be considered with pneumonia?

A
  • HIV infection
  • Organ transplantation: bone marrow and solid organs
  • Malignancies: related to malignancy or its treatment (leukopenia, altered mentation, aspiration, emesis)
  • Autoimmune diseases/Tx: steroids, anti-TNF
25
Q

Nuances of pneumonia in immunocompromised host:

  • Defenses
  • Fever?
  • CXR
  • Tx?
A
  • Net state of immunosuppression” – host factors that contribute to infectious risk
  • Fever may or may not be present
  • Rate of progression of disease
  • Radiographic pattern may be abnormal
  • Aggressive diagnostic measures

—- Specific etiologic diagnosis is essential

—- Differential dx includes non-infectious processes

  • Immediate treatment intervention
26
Q

What etiologic causes of pneumonia or worrisome in the different stages of lung transplants?

A

Early (under 1 mo)

  • Bacteria
  • Aspiration
  • Nosocomial pathogens

Middle (1-4 mo)

  • Pneumocystic
  • Aspergillus
  • CMV

Late (> 6 mo)

  • Pneumocystis
  • Granulomatous: nocardia, reactivation of fungi, mycobacteria
27
Q

Epidemic of _____ is a looming threat to TB control efforts

A

Epidemic of diabetes mellitus is a looming threat to TB control efforts

28
Q

What are risks for TB infection?

A
  • Close contact of person with TB
  • Persons from or frequent visitors to countries of high TB burden
  • Congregate settings – residents and employees
  • Health care workers
  • Low income, drug/alcohol abuse, poor access to health care
  • Infants, children, adolescents
29
Q

What is MDR-TB?

A

Multi-drug resistant TB Resistance to both:

  • Isoniazide
  • Rifampin
30
Q

What are characteristics of a latent TB infection (LTBI)?

A
  • History of exposure to TB
  • No symptoms
  • Immune response to TB antigens

—-Positive TST or

—-Positive interferon gamma release assay (IGRA) – Quantiferon TB or T Spot TB

  • Normal CXR
31
Q

What are high risk groups for TB? What is considered positive on a tuberculin skin test (TST)?

A
  • HIV or immunosuppressed
  • Close contact of TB pt
  • Abnormal CXR

Positive > 5mm

32
Q

What are moderate risk groups for TB? What is considered positive on a tuberculin skin test (TST)?

A
  • Recently infected (under 2 yrs) = recent converter
  • High risk medical conditions: DM, cancer of head/neck, lung, organ transplant

Positive > 10 mm

33
Q

What are low risk groups for TB? What is considered positive on a tuberculin skin test (TST)?

A

None of the other conditions (HIV/immunosuppressed, close contact, abnromal CXR, high risk medical conditions like DM, cancer, organ transplant…)

Positive > 15 mm

34
Q

What is the natural history/course of LTBI in an HIV negative pt?

A
  • No further problem with no evidence of active disease (90%)
  • Primary infection is not well contained and active disease develops within 2 years (lower lobe, hilar, pleural) (5%)
  • “Reactivation of previously contained, dormant TB (usually > 2 years after primary infection (5%)
35
Q

What is the natural history/course of LTBI in an HIV pt?

A

Risk for active TB: 7-10% per year

36
Q

Treatment of LTBI?

A
  • Standard therapy: 4 first line drugs

—- Intensive phase = RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) for 2 mo

—– Continuation phase = RI for 4 mo

  • Provide safest, most effective therapy in shortest time: decrease infectivity, morbidity mortality
  • Adherence to therapy- DOT, in all
  • Major determinant of outcome is adherence and completion
  • Children treated same as adults
  • Extrapulmonary TB treated the same
  • Contact investigation = key to dz prevention (pic 2)
37
Q

What are risks for active TB?

A
  • Previously untreated TB (stable, fibrotic pulmonary lesion)
  • HIV
  • Silicosis
  • Use of anti-TNF, chronic steroids
  • Malignancy – head and neck, lung
  • Chronic renal failure
  • Diabetes mellitus
  • Alcoholism
  • Active smoker
  • Malnutrition
  • Post gastrectomy
38
Q

Characteristics of primary TB (pathologically/anatomically)?

A
  • Lower lobe involvement
  • Pneumonic pattern
  • Hilar LAD
  • Pleural effusion
39
Q

Characteristics of reactivation TB (who gets it, sites, anatomy)

A
  • Majority of pts with active TB
  • Endogenous reactivation of latent infection
  • Occurs in sites that were disseminated during the primary infection
  • Most common site = apical posterior segment of lung (80%)
40
Q

What clinical features aid in the diagnosis of TB?

A
  • Risk factors for exposure
  • Signs and symptoms: usually chronic (wks - mos) and non-specific

Pulmonary Sx:

  • Persistant cough
  • Hemoptysis
  • Dyspnea

Systemic Sx:

  • Malaise, fatigue
  • Fever
  • Weight loss, anorexia
  • Night sweats
41
Q

How can the microbiologic diagnosis be made for TB?

A

Acid fast stain: Ziehl Neelsen or auramine fluorescence

  • Three sputum specimens ~50% positive
  • Culture: 2-6 weeks
  • Drug susceptibility: 1-2 weeks

Molecular technology

  • Nucleic acid amplification – PCR based
  • Drug susceptibility – detect gene mutation
42
Q

How can therapy be monitored?

A

Monthly sputum culture until negative

  • 80% are culture negative in 2 months
  • If positive > 2 months, repeat susceptibility

Serial CXR are not recommended

  • End of treatment CXR – future comparison

Clinical evaluation monthly

  • Adverse reactions and adherence to therapy

Treat co-morbidity – DM, COPD, HIV

Supportive environment

43
Q

SUMMARY

A
  • Emerging threats to global TB control
  • Treatment of LTBI – important role in TB elimination
  • Clinical presentation of TB is varied
  • Close clinical follow up and partnership with public health department – ensure completion of treatment
  • Clinical manifestations of pneumonia are non-specific
  • Epidemiologic factors are useful in narrowing the possible etiologic agents
  • Treatment should be directed to the most likely pathogen(s) and initiated without delay
  • Clinical features that predict mortality help guide decision for hospitalization

MS2 Respiratory (26 decks)

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