B4.075 Lower Airway Infection Flashcards
features of acute bronchitis
cough (may be purulent) not usually associated with changes in vitals self limiting usually viral no or symptomatic treatment antibiotics not indicated
what distinguishes pneumonia from acute bronchitis
similar symptoms BUT
associated with changes in vitals and/or end organ function
changes on CXR
alveoli involvement
definition of pneumonia
inflammation of lung parenchyma caused by bacteria, virus, or fungi which is characterized by intra-alveolar exudation
route of entry of pneumonia causing pathogens
aspiration
inhalation
bloodborne
what causes a tip in host/organism dynamic resulting in symptoms of pneumonia
defect in host defenses
virulent organisms
overwhelming inoculum
mechanical and structural defenses
nose cough/gag airway branching mucociliary clearance normal oropharengeal flora (acidic)
cellular defenses
macrophages
epithelial cells
neutrophils
humoral/molecular defenses
IgG, IgA
cytokines
colony stimulating factors
discuss the progression of pneumonia
edema: presence of proteinaceous exudates and often bacteria in small airways and alveoli
inflammatory debris: erythrocytes, neutrophils, fibrin
resolution: macrophages predominate, inflamm debris cleared
pattern of bronchopneumonia
alveoli filled with exudate or purulent organisms
pattern of interstitial pneumonia
involved interstitium, alveolar walls, and connective tissue
alveoli not fully filled
pattern of military pneumonia
numerous discrete lesion of hematogenous spread
pneumonia symptoms seen during clinical evaluation
cough fever pleuritic chest pain dyspnea sputum production rapid onset of symptoms GI symptoms altered mental status
what is one of the first systemic organs affected in pneumonia?
kidneys
sometimes see renal failure
vitals associated with pneumonia
fever
tachypnea
tachycardia
hypotension
lab findings w pneumonia
leukocytosis
left shift
lung findings w pneumonia
crackles
egophany
specific testing done when called for
sputum culture blood culture urinary antigens resp viruses PCR procalcitonin
what organisms are identified by PCR
chlamydia pneumonia
mycoplasma pneumonia
what organisms are identified by urinary antigens
strep pneumo
legionella
why is alcohol abuse a indication for extensive testing
weakened defense systems
high risk for systemic involvement
indications for most extensive diagnostic testing
ICU admission
alcohol abuse
pleural effusion
which test is particularly important in diagnosing pneumonia in a patient w severe chronic lung disease
sputum culture
works better in these patients than other
common outpatient pneumonia
step pneumo mycoplasma pneumo h. flu chlamydia pneumo resp viruses
common non ICU inpatient pneumonias
strep pneumo mycoplasma pneumo chlamydia pneumo h. flu legionella aspiration resp viruses
common ICU pneumonias
strep pneumo staph aureus legionella gram neg bacilli h. flu
distinct pathogens in alcoholism
oral anaerobes
klebsiella
distinct pathogens in COPD and/or smoking
pseudomonas
moraxella
distinct pathogens with lung abscesses
CA-MRSA
pathogens associated with early HIV infection
similar to non-HIV population
strep pneumo
h flu
pathogens associated with hotel or cruise stay
legionella
pathogens associated with late HIV infection
opportunistic
multiple fungi
pseudomonas
h flu
pathogen associated with whooping cough
bordetella pertussis
distinct pathogens with structural lung disease (bronchiectasis)
pseudomonas
burkholderia cepacia
staph aureus
(drug resistant)
2 main risk stratification tools
PORT Score/PSI
CURB65
how does the PORT score work
if you have any severe indications listed in step 1, move to step 2
step 2 lists demographics, comorbidities, exam findings, lab/radiograph findings and calculates a score
CURB65
confusion BUN >7 resp > 30 SBP <90, DBP <60 age > 65
curb score 2
admit
curb score 3-5
consider ICU
HCAP
health care associated pneumonia
“at risk” for MDR pathogens
nursing home, dialysis, infusion center
hospitalization in previous 90 days
HAP/VAP
high risk for MDR pathogens
occurs 48 hours after admission
VAP- 48 hours after intubation
risk factors for MDR VAP
prior IV antibiotic use within 90 d septic shock ARDS precedingVAP 5 or more days of hospitalization acute renal replacement therapy
risk factors for MDR HAP
prior IV antibiotic use within 90 d
recommended antibiotics for outpatient CAP
- previously healthy and no use of antimicrobials within 3 months: macrolide
- presence of comorbidities: fluoroquinolone OR B lactam + macrolide
recommended antibiotics for non ICU inpatient CAP
fluoroquinolone OR B lactam + macrolide
recommended antibiotics for ICU CAP
B lactam (ceftriaxone) + azithromycin OR fluoroquinolone
what organisms are covered in VAP recommended treatment
MRSA and double antipseudomonal/gram neg coverage
recommended antibiotics for VAP
A. gram + antibiotics with MRSA activity: vancomycin OR linezolid
B. gram neg antibiotics with antipseudomonal activity (B lactam based): piperacillin/tazobactam OR cephalosporin OR carbapenem OR monobactams
C. gram nep antibiotic with antipseudomonal activity (non B lactam based): fluoroquinolone OR aminoglycoside OR polymixin
most common treatment for VAP
vanc + piperacillin/tazobactam + ciprofloxacin
duration 7-14 days
de-escalate with culture results
adjunctive management with pneumonia
assess for pleural effusion
biomarkers
steroids
vaccination/prevention
uncomplicated parapneumonic effusion
can result from inflammation without infected fluid
complicated parapneumonic effusion
fluid resulting from infected pleural space
has to be drained completely
antibiotics poorly penetrate the space
which imaging modalities are most sensitive for pleural effusion
ultrasound
CT
what procalcitonin
a peptide precursor of calcitonin that is released by parenchymal cells in response to bacterial toxins
why is procalcitonin evaluated
differentiates infectious from noninfectious pneumonia
determines when to stop antibiotics
why are steroids potentially beneficial in pneumonia
counteract inflammatory response in CAP that is the source of much of the end organ damahe
numerous adverse effects as well, however
who would benefit more from steroids?
sicker patients
pneumococcal vaccine recommendations
all persons >65
high risk persons 2-64 years of age
current smokers
flu vaccine recommendations
all persons > 50
all persons over 6 mo without a contra-indication
what are pneumococcal vaccines aimed at
aimed at capsule of bacteria
