CA and nosocomial Pneumonia

Question 1

Very generally, what parts of the immune system if deficient can give rise to opportunistic resp tract infections?

Answer 1

Humoral, Cell mediated, granulocyte abnormality, other. Anywhere in the system

Question 2

What are some causes of immune deficiency? How? (in addition to inherited)

Answer 2

*HIV (kills CD4)
Corticosteroid therapy (lower neutrophils)
Lymphoma & treatment, sarcoidosis
Transplantation (all pts have lowered immuno.)
Congenital (e.g. severe combined immunodeficiency, di George’s syndrome)

Question 3

Infections secondary to HIV

Answer 3

M. tuberculosis, Streptococcus pneumoniae, Pneumocystis jiroveci, cryptococcus, endemic fungi

Question 4

Pulm infections related to transplants

Answer 4

CMV and Pneumocystis jiroveci pneumonia. Less likely if both donor and recipient negative for them.

Question 5

Pulm infections related to low neutrophil count

Answer 5

Bacteria, then fungi (aspergillus). Rarely the “normal” pneumonia bugs

Question 6

Tx for immunodeficiency opportunistic pneumonias

Answer 6

Prophylaxis is a big deal and close monitoring. Maybe stem cell transplant in rarer cases.

Question 7

Pneumonias that aren’t community acquired….

Answer 7

Hospital acquired and ventilator acquired

Question 8

Source of nosocomial pneumonia

Answer 8

Aspirated upper airway microbes (may be altered due to 1˚ illness) or aspirated GI refluxed microbes. Also biofilms in indwelling lines, or bugs caught in hospital

Question 9

Common pathogens of nosocomial pneumonia

Answer 9

Coliforms, MSSA/MRSA, Pseudomonas, others.

Question 10

Dx of nosocomial pneumonia

Answer 10

CXR and symptoms: fever, hypoxia, high wbc, etc. Some don’t have normal symptoms; portable Xray not great; hard to get pure sample.
Can go invasively with bronchoscope/brush combo.

Question 11

Tx of nosocomial Pneumonia

Answer 11

Can do best guess and broad spectrum it. Depends on pt risk, previous Rx, length of (H) stay, etc.
Early: fluoroquinolone/3rd gen cephalosporin.
Late/severe: Pip/tazo, carbapenem, vancomycin
Prevention!!

Question 12

Definition of community acquired pneumonia

Answer 12

inflammation of lung, usually from infection. Can be typical/atypical. Classified by source and where in lung.

Question 13

Microbial causes of community acquired pneumonia

Answer 13

Typical: S pnumo, H flu, S aureus, others.
Atypical: M pneumo, legionella, others
Can also have viral, sometimes fungal (BC/East Canada)

Question 14

Common symptoms of community acquired pneumonia

Answer 14

Fever
Dyspnea 
Cough
Sputum production
Pleuritic chest pain
Mental status changes (might be only sign in elderly)

Question 15

Signs of community acquired pneumonia

Answer 15

Common signs include:
Look Sick
Increased temperature
Increased respiratory rate/heart rate
Dullness to percussion 
Diminished breath sounds on auscultation
Bronchial breath sounds, crackles, wheezes, egophony
In severe cases respiratory failure & septic shock

Question 16

Dx of community acquired pneumonia

Answer 16

CXR is gold. Can do sputum and blood culture, but low yield.

Question 17

Associated things with community acquired pneumonia

Answer 17

If patient is under 50, should check HIV and IgG deficiency (uncommon in this age).
Can also be harbinger of cancer

Question 18

Tx for community acquired pneumonia

Answer 18

Vaccines (influenza, pneumococcal).
Quit smoking
Antibiotics!
If effusion - need thoracocentesis to determine whether complicated or not.

Question 19

If community acquired pneumonia doesn’t resolve, what could be the reason?

Answer 19

Wrong antibiotic/drug fever
Wrong bug
Lung abscess
Empyema 
Hydrostatic pulmonary edema
Inflammatory disorders
Pulmonary embolism
Occult cancer