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F2 E3 Shea > CAP > Flashcards

CAP Flashcards

1
Q

What are the 4 ways pneumonia (PNA) can be transmitted?

A
  1. Aspiration from the oropharynx
  2. Inhalation of contaminated droplets
  3. Hematogenous spread
  4. Extension from infected pleural or mediastinal space

(just b/c you are exposed to someone w/ PNA doesn’t mean you will get PNA)

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2
Q

Pathophysiology of what?

  • Proliferation of microbial pathogens at the alveolar level when the capacity of the alveolar macrophages to ingest or kill microorganisms is exceeded.
  • Alveolar macrophages initiate an inflammatory response to increase the lower respiratory tract defenses
A

Pneumonia

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3
Q

What are the 3 ways PNA can be classified?

A
  1. CAP
  2. HAP
  3. VAP
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4
Q

T/F: CAP is the 2nd leading cause of death

A

FALSE

CAP is the 8th leading cause of death

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5
Q

When is CAP most commonly seen?

A

Winter

(b/c there is seasonal variation)

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6
Q

Which disease?

Men > women

African Americans > caucasians

A

CAP

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7
Q

Risk factors for what?

  • >65y/o
  • Alcoholism and ALOC (due to lack of gag reflex)
  • Tobacco use
  • Immunosuppression/HIV
  • Comorbidities (asthma, COPD, cardiac, cerebrovascular, DM, dementia, etc)
  • Malnutrition
  • Institutionalization
  • Other underlying respiratory illness (lung cancer, cystic fibrosis, bronchogenic obstruction)
A

CAP

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8
Q

Which 8 comorbidities are risk factors for CAP?

A
  1. Asthma
  2. COPD
  3. Cardiac
  4. Liver
  5. Cerebrovascular
  6. Seizure disorder
  7. DM
  8. Dementia
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9
Q

Which 3 underlying respiratory illnesses are risk factors for CAP?

A
  1. lung cancer
  2. Cystic fibrosis
  3. Bronchogenic obstruction
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10
Q

What is the MC bacterial cause of typical CAP?

A

S. pneumoniae

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11
Q

What are the top 3 MC pathogens that cause atypical CAP

A

1. Mycoplasma pneumoniae

2. Chlamydophila pneumoniae

3. Legionella spp.

(these are not susceptible to B. lactams)

“CLM”

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12
Q

What is the MC viral cause of CAP?

A

Influenza

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13
Q
A
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14
Q

What are 8 possible clinical presentations of CAP?

A
  1. Fever
  2. cough (+/- sputum/hemoptysis)
  3. Dyspnea
  4. Chest discomfort
  5. pleurisy
  6. fatigue, weakness
  7. GI sxs (anorexia, abd pain, N/V/D, failure to thrive)
  8. mental status changes (esp in elderly)
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15
Q

What are 6 clinical presentation signs in CAP

A
  1. Fever (or hypothermia)
  2. Tachypnea
  3. Tachycardia
  4. Low O2 sat
  5. Rales
  6. Signs of consolidation

*clinical presentation is not super sensitive- need CXR*

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16
Q

Which pathogen?

  1. Sudden onset of chills
  2. rust colored sputum
A

S. pneumoniae

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17
Q

Which pathogen?

  1. children and adolescents
  2. asymptomatic or mild
  3. CXR- reticulonodular pattern/patchy areas of consolidation
A

M. pneumoniae

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18
Q

Which pathogen?

  • GI disorders (watery diarrhea)
  • Confusion or encephalopathy
  • Outbreaks usually from contaminated water sources
A

Legionella

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19
Q

Which pathogen?

•Cavitary infiltrate or necrosis

  • Gross hemoptysis
  • Rapidly increasing pleural effusion
A

MRSA

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20
Q

Which pathogen?

  • Comorbidities usually include alcohol abuse, DM, severe COPD
  • “currant jelly” sputum (thick, mucoid, blood-tinged)
A

Klebsiella pneumoniae

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21
Q

What do you see on CBC w/ CAP?

A

leukocytosis w/ left shift

22
Q

What do you see on CXR in CAP?

A

Deonstratable infiltrate

  • lobar
  • interstitial
  • cavitation
23
Q

What is the gold standard for diagnosing CAP?

24
Q

What can you order to help diagnose pathogen responsible for CAP if your patient is not responding to tx?

A

urine antigen tests (S. pneumonia, Legionella)

25
Q

What is the first step in the Pneumonia Severity Index (used to determine if suitable for inpatient or outpatient tx of CAP)

A

If positive to any of the following then go to step 2:

  • >50y/o
  • Coexisting conditions (neoplastic dz, HF, cerebrovascular dz, renal dz, liver dz)
  • abnormal vitals, altered mental status

(if negative for all then outpatient)

26
Q

What is step 2 of the Pneumonia Severity Index (used to determine if outpt or inpt tx for CAP)

A

Risk stratification- if score is < 70 then outpatient

*basically- if patient is over 65ish + comorbidities, nursing home resident or crappy vitals–> ADMIT

  • Points for age in yrs; -10 for female
    • (ex: 65pts for 65y/o man, 55pts for 65y/o woman)
  • Nursing home resident
  • comorbidities (HF, CKD, etc)
  • AMS
  • RR> 30
  • SBP<90
27
Q

What is CURB 65 and what is it used for?

A

Used to determine if inpatient or outpatient tx of CAP

Confusion

Urea > 7 mmol/L (BUN > 20 mg/dL)

Respiratory Rate ≥ 30 breaths/minute

Blood pressure (SBP <90 or DBP <60)

65- ≥ 65 years old

28
Q

How is CURB 65 scored (which score is outpatient vs inpatient)

A

Score 0-1: outpatient

Score 2: Admit

Score 3-5: assess for ICU care

29
Q

What is different about the CRB-65 compared to the CURB-65? How is it scored?

A

–Removes need for labs (BUN)

–Score of 0 = low predicted mortality–> no need for hospitalization

–Score 1-2 = consider for hospitalization (increased risk mortality)

–Score 3-4 = urgent hospitalization +/- ICU

30
Q

What do IDSA/ATS guidelines recommend for outpatient tx of CAP in a pt that is previously healthy and has not had abx w/in the last 3 months

A

treat empirically for at least 5 days w/ :

macrolide

or

Doxycycline

31
Q

What do IDSA/ATS guidelines recommend for outpatient tx of CAP in a pt w/ risk factors for macrolide resistant S. pneumoniae or antibiotic use within the past 3 months

A

Treat empirically for at least 5 days w/:

Respiratory fluoroquinolone

OR

beta-lactam (first line= high dose amoxicillin or amoxicillin-clavulanate)* PLUS macrolide

*alternative choice for beta lactam= ceftriaxone, cefpodoxime, cefuroxime

32
Q

What is the duration of CAP treatment- outpatient?

A
  • At least 5 days
33
Q

If you have a patient with CAP that you are treating on an outpatient basis, what should you say to reassure the patient in regards to duration of sxs?

A
  1. Median time to resolution:
    • 3 days for fever
    • 14 days for cough and fatigue
  2. At least 1/3 will have at least one symptom at 28 days
34
Q

When should you consider follow up CXRs for a pt w/ CAP that you are treating outpatient?

A

if they remain symptomatic

smokers

elderly

35
Q

What is tx for CAP if inpatient but non-ICU?

A

Respiratory fluoroquinolone

OR

beta-lactam plus a macrolide

(tx for a min of 5 days)

36
Q

What is tx for CAP if in the ICU (not PCN allergic)?

A

anti-pneumococcal beta-lactam PLUS azithromycin

or

anti-pneumococcal beta-lactam PLUS respiratory fluoroquinolone

37
Q

What is tx for CAP if in the ICU if patient is PCN allergic?

A

respiratory fluoroquinolone

PLUS

aztreonam

38
Q

CAP tx- inpatient (ICU):

What are the 7 risk factors for Pseudomonas?

A
  1. Alcohol use disorder
  2. Cystic fibrosis
  3. Neutropenic fever
  4. Recent intubation
  5. Cancer
  6. Organ Failure
  7. Septic Shock

“CANCORS”

39
Q

CAP tx- inpatient (ICU):

What are the 4 risk factors for MRSA?

A
  1. ESRD
  2. IV drug abuse
  3. Prior antibiotic use
  4. influenza
40
Q

How do you tx CAP if pt is inpatient (ICU) and there is pseudomonas risk?

A

Antipneumococcal, antipseudomonal beta lactam*

plus either ciprofloxacin or levofloxacin (750 mg)

OR

above beta-lactam* + aminoglycoside + azithromycin

OR

above beta-lactam* + aminoglycoside + respiratory fluoroquinolone

*e.g. cefepime, piperacillin-tazobactam

for PCN allergic substitute aztreonam for above beta-lactam

41
Q

How do you tx CAP inpatient (ICU) if MRSA risk?

A

Add vancomycin or linezolid

42
Q

How do you tx CAP if pt is inpatient (ICU) and there is pseudomonas risk AND pt is PCN allergic?

A

aztreonam + either ciprofloxacin or levofloxacin (750 mg)

OR

aztreonam + aminoglycoside + azithromycin

OR

aztreonam + aminoglycoside + respiratory fluoroquinolone

(same as tx for non-PCN allergic but replacing beta lactams w/ aztreonam)

43
Q

In a pt w/ CAP receiving IV abx- what criteria must be met in order to change to oral tx?

A
  • overall clinical improvement
  • hemodynamically stable
  • able to take oral meds
  • improvement in fever, respiratory status and WBC
44
Q

What is the duration of inpatient treatment?

A

•Minimum of 5 days and all of the following:

  • Afebrile for 48-72 hours
  • Supplemental O2 not needed
  • Heart rate < 100
  • RR < 24
  • SBP ≥ 90 mm Hg
45
Q

What is an important aspect of CAP treatment?

A

smoking cessation

46
Q

What are 3 complications of CAP?

A
  1. Bacteremia
  2. Sepsis
  3. Cardiac complications
    • ​​ heart failure
    • MI
    • arrhythmia
47
Q

How is CAP prevented?

A

Vaccinations!

48
Q

Which vaccinations are given to prevent CAP? Who gets them?

A

Influenza: all patients

Sequential administration of PCV13 and PPSV23: >65y/o

  • When possible give PCV13 first; followed by PPSV23 one year later
  • If already received PPSV23, give PCV13 at least 1 year after most recent PPSV23 dose
49
Q

What 6 conditions in an immunocompetent pt would be indications to give PPSV23 vaccine at an earlier age (19-64)?

A
  1. alcoholism
  2. chronic heart dz
  3. chronic liver dz
  4. chronic lung dz
  5. cigarrette smoking
  6. DM

“HALLD”

50
Q

how long after receiving PCV13 is it recommended to give PPSV23 to immunocompromised patient that is 19-64 y/o?

A

>8 weeks after PCV13

51
Q

how long after receiving first dose of PPSV23 is it recommended to be revaccinated w/ PPSV23 in immunocompromised patients that are 19-64 y/o?

A

>5 yrs after 1st dose of PPSV23

F2 E3 Shea (16 decks)

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