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Physiology > CAP > Flashcards

CAP Flashcards

1
Q

Phases in lobar pneumococcal pneumonia

A

Edema (Congestion)
Red Hepatization
Gray Hepatization
Resolution (Final phase)

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2
Q

Initial phase w/ the presence of proteinaceous exudate and bacteria in the alveoli

rarely evident in clinical or autopsy specimens because of the rapid transition to the next phase

A

EDEMA

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3
Q

presence of ERYTHROCYTES in the cellular intraalveolar exudate

neutrophils influx - more important with regard to host defense

bacteria are occasionally seen in pathologic specimens collected during this phase

A

RED HEPATIZATION

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4
Q

no new erythrocytes are extravasating and those already present have been lysed and degraded

NEUTROPHILS - predominant cells

abundant fibrin deposition
(-) bacteria

corresponds with SUCCESSFUL CONTAINMENT OF THE INFECTION and IMPROVEMENT IN GAS EXCHANGE

A

GRAY HEPATIZATION

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5
Q

final phase

MACROPHAGE reappears as the dominant cell type in the alveolar space, and the debris of neutrophils, bacteria, and fibrin has been cleared, as has the inflammatory response

A

RESOLUTION

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6
Q

MC pattern in nosocomial pneumonias

A

bronchopneumonia pattern

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7
Q

TYPICAL BACTERIAL PATHOGENS (CAP)

A

• S. pneumoniae
• Haemophilus influenzae
• S. aureus
• gram- (-) bacilli - Klebsiella pneumoniae and Pseudomonas aeruginosa

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8
Q

ATYPICAL BACTERIAL PATHOGENS

A

Chlamydia pneumoniae
Legionella species (in inpatients)
Mycoplasma pneumoniae
respiratory viruses - influenza viruses, adenoviruses, human metapneumovirus, and respiratory syncytial viruses

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9
Q

Play a significant role only when an episode of aspiration has occurred days to weeks before presentation of pneumonia

A

Anaerobes

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10
Q

MCC of CAP

A

Strep pneumoniae

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11
Q

complicate influenza infection

A

S. aureus pneumonia

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12
Q

RISK FACTORS FOR CAP:

A

• alcoholism
• asthma
• immunosuppression
• institutionalization
• age of ≥70 years

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13
Q

RISK FACTORS FOR PNEUMOCOCCAL PNEUMONIA:

A

• dementia
• seizure disorders
• heart failure
• cerebrovascular disease (CVD)
• alcoholism
• tobacco smoking
• chronic obstructive pulmonary disease (COPD)
• HIV infection

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14
Q

more likely in patients with skin colonization or infection with CA-MRSA

A

CA-MRSA pneumonia

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15
Q

Tend to infect patients who have RECENTLY BEEN HOSPITALIZED and/or RECEIVED ANTIBIOTIC THERAPY or who have comorbidities such as alcoholism, heart failure, or renal failure

A

Enterobacteriaceae

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16
Q

Particular problem in patients with SEVERE STRUCTURAL LUNG DISEASE, such as bronchiectasis, cystic fibrosis, or severe chronic obstructive pulmonary disease (COPD)

A

P. aeruginosa

17
Q

RISK FACTORS FOR LEGIONELLA INFECTION:

A

• diabetes
• hematologic malignancy
• cancer
• severe renal disease
• HIV infection
• smoking
• male gender
• recent hotel stay or ship cruise

18
Q

CLINICAL MANIFESTATIONS of CAP

A

• febrile with tachycardia
• cough - either nonproductive or productive of mucoid, purulent, or blood-tinged sputum
• gross hemoptysis - suggestive of CA-MRSA pneumonia
• involvement of the pleura  pleuritic chest pain
• 20% of patients - GI symptoms such as nausea, vomiting, and/or diarrhea
• OTHER SYMPTOMS - fatigue, headache, myalgias, and arthralgias
• ↑ respiratory rate and use of accessory muscles of respiration – common

19
Q

CLINICAL MANIFESTATIONS of CAP

A

• febrile with tachycardia
• cough - either nonproductive or productive of mucoid, purulent, or blood-tinged sputum
• gross hemoptysis - suggestive of CA-MRSA pneumonia
• involvement of the pleura –> pleuritic chest pain
• 20% of patients - GI symptoms such as nausea, vomiting, and/or diarrhea
• OTHER SYMPTOMS - fatigue, headache, myalgias, and arthralgias
• ↑ respiratory rate and use of accessory muscles of respiration – common

20
Q

PE findings in CAP

A

• PALPATION - ↑ or ↓ TACTILE FREMITUS
• PERCUSSION - can vary from DULL to flat, reflecting underlying consolidated lung and pleural fluid, respectively
• AUSCULTATION - CRACKLES, BRONCHIAL BREATH SOUNDS, and PLEURAL FRICTION RUB (possible)

21
Q

DIFFERENTIAL DIAGNOSIS INCLUDES BOTH INFECTIOUS AND NONINFECTIOUS ENTITIES:

A

acute bronchitis
acute exacerbations of chronic bronchitis
heart failure
pulmonary embolism
hypersensitivity pneumonitis
radiation pneumonitis

22
Q

often necessary to differentiate CAP from other conditions

A

Chest radiography

23
Q

often necessary to differentiate CAP from other conditions

A

Chest radiography

pneumatoceles - suggest infection with S. aureus
upper-lobe cavitating lesion - suggests tuberculosis

24
Q

May be of value in a patient with SUSPECTED POSTOBSTRUCTIVE PNEUMONIA caused by a tumor or foreign body or suspected cavitary disease

A

CT

25
Q

specific views of chest radiograph should be requested?

A

Standing PA and LATERAL views of the chest in full inspiration comprise the best radiologic evaluation of a patient suspected of having pneumonia. (Grade A)

26
Q

Sputum Gram Stain and Culture

A

sputum sample:

> 25 neutrophils/LPF

<10 squamous epithelial cells/LPF

27
Q

The standard for diagnosis of respiratory viral infection

A

PCR of nasopharyngeal swabs

28
Q

CURB-65 criteria - severity-of-illness score

A

Confusion

Urea >7 mmol/L

Respiratory rate ≥30/min

Blood pressure - systolic ≤90 mmHg/ diastolic ≤60 mmHg

Age ≥65 years

score of 0 - among whom the 30-day mortality rate is 1.5% - can be treated outside the hospital

score of 2 - the 30-day mortality rate is 9.2%, and patients should be admitted to the hospital

0-1 - treat as outpatient
2 - admit patient
>3 - consider ICU admission

29
Q

Response to therapy is expected w/ 24-72 hrs of initiating treatment

A

fever decreases w/n 72 hrs
temp normalizes w/n 5 days
respiratory signs (tachypnea) return to normal

30
Q

MINIMAL INHIBITORY CONCENTRATION (MIC) CUTOFFS FOR PENICILLIN IN PNEUMONIA

A

≤2 μg/mL - susceptibility

> 2–4 μg/mL - intermediate

≥8 μg/mL- resistant

31
Q

RISK FACTORS FOR PENICILLIN-RESISTANT PNEUMOCOCCAL INFECTION:

A

recent antimicrobial therapy

age of <2 years or >65 years

attendance at day-care centers

recent hospitalization

HIV infection

32
Q

The most important risk factor for antibiotic-resistant pneumococcal infection

A

use of a specific antibiotic w/n the previous 3 months

33
Q

Previously healthy and no antibiotics in past 3 mos

A

macrolide
CLARITHROMYCIN 500 mg PO BID
OR
AZITHROMYCIN 500 mg PO once then 250 mg qd

OR
DOXYCYCLINE 100 mg PO BID

34
Q

Comorbidities or antibiotics in past 3 mos: select an alternative from a different class

A

respiratory fluoroquinolone
MOXIFLOXACIN 400 mg PO qd
GEMIFLOXACIN 320 mg PO qd
LEVOFLOXACIN 750 mg PO qd

OR

beta lactam
preferred
high dose AMOXICILLIN 1 g TID
OR
AMOXICILLIN/CLAVULANATE 2 g BID
alternatives
CEFTRIAXONE 1-2g IV qd
CEFPODOXIME 2OO mg PO bid OR
CEFUROXIME 500 mg PO bid PLUS a macrolide

35
Q

Inpatients, NON- ICU

A

respiratory fluoroquinolone
MOXIFLOXACIN 400 mg PO or IV qd
LEVOFLOXACIN 750 mg PO or IV qd

beta lactam
CEFTRIAXONE 1-2g IV qd
AMPICILLIN 1-2 g IV q4-q6
CEFOTAXIME 1-2 g q8h
ERTAPENEM 1 g IV qd

PLUS
macrolide
ORAL CLARITHROMYCIN or AZITHROMYCIN or IV AZITHROMYCIN once, then 500 mg qd

36
Q

Inpatients, ICU

A

beta lactam
CEFTRIAXONE 2 g IV qd
AMPICILLIN-SULBACTAM 2 g IV q8h
OR
CEFOTAXIME 1-2 g IV q8h

PLUS
either AZITHROMYCIN or a FLUOROQUINOLONE

37
Q

If Pseudomonas is a consideration

A

*antipseudomonal beta lactam
PIPERACILLIN/TAZOBACTAM 4.5 g IVq6h
CEFEPIME 1-2 g IV q12h
IMIPENEM 500 mg IV q6h
MEROPENEM 1 g IV q8h

PLUS
either
CIPROFLOXACIN 400 mg IV q12h
OR
LEVOFLOXACIN 750 mg IV qd

*above beta lactam PLUS an aminoglycoside AMIKACIN 15 mg/kg qd
OR
TOBRAMYCIN 1.7 mg/kg qd

PLUS
AZITHROMYCIN

*above beta lactams PLUS aminoglycoside PLUS and antipneumococcal fluoroquinolone

38
Q

If CA-MRSA is a consideration

A

ADD LINEZOLID 600 mg IV q12h

OR

VANCOMYCIN 15 mg/kg q12 h initiall w/ adjusted dose

PLUS
CLINDMYCIN 300 mg q6h

39
Q

Discharge Criteria

A

during the 24 hrs before discharge

temp 36-37.5
pulse <100/min
RR 16-25/min
SBP >90 mmHg
blood O2 saturation >90%
functioning GIT (allowing use of oral antibiotics)

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