Chapter 65: Community-Acquired Pneumonia, Aspiration Pneumonia, and Noninfectious Pulmonary Infiltrates Flashcards
Hospital-acquied pneumonia define as
New infection occurring ≥48 h after hospital admission
Ventilator-acquired pneumonia
New infection occurring ≥48 h after endotracheal intubation
Community-acquired pneumonia
Acute pulmonary infection in a patient who is not hospitalized or residing in a long-term care facility ≥14 d before presentation
Bacterias that produce pneumonia by hematogenous seeding
Staphylococcus aureus or Pneumococcus
Most common etiologic agent of CAP?
Pneumococcus
What are the atypical organisms that cause pneumonia?
- Mycoplasma
- Chlamydia
- Legionella
Two organisms that account for the most severe CAP in otherwise healthy adults are?
- Streptococcus pneumoniae
- Legionella
What are the special populations with pneumonia?
- Nursing homes residents
- Chronic alcoholism
- HIV
Types of imaging seen in patient with pneumococcal pneumonia?
Lobar pneumonia
Upon auscultation, you heard inspiratory rales, bronchial breath sounds pleural effusion and rhonchi, and wheezing. What does it mean?
- Alveolar fluid (inspiratory rales)
- Consolidation (bronchial breath sounds)
- Bronchial congestion (rhonchi and wheezing)
The patient had a history of recently hospitalized, debilitated,
or immunocompromised patients with fever, dyspnea, and cough. Chest Xray has bilateral lower lobe infiltrates. What is the most likely etiology of pneumonia?
P. aeruginosa
The patient had gradual onset, fever, dyspnea, and pleuritic chest pain; especially in the elderly, sickle cell patients, diabetes and COPD. Chest Xray shows pleural effusions and multilobar infiltrates. What is the most likely etiology of pneumonia?
Haemophilus influenza
A patient at nursing home that had history of alcoholism presented with brown currant jelly sputum. What is the most likely etiology of pneumonia?
Klebsiella pneumoniae
Sudden onset, fever, rigors, pleuritic chest pain, productive cough, dyspnea with rust-colored sputum. What is the most likely etiology of pneumonia?
Streptococcus pneumoniae
Consideration in patients with chronic lung disease, patients with laryngeal cancer, immunosuppressed patients, nursing home patients, after viral infection or others at risk for aspiration pneumonia
Staphylococcus aureus
Why atypical agents cause pneumonia do not respond to B-lactam antibiotics?
The lack cell wall
Patients at higher risk include cigarette smokers, patients with chronic lung disease, transplant patients, and the immunosuppressed. Most common in summer because it is not seasonal and complicated with GI symptoms. Chest xray shows patchy infiltrates with occasional hilar adenopathy and pleural effusion. What is the most likely etiology of pneumonia?
Legionella pneumonia
To confirm Legionella pneumonia. What test to do?
Urinary Legionella antigen test
Causes mild subacute illness with sore throat, mild fever and nonproductive cough. Chest xray showed patchy subsegmental infiltrate and linked to adult-onset asthma. What is the most likely etiology of pneumonia?
Chlamydia pneumonia
Frequently associated with retrosternal chest pain. What is the most likely etiology of pneumonia?
Mycoplasma pneumonia
Causative agent of Q fever. transmitted via infected animals dried urine that is inhaled or unpasteurized milk.
Coxiella burnetii
Treatment for Q fever (Coxiella burnetti)
Doxycycline or respiratory quinolone is the first-line treatment
True or False:
Antivirus is recommended for pregnant patients because they are more susceptible
True
Blood cultures are recommended for which patient with CAP?
- ICU
- Leukopenia
- Cavitary lesions
- Severe liver disease
- Alcoholic
- Asplenia
- Pleural effusion
When to obtain Legionella urine antigen in a patient with CAP?
- ICU
- Alcoholics
- History of travel in past 2 weeks
An etiologic agent that produces lung abscesses in pneumonia
- S. aureus
- Klebsiella
An etiologic agent that mimics lung masses
- Pneumococcal (round pneumonia)
- Staphylococcal
True or False:
In general, patients with atypical or viral pneumonia are more likely to have unilobar or focal infiltrates than patients with bacterial pneumonia
False
In general, patients with bacterial pneumonia are more likely to have unilobar or focal infiltrates than patients with viral or atypical pneumonia
True or False
Hilar adenopathy is not common in patients with atypical pneumonia
False
Hilar adenopathy is more common in patients with atypical pneumonia
Compared to nonalcoholic, the alcoholic has greater oropharyngeal colonization of what?
Gram- negative bacteria
The most common pathogen causing pneumonia in alcoholics
S. pneumoniae (also Klebsiella and Haemophilus)
True or False
Infections due to S. pneumonia and influenza are associated with increased morbidity and mortality in diabetic patients.
True
Antibiotic use in pregnant patients with pneumonia in ED
Acyclovir
The most common cause of acquired immuno- deficiency syndrome-related death in pregnant women in the United States, with a mortality rate of approximately 50%.
Pneumocystis jirovecii
Drug that improves survival compared with paitient treated with trimethoprim-sulfamethoxazole alone in PCP in pregnant
- Pentamidine
- Steroids
- Eflornithine
The most common serious viral infection in the elderly
Influenza
Postinfluenza bacterial pneumonia is most commonly caused by S. pneumoniae, S. aureus, or H. influenzae
Postinfluenza bacterial pneumonia is most commonly caused by S. pneumoniae, S. aureus, or H. influenzae
Temperature that gives clue of serious bacterial infection
> 38.3
Eight variables are significant independent predictors of pneumonia in nursing home patients
- Increased pulse rate
- Respiratory rate ≥30 breaths/min
- Temperature ≥38°C (100.4°F)
- Somnolence or decreased alertness
- Presence of acute confusion
- Lung crackles on auscultation
- The absence of wheezes
- Increased leukocyte count
The most frequently reported pathogens among patients with nursing home–acquired pneumonia are
- S. pneumoniae
- Gram-negative bacilli
- H. influenzae
The most common cause of bacterial pneumonia in patients with HIV
S. pneumoniae is the most common cause of bacterial pneumonia in patients with HIV. Also P. aeruginosa
Level of CD4 that likely to cause pneumonia
> 800cells/mm3
Level of CD4 that likely to cause pneumocystic pneumonia
<200cells/mm3
Between CD4 of 250 and 500 cells/mm3, infection from which infection?
Between 250 and 500 cells/mm3, infection from M. tuberculosis, Cryptococcus neoformans, or Histoplasma capsulatum poses a greater risk
In AIDS patient, miliary pneumonia on CT scan or chest radiograph may present what?
Varicella pneumonia
Patient with uncomplicated pneumonia can send home with what antibiotics?
- Clarithromycin 1000mg/tab OD x 7d ays
- Azithromycin 500mg/tab OD on day 1 and 250mg/tab OD on day 2-5
- Doxycycline 100mg BID x 10-14 days
Patient with complicated pneumonia can send home with what antibiotics?
- Levofloxacin 750mg/tab OD x 5 days
- Moxifloxacin 400mg/tab OD x 7–14 days
- Azithromycin 500mg/tab OD on day 1 and 250mg/tab OD on day 2-5
What kind of disease you should not give fluoroquinolones?
Myastenia gravis
Admitted patients with pneumonia that is non-ICU can be given with
- Levofloxacin 750mg IV
- Moxifloxacin 400mg IV
- Ceftriaxone 1g IV plus Azithromycin 500mg IB
Why respiratory fluoroquinolone is discouraged in in-patient with pneumonia?
Avoid resistance and Clostridium difficile outbreaks.
The best studied and recommended tool in the disposition of pneumonia patient
Pneumonia severity index
A score of ___ in CURB-65 or CRB-65 shows the low mortality rate
<2
How to know who to admit to ICU in patient with pneumonia?
Pneumonia Severity Index class V and CURB-65 patients with a score of ≥3 may need intensive care
The second leading cause of infection in nursing homes
Aspiration pneumonia second to UTI
The leading cause for transfer from nursing home to the hospital and the leading cause of death in nursing home patients
Aspiration pneumonia
Symptoms of aspiration pneumonia usually resolve within
48 hours
Aspiration of such pills will cause local inflammation and lead to bronchial stenosis
- Potassium
- Iron
- Metformin
Aspiration of such pills will cause bronchial obstruction
- Sucralfate
- Pomegranate
The main symptom of noninfectious pulmonary infiltrates is?
Dyspnea
The most common manifestation of pulmonary vasculitis from asymptomatic chest radiograph abnormalities to severe respiratory failure
Diffuse alveolar hemorrhage
Necrotizing granulomatous vasculitis with involvement of upper respiratory tract, lung parenchyma, and kidneys.
Wegener’s
Vasculitides are an allergic eosinophilic condition. most are asthmatic
Churg-Strauss disease
Unknown origin but produces noncaseating pulmonary granulomas
Sarcoidosis
Autoimmune disease affects the lungs and kidneys due to autoantibodies to type IV collagen
Anti–glomerular basement membrane antibody disease (Goodpasture’s syndrome)
Most common cause of leukemic infiltrates with peripheral blast cell counts exceed 100000/mL
Myeloid leukemia
