Clinical and Pathological Correlation of Pneumonia

Question 1

What is rusty sputum characteristic for?

What is current jelly characteristic for?

Answer 1

Pneumococcal pneumonia

Klebsiella

Question 2

When the patient says E but it is heard as A, what does this indicate?

Answer 2

Consolidation

Question 3

What are the causes of fluffy CXR?

Mnemonmic device?

Answer 3

Alveolar

PeCanPIE

Question 4

Etiology of CAP most common?

Answer 4

Technically NOT IDENTIFIED IS MOST COMMON. When there is an organism, it is Streptococcus pneumoniae

Question 5

What is pneumonia vs. pneumonitis?

Answer 5

Pneumonia means INFECTION OF THE LUNG PARENCHYMA!. Pneumonitis can JUST MEAN INFLAMMATION. can be infection or something else.

Question 6

Why is Atypical pneumonia atypical?

What are the associated organisms?

Answer 6

ATYPICAL BECAUSE OF THE PATHOGEN

Can be moderate to no sputum, no physical findings of lung consolidation with moderate to no elevation in WBCs and lack of alveolar exudate.

Atypicals are

Mycoplasma pneumoniae

Chlamydia pneumoniae

Chylamydia trachomatis (newborns)

Legionella pneumophila

.

Question 7

What would not cause you to suspect pseudomonas and why?

bronchiectasis

steroids greater than 10mg/day

alcoholism

Broad specturm abx >7 days in past month

malnutrition

Answer 7

Alcoholism because while it is an immunosuppressant, just not for pseudomonas aeruginosa

Question 8

What is the characteristic for pseudomonas aeruginosa

Answer 8

cystic fibrosis patients

Question 9

What organism should you suspect in alcoholics?

Answer 9

ALPS, alcoholic low white count Sepsis

SUSPECT KLEBISELLA AND PNEUMONCOCCAL PNEUMONIA.

Question 10

What are the modifying factors for PCN resistant and drug resistant pneumococci

Answer 10

age>65

betalactam within past 3 months

alcoholism

immunosuppression

multiple medical comorbidities

exposure to child at a day care

Question 11

when should you suspect enteric gram negatives?

Answer 11

nursing home resident

cardiopulmonary disease

multiple medical comorbidities

recent antibiotic therapy

Question 12

When should you suspect pseudomonas aeruginosa?

Answer 12

Bronchiectasis

steroids>10mg/day

BSA>7days in past month

malnutrition

Question 13

Treatments for:

Outpatient without modifying risk factors or cardiopulmonary disease

vs.

Outpatient with modifying risk factors or cardiopulmonary disease

Answer 13

Advanced generation macrolide or doxycycline

vs.

Oral beta lactam plus (macrolide or doxycycline)

or Antipneumoncoccal fluoroquinolone alone

Question 14

WHen should you admit a patient?

Answer 14

CURB-65

Confusion

Urea (>19.1 mg/dl)

Respiratory rate>30 breaths/min

Blood pressure <90 systolic or (<or></or>

<p>Age greater than or equal to 65.</p>

</or>

Question 15

What to do for diagnostic evaluation?

Time to first dose of antibiotic?

Answer 15

CXR, 2 sets of pre treatment blood cultures.

Sputum gram stain and culture. if patient has productive cough, do not withold antibiotics.

Give first dose abx before 8 hours after presentation

Question 16

What do you want for a sputum?

Answer 16

no squamous cells and lots of white cells. (25 and less than 3 epithelial cells)

Question 17

Treatments for

Hospitalized non icu without c-p disease or modifying risk factors

vs.

Hospitlaized non icu with c-p diseae or modifying risk factors

Answer 17

IV macrolide alone (if intolerate, iv beta lactam plus doxycycline)

or antipneumococcal fluoroquinolone alone

vs.

IV beta-lactam plus (macrolide or doxycycline)

Antipneumococcal fluoroquinolone alone

Question 18

Treatment if

ICU admited without risk factor for pseudomonas aeruginosa

vs.

Hospitalized non ICU w/ risk factor for pseudomonas aeruginosa

Answer 18

IV beta lactam (cefotaxime, ceftriaxone) plus IV macrolide

or Antipneumococcal fluoroquinolone alone.

UVa- if MRSA colonized, gram + cocci in sputum can give IV vancoymycin

vs.

IV beta-lactam with antipseudomonal activity plus antipseudomonal fluoroquinolone (cipro)

IV beta-lactam with antipseudomonal activity plus aminoglycoside plus IV atypical coverage

Question 19

When can you say resolution of CAP?

Answer 19

in uncomplicated stable patient 72 hrs permitted for response.

• fever resolves 2-4 days after onset of abx
• WBC resolves by 4 days after onset of ABX
• PEx findings can persist >7 days in 20-40%

Clearing of opacities on CXR, 50% by 2 weeks, 67% by 4 weeks, 75% by 6 weeks (so if you don’t think theres a high likelihood of a cancer you would wait 6 weeks for a follow up with specialist otherwise you’re wasting their time and money)

Question 20

What is the criteria to be met for IV to oral therapy?

Answer 20

Improvement of fever

improvement in cough and respiratory distress

Improvement in leukocytosis

Normal GI tract absorption

Question 21

How long for therapy to be in uncomplicated stable patients?

When to arrange followup?

Anything else?

Answer 21

Total course of therapy 7-14 days (or 10 to make it simpler)

Arrange follow up in 2-3 days

Pneumovax and influenza vaccines