Community Acquired Pneumonia Flashcards
The Pathogenesis of Pneumonia?
inflammation of parenchymal structures of the lung in the lower respiratory tract (alveoli and bronchioles)
How to classify Community Acquired pneumonia?
(how it occurred)2
How to classify Nsocomial pneumonia?
3
- Pneumonia occurred outside of the hospital or within 48 hours of hospital admission.
- In a person who has not resided in a nursing home or hospital in the prior 2 weeks.
- Hospital acquired
- Ventilator associated
- Health care associated
Both are still most commonly ccause by strep pneumo
Classification is further based on etiologic agents
Typical? (where is the infection and the type of bug)
Atypical? (where is the infection and the type of bug 2)3
- Caused by bacteria that multiply IN the alveoli
- Caused by infectious agents that multiply in the spaces BEWTEEN the alveoli (septum and interstitum)
- Viral infections
- Mycoplasm
(lack a cell wall around their cell membrane)
How is the bacteria able to infect the host?
Defect in the usual respiratory defense mechanisms
–Cough, cilia, immune response
Which type has a quick onset and more trouble with gas exchange/breathing?
CAP
CAP risk factors?
10
Advanced age Alcoholism Tobacco use COPD Asthma Immunosuppression Underweight Regular contact with children Frequent visits to a health care provider Gastric acid suppressive therapy (bacteria that would have been normally killed by the acid)
Most common bacterial etiologies of CAP?
10
Strep pneumoniae H. influenzae Mycoplasma pneumoniae Chlamydia pneumoniae Staph aureus Neisseria meningitidis M catarrhalis Klebsiella pneumoniae Gram negative rods Legionella
Viral causes of pneumonia?
5
Influenza A & B Rhinovirus Respiratory syncytial virus Adenovirus Parainfluenza virus
Etiology based on pt symptom severity. Outpatient most common bugs?
4
S. pneumoniae
M. pneumoniae
C. pneumoniae
Respiratory viruses
Etiology based on pt symptom severity. Hospital Non-ICU most common bugs?
6
S. pneumoniae M. pneumoniae C. pneumoniae H. influenzae Legionella Respiratory viruses
Etiology based on pt symptom severity. Inpatient ICU most common bugs?
6
S. pneumoniae Legionella H. influenza Enterobacteriaceae Staph aureus Pseudomonas
If pneumonia is insidious onset with a possibility of immunocompromise what infection should we consider?
fungal
Factors that may suggest Legionella? 7
- recent travel
- High fever (>104)
- Male
- Multilobar involvement
- GI symptoms (watery diarrhea)*** only one
- Neurologic involvement
- Diffuse parenchymal involvement on xray
What time frame and situations where travel could be the cause of Legionella?
Within 2 weeks
Hotel stays or cruise ships
Most common etiology that
May have rust colored sputum?
Streptococcus pneumoniae
Etiology if pt is
Mycoplasma pneumonia
walking pneumonia
General Symptoms of Pneumonia
15
Fever Cough \+/- sputum production Dyspnea Sweats Chills Headache *Rigors (involuntray muscle constraction) *Pleuritic chest pain *Pleurisy *Hemoptysis Fatigue Myalgias Anorexia Abdominal pain
General Signs of Pneumonia?
9
Appear acutely ill Fever May have hypothermia (elderly)**** Tachypnea Tachycardia Decreased SpO2 Rales/Crackles (inspiratory) Bronchial breath sounds Dullness to percussion
What is different about the presentaton in the elderly?
5
- More likely to have subtle symptoms
- Weakness
- Decline in functional status
- Confusion or change in mental status
- Tachypnea is common
Out patient diagnostic tests
4
CXR +/-
Urinary antigen testing +/-
CBC +/-
BMP +/-
Inpatient diagnostic tests?
11
- Chest x-ray
- Sputum gram stain
- Urinary antigen testing
- -S. pneumonia*
- -Legionella** - Rapid antigen test for influenza
- Prior to initiation of antibiotic therapy
- Sputum culture
- Blood culture (2 sets)
- CBC with differential
- CMP
- Arterial blood gases for hypoxic patients
- Consider HIV testing in all adult patients
When would we order an S. pneumonia urinary antigen test?
6
order if
- leukopenia,
- asplenia,
- active ETOH use,
- chronic severe liver disease,
- pleural effusion,
- ICU admission
When would we order a Legionela urinary antigen test?
4
order if
- active ETOH use,
- travel within the last 2 weeks,
- pleural effusion,
- ICU admission
What kind of XRays should we order? 2
What would be our findings on a chest Xray?
5
HOw do chest Xrays help us? 2
How long could it take to clear?
Always order a PA and Lateral Xray if possible
- patchy opacities,
- lobar consolidation with air bronchograms,
- diffuse alveolar or
interstitial opacities, - pleural effusions,
- cavitation
Helpful to assess severity
Assess response to therapy
May take 6 weeks to completely clear
If pleural effusion is present what should we consider?
Diagnostic evaluation of pleural fluid includes what?
7
thoracentesis
Glucose, LDH total protein leukocyte count pH gram stain culture
If cavitary opacities are seen what should we order?
We probably need to obtain samples from what?
Order fungal tests on the sputum and test for mycobacterium
bronchoscopy
First thing we need to decide when treating pneumonia?
First determine if the patient warrants hospital admission or if it is safe to treat as an outpatient
Should we hospitalize a pt?
5
We hospitalize if they have how many?
C Confusion U BUN > 19 mg/dl R RR > 30 min B BP 1 The higher the number of points the higher the mortality
Whats the sensitivity of the CURB-65?
What is the CURB-65 really good at predicting?
What test is more sensitive for needing intensive respiratory support?
Sensitivity of 39% for identification of those needing intensive respiratory support
30 day mortality
0-1 = 0.7-2.1%
2 = 9.2%
≥3 = 15-40%
Pneumonia
Severity
Index
74% sensitivity for prediction
Empiric antibiotic treatment for Not hospitalized
No-Comorbidities?
3
Azithromycin
Or Clarithromycin
Or Doxycycline
Empiric antibiotic treatment
Not hospitalized + Comorbidities?
3
Respiratory FQ
Or Azithromycin or Clarithromycin +
high dose Amox
or high dose Amox-CL
or cefdinir, cefpodoxime, cefprozil
Empiric antibiotic treatment Hospitalized, Not in the ICU?
2
Respiratory FQ
Or Macrolide +
Beta lactam
Cefriaxone Rocephin!
Ampicillin
Cefotaxime
(need broader coverage)
Empiric antibiotic treatment
Hospitalized in the ICU?
2
Unless you are at risk for pseudomonas
2
Respiratory FQ or Azithro
+ antipseudomonal beta lactam
Cefotaxime, ceftriaxone, ampicillin/sulbactam
Antipseudomonal beta lactams:
Piperacillin/tazobactam, cefepime, imipenem, miropenem
+ Cipro or levo
Confusion can be a sign of what?
What is BUN a reading of?
BP?
hypoxia or increased CO2
electrolyte distrubance
Renal funtion (dehydrated? getting out of bed to take in fluids? If infection is systemic - bad renal function?)
sepsis
Timing of treatment:
Best outcome if antibiotics are started within?
Where should the first dose be given?
6 hours of admission
ER
In which situations is Therapy is subject to change for pneumonia?
5
- Based on severity of presentation
- Recent antibiotic use in the last 3 months
- Post influenza infection (staph)
- Suspicion of drug resistant organisms in the community
- After obtaining culture and sensitivity results
Minimum duration of therapy for pneumonia?
How long must they be afebrile before stopping treatment?
Average length for meds other than a Zpack?
Minimum of 5 days
Afebrile for 48-72 hrs
Average for meds other than Azithro 5-7 days unless severe infection or other sites infected
Prevention of pneumonia?
2
- Pneumococcal vaccine (against 23 strains of S pneumonia)
2. Seasonal influenza vaccine
ANEROBIC PULMONARY INFECTIONS risk factors?
11
- Decreased level of consciousness due to drug or ETOH use
- Seizures
- General anesthesia
- CNS disease
- Impaired swallowing
- GERD
- Hiatal hernia
- Tracheal tubes
- Nasogastric tubes
- Peridontal disease
- Poor dental hygiene
Pathogenesis of anerobic pulmonary infections?
Inhalation of oropharyngeal secretions colonized by pathogenic bacteria
–Macroaspiration and chronic microaspiration
Which part of the lungs do anerobic pulmonary infections go?
Two examples?
Goes to the dependent lung zones
Example:
–Posterior segments of the upper lobes
—Superior and basilar segments of lower lobes
Anerobic lung infections cause what conditions?
3
Necrotizing pneumonia
Lung abscess
Empyema
Anerobic Pathogens that are causing these lung infections?
4
Prevotella melaninogenica
Peptostreptococcus
Fusovacterium nucleatum
Bacteroides
Symptoms of anerobic lung infections?
4
Onset?
Fever,
weight loss,
malaise
Cough productive of foul smelling sputum
Insideous
Work up for anerobic infections?
2
What can you not do?
CXR and most likely a CT scan of the chest
Cannot do a sputum culture for anerobes due to contamination from oropharyngeal secretions
If a sputum sample is needed for anerobic lung infections what do you need to do?
Bronchoscopy or transthoracic/transtracheal aspiration
If aspiration is suspected for anerobic lung infections what do you need to do?
a swallowing evaluation is needed
Treatment - DOC for anerobic lung infections?
3
Clindamycin**
Or Augmentin
Or Amoxicillin or PCN G + metronidazole
Describe the duration of treatment for anerobic lung infections?
If antibiotic treatment doesnt work what may be required?
Longer courses of therapy are generally needed
Continue antibiotics until CXR improves which may be a month or more
If lung abscess, continue antibiotics until resolution of abscess
May require surgical removal of abscess or empyema
Consider anerobic infection if what is present?
4
Aspiration pneumonia is caused by anerobes but probably isnt the number one cause. BUT it does have to be in your dif.
- lung abscess,
- empyema,
- necrotizing pneumonia or 4. significant risk factors like recent LOC due to multiple factors
