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Infectious Disease > Community acquired pneumonia > Flashcards

Community acquired pneumonia Flashcards

1
Q

What is the most common cause of CAP?

A

gram + -> strep pneumo

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2
Q

Pathogenesis of pneumonia?

A

inflammation of parenchymal structures of the lung in the lower respiratory tract (alveoli and bronchioles)

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3
Q

Differentiation b/t CAP and nosocomial pneumonia?

A

CAP: occurred outside of hospital or w/in 48 hours of hospital admission
- in a person who has not resided in a nursing home or hospital in past 2 weeks

Nosocomial pneumonia: hospital acquired, ventilator associated, health care associated (more drug resistant and virulent)

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4
Q

Typical and atypical pneumonia?

A

typical: caused by bacteria that multiply in alveoli, neutrophils and pus in alveoli, congregate in alveoli sacs, multiply and produce pus
atypical: caused by infectious agents that multiply in spaces b/t alveoli (septum and interstitum)
- viral infections, mycoplasm (lack a cell wall around their cell membrane)

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5
Q

Pathogenesis of pneumonia?

A
  • defect in usual respiratory defense mechanisms (cough, cilia, immune response)
  • large infectious inoculum or a virulent pathogen overwhelms the immune system
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6
Q

Definition of CAP?

A

pneumonia infection occurred outside the hospital or w/in 48 hrs of hosp. admission
- patients who are residents of long term care facilities are not included her because they are living in a healthcare facility

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7
Q

Epidemiology of CAP

A
  • 4-5 million cases a year in U.S.
  • 25% will require hospitalization
  • most common infectious cause of death world wide
  • among top 3 causes of death worldwide
  • incidence peaks in winter months
  • more common in older adults > 65
  • incidence has decreased since pneumococcal vaccine
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8
Q

RFs for CAP?

A
  • advanced age
  • alcoholism (aspiration)
  • tobacco use
  • COPD
  • asthma
  • immunosuppression
  • underweight
  • gastric acid suppressive therapy: allows pathogens to survive in gastric contents that normally would be killed by acid
  • regular contact with kids (daycare)
  • frequent visits to a health care provider
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9
Q

Most common causative agents of CAP?

A
  • strep pneumo (#1 causative agent)
  • H. influenzae
  • mycoplasma pneumoniae
  • chlamydia pneumoniae
  • staph aureus
  • Neisseria meningitidis
  • M catarrhalis
  • klebsiella pneumonia
  • gram - rods
  • legionella
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10
Q

Viral causes of pneumonia?

A 
influenza A & B
rhinovirus
respiratory syncytial virus (kids)
adenovirus
parainfluenza virus
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11
Q

Outpt causative agents of pneumonia?

A
  • S. pneumoniae
  • M. pneumoniae
  • C. pneumoniae
  • respiratory viruses

(less severe)

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12
Q

hosp. non-ICU causative agents of pneumonia?

A
  • S. pneumo
  • M. pneumo
  • C. pneumo
  • H. influenzae
  • legionella
  • respiratory viruses
    (worse symptoms)
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13
Q

Inpatient ICU agent of pneumonia?

A
  • S. pneumo
  • Legionella (bad)
  • H. influenza
  • enterobacteriaceae*
  • staph aureus*
  • pseudomonas*
    (*= virulent)
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14
Q

What other etiologies might be causing pneumonia?

A
  • fungal: if insidious onset with a possibility of immunocompromise (on immunosuppressive meds, HIV?) consider fungal etiologies
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15
Q

What factors would suggest legionella as the causative agent?

A

Recent travel within 2 weeks, hotel stays or cruise ships

  • high fever >104 F
  • male
  • multilobar involvement
  • GI sxs (watery diarrhea) **unique to legionella
  • neuro involvement
  • diffuse parenchymal involvement on xray
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16
Q

Tips to determine etiology?

A
  • strep pneumo: most common, may have rust colored sputum

- mycoplasma pneumonia:

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17
Q

General sxs of pneumonia

A
  • fever
  • cough
  • +/- sputum production
  • dyspnea
  • sweats
  • chills
  • H/A
  • rigors
  • pleuritic chest pains
  • pleurisy
  • hemoptysis
  • fatigue
  • myalgias
  • anorexia
  • abdominal pain
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18
Q

Signs of pneumonia

A
  • appear acutely ill
  • fever
  • may have hypothermia (elderly) 36 C
  • tachypnea
  • tachycardia
  • decreased SpO2
  • Rales/crackles (inspiratory)
  • bronchial breath sounds
  • dullness to percussion
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19
Q

Elderly presentation of pneumonia?

A
  • more likely to have subtle symptoms
  • weakness
  • decline in fxnl status
  • confusion or change in mental status
  • tachypnea is common
20
Q

out pt dx tests?

A 
CXR: +/-
urinary antigen testing: +/- (strep pneumo, legionella)
CBC: +/-
BMP: +/- 
( maybe not necessary in younger pts)
21
Q

inpt dx tests?

A

CXR
sputum gram stain
urinary antigen testing: s. pneumo, legionella
- rapid antigen test for influenza
- prior to initiation of abx therapy: sputum culture (2 sets) -> want to start abx within 6 hours
- CBC with diff
- CMP (legionella messes with electrolyte balance)
- arterial blood gases for hypoxic patients
- consider HIV testing in all adult patients

22
Q

What kind of CXR should be ordered and what will you see on the films?

A
  • always order a PA, and lateral Xray if possible
  • findings: patchy opacities, lobar consolidation with air bronchograms, diffuse alveolar or interstitial opacities, pleural effusions, cavitation
23
Q

Why are CXRs helpful?

A
  • helpful to assess severity
  • assess response to therapy
  • may take 6 weeks to completely clear (f/u until CXR is clear)
24
Q

What should be considered if pt presents with pleural effusion?

A
  • consider a thoracentesis
  • dx eval of pleural fluid includes: glucose, LDH, total protein, leukocyte count, pH, gram stain and culture
  • fluid will shift if turned on side
  • pleural effusion occurs in cancer, cancer increases risk for pneumonia because of decrease in immunity
25
Q

When should fungal dx testing be done?

A
  • order fungal tests on sputum and test for mycobacterium if cavitary opacities are seen
  • likely need to obtain samples from bronchoscopy
26
Q

When should CA-MRSA pneumonia be considered?

A

when:

  • influenza infection preceded present illness
  • necrotizing pneumonia (destroying the lung tissue)
  • empyema: collection of pus secondary to infection
  • respiratory failure or shock
  • if MRSA infection: tx with vanco or linezolid
  • CA MRSA is genetically different from HA MRSA
27
Q

1st step in tx of pneumonia?

A
  • determine if the pt warrants hospital admission or if it safe to tx as an output
28
Q

What is CURB-65?

A 
C= confusion
U= BUN> 19 mg/dl
R= RR> 30 min
B= BP= 90/60
age = >65
* 1 pt for each yes, hospitalize if > 1, higher the points the higher the mortality
* get confusion from being hypoxic, hyper carbon -> dehydration, elect. imbalance
* hypotension: worried about sepsis
29
Q

Is CURB-65 a good indicator of tx for pneumonia?

A
  • low sensitivity (39%) for ID of those needing intensive respiratory support
  • it is good at predicting 30 day mortality:
    0-1: 0.7-2.1%
    2 = 9.2%
    3 or more = 15-40%
30
Q

How sensitive is the pneumonia severity index?

A
  • 74% sensitivity for prediction of those needing intensive respiratory support
31
Q

Empric abx tx for non-hosp and no comorbidity patients?

A
  • azithro or clarithomycin or doxy (covers H. flu and is better for pts with hx of smoking
32
Q

Empiric abx tx for non-hosp. patients with comorbidities?

A
  • Resp FQ or azithro or clarithro + high dose amox or high dose Amox-CL or cefdinir, cefpodoxime, cefprozil
33
Q

Empiric abx tx for hospitalized pts not in the ICU?

A
  • Respiratory FQ (levo)

- or macrolide + Beta lactam: cefriaxone, ampicillin, cefotaxime

34
Q

Empiric abx tx for hospitalized pts in the ICU?

A
  • respiratory FQ or Azithro
    • antipseudomonal B-lactam: cefotaxime, ceftriaxone, ampicillin/sublactam
  • if at risk for pseudomonas add antipneumococcal + antipseudomonal b-lactams: piperacillin/tazobactam, cefepime, imipenem, miropenem + cipro or levo
    or
    antipseudomonal B-lactam + aminoglycoside + azithro or resp. FQ
  • If MRSA is suspected: add vanco
35
Q

When is the best time to start abx?

A
  • best outcomes if abx started within 6 hours of admission

- customary to require first dose to be given in ED

36
Q

Why would you change the therapy?

A
  • based on severity of presentation
  • recent abx use in the last 3 months
  • post influenza infection -> think staph (MRSA)
  • suspicion of drug resistant organisms in the community
  • after obtaining culture and sensitivity results
37
Q

Duration of abx therapy?

A
  • min. of 5 days (tx longer then a week, no benefit)
  • afebrile for 48-72 hours
  • average for meds other than azithro 5-7 days unless severe infection or other sites infected
  • azithro has a very long half life so duration of therapy doesn’t equate to other drugs
38
Q

Prevention of pneumonia?

A
  • pneumococcal vaccine (against 23 strains of S. pneumonia), seasonal influenza vaccine
39
Q

RFs of anaerobic pulmonary infections?

A
  • decreased level of consciousness due to drug or ETOH use
  • seizures
  • general anesthesia
  • CNS disease
  • impaired swallowing
  • GERD
  • hiatal hernia
  • tracheal tubes
  • NG tubes
  • periodontal disease
  • poor dental hygiene
40
Q

Pathogenesis of anaerobic pulmonary infections?

A
  • inhalation of oropharyngeal secretions colonized by pathogenic bacteria: macro aspiration and chronic micro aspiration
  • Goes to dependent lung zones: posterior segments of upper lobes and superior and basilar segments of lower lobes
41
Q

What do anaerobic lung infections cause?

A
  • necrotizing pneumonia
  • lung abscess
  • empyema
42
Q

What are the anaerobic pathogens?

A
  • Prevotella melaninogenica
  • Peptostreptococcus
  • Fusovacterium nucleatum
  • Bacteroides
43
Q

Symptoms of anaerobic lung infection?

A

onset: insidious
fever, wt loss, malaise
- cough productive of foul smelling sputum

44
Q

Work up of anaerobic lung infection?

A
  • CXR and most likely CT scan of chest (won’t see extent of damage with CXR -> need CT)
  • can’t do sputum culture due to contamination from oropharyngeal secretions
  • if sputum sample is needed:
    do a bronchoscopy or transthoracic/transtracheal aspiration
  • if aspiration suspected a swallowing eval is needed -> RF: is having sleep apnea
45
Q

Tx of anaerobic lung infection?

A
  • DOC:
    Clindamycin
    or augmentin
    or amoxicillin or PCN G + metronidazole
  • longer courses of therapy are generally needed, continue abx until CXR improves which may be a month or more
  • lf lung abscess -> continue abx until resolution of abscess
  • may require surgical removal of abscess or empyema
46
Q

When should you consider an anaerobic infection?

A

if lung abscess, empyema, necrotizing pneumonia or sig. risk factors like recent LOC due to multiple factors

  • not all cases of aspiration pneumonia are caused by anaerobes.

Infectious Disease (27 decks)

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