Community Acquired Pneumonia

Question 1

Definition of CAP

Answer 1

infection of alveoli, distal airways, and interstitium of lungs occurring outside of hospital setting

Question 2

Definition of HCAP (health care associated PNA)

Answer 2

1) non-hospitalized pt received IV therapy, wound care within 30 days
2) nursing home or other long-term facility resident,
3) sxs after 48 hrs of hospitalization, or 90 days after hospitalization if discharged
4) attendance at a hospital or HD clinic within past 30 days

Question 3

Sxs of general CAP

Answer 3

cough, fever, pleuritic chest pain, sputum production, SOB, hypoxia, respiratory distress

Question 4

Sxs of typical pneumococcal CAP

Answer 4

SUDDEN onset fever, productive cough with rust-colored sputum

Question 5

Sxs ATYPICAL CAP

Answer 5

• INSIDIOUS onset, dry cough, HA, myalgias, sore throat, CXR worse than clinical presentation
• Mycoplasma pneumoniae

Question 6

CAP organisms

Answer 6

S pneumoniae, M pneumoniae, Haemophilus influenzae, Chlamydophila pneumoniae, respiratory viruses (influenza or adenovirus)

Question 7

Historical findings to determine organsism

Answer 7

1) Bird exposure – Chlamydia psittaci
2) American SW – coccidioidomycosis
3) Endemic Mississippi valley – histoplasmosis
4) Immunocompromised – PJP
5) Immunocompromised, incarceration, immigrant – TB

Question 8

HCAP organisms

Answer 8

MRSA, Pseudomonas, Acinetobacter, MDR-Enterobacteriaceae

Question 9

Risk stratification of CAP

Answer 9

CURB65 (admit with score >2, 30-day mortality 9.2%)

• C-onfusion (1 pt)
• U-rea >20mg/dL (1 pt)
• R-espiratory rate >30/min (1 pt)
• B-lood pressure systolic <90mmHg
• 65-or older (1 pt)
• consider if able to take PO intake and outpt follow-up

Question 10

Reasons CXR would be clear in PNA pts

Answer 10

1) too early

2) neutropenic pt

Question 11

CXR with lobar consolidation suggests _____.

Answer 11

S. pneumoniae, +/- parapneumonic effusion

Question 12

CXR: Diffuse interstitial opacities suggets _____.

Answer 12

Pneumocystis PNA or viral processes

Question 13

CXR: Pneumocystis PNAs almost never present with _____.

Answer 13

pleural effusions

Question 14

CXR: Bilateral apical alveolar opacities suggests _____.

Answer 14

Tuberculosis

Question 15

CXR: cavitation suggests…

Answer 15

necrotizing PNA – S. aureus, TB or gram negative (Klebsiella, Pseudomonas)

Question 16

When do you do serial CXRs on inpatients with PNA?

Answer 16

no clinical improvement, pleural effusion, or necr`otizing

Question 17

When to order serologic tests

Answer 17

Legionella, mycoplasma, or Chlamydia pneumoniae

Question 18

When to do fiberoptic bronchoscopy with BAL?

Answer 18

• Seriously ill, immunocompromised, no clinical improvement on therapy
• Direct sampling from lower resp tract, can do direct fluorescent AB testing

Question 19

Empiric outpatient therapy for CAP

Answer 19

Minimum 5 days of one of the following

• macrolides (azithromycin)
• doxycycline
• moxifloxacin or levofloxacin (antipneumococcal quinolones)

Question 20

Empiric inpatient therapy for CAP

Answer 20

IV 3rd gen cephalosporin, plus macrolide or antipneumococcal quinolone

Question 21

Empiric hospital or ventilator acquired PNA

Answer 21

1) Antipseudomonal beta-lactam (piperacillin or cefepime)

2) aminoglycoside

Question 22

Non-pharmacologic post-recovery care

Answer 22

Influenza and pneumococcal vaccines, and smoking cessation

Question 23

Abx choice for MRSA PNA

Answer 23

Linezolid or vancomycin

Question 24

Aspiration PNA location in recumbent patients

Answer 24

posterior segments of upper lobes and superior segments of lower lobes

Question 25

Treatment of aspiration PNA

Answer 25

• Ampicillin-sulbactam (cover S pneumo, H flu, gram negative and oral anaerobes)
• Transition to Augmentin, clindamycin if PCN allergy