Community Acquired Pneumonia

Question 1

Clinical Features of Pneumonia

Answer 1

• Cough
• fever
• sputum production
• pleuritic chest pain

Question 2

Causes of pneumonia

Answer 2

• poor pulmonary toilet
• Natural tracheal barrier compromised (in VAP)
• Contaminated secretions pool & leak around the ET tube (in VAP)

Question 3

CURB- 65 Definition

Answer 3

• C = confusion
• U = Urea > 7; BUN > 20
• R = Resp Rate > 30
• B = Blood Pressure –> systolic < 90; diastolic < 60
• 65 = Age > 65 yrs

Question 4

CURB-65 Significance

Answer 4

Each of the 5 criteria is worth 1 pt, add them together:

• 0-1pts: mild pneumonia (there’s only a 3% chance that your patient will go home & die)
• 2 pts: moderate (9%)
• if you’re in the 4s & 5s then you should probably be admitted to the ICU

Question 5

Minor Criteria for Severe CAP

Answer 5

• RR > 30breaths/min
• PaO2/FiO2 ratio < 250
• Multi-lobar infiltrates
• Confusion/disorientation
• Uremia (BUN level > 20mg/dL)
• Leukopenia (WBC count < 4000 cells/mm^3)
• Thrombocytopenia (plt count < 100,000 cells/mm^3)
• Hypothermia – core temp < 36 degrees celsius
• Hypotension requiring aggressive fluid resuscitation

Question 6

Major Criteria for Severe CAP

Answer 6

• Invasive mechanical ventilation

- Septic shock w/ the need for vasopressors

Question 7

When to admit a CAP patient to the ICU:

Answer 7

• must meet 1 Major criteria for severe CAP or 3 minor criteria for severe CAP

Question 8

Outpatient Etiology of CAP

Answer 8

• Streptococcus pneumoniae
• Mycoplasma pneumoniae
• Haemophilus influenzae
• Chlamydophila pneumoniae
• Respiratory viruses

Question 9

Inpatient (non-ICU) Etiology of CAP

Answer 9

• S. pneumoniae
• M. pneumoniae
• C. pneumoniae
• H. influenzae
• Legionella species
• Aspiration
• Respiratory viruses

Question 10

Inpatient ICU Etiology of CAP

Answer 10

• S. pneumoniae
• Staphylococcus aureus
• Legionella species
• Gram-negative bacilli
• H. influenzae

Question 11

Outpatient Treatment of CAP

Answer 11

1. Previously health & no use of antimicrobials w/in 3 months: a macrolide (1st line; strong rec); alternative: doxycycline (weak rec)
2. Presence of comorbidities such as chronic heart, lung, liver, or renal disease; DM; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; or use of antimicrobials w/in the previous 3 months (in which case an alternative from a differenct class should be selected): a respiratory FQ (moxi, gemifoxacin, or Levaquin [750mg]) - strong rec; A beta-lactam + macrolide (strong rec) –> beta-lactam must have reasonable activity such as high dose amoxil, augmentin, or a decent cephalosporin

Question 12

Inpatient Non-ICU Treatment of CAP

Answer 12

• a respiratory FQ (strong rec)

- a beta lactam + a macrolide (strong rec)

Question 13

Inpatient ICU Treatment of CAP

Answer 13

• a beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) + either azithromycin (level II) or a respiratory FQ (level I)
• For PCN allergic patients: respiratory FQ & aztreonam

Question 14

When to Switch to PO

Answer 14

• Temp < 37.8 degrees celsius
• HR < 100 beats/min
• RR < 24 breaths/min
• Systolic BP > 90mmHg
• Arterial O2 saturation > 90% or pO2 > 60mmHg on room air
• Ability to maintain oral intake
• Normal mental status

Question 15

Duration of therapy

Answer 15

• minimum of 5 days (level I)
• should be afebrile for 48-72 hours
• AND should have no more than 1 CAP-associated sign of clinical instability