Community-acquired Pneumonia EXAM II

Question 1

What are the factors affecting the type of bug a patient may likely be infected with?

Answer 1

-Setting
-Timing
-Patient risk factors: age, diseases (comorbidities)
-Community risk factors (diseases currently circulating)

Question 2

Which pathogen is associated with “walking pneumonia”?

Answer 2

Mycoplasma
-able to walk
-often in younger patients (mid 20’s)

Question 3

How is Pneumonia clinically diagnosed?

Answer 3

-Set of symptoms - physical findings
-lungs sounds
-X-ray

Question 4

Clinical Presentation Community-acquired Pneumonia

Answer 4

-Fever, chills, productive cough, dyspnea
-Rust-colored sputum or hemoptysis (coughing blood –> broken capillaries)
-Pleuritic chest pain (painful breathing)
-Tachypnea (breathe faster)
-Tachycardia (faster heart rate)
-Leukocytosis

Question 5

Definition CAP

Answer 5

Pneumonia developing outside of the hospital or 48 before being admitted to the hospital

Question 6

What are the CAP risk factors?

Answer 6

-Age >65
-Diabetes
-Asplenia (no spleen), immunocompromised
-chronic CV, pulmonary, renal, and liver disease
-smoking, alcohol abuse

Question 7

What are the consequences of having the CAP risk factors?

Answer 7

-more likely to be infected with CAP
-more likely to be hospitalized because of CAP

Question 8

What are the pathogens to likely cause CAP?

Answer 8

-Strep pneumo - Gram positivee - PBP alterrations
-Haemo flu and M. cat - Gram neg producing ß-lactamase

-Mycoplasma (atypical)
-Chlamydophila (atypical)
-Legionella (rare) (atypical)

Question 9

Which drugs cover atypical pathogens?

Answer 9

-Macrolides
-Tetracycline
-Quinolones

Question 10

What are the common causes of CAP?

Answer 10

-often viral (more than 50% –> still treating with antibiotics bc we often don’t get a culture, and pt gets pretty sick if it is bacterial)

-bacterial

Question 11

What are the uncommon causes of CAP?

Answer 11

-Staph aureus
-Ecoli and Klebsiella pneuomiae

Question 12

When to consider Staph aureus, Ecoli, and Klebsiella in CAP?

Answer 12

-Staph aureus: Cystic fibrosis, Post-viral (developing pneumonia after viral flu)

-Ecoli and Klebsiella pneumoniae (GI tract): Diabetes (gastroparesis - slowing of the motility of the stomach), chronic alcoholism (aspiration pneumonia)

Question 13

Why are patients more likely to develop CAP with Staph aureus after getting the flu?

Answer 13

-virus causes inflammation and creates a friendly environment for Staph aureus

-immunosuppressed status

Question 14

What are the diagnostic testing options?

Answer 14

-Procalcitonin: sensitivity for bacteria 38-91% -> still treat empirically

-MRSA PCR:
if negative -> rules out MRSA at 96% -> take MRSA meds off
if positive from nasal swab, the possibility of also being in the lung

Question 15

A patient comes to the clinic and has influenza and CAP, how to treat?

Answer 15

-high-risk patient
-Antiviral and antibiotic, regardless of the duration of the illness; REGERDLESS of inpatient or outpatient
-consider Staph aureus!

Question 16

Meaning of CURB65

Answer 16

C - Confusion
U - Urea > 7 mmol
R - RR > 30
B - SBP (systolic BP) and DBP (diastolic BP)
65 - >65 or older

-Pneumonia severity index
-they help to determine if a patient is appropriate to be hospitalized

Question 17

Treating young healthy individuals - CAP

Answer 17

-young, healthy, no risk factor for MRSA or Pseudomonas
-One-regimen

-Option 1: Amoxicillin for Strep (in practice Augmentin which also picks up gram negatives)

-Option 2: Doxycycline or macrolide for atypicals

Question 18

How to treat patients with comorbidities - CAP?

Answer 18

-Two-dose regimen
-cover ß-lactamase producing pathogen:
Augmentin or 3rd Gen Cephalosporin

-cover atypical pathogens
Doxycycline or Macrolide

Question 19

Why are Quinolones often NOT preferred for atypical pathogens?

Answer 19

-Side effects:
-QTc prolongation
-peripheral neuropathy
-Tendon rupture
-altered mental status

Question 20

How to treat Inpatient?

Answer 20

-IV beta lactam + macrolide
-if risk for MRSA or Pseudomonas –> add empiric treatment (Vancomycin)
-test for MRSA -> if negative -> deescalate

Question 21

What is an example of an IV 3rd Gen Cephalosporin?

Answer 21

IV
-Ceftriaxone (Rocephine) + Doxycycline

OR

for inpatients add macrolide (Azithromycin)

Question 22

What are oral options for outpatient treatment - CAP?

Answer 22

ORAL:
-Augmentin
-Cefdinir

for outpatient add macrolide if the patient has comorbidities

Question 23

Why is Clarithromycin often NOT preferred as macrolide?

Answer 23

-Taste disturbance
-CYP3A4 inhibition
-QTc prolongation, sudden cardiac death

Question 24

What to counsel on for Doxycycline?

Answer 24

-Take with a glass of water
-Sit straight up for 30 minutes to prevent ulceration in the esophagus
-Space antiacids (chelation)
-Photosensitivity

Question 25

When is it appropriate to use Steroids?

Answer 25

-not recommended for CAP alone
-patients in shock from their pneumonia
-pneumonia with COPD

Question 26

Duration of treatment for CAP?

Answer 26

5-7 days
if no improvement after 5 days assess for resistant organisms and change the drug