Evaluation Of Pneumonia

Question 1

Community-acquired pneumoniae (CAP)

Answer 1

Acute Infection of the lower respiratory tract not in a health care setting

#1 infection-related deaths in 65 yrs+ 
- most commonly infect people under the age of 5 and over the age of 60 

Co-morbidities and viral respiratory infections are high risk for this also

Question 2

Hospital acquired pneumonia (HAP)

Answer 2

Chronic infection of the lower respiratory tract that is acquired 48hrs + after hospitalization.

also includes ventilator-associated pneumonia (VAP) which is 2 days after endotracheal intubation

Question 3

Clinical symptoms of pneumonia

Answer 3

Cough

Fever/chills

Fatigue

Chest pain (pleuritis) (not always)

Possible nausea/vomiting/diarrhea

Dyspnea (especially on exertion)

Question 4

Clinical signs of pneumonia

Answer 4

Auscultation

• rales/crackles (usually unilaterally)
• wheezing and dyspnea

Palpation/percussion

• dullness
• Fremitus

Imagining:

• chest xray shows consolidated haziness unilaterally usually in lower lung bases (CAP)
• chest xray shows diffuse haziness with nodule apperance (VAP/HAP)
• chest xray shows lobar pattern, which looks like a literal lobe of the lung (bacterial CAP)
• POCUS: shows B lines
• Dont get lab cultures for outpatient, only for inpatient*

Question 5

Typical vs atypical pneumonia patterns

Answer 5

Typical:

• generally lobar pattern w/ generally typical pathogens on cultures (more consolidated)
• usually staph/strep pathogens*

Atypical:

• interstital patterns that are diffuse and usually atypical pathogens on cultures (nothing gram stains)
• usually mycoplasma and legionella*

Question 6

Pseudomonas aeruginosa

Answer 6

Atypical pneumoniae pathogen seen at higher rates in patients with structure lung diseases (COPD/CF, chronic bronchitis, ETC)

Question 7

What is the most common agent for pneumonia

Answer 7

Streptococcus pneumoniae

Question 8

Possible labs for pneumonia

Answer 8

note for CAP, its not needed unless patient is high risk

1) gram stains
- typical

2) blood cultures
- typical

3) urinary antigen tests (UAT)
- for legionella and pneumococcal
- atypical

4) Polymerase chain reaction (PCR)
- atypical
- for legionella, mycoplasma and chlamydia
- used for viral as well

Question 9

Treatment for pneumonia

Answer 9

Antibiotic selection

• based on clincial reasoning and labs if needed
• also risk factors and history

Supportive care (if needed)

OMM (if needed)

• rib raising
• thoracic pumps

Question 10

Antibiotic treatment specifics

Answer 10

Inital treatment is always empirical (based on reasoning and history)
- this is for both outpatient and inpatient

1) Healthy patient initial w/ no antibiotics in last 3 months = macrolides or doxycycline
- can also use amoxicillin

2) non-ICU patient w/ Comorbidities or antibiotics in the last 3 months = B-lactam or amoxicillin/clavulanate w/ a macrolide
- also ceftriaxone or cefpodoxime can be used in place of amoxicillin.

3) ICU patients
- B-lactam w/ azithromycin or Fluroquinolone

Question 11

Treatment for pseudomonas specific pneumonia

Answer 11

Piperacillin/tazobactam or cefepime/impenem

Also must include one of the following:

1) ciprofloxacin or levofloxacin
2) z-PKA
3) Aminoglycosides

Question 12

Treatment for MRSA-induced pneumonia

Answer 12

Piperacillin/tazobactam or cefepime/impenem

- And add with linezolid or vancomycin w/ clindamycin

Question 13

CURB-65 score

Answer 13

Tool used to determine severity of CAP illness

Age over 65? = 1 pt 
Confusion present? = 1 pt 
Uremia (BUN > 20)? = 1 pt 
Respiratory rate >30? = 1 pt
BP < 90? = 1 pt
Severe acidosis (pH < 7.3) = 1pt

Greater than or equal to 2 = hospitalization

3-5 = ICU

Question 14

Treatment for flu-induced pneumonia

Answer 14

Neuraminidase inhibitor (Oseltamivir) must be added