flu, bronchitis, PNA Flashcards
how is the flu transmitted?
respiratory droplet and contact
etiology of influenza?
influenza virus, type A&B
how long is incubation period for flu?
1-4 days
what are symptoms of the flu?
abrupt onset headache fever/chills myalgia malaise cough
what physical exam findings do you see with flu?
hot, dry skin
PND
mild cervical LAD
negative chest exam
what is first line diagnostic test for flu?
RAT
what indications are there for flu treatment?
illness requiring hospitalization
progress, severe, or complicated illness
high risk for complications
who are high risk flu groups?
extremes of age chronic illnesses immunosuppression pregnancy or post-partum (2 weeks) children <19 y/o on chronic ASA therapy american indians and alaskan natives morbidly obese (BMI >40) nursing home residents
what medication treats the flu?
antiviral meds: neuraminidase inhibitors for influenza A/B
oseltamivir (tamiflu)
zanamivir (relenza)
peramivir (rapivab)
when should you initiate medication tx?
within first 24-48 hours
what are adverse effects of tamiflu?
N/V
what are adverse effects of relenza?
bronchospasm, decreased respiratory function
what are complications of flu?
pneumonia sinusitis otitis media rhabdomyolysis CNS involvement cardiac complication
who needs the flu vaccine?
+6 months and up
how many flu shots does a first-time child get?
two vaccines administered 4 weeks or more apart
can someone with egg allergy receive a flu vaccine?
yes, if the allergy is severe, they can get the vaccine in a medical setting
do adults 65+ get the same flu vaccine as someone younger?
no, they get a HIGHER dose vaccine
what is the gold standard for influenza dx?
viral culture
what is the main cause of acute bronchitis
viral
what is the bacterial cause of acute bronchitis that needs treatment?
bordetella pertussis (need ABX)
what is the clinical presentation of acute bronchitis?
cough > 5 days (usually 1-3 weeks) afebrile chest wall tenderness wheezing mild dyspnea
what do you see on physical exam for acute bronchitis
wheezing
rhonchi (clears with coughing)
negative for rales and signs of consolidation
any specific diagnostics for acute bronchitis?
no
how do you manage acute bronchitis?
symptomatic treatment?
what is the etiology of pertussis?
bordetella pertussis
pertussis occurs in who mostly?
< 2 y/o
how is pertussis transmitted?
respiratory droplets
what is the incubation period for pertussis?
7-17 days
what are the three stages of pertussis?
catarrhal
paroxysmal
convalescent
what is the catarrhal stage of pertussis?
1-2 weeks of malaise, rhinorrhea, mild cough, mild fever, lacrimation, and conjunctival injection
what is the paroxysmal stage of pertussis?
begins in 2nd week and can last 2-3 months; paroxysmal cough (sudden bursts of rapid, consecutive coughs followed by a deep high pitched inspiration +/- syncope or emesis
what is the convalescent stage of pertussis?
1-2 weeks of gradual reduction in frequency and severity of cough
what is the treatment for pertussis?
macrolide any
what will you see on the CBC for pertussis?
elevated white count
what is prevention for pertussis?
vaccination DTap - infants Tdap booster for 11-18 y/o single tdap dose - all adults Tdap 27-36 weeks gestation for pregnant women
what are common serious complications in under 1 y/o
apnea and hospitalization
what can cough lead to in pertussis?
subconjunctival hemorrhage, abdominal wall hernia, rib fractures, urinary incontinence, lumbar strain
how is PNA transmitted?
respiratory droplet
what are the classifications of PNA?
CAP
HAP
VAP
what is the most common cause of CAP?
Strep pneumo
what are atypical causes of CAP?
mycoplasma pneumoniae
chlamydophila pneumoniae
legionella spp.
what is the main viral cause of CAP?
influenza
what are symptoms of CAP?
fever, cough, myalgia, sweats, GI symptoms, mental status changes, pleurisy
what are signs of CAP?
tachypnea tachycardia low O2 sat rales signs of consolidation
What is the presentation of S. pneumoniae?
sudden onset of chills
rust colored sputum
What is the presentation of M. pneumoniae?
children and adolescents
asymptomatic or mild
CXR - reticulonodular pattern and/or patchy areas of consolidation
What is the presentation of Legionella?
watery diarrhea
confusion or encephalopathy
outbreaks usually from contaminated water sources
What is the presentation of MRSA?
cavitary infiltrate or necrosis
gross hemoptysis
rapidly increasing pleural effusion
What is the presentation of Klebsiella pneumoniae?
alcohol abuse disorder, DM, severe COPD
currant jelly sputum
what would you see on CXR for CAP?
demonstrable infiltrate: lobar, interstitial, cavitation
what is the purpose of the pneumonia severity index (PSI)?
helps decide whether pt should be inpatient or outpatient
what is the CURB 65 score?
inpatient/outpatient Confusion Urea >7 (BUN > 20 mg/dL) RR > 30 breaths/min BP (SBP <90 or DBP 60 or less) 65 and older
what do the CURB 65 scores tell you?
0 outpatient
1-2 = consider hospitalization
3-4 urgent/assess for ICU care
what med do you give to someone with CAP and no other problems in outpatient setting?
macrolide or doxycycline
what med do you give to someone with CAP and have other comorbidities like respiratory, cardiac, kidney, diabetes, etc. in outpatient setting?
respiratory fluroquinolone
if a patient with CAP has used an ABX within the past 3 months or has macrolide resistant S. pneumo, what are your medication choices?
respiratory fluoroquinolone OR beta-lactam plus macrolide
what are your first-line beta-lactam choices for someone with CAP
high dose amoxicillin or augmentin
if pt with CAP is allergic to PCN, what could you give them instead?
ceftriaxone, cefpodozime, or cefuroxime
how long should your pt with CAP be on antibiotics in outpatient setting?
at least 5 days
what is the duration of time for fever and cough/fatigue in pt with CAP?
3 days for fever
14 days for cough and fatigue
what is the median time of return to work in a pt with CAP?
6 days
what is the treatment for a pt with CAP admitted to hospital, non-ICU?
respiratory fluroquinolone OR beta-lactam plus macrolide
what is the treatment for a pt with CAP admitted to the ICU?
anti-pneumoccocal beta-lactam plus azithromycin OR anti-pneumococcal beta-lactam PLUS respiratory fluoroquinolone OR respiratory fluroquinolone plus aztreonam (in PCN allergic pts)
what ICU pts with CAP are at risk for pseudomonas?
alcohol use d/o CF neutropenic fever recent intubation cancer organ failure septic shock
what ICU pts with CAP are at risk for MRSA?
ESRD
IV drug abuse
prior antibiotic use
influenza
if pt with CAP in the ICU is at pseudomonas risk, what are the treatment options?
antipneumococcal, antipseudomonal beta lactam PLUS ciprofloxacin or levofloxacin
OR
above beta-lactam PLUS aminoglycoside PLUS azithromycin
OR
above beta-lactam
PLUS aminoglycoside PLUS respiratory fluroquinolone
if pt with CAP in the ICU is at risk for MRSA, what do you add?
vancomycin or linezolid
what are criteria for change to oral treatment in pts with CAP?
improving clinically overall
hemodynamically stable
able to take oral medications
improvement in fever, respiratory status, and WBC
in a pt with CAP, what is the duration of treatment?
minimum of 5 days and: afebrile for 48-72 hours supplemental O2 not needed HR <100 RR <24 SBP 90 or greater
what should you tell the pt with CAP to stop doing?
smoking
what are complications with CAP
bacteremia sepsis heart failure MI arrhythmia
what vaccinations should a pt that 65 and older get for CAP prevention?
PCV13 (First) and PPSV23
influenza vaccine
what kinds of pts that are 2-64 y/o should get the PPSV23 or PCV13?
pts at high risk or 19-64 y/o that smoke cigarettes
define HAP (nosocomial)
48 hours or more after admission and did not appear to be incubating at the time of admission
define VAP
a type of HAP that develops more than 48-72 hours after endotracheal intubation
what causes HAP and VAP?
aerobic gram-neg bacilli
gram-pos cocci
how to diagnose HAP/VAP?
new lung infiltrate plus evidence that the infiltrate is of infectious origin
- new onset of fever
- purulent sputum
- leukocytosis
- decline in oxygenation
what are risk factors for MRD pathogens?
antimicrobial therapy in previous 90 days
current hospitalization 5 days or greater
admission from nursing home
high frequency of ABX resistance in community
immunosuppresive disease
what is the duration of treatment for HAP/VAP?
14-21 days
pts that respond to initial treatment may limit to 7 days
what further evaluation could you do for non-resolving PNA?
chest CT
fiberoptic bronchoscopy
thoracoscopy
open lung biopsy
what are examples of fungal PNAs?
histoplasmosis
blastomycosis
coccidiodomycosis
pneumocystis jirovecii pneumoni (HIV-related)
what is the etiology of pneumocystis pneumonia?
pneumocystis jirovecii
what is the most common opportunistic infection in patients with AIDS?
pneumocystis pneumonia
what are risk factors of pneumocystis pneumonia?
prior PCP episode, oral thrush, recurrent bacterial PNA, unintentional weight loss, high plasma HIV RNA level
what is the clinical presentation of a pt with pneumocystis pneumonia?
fever, cough, dyspnea
fatigue, chills, chest pain, weight loss
tachypnea, crackles, rhonchi, often co-infected with oral thrush
how to treat pneumocystis pneumonia?
bactrim x 21 days +/- corticosteroids
define aspiration PNA
displacement of gastric contents to the lung causing injury and infection
what are risk factors for aspiration PNA
ALOC
CNS disease
dysphagia
tracheal/NG tube
how does pt with aspiration PNA present?
cough with foul smelling purulent
poor dentition
what can you see on CXR in someone with aspiration PNA?
RLL infiltrate COMMON
cavitary consolidation, air-fluid level
how do you get a culture in a pt with aspiration PNA?
transthoracic aspiration
thoracentesis
bronchoscopy
what ABX can you use to treat a pt with aspiration PNA?
clindamycin or augmentin
OR
PCN plus metronidazole
