ICL 2.4: Lower Airway Infections & Pneumonia Flashcards
65 year old woman presents to ED with productive cough fatigue and fever for 3 days. her temperature is 103F and she looks ill.
The triage nurse already drew labs including blood cultures, inserted a line and ordered a CXR under your name.
CXR shows R upper lobar pneumonia
does the patient have an infection and what is the etiology? do you need to treat her and how?
this points towards infection but we don’t know what’s causing it, we need a workup
probably has pneumonia…
what do you need to ask when taking a history in a patient presenting with cough/SOB?
- duration of symptoms
- associated symptoms: wheezing, chest pain, weightless, fever, edema?
- fever?
- where is the patient coming from? house, hospital, nursing home?
- prior use of antibiotics?
- comorbidities?
- social history: alcohol, drugs, smoking?
- occupational history and exposures
- travel?
history is SO important!
why does the duration of symptoms matter when taking a history of a patient presenting with cough/SOB?
prolonged symptoms suggest underlying chronic lung disease, fungal etiology, noninfectious etiology
short duration goes more with infection, but cannot differentiate between specific etiologies
staph and pneumococcus frequently present after a viral syndrome
what does fever tell you about a patient presenting with cough/SOB?
fever is usually absent in bronchitis, present in pneumonia
but neither absence not absence are diagnostic
what are the myths involving coughs?
- productive cough in itself does not equal infection
- thicker or colored sputum does NOT indicate a bacterial etiology; it could be viral!
- “rusty sputum” does not equal pneumococcus
- blood streaks in sputum do not equal cancer or TB
- hemoptysis DOES requires urgent evaluation
what is the location, cause, testing, and treatment for community acquired pneumonia?
CAP is acquired outside of the hospital; includes nursing homes
caused mainly by pneumococcus, hemophilus and moraxella – can also be caused by viruses, legionella or mycoplasma
specific testing is only used if they’re super sick; treat empirically for 5 days
what is the location, cause, testing, and treatment for hospital/ventilator acquired pneumonia?
HAP/VAP is pneumonia that develops 48 hours after hospital admission
caused by more resistant organisms like MRSA or gram negatives like pseudomonas and klebsiella
obtaining blood and sputum culture is super important; treat empirically followed by de-escalation once you figure out the specific organism for 7 days
when do you do a PE when evaluating a patient presenting with cough/SOB?
don’t jump directly from history to auscultation! first observe, record vitals, palpate and percuss the patient with pulmonary symptoms
pay attention to other systems like swollen painful joints, JVD, leg edema, clubbing, cyanosis
- tactile fremitus
- percussion
- auscultation
what are the different sounds you can hear during lung auscultation and what do they mean?
- rhonchi = secretions in medium sized airways that cause low pitched, rattling lung sounds that often resemble snoring –> can be heard in patients with chronic obstructive pulmonary disease (COPD), bronchiectasis, pneumonia, chronic bronchitis, or cystic fibrosis
- crackles or rales = alveolar disease
- egophony = EE->A signifies consolidated lung
- pectoriloquy = bronchial sounds where vesicular sounds are expected
what is CURB-65?
Ⓒonfusion
Ⓤremia; BUN >20
Ⓡexpirations > 30
Ⓑlood pressure <90 systolic or <60 diastolic
⑥⑤ years+
0-1 points is oupatient
2: inpatient
3-5: ICU
pneumonia severity index (PSI) is more accurate
what’s the problem with using CURB-65?
it’s cookbook medicine! this is not a perfect thing and is a little too cookie cutter
people with dementia or CKD would automatically get a point! this isn’t accurate
what additional concerns would warrant admission in a patient with SOB?
- inability to take oral medications
- cognitive or functional impairment
- social issues that could impair medication adherence or ability to return to care for clinical worsening like substance abuse, homelessness or their residence is far from a medical facility
what is a SMART COP score?
it’s a score that determines the need for intensive respiratory or vasopressor support (IRVS)
it’s 79% specific and 64% sensitive in predicting ICU admission but several elements aren’t always available like PaO2, pH or albumin levels
Ⓢystolic < 90 Ⓜultilobar involvement Ⓐalbumin <3.5 Ⓡespirations >30 Ⓣachycardia > 125 Ⓒonfusion Ⓞoxygen saturation <90 ⓅH < 7.35
65 year old woman presents to ED with productive cough fatigue and fever for 3 days.
Her temperature is 103F and she looks ill but is oriented and conversant
The triage nurse already drew labs including blood cultures, inserted a line and ordered a chest xray under your name.
She lives alone, has well controlled DM, she has not been admitted to a hospital in the past 5 years, she does not smoke. She has 2 grandchildren 5 and 11 that she babysits weekdays. They are both healthy. Used to work in an office, no exposures. No weight loss
On exam RR 20, HR 115, BP 100/65; she has dullness on percussion increased fremitus and rhonchi in right anterior fields, but some can be heard in posterior lung fields too.
Creatinine is 1.3 and BUN 35 mg/dl
- do you want to treat inpatient or outpatient?
- what additional tests do you want?
- how do you treat her?
CAP
1. inpatient because CURB65 score is 2
- no additional testing, treat empirically –> most people with CAP are treated empirically because the workup is disappointing and doesn’t really help that much
- treat with ceftraixone and azithromycin
if she has a contraindication for azithromycin, give doxycycline with the ceftraixone
if she was allergic to penicillin give cephalosporins! macrolides used to be the answer but there is 100% pneumococcal resistance to macrolides in japan and it’s pretty high here in the US too so this isn’t a good choice on its own
if she can’t tolerate cephalosporins, give respiratory quinolones
when do you get a sputum culture?
they’re only done for people who are admitted for severe CAP or if they’re being treated for MRSA or pseudomonas
sputum cultures are NOT for outpatients because by the time you get the results the treatment is done
what is the criteria for a good sputum culture?
expectorated sputum is many times contaminated with oral flora
labs have criteria for sputum rejection based on number of epithelial cells
culture cannot be interpreted and has no value in the absence of clinical data
semiquantitative cultures are preferred (reported as 1+ to 4+)
it is important to obtain sputum before administering antibiotics
cultures can reveal colonizers of respiratory tract that are almost never pathogens and aren’t causing an infection like Candida, coagulase negative staph, enterococci, diphtheroids, some streps
what do blood cultures tell us when evaluating a patient with cough/SOB?
yield is low; only 2-9% BC are positive in pts with CAP
contaminated cultures that show coag negative staphylococci can lead to inappropriate use –> staph aureus from a blood culture is pathogenic so you need to make sure it’s actually coming from the blood and not from contamination
may be associated with prolonged hospital stay
they’re only recommended only if there are risk factors for MRSA and pseudomonas infection because otherwise you’re probably not going to get anything from a blood culture
what are the 2 microbes found in urine antigens?
- legionella
2. streptococcus pneumoniae
when would you do a streptococcus pneumoniae urine antigen test?
recommended in severe CAP (subset of inpatients)
sensitivity ~ 70%
when would you do a legionella urine antigen test?
not for outpatients
it detects only Legionella pneumophila serotype 1 (80% of cases)
70-80% sensitive
useful in outbreaks
recommended in severe CAP (subset of inpatients)
if high suspicion, sputum culture or PCR may be more sensitive
when would you suspect legionella?
- diarrhea
- hyponatremia
- hot tubs, cooling towers, travelers
65 year old woman presents to ED with productive cough fatigue and fever for 3 days.
Her temperature is 103F and she looks ill.
The triage nurse already drew labs including blood cultures, inserted a line and ordered a chest xray under your name. it shows a lobar infiltrate.
Pt lives in a nursing home due to advance dementia, has well controlled DM, she has not been admitted to a hospital in the past 5 years, she does not smoke.
On exam RR 20, HR 115, BP 100/65; she has dullness on percussion increased fremitus and rhonchi in right anterior fields, but some can be heard in posterior lung fields too.
Creatinine is 1.3 and BUN 35 mg/dl
there is NO reason to change recommendations – nursing home patients should generally be treated for CAP
still treat with ceftraixone and azithromycin
remember, HCAP (Healthcare associated pneumonia) is dead and buried –> HCAP risk factors were not shown to predict high [revalence of antibiotic resistant pathogens
HCAP designation led to a significant increase in use of broad spectrum antibiotics without improving outcomes
65 year old woman presents to ED with productive cough fatigue and fever for 3 days.
Her temperature is 99F and she looks stable
a chest xray under your name and it shows a right upper lobe infiltrate
She lives alone, has no chronic conditions and has not been admitted to a hospital in the past 5 years, she does not smoke. She has 2 grandchildren 5 and 11 that she babysits weekdays. They are both healthy. Used to work in an office, no exposures. No weight loss
On exam RR 20, HR 90, she has dullness on percussion increased fremitus and rhonchi in right anterior fields, but some can be heard in posterior lung fields too.
Creatinine is 0.9, BUN 12
high dose amoxicillin
cephalexin = 1st generation cephalosporin which has poor respiratory pathogen coverage –> they’re good for skin cellulitis or streptococcus infections; not pneumonia!
what is the treatment for outpatient CAP in someone without any comorbidities?
- amoxicillin
or
- doxycycline
or
- macrolide (if local pneumococcal resistance is <25% which isn’t the case anywhere in the US so never use it by itself)
what is the treatment for outpatient CAP in someone with comorbidities?
combination therapy with:
1. amoxicillin/clavulanate or cephalosporin
AND
- macrolide or doxycycline
OR
- monotherapy with respiratory fluoroquinolone
how do you treat nonsevere inpatient CAP?
one of the following:
- β-lactam + macrolide(ampicillin/sulbactam, ceftriaxone or ceftaroline) + (azithromycin or clarithromycin)
- monotherapy with a respiratory fluoroquinolone (levofloxacin or moxifloxacin)
- β-lactam + doxycycline
how do you treat severe inpatient CAP?
- β-lactam + macrolide(ampicillin/sulbactam, ceftriaxone or ceftaroline) + (azithromycin or clarithromycin)
- β-lactam with a respiratory fluoroquinolone (levofloxacin or moxifloxacin)
- add coverage for MRSA (vancomycin or linezolid) and Pseudomonas (piperacillin/tazobactam, cefepime) if recently hospitalized and received parenteral antibiotics; obtain MRSA nasal PCR
what is the predictive value of a nasal swab for MRSA pneumonia?
99% accurate for negative results; so a negative result means you definitely don’t have MRSA pneumonia
but the positive predictive value is only 30% which is horrible; so you could be colonized and the test would show you do not have pneumonia with MRSA
A 29 year old US Army captain is visiting his family. During the past week he was deployed for training to a camp where there was an outbreak of viral illness. The day after the flight home he develops red eye, a dry cough, sore throat and hoarse voice. He blames the air conditioning, but many of the recruits under his command had a similar syndrome; there were no cases that required hospitalization. What is the most likely etiology of his illness?
A. Influenza
B. COVID-19
C. Zika
D. Adenovirus
E. Rotavirus
D. Adenovirus
which viruses can cause pneumonia?
- adenovirus
- COVID19
- metapneumovirus
- CMV pneumonitis
- RSV
- rhinovirus
- MERS-CoV
- VZV
- influenza
which populations does each of the viruses that can cause pneumonia effect?
- adenovirus: severe PNA in newborns, outbreaks in recruits, adults in chronic care facilities, watch for conjunctivitis among symptoms
- influenza: seasonal; severe myalgias, high fever; can be followed by staph and pneumococcus
- COVID19: profound fatigue, anosmia/dysgeusia, infiltrates are peripheral
- metapneumovirus: elderly
- CMV pneumonitis: almost exclusively in transplant, severely immunocompromised pts.
- RSV: immunocompromised pts., elderly. Bronchiolitis in children <2yo, most common cause of viral pneumonia in children
- rhinovirus: rarely causes PNA, most of the time upper resp infections
- MERS-CoV: camel exposure, travel from middle eastern country; high mortality
- VZV: pregnant nonimmune severe pneumonia after exposure to elderly with zoster
how do you differentiate between viral and bacterial pneumonia?
procalcitonin levels which is the precursor of calcitonin
sensitivity ranges from 38-91%
low procalcitonin PLUS clinical judgement can be used to stop antibiotics because it’s probably a different etiology!
it can also be used to stop antibiotics when the level has decreased by 80% from the peak
however, it should NOT be used to determine if antibiotics should be started!!!!!
usually does not rise in fungal mycobacterial and atypical respiratory bacteria
when can procalcitonin levels be falsely elevated?
- trauma
- postoperatively
- burns
- renal insufficiency
- ischemic stroke
- shock
so not everyone with hypercalcitonin needs to get antibiotics
65 year old woman presents to ED with productive cough fatigue and fever for 3 days.
Her temperature is 103F and she looks ill.
No history of heart failure
CXR shows a lobar infiltrate
Productive sputum
She has rhonchi on exam and no edema
gram stain shows lance-shaped Gram positive diplococci
procalcitonin is <0.05 (normal)
diagnosis?
streptococcus pneumoniae
CXR with local infiltrate
bacterial pneumonia!
prolactin level doesn’t mean anything here because clinical signs suggest pneumonia
65 year old woman presents to ED with cough fatigue, fever, pleuritic chest pain for 1 day.
Her temperature is 103F and she looks ill.
History of heart failure EF 10% and ESRD
chest xray shows “bibasilar infiltrates vs pulmonary edema – clinical correlation suggested”
Thin frothy sputum
She has wet rales on exam and 2+ pedal edema
Sputum was not obtained and she cannot make urine
procalcitonin is <0.05 (normal)
she probably doesn’t have pneumonia, she just has CHF
fever could be explained by bacteremia from her line
A 30 year old with no medical problems presents to an urgent care center with 4 days of cough productive of moderate amount of sputum. Initially the cough was dry, but over the past day or 2 it became productive. Has no fever, but feels tired and has some abdominal discomfort and nausea from so much coughing.
stable vitals, afebrile, exam reveals some coarse wet rales bilaterally
CXR shows bronchial wall thickening/peribronchial cuffing
diagnosis?
bronchitis caused by virus
90% of bronchitis is viral so doesn’t require antibiotics
how do you treat bronchitis?
treatment is symptomatic:
1. throat lozenges, hot tea, honey, and/or smoking cessation
- dextrometorphan/guaifenesin; avoid codeine
- bronchodilators should be reserved for patients with wheezing or underlying lung disease
- avoid steroids and ibuprofen
- patient education – reassure that it typically resolves in 1-3 weeks
make a plan in case your recommendations do not work
most cases of bronchitis are viral but in spite of this, 50-90% of patients receive antibiotics for bronchitis
why do physicians prescribe antibiotics for conditions that do not require them?
- insecurity / uncertainty of diagnosis
- fear of legal recourse
- fear of losing a client
- patient satisfaction (objectivized by scores)
- thought of the patient expectations
- time constraints
- decision fatigue
- assuming that other doctors are the problem
55 year-old man is brought in by his roommate to ED with productive cough fatigue and fever for 3 days.
His temperature is 103F and he looks altered.
he vomited earlier after a binge drinking episode
The triage nurse already drew labs including blood cultures, inserted a line and a chest xray was obtained, shows a right lower lobe infiltrate.
How is this case different and does it influence the antibiotic choices?
aspiration pneumonia
if community acquired think oral flora usually covered by CAP regimens
if hospital acquired, think gut flora and MRSA in addition to the above
anaerobic coverage is not as important as previously thought; treating aerobic bacteria is much more important!
aspiration pneumonia is hard to distinguish from chemical pneumonitis….
55 year-old man is brought in by his roommate to ED with productive cough fatigue and fever for 3 days.
His temperature is 103F and he looks altered.
he vomited earlier after a binge drinking episode
The triage nurse already drew labs including blood cultures, inserted a line and a chest xray was obtained, shows a right lower lobe infiltrate.
while the admitting physician was placing orders and the nurse is busy with another client, the patient wakes up and walks out of the ED.
2 weeks later she presents with persistent high grade fevers, pleuritic chest pain, copious purulent sputum with blood streaks
what is the concern now?
abscess can develop in people with untreated aspiration pneumonia
60 y/o man admitted with heart failure exacerbation and pulmonary edema was intubated in cardiac intensive care unit for 3 days. Extubated and was improving, but while waiting for placement to rehab facility, on day 6 of hospitalization develops cough, his dyspnea worsens, becomes febrile 102F and CBC shows leukocytosis with left shift.
Chest xray shows a left lower lobe infiltrate
What is the next step in management to guide the treatment?
A. Treat empirically. Sputum cultures do not correlate well with true etiological agent
B. Obtain a sputum multiplex PCR for bacterial DNA
C. Perform a transthoracic needle biopsy of lung parenchyma
D. Perform a bronchoscopy with bronchoalveolar lavage
E. Obtain expectorated sputum for Gram stain and culture
E. Obtain expectorated sputum for Gram stain and culture
he has HAP so it’s really important to know what you’re treating
A is for CAP
D is invasive
when should a bronchoscopy be performed?
- when mycobacterial disease is suspected
- unclear etiology and no response or poor response to standard treatment
- in immunocompromised host (steroids, chemotherapy, HIV, transplant) –> will usually be caused by pneumocystis or fungal infections
- centrally located lung masses or nodules > biopsy
- airway obstruction
- hemoptysis – localize bleeding and obtain samples
- mucus impaction
- foreign body removal
what is the indication for transthoracic needle biopsy/aspirate?
it’s usually just for if you need to rule out malignancy
don’t put needles in people’s lungs, it’s high risk and 1/10 will get a pneumothorax while 1/20 have significant bleeding
what do you use to treat HAP/VAP?
empiric treatment is based on severity and risk factors
- do local epidemiology and antibiogram
- recent exposures to more or less broad spectrum antibiotics
usually caused by pseudomonas, resistant Gram negatives and MRSA need to be covered
what do you use to treat pseudomonas?
use double coverage in:
- in severely ill patients, with respiratory failure and shock, until susceptibilities are available;
- in VAP, in units where there is 10% resistance to the drug considered for monotherapy (a beta-lactam)
ceftriaxone is useless against pseudomonas
which antibiotics are used for HAP?
- Piperacillin/tazobactam (gram -, anaerobes, streptococci but not great for staph)
- cefepime (doesn’t cover enterococci but they don’t cause pneumonia so they’re used a lot)
- ceftazidime (no gram + coverage)
- aztreonam (only for people who are allergic to cephalosporin, only covers gram -)
- meropenem (broad spectrum)
- levofloxacin (respiratory quinolone for inpatient use)
- aminoglycosides
- vancomycin (MRSA)
- linezolid (MRSA)
NOT daptomycin (doesn’t work in the lungs because of surfactant)
65 year old woman presents to ED with productive cough fatigue and fever for 3 days.
Her temperature is 103F and she looks ill.
The triage nurse already drew labs including blood cultures, inserted a line and ordered a chest xray under your name.
She lives in a nursing home due to advanced dementia, has DM, she used to smoke a pack a day until 3 years ago.
Recently (7 days ago) she was discharged from a hospital, where she was treated for UTI and leg cellulitis with broad spectrum antibiotics.
On exam she has dullness on percussion increased fremitus and rhonchi in right anterior fields, but some can be heard in posterior lung fields too.
how would you treat?
HAP
needs broad spectrum antibiotics
give cefapine + aminoglycoside + something for MRSA
an otherwise healthy young patient spent a week in a cabin in Colorado; 1 week after returning to Ohio develops malaise fever cough and SOB. Presents to ED with rapidly progressive symptoms and requires intubation.
He has leukocytosis, thrombocytopenia, develops shock with hypotension and multiorgan failure
What is the vector?
hantavirus!!
from mice poop!
what is hantavirus pulmonary syndrome?
Sin nombre virus
dry climate; historically Indian reservations, 4 corners states
no vector; caused by inhaled aerosolized rat urine
high mortality
no specific treatment
4 poker players develop similar clinical pictures and imaging – dry cough, fever, minimal findings on chest exam. Headache, myalgias. None of them sick enough to be admitted.
A cat delivered stillborn kittens while the patients were playing poker in the same room 2 weeks prior to onset of symptoms.
[as an alternative, this is a farmer who assisted a cow or a goat to deliver]
diagnosis?
Q fever = coxiella burnetii
long incubation
serologic diagnosis, PCR, usually not culture (require biosafety level 3
pneumonia usually is mild but symptoms can persist a long time
hepatitis – AST/ALT are high in majority of patients
endocarditis is rare
A 38-year-old man from Nantucket was admitted three days ago with a dense pneumonia and a pleural effusion. He has been treated with azithromycin and ceftriaxone but is not improving.
His illness began abruptly two days PTA with fever and chills; he began to cough the following day and developed pleuritic pain. He has scant sputum production.
On exam, he is febrile with a normal pulse; there are crackles and percussion dullness in the right chest.
The WBC is normal; the pleural fluid is exudative with a lymphocyte predominance. Admission sputum culture grew normal flora; the pleural fluid was sterile.
He is an accountant, has no recent travel history, and no exposure to ill persons. His only possible animal exposure occurred 4 days before he became ill when he was mowing his lawn, and some kind of small animal darted out from behind a bush and was pulverized by the mower blades.
diagnosis?
francisella tularensis
what is tularemia?
outbreak of pulmonary tularemia described in Massachusetts
transmitted by tick bite, fleas, mosquitoes, direct contact with infected animals; airborne spread through dust, hay, water
very virulent organism – aerobic Gram negative coccobacillus
usually not seen on Gram stain of specimens. Requires cysteine for growth Let lab know if you suspect it, it does grow in regular media too
survives in macrophages
patients are quite ill, can develop hepatitis and renal failure
bioterrorism agent
treatment with streptomycin or gentamycin; ciprofloxacin and doxycycline for mild disease
