into alveoli Neutro from pulm capillary to alveoli phagocytosis, release cytokine inflammation --> neutrophilic exudate

Bacteria Mycobacteria viral fungal Rickettsial (q fever) parasitic mixed

Onset rapidity Fever degree Shaking chills? cough - prod/non Dyspnea Pleuritic chest pain other conditions? tobacco? Exposures (triggers, occupational) travel

Gen = Toxic? Fever Tachycardia Tachypnea O2sat breath sounds

CXR CBC (leukoctyosis, left shift, bandemia) Sputum Gram/culture Blood culture

Classic PNA s/s CXR appearance respond to ABX

less ill-appearing CXR different need different ABX

Single shaking chill Cough, rust color sputum Fever Pleuritic pain Signs of consolidation Bug? DX test results?

Strep Pneumoniae MC CAP Lancet shaped G+ diplococci on G-stain also urinary S. Pneumo antigen test

Infections Flashcards by O lawformonde

Pneumonia

Path

into alveoli
Neutro from pulm capillary to alveoli
phagocytosis, release cytokine
inflammation –> neutrophilic exudate

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Pneumonia

Causes

Bacteria
Mycobacteria
viral
fungal
Rickettsial (q fever)
parasitic
mixed

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Rickettsia

organism

Q fever
Coxiella Burnetti
Rickettsia typhi

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Pneumonia

Onset rapidity
Fever degree
Shaking chills?
cough - prod/non
Dyspnea
Pleuritic chest pain
other conditions? tobacco?
Exposures (triggers, occupational)
travel

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Pneumonia

Gen = Toxic?
Fever
Tachycardia
Tachypnea
O2sat
breath sounds

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Pneumonia

Breath sounds

Rhonchi
Bronchial
reduced/distant
Egophany

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Pneumonia

CXR
CBC (leukoctyosis, left shift, bandemia)
Sputum Gram/culture
Blood culture

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Pneumonia

Sputum

Adequate :
>25 neutrophils/HPF
<10 epithelial cells/HPF

Gram (immediate)

Culture (48-72)

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Pneumonia

Use bronchoscopy if….

immunosuppressed
no sputum (TB?)
w/ neoplasm/FB
no response to ABX

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CAP typical

Classic PNA s/s
CXR appearance
respond to ABX

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CAP atypical

less ill-appearing
CXR different
need different ABX

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Pneumonia

Typical Organisms

Strep pneumoniae
H influ
Moraxella catarrhalis

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Pneumonia

Atypical Organisms

Mycoplasma pneumo
Chlamydia Pneumo
Legionella pneumophilia
Clamydia psittaci
Francisella tularensis
Coxiella burnetii (q fever)
Fungal

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alchohol associated w/

klebsiella
S. pneumo
TB

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COPD associated w/

H flu
M. catarrhalis
Pseudomonas
Legionella

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Dementia associated w/

anaerobes

enteric Gram -

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Single shaking chill
Cough, rust color sputum
Fever
Pleuritic pain
Signs of consolidation

Bug? DX test results?

Strep Pneumoniae

MC CAP

Lancet shaped G+ diplococci on G-stain
also urinary S. Pneumo antigen test

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Strep Pneumoniae

Suppuritive complications

sinusitis
endocarditis
meningitis
parapneumnonic effusion/empyema

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Strep Pneumoniae

Tx
Inpatient? Outpatient?

Inpatient= 
*Respiratory fluoroquinolone
(moxi, gemi, levo) 
OR 
*B-lactam+macrolide

Outpatient+
*Macrolide (azithro, clarithro, erythro) + B lactam (Amoxi, augmentin) if resistant

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Pneumococcal vaccine

When/How to give?

> 65 y/o, current smoker, or dz/old/immunocompromised

2 separate vaccines

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cause of pneumonia in adults (3-38% of cases)
Associated with COPD and alcoholism, older or immunosuppressed
High fever, chills, cough with purulent sputum, abdominal pain & diarrhea
Pleural effusion common
Hyponatremia and ↑LDH
Encapsulated strains more virulent
B-lactamase production common

Bug? DX test?

Haemophilus Influenzae Pneumonia
2nd MC

*Urine Legionella Ag = L pneumophilia (90% cases)
*Sputum culture = G(-) rods
((G(-) cocci = M.catarrhalis))
*PCR
*Serology

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Haemophilus influenzae

Azithromyacin OR respiratory fluoroquinolone

Prevent = Hib vaccine

Hospitalization

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Gradual onset
Low grade fever & other systemic symptoms more prominent
Non-productive cough
Diffuse or patchy infiltrate on CXR with little or no pleural effusion

Atypical Pneumonia

includes “walking pneumonia”

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Atypical pneumonia

MC
LC

MC YOUNG= Mycoplasma (young adult), Chlamydophila (school age children)

MC OLD/IMMUNO = Legionella

LC= Psittacosis, tularemia, Q fever

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*MC cause = LRI young adults *Sore throat, nonproductive cough, headache, bullous myringitis *X-rays often appear worse than clinical findings *DX = clinical + serology confrimation (cold agglutinins) or culture

Mycoplasma pneumoniae MC Atypical Pneumonia

Mycoplasma Tx

macrolide NO B-LACTAM (no cell wall)

Viral pneumonia Organisms?

IMMUNOCOMPROMISED/ PREMATURE/ LUNG DZ * RSV (MC kids) * Flu * Adenovirus (kids, military) * Coronavirus * CMV * HSV, VZV

Viral Pneumonia Tx

* supportive | * antivirals (Neuraminidase inhibitor, Ribavirin inhaled)

*RLL, RML = MC *Possible Abcess, air fluid levels *lead to chemical pneumonitis, bronchial obstrucion, or bacterial pneumo *MC Anaerobic (some mixed aerobe/anaerobe)

Aspiration Pneumonia

Aspiration Peumonia Tx

for oral flora + anaerobes B-lactam + clindamycin

CAP DX

* Hx * CXR * +/-Gram * +/-sputum/blood * +/-Legionella/pnuemo UAT

CAP Tx Healthy? Comorbidity?

CONSIDER LOCAL Outpatient/healthy *Macrolides *Doxy Inpatient/Co-morbidity * Fluoroquinolones * Oral B-lactam + macrolide * Amoxi (high dose) + clav ICU *B-lactam + fluoroquinolone

CURB65

``` 0-1 = low risk 2 = your call 3+= admit ```

Empyema cause

MC anaerobes EMERGENCY

* Nasal/pharyngeal complaints then cough * Sputum common * tracheal involvment? substernal chest pain

Acute Bronchitis DX: Hz + PE

Acute Bronchitis Tx

Symptomatic (fluids, cough suppressant) *cough persists? CXR NO ABX

Influenza Incubation/shedding

Incubation = 1-4 days Shedding = day before s/s start to 5-10 days after onset

Abrupt onset of: * Fever * Myalgias * Pounding headache * Fatigue * Non-productive cough * Non-exudative pharyngitis (sometimes) * tachycardia * NO rhinorrhea

Influenza

Influenza Dx

rapid flu Rule out: Pneumonia = CXR Strep = Rapid strep/throat culture

Influenza Tx

* Rest * Hydration * NSAIDS (fever/myalgias) * Stay home * Avoid immunocompromised * Neurmindase inhibitor (oseltamivir, zanamivir, Peramivir) W/IN 48 HOURS

TB Incubation period

2-12 weeks

TB locations

* Lungs * Lymph nodes * Vertebral bodies * Adrenal glands * Meninges * GI tract

Latent TB s/s

NONE | get PPD

TB Skin test >5mm

HIV+ close contacts Fibrotic CXR lesion transplant patient

TB skin test >10mm

* High prevalence country * HIV- * long-term care faciility * medically underserved

TB skin test >15 mm

everyone else

Latent TB Tx

Isoniazid / Isoniazid + Rifapentine / Rifampin

* Cough * Weight loss/ anorexia/ cachexia * Fever * Night sweats * HEMOPTYSIS * Chest pain * Fatigue

Active TB

TB DX

CXR = * Reactivation: Coin lesions/ cavitations * Primary: middle/lower consolidation * Miliary TB Sputum stain = Acid-fast bacilli

Active TB Tx

4 drug x 6 mos * Pyrazinamid * Isoniazid * Rifampin * Ethambutol/Streptomycin OBSERVE for S.E. Not infectious after 2 weeks tx

* pneumo s/s * dry cough * hz of environmental exposure

Fungal Pneumo

Primary Fungal Pneumonia Organisms

* Blastomyces dermatidis * Coccidioides immitis * Histoplasma capsulatum

Opportunistic Fungal Pneumonia Organisms

* Aspergillus species * Candida species * Pneumocystis jirovecii

* Dense infiltrate typically upper lobe w/ hilar adenopathy * MC asymptomatic * fever * dry cough * chest pain/myalgias / arthralgias * sometimes erythema nodosum * travel to Southwest

Coccidioidomycosis Tx Itraconazole / fluconazole

Coccidioidomycosis Tx

Itraconazole / fluconazole

* planting new grass/ turning soil * Yardwork w/ chickens * Tearing down old buildings * Bat cave * usually near Mississippi-Ohio River valley

Histoplasmosis Tx. Amphotericin THEN itraconazole

NO HILAR/ MEDASTINIAL ADENOPATHY * Men w/ outdoor occupations * Acute: asymtomatic, pulm infiltrate, fever, cough * Chronic: productive cough, fever, night sweats, weight loss, hemoptysis, dyspnea, cavitary lesion * Southeast/East

Blastomycosis Tx. itraconazole

Blastomycosis

itraconazole

Primary TB

Initial infection CONTAGIOUS

Latent (Chronic) TB

Caseating gruanulomas (control initial infxn) PPD (+) 2-4 weeks after infxn NOT CONTAGIOUS

Secondary TB

low immunity reactivates latent TB apex/upper lobes w/ caseating granuloma CONTAGIOUS

* Contaminated water supplies, air con/coolers * GI s/s * UP LFTs, hyponatremia * no person-to-person

Legionella Pneumonia

* after viral illness * Immunocompromised + elderly * ABSCESS * Bilateral w/ multilobar infiltrates

Staphylococcus aureas Gram (+)

* ETOHolics * Cavitary lesions, upper lobes (especially R) * chronic illness, aspiration

Klebsiella pneumonaie Gram (-) bacilli

aspiration of acidic gastric contents

pneumonitis

Interstitial pneumonia bug?

virus | mycoplasma

Alveolar pneumonia bug?

bacteria

Primary Pneumonia

CAP

Secondary Pneumonia

* Hospital (nosocomial) | * Pseudomonas (vascular lesion)

Childhood pneumococcal vaccination

PCV13

Elderly/chronic dz Pneumococcal vaccine

PPSV23

Legionella Tx

* Levofloxacin | * Azithromycin