Infections Flashcards
Pneumonia
Path
- into alveoli
- Neutro from pulm capillary to alveoli
- phagocytosis, release cytokine
- inflammation –> neutrophilic exudate
Pneumonia
Causes
- Bacteria
- Mycobacteria
- viral
- fungal
- Rickettsial (q fever)
- parasitic
- mixed
Rickettsia
organism
Q fever
Coxiella Burnetti
Rickettsia typhi
Pneumonia
Hx
- Onset rapidity
- Fever degree
- Shaking chills?
- cough - prod/non
- Dyspnea
- Pleuritic chest pain
- other conditions? tobacco?
- Exposures (triggers, occupational)
- travel
Pneumonia
PE
- Gen = Toxic?
- Fever
- Tachycardia
- Tachypnea
- O2sat
- breath sounds
Pneumonia
Breath sounds
- Rhonchi
- Bronchial
- reduced/distant
- Egophany
Pneumonia
Dx
- CXR
- CBC (leukoctyosis, left shift, bandemia)
- Sputum Gram/culture
- Blood culture
Pneumonia
Sputum
Adequate :
>25 neutrophils/HPF
<10 epithelial cells/HPF
Gram (immediate)
Culture (48-72)
Pneumonia
Use bronchoscopy if….
- immunosuppressed
- no sputum (TB?)
- w/ neoplasm/FB
- no response to ABX
CAP typical
- Classic PNA s/s
- CXR appearance
- respond to ABX
CAP atypical
- less ill-appearing
- CXR different
- need different ABX
Pneumonia
Typical Organisms
- Strep pneumoniae
- H influ
- Moraxella catarrhalis
Pneumonia
Atypical Organisms
- Mycoplasma pneumo
- Chlamydia Pneumo
- Legionella pneumophilia
- Clamydia psittaci
- Francisella tularensis
- Coxiella burnetii (q fever)
- Fungal
alchohol associated w/
klebsiella
S. pneumo
TB
COPD associated w/
H flu
M. catarrhalis
Pseudomonas
Legionella
Dementia associated w/
anaerobes
enteric Gram -
- 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
Strep Pneumoniae
Suppuritive complications
- sinusitis
- endocarditis
- meningitis
- parapneumnonic effusion/empyema
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
Pneumococcal vaccine
When/How to give?
> 65 y/o, current smoker, or dz/old/immunocompromised
2 separate vaccines
- 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
Haemophilus influenzae
Tx
Azithromyacin OR respiratory fluoroquinolone
Prevent = Hib vaccine
Hospitalization
- 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”
Atypical pneumonia
MC
LC
MC YOUNG= Mycoplasma (young adult), Chlamydophila (school age children)
MC OLD/IMMUNO = Legionella
LC= Psittacosis, tularemia, Q fever
*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
