Infections of the Respiratory system - Schoenwald Final Flashcards
Which organisms contain lipopolysaccharide in their cell walls, gram negative or gram positive?
Gram negative organisms contain lipopolysaccharide in their cell walls.
Color of gram negative and gram positive organisms?
Gram negative = pink
Gram positive = purple
What about gram negative organisms makes them more likely to cause fever and septic shock?
Gram negative organisms contain lipopolysaccharide, which is a potent inducer of cytokines, which are associated with fever and septic shock.
What bacteria is a gram positive cocci in chains?
Strep
What bacteria is a gram positive cocci in clusters?
Staph
E Coli, Kelbsiella, Pseudomonas, and Haemophilus, can all be described as \_\_\_\_\_\_\_\_\_\_. A) Gram negative cocci B) Gram positive rods C) Spirochetes D) Gram negative rods
D) Gram negative rods
T/F? Streptococcus pyogenes is a part of the normal flora of the lungs?
False. Lungs should be sterile, no normal flora!
What of the following is responsible for the most respiratory tract infections? A) Viruses B) Strep Pneumo C) H. Influenzae D) Fungal
A) Viruses
Strep pneumo is the most common bacterial cause of which of the following?
A) Acute bacterial sinusitis
B) Community acquired pneumonia
C) Acute exacerbation of chronic bronchitis
D) Two of the above
E) All of the above
D) two of the above
The correct choices are A and B
First and second line therapy for bacterial sinusitis in adults without allergies?
1st line = Augmentin 500/125 TID or 875/125 BID
2nd line = Doxycycline 100mg BID or 200mg QD
(or augmentin 2000/125 BID)
Treatment options for adults with bacterial sinusitis with B lactam allergy?
Doxycycline 100mg BID or 200mg QD OR Levofloxacin 500mg QD OR Moxifloxacin 400mg QD
T/F?
The correct treatment for sinusitis in a 5 year old with a beta lactam allergy is doxycycline.
False, children cannot take doxycycline.
What is the correct treatment for sinusitis in a child?
Augmentin 45mg/kg/day bid
Correct treatment depends on type of reaction to B lactams.
Type 1 hypersensitivity = levofloxacin 10-20mg/kg/day
Non-type 1 hypersensitivity = clindamycin 30-40mg/kg/day
Duration of treatment for sinusitis in adults vs children?
Adults 5-7 days
Children 10-14 days
T/F? Macrolides are not recommended for empiric therapy of sinutisis.
True
A patient is admitted to the hospital for hypoxia and SOB with no signs of pneumonia on CXR. The following day a repeat CXR is done and the pt is diagnosed with pneumonia. Is this CAP or hospital acquired pneumonia?
CAP can be diagnosed within 48 hours of admission.
Remember signs of pneumonia on x ray and lag behind the patients presentation.
Patients with alcoholism or who are asplenic are at risk for infection by what type of organisms?
encapsulated organisms, such as strep pneumo
What is the most common bacterial cause of CAP?
Strep pneumo!
What organisms cause atypical pneumonia?
Mycoplasma, chlamydia, and legionella
What bacteria is responsible for walking pneumonia?
Mycoplasma
What is a Curb 65 score used for?
To determine if a patient with pneumonia needs hospital admission
What are the 5 components of a curb 65 score?
Confusion BUN>20mg/dl Resp rate >30 systolic BP <90 or diastolic BP<60 Age>65
What curb 65 score warrants hospital admission?
Generally score of 2 warrants admission to the medical floor
Score of 3-5 you should consider ICU admission
But remember, if the patient had comorbidities, they may need admission with a lower curb65 score
What diagnostic testing might you suspect to have pneumonia?
Sputum culture and gram stain (controversial)
CXR
CBC (looking for increased white count)
If effusion is present:
Pleural fluid analysis including cultures, glucose, LDH, and cell count
T/F? Strep pneumo is normal flora of the mouth.
False. Strep pneumo is ALWAYS pathogenic. Never normal flora.
Upon seeing a rusty colored sputum, what bacteria might come to mind?
Strep pneumo
What are the indications to give a pneumonia vaccine?
Age >65
OR
asplenic or immunocompromised patients ages 19-64
What two PNA vaccines did we learn about? Which covers more strains?
Prevnar 13 and pneuomovax 23
Pneumovax covers 23 strains while prevnar covers only 13
What are good treatment options for a known strep pneumo infection?
Penicillins, macrolides, and fluoroquinalones
What are good treatment options for a known H. influenzae infection?
Augmentin, macrolides, cephalosporins, fluoroquinalones
What bacteria would come to mind if a question gives details about a ventilation system or decorative fountain?
Legionella
What classes of antibiotics are used for atypical PNA’s?
Macrolides, fluoroquinalones, and tetracyclines
Based on 2007 guidelines (there are new 2019 guidelines, but our PANCE will not have changed the questions yet) what are empiric tx options for PNA, PNA with comorbidities, and for PNA in regions of >25% pneumococcal macrolide resistance?
PNA with no comorbidities = macrolide or doxycycline
PNA with comorbidities (such as COPD, diabetes, lung or renal disease) = fluoroquinolone OR B lactam plus macrolide
PNA in region of >25% pneumococcal macrolide resistance = fluoroquinolone or B lactam plus macrolide
Based on new 2019 guidelines, what are empiric tx options for PNA, PNA with comorbidities, and PNA in region with greater than 25% pneumococcal macrolide resistance?
PNA with no comorbidities = amoxicillin or doxycycline or macrolide if resistance <25%
PNA with comorbidities = augmentin
OR
cephalosporin plus macrolide or doxy
OR
Monotherapy with levofloxacin or moxifloxacin
What is the most common strain of influenza to catch?
A is most common
How many types of influenza are there?
Which can infect humans, which can infect other mammals?
- A, B and C
B and C infect ONLY humans
A infects humans AND other mammals
A human is found to be infected by a strain of influenza called H2N6. Is this an A, B, or C strain of flu?
This is an A strain. Only A strains are further classified by surface proteins
Explain the classification or A strains of influenza.
H stands for hemaglutanin which is a protein on the surface of the virus responsible for binding to host cells
N stands for neraminadase, which is thought to be responsible for the virulence of the strain.
What is an antigenic shift?
It is when 2 different strains of flu viruses combine to make a new strain of flu. Humans or animals can be a vector for an antigenic shift
What is antigenic drift?
Antigenic drift is the slower change in flu strains that results from point mutations over time
What patient populations should not be given the flumist live nasal vaccine?
Immunocompromised patients due to the theoretical risk and asthma because it could cause bronchospasms
What is the difference between a trivalent and a quadrivalent vaccine?
Trivalent covers 2 A strains and 1 B strain, quadrivalent covers 2 A strains and 2 B strains
What is a high dose flu vaccine and who receives them?
a high dose flu vaccine is 4 times the regular dose, and ages 65 and up receive them
Which of the following antivirals should not be used for influenza?
a) Baloxavir (xofluza)
b) Amantadine (gocovri)
c) Oseltamivir (tamiflu)
d) Zanamivir ( Relenza)
e) They can all be used for treatment of influenza
b) amantadine
What organisms should be considered in a hospital acquired pneumonia?
Pseudomonas, acinetobacter, staph aureus, heamophilus, klebsiella, and E coli
A college student presents to the emergency room with cough, SOB, and sulfur smelling sputum a few days after “going too hard partying”. He admits to waking up covered in vomit. What diagnosis should you consider and why?
Aspiration pneumonia.
Increased risk with alcohol and drug use.
Foul smelling sputum is a common sign.
What organisms should be considered for causing aspiration pneumonia?
Anaerobic organisms such as peptostrep, prevotella, fusobacterium, bacteroides
Treatment for aspiration pneumonia?
piperacillin/tazo
or
clindamycin
What patient population is particularly vulnerable to MRSA pneumonia?
children
MOST effective antibiotic for MRSA pneumonia?
linezolid (Zyvox)
although vancomycin is historically the drug of choice, Zyvox is more effective
T/F? An empyema is a buildup of fluid and debris in the alveoli.
False. An empyema is a buildup of fluid and debris in the pleural space.
What is the most common cause of an empyema?
Untreated or complicated PNA accounts for 70% of cases
Treatment for an empyema?
SURGICAL DRAINAGE
then antibiotics tailored to organism
What is more common for aspiration PNA? right or left sided?
right due to the angle of the right mainstem bronchus being more vertical
What is the definition of chronic bronchitis?
Daily cough, with production of sputum for 3 months, 2 years in a row.
What are the three cardinal symptoms of acute exacerbation of chronic bronchitis (AECB)?
Increased SOB, increased sputum volume, increase sputum purulence
What is suggested by presence of 2 or 3 of the cardinal symptoms of AECB?
Bacterial etiology
What are the 3 major bacterial pathogens of AECB?
H. Influenzae (30-59%)
Strep Pneumo (15-25%)
M. Catarrhalis (3-22%)
1st line treatment for AECB?
Augmentin
When are antibiotics indicated for acute bronchitis?
If the symptoms have lasted 10-14 days, any second sickening, or a spike in fever several days into sickness
Most common organism to cause fungal lung infections?
Aspergillus
When to treat with fluconazole vs. voriconazole.
Fungal infections are caused by either molds or yeasts.
Fluconazole is effective against yeasts
Voriconazole is effective against molds
What is a typical fungal x ray finding?
A round lesion is characteristic of a fungal infection
What are the 3 stages of pertussis (whooping cough)?
Catarrhal stage
Paroxysmal stage
Convalescent state
Describe the Catarrhal stage and how long it lasts.
coryza, low grade fever, mild occasional cough, gradually worsens. Lasts average 7-10 days
Describe the paroxysmal stage and how long it lasts
Numerous rapid coughs, difficult to expel thick mucous. Long aspiratory effort with high pitched whoop. Cyanosis, vomiting, and exhaustion.
Lasts 1-6 weeks on average
Describe the convalescent stage and how long it lasts.
Period of gradual recovery over 7-10 days
What diagnostic testing is available for pertussis?
A sputum culture is effective from onset to the end of week 2.
PCR testing is effective from onset to the end of week 4.
Serology testing is effective from the end of week 2 until 8 to 12 weeks post onset.
1st and 2nd line therapy for pertussis?
1st line - macrolides
2nd line - bactrim (TMP SMX)
Is prophylaxis indicated for pertussis?
Yes, prophylaxis of contacts within 3 weeks of exposure is indicated with bactrim or macrolides
What is the most common opportunistic infection in HIV patients?
Pneumocystis pneumonia
aka
Pneumocystis jerovecii
Is a pneumocystis pneumonia a fungal, viral, or bacterial infection?
fungal
What is the gold standard test for pneumocystis jerovecii pneumonia?
Sputum for silver stain
PCR testing is now replacing silver stain test though
What is the classic CXR appearance of pneumocystis jerovecii pneumonia?
Bilateral diffuse hilar opacification
What medication is used for treatment and prophylaxis of pneumocystis jerovecii pneumonia?
Bactrim
What is the #1 infectious disease killer worldwide?
Tuberculosis
What bacteria causes tuberculosis?
mycobacterium tuberculosis
Are the upper or lower lobes more commonly involved with TB?
Upper lobes
What stain is used to look for TB?
Acid fast stain
T/F? Positive acid fast bacilli is always TB.
False, other mycobacteria also stain acid fast positive, such as actinomyces.
Is latent TB contageous?
No
Does latent TB cause a positive PPD test?
In 10-20% of patients, latent TB will cause a positive PPD.
Which if the following is a positive PPD test?
a) A patient with 0mm of induration after 60 hours post placement
b) A patient with 15mm of erythema 60 hours post placement
c) A patient with 10mm of induration 36 hours post placement
d) A patient with 15mm induration 70 hours post placement
D) A patient with 15mm induration 70 hours post placement
Tips for reading a PPD:
A PPD should be read by the induration, not erythema.
A PPD should be read 48-72 hours post placement
15mm induration is a positive test in persons with no known risk for TB, as risk factors increase the size of induration required for a positive test decreases.
What is anergy?
The inability to react to a PPD because of a weakened immune system
How do you test for anergy?What does a positive test look like?
To test for anergy, you do a subcutaneous injection of saline, and yeast, the same way you do a PPD.
Everyone should respond to yeast, because everyone has been exposed. No one should respond to saline, because you shouldn’t have an immune response to it.
If there is no induration to yeast or saline, the patient has anergy.
What diagnostics should be initiated after a patient has a positive Quantiferon TB test?
CXR and sputum culture and stain, to determine active or latent disease to determine treatment.
Which of the following tests should be preformed before initiating treatment of active TB?
a) HIV test
b) visual acuity
c) ALT and AST
d) all of the above
d) all of the above
You are treating a HIV positive patient for latent TB, which treatment regimen is NOT appropriate?
a) Isoniazid and Rifapentine once weekly x 3 months
b) Rifampin daily x 4 months
c) Isoniazid daily x 6 months
d) none of the above treatment regimens are appropriate
b) Rifampin
NEVER give rifampin to an HIV positive patient. It deactivates HIV meds
What is the most common latent TB treatment?
What is a common side effect?
Rifampin PO QD x 4 months
common side effect is bright orange urine
A common side effect of Isoniazid is _______. This side effect can be reduced by giving PO Vitamin B6 along with the Isoniazid.
Peripheral neuropathy
When is it appropriate to treat active TB with one medication?
a) when the therapy is directly observed
b) if the patient doesn’t like swallowing pills
c) if the patient has elevated liver function tests
d) it is never appropriate
d) it is never appropriate
What TB medication is associated with eye damage?
Ethambutol
“Eye = E”
What TB medication is associated with arthralgia?
Pyrazinamide
What TB medication is associated with ear damage?
Streptomycin
What is the most common treatment of active TB in the initial phase?
Isoniazid, rifampin, pyrazinamide, and ethambutol
What medication used for treatment of active TB is contraindicated by pregnancy?
Pyrazinamide
as well as streptomycin
What is the most common atypical mycobacterium infection in the US?
Mycobacterium avium complex
What patient population is more susceptible to infections of mycobacterium avium complex?
Females of Asian descent
What occurs during bronchiectasis.
Permanent and abnormal dilation and destruction of large bronchi
What is the major cause of bronchiectasis?
Cystic fibrosis (50% of cases)
Cystic fibrosis is characterized by what findings?
Abnormal mucus production and viscosity causing obstructions
Chronic lung infections
A CF patient is found to have a lung infection caused by Stenotrophomonas. What antibiotic should you treat that patient with?
Bactrim
You are on a mission trip providing medical care to children in the south pacific. A mother brings you a child with a low grade fever, sore throat, and loss of appetite. You inspect the oropharynx and find a firm, fleshly adherent mass in the back of the throat. Your attempt to dislodge to mass causes bleeding. What disease do you suspect?
a) Pertussis
b) Diphtheria
c) croup
d) mouth cancer
b) Diphtheria
What treatments are available for Diphtheria in the US?
Equine antitoxin available from CDC
Erythromycin or Penicillin
preventative tx with dpT in children or TDAP in adults.
