Infectious Disease Pt 2 Flashcards
Your imaging is showing an entire lobe has been “wiped out”. What is your first thought?
PNA. And inversely, if you thought your patient had PNA, but you see capsules or some diffuse process, EXPAND your DDx
if you smoke or have COPD, you are at risk for infection by what pathogens?
h.flu and strep
if you live in a SNF, you are at risk for infection by what pathogens?
strep, TB, hflu, gram negatives
If you have h/o ETOH abuse, you are at risk for infection by what pathogens?
strep, gram negs, anaerobes
If you have exposure to bats, you are at risk for infection by what pathogens?
histoplasma capsulatum
if you have exposure to birds, you are at risk for infection by what pathogens?
Cryptococcus neoformans and chlamydia
If you have recently had the flu, you are at risk for infection by what pathogens?
staph, strep, hflu
If you have CF, you are at risk for infection by what pathogens?
pseudomonas infections
If you are an IV drug user, you are at risk for infection by what pathogens?
staph, TB, anaerobes
If you aspirated, you are at risk for infection by what pathogens?
anaerobes
If you have HIV, you are at risk for infection by what pathogens?
pneumocystis carinii
What is the #1 cause of CAP (community acquired pna)?
strep. pna
What pna causing germ causes dyspnea and diarrhea and is associated with a water source?
Legionella
What pna causing bug also causes abscesses to form in the lungs. It is characterized by a dry cough and headache. Often, it is associated with IV drug abusers
staph aureus
Which PNA causing germ presents with a fever and a rusty colored sputum?
strep. PNA
Which PNA causing germ is most common amoung alcoholics and diabetic patients? It presents with hemoptysis and currant jelly colored sputum. CXR’s often reveal lobar consolidation
K. PNA
You have PNA and you have COPD second to smoking. Your PNA is most likely caused by what germ?
H. PNA
You have a patient with CAP. She is a healthy 29 yof with no risk factors. What is the BEST way to treat her?
as an outpatient using either 1) MACROLIDE 2) FLOROQUINOLONE, or 3) DOXYCYCLINE
Your healthy 29 yo patient with CAP is allergic to one of the preferred medications. What the heck are you going to do now?
AUGMENTIN or BETA LACTAM
Uh oh, you have a 53 year old female patient with HTN, DM, and COPD. She is in your office coughing up sputum. You detect crackles in her lungs. Vitals: temp 102.1 HR 103 BP 150/95 resp 18 O2sat–94. She is A&Ox4. Her CBC and CMP show elevated WBC, otherwise wnl. You don’t need a CXR to know this is PNA. How will you treat?
MACROLIDE, FLOROQUINOLONE, or DOXY
Patient has comorbidities, so you have to determine her “prognostic index”. Meaning…how severe is this? Using the CURB65, you determine she is actually low risk (1/5 risk factors). So she can be treated as an outpatient.
What types of symptoms typically occur with a CAP infection?
fever (90%), cough, tachycardia, crackles/rales, tachypnea (>24), tachycardia
You suspect your patient has PNA because they have a cough and crackles. Your patient’s vital signs are stable. Do you need to do a CXR?
No. The absence of v/s abnormalities (fever, tachypnea, tachycardia) has a 99% negative predictive value of PNA. But of course, you want to follow up with your patient to make sure none of these things have developed.
What kinds of tests can you use to make a definitive diagnosis?
CXR is standard. sputum culture or staining. labs (CBC, chem panel), blood cultures
What is a simple way to measure severity of a PNA infection?
CURB-65. Evaluate for confusion, Urea (BUN), Respirations, Blood Pressure, Age>65. Assign 1 point to each abnormal finding. If score is 0-1 treat as outpatient. Score of 2 use clinical judgment, score 3+ requires admission
Your 50 year old male patient with high cholesterol, 20 pack/year history, and COPD is in your office coughing up sputum. You detect crackles in his lungs. Vitals: temp 103.0 HR 116 BP 165/100 resp 26, O2sat–95. He seems alert to self and place, but is not sure what time it is. The history he gives you doesn’t make complete sense. His CBC and CMP show elevated WBC, and an elevated BUN. You don’t need a CXR to know this is PNA. What is his CURB65 score? How will you treat?
Admit! IV BETA LACTAM and a MACROLIDE…… OR IV FLOROQUINOLONE alone
(This patient’s CURB65 is a 4/5)
What criteria would constitute a diagnosis of HCAP (health care associate pna) vs regular old CAP?
1) SNF patient (or other care fascility
2) Dialysis patient (dialyzed w/in 30 days)
3) Hospitalized at least 2 days out the past 90 days (but not withing 48 hours)
4) Receives home IV/wound care in the last 30 days
What criteria would constitute a diagnosis of HAP (hospital acquired pna) vs CAP or HCAP?
PNA develops over 48 hours after a hospital admission and was not incubating at time of admission
What antibiotic would you add, if you had a suspicion that the pna germ was MRSA?
Vancomycin
If your patient is unable to clear their secretions during an PNA infection, what bug are you worried about? How would you treat?
Pseudomonas (anaerobe), treat with IV antipseudomonal beta lactam AND either IV QUINOLONE or IV AMINOGLYCOSIDE for a MINIMUM of 14 days EVERY TIME (high resistance rate)
Who should you be recommending the pneumovax for?
everyone >65. Immunocompromised. SNF residents. People over the age of 2 years with diseases of the heart, lungs, liver. With DM, ETOH abuse, tobacco use, CSF problems
Who gets viral pna?
kids under 3, typically
Who’s the big trouble maker in viral pna?
RSV, parainfluenza
How can we treat viral pna?
Gandolf, acyclovir, oseltamivir, a bunch more I don’t think we need to know
What, specifically, should you know about fungal PNA?
it exists. it is BAD!
Necrosis of the pulmonary parenchyma caused by microbial infection
pulmonary abscess
Who usually gets pulmonary abscesses?
people at risk of aspiration, IV drug users
How would you treat pulmonary abscess?
CLINDAMYCIN (because abscesses are usually anaerobic)……or Beta lactam if suspect staph. Vancomyciin if MRSA….and if abx fail, may need surgical excision.
Your patient has PNA and you notice a pleural effusion has developed, you decided to do a thoracentesis to make a definitive dx. It appears that the effusion was full of bacteria and appeared milky. What have you discovered?
Empyema
What if you suspect an empyema, but do not want to risk a thoracentesis. What other diagnostic tools could help you make this diagnosis?
Low glucose, high LDH (lactate dehydronase–which indicates tissue damage), high protein, low pH.
How do you treat an empyema?
chest tube + abx (not specified which ones)
What are the potential complications of empyema?
pleural thickening, reduced lung fxn, death
