Infectious Disorders: PNA, TB, Bronchi, Bronchio, Epiglottitis, Croup Flashcards by Brianna Spahn

Most common cause bacterial CAP worldwide

Streptococcus pneumonia

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Rate and season of CAP

5-6 cases / 1000 ppl (or ~2 million / year in US)

More common in winter
Men / Black ppl
Elderly

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Technical differentiation between CAP and hospital-facility acquired pneumonia

A person w CAP has not been hospitalized or in long term care facility for at least 14 days

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Clinical features CAP

1-10 day history increasing cough

Purulent sputum
Pleuritic chest pain

SOB
Tachycardia

Fever
Sweats
Rigors

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3 microorganisms that cause 85% of CAP

Streptococcus pneumonia
Moraxella catarrhalis
Haemophilus influenza

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Physical exam findings CAP

Lung Exam:

Rales/Crackles
Increased tactile fremitus (consolidation)

Bronchial breath sounds over an area of consolidation
“Dense consolidation of the lung parenchyma, as can occur with pneumonia, results in the transmission of large airway noises (i.e. those normally heard on auscultation over the trachea… known as tubular or bronchial breath sounds) to the periphery. “

“Altered breath sounds”

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What does “dullness to percussion” and/or decreased tactile fremitus indicate on physical exam?

Pleural effusion

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What physical exam findings indicate lung consolidation

Increased tactile fremitus
“special” tests (bronchophony, ego phony, whisper)

Bronchial breath sounds - Dense consolidation of the lung parenchyma, as can occur with pneumonia, results in the transmission of large airway noises (i.e. those normally heard on auscultation over the trachea… known as tubular or bronchial breath sounds) to the periphery.

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Consolidation vs effusion?

Consolidation occurs when the normally air filled lung parenchyma becomes engorged with fluid or tissue.
In the presence of consolation, fremitus becomes more pronounced.

Fluid, known as a pleural effusion, can collect in the potential space that exists between the lung and the chest wall, displacing the lung upwards. Fremitus over an effusion will be decreased.

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Most basic CAP workup

H&P
CXR
Pulse Ox

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Additional CAP diagnostics

Routine Lab: CBC, BMP, LFT
Sputum culture / gram stain
Blood culture
ABG (hospital setting)

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CXR findings PNA

Lobar or segmental infiltrates

Air bronchograms*
*refers to the phenomenon of air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white). It is almost always caused by a pathologic airspace/alveolar process, in which something other than air fills the alveoli.

Pleural effusions

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Treatment for pleural effusion?

Thoracentesis in hospital setting

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CURB 65 scoring to determine outpatient / inpatient treatment of CAP

C - Confusion
U - Blood Urea Nitrogen 20mg/L or up
R - Respiratory rate 30/min or up
B - BP < 90 / < or = 60 (89/60 or below)
65 - Age 65 or up

Scores: 
0-1 = outpatient
2 = closely observed outpatient or inpatient observe, depending on risk factors of patient
3 = inpatient
4 or 5 = inpatient / ICU

Other considerations for Hospitalization: HI 5

- Hemodynamic instability
- Involvement of more than one lobe
- 50 yrs + with comorbidities

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Outpatient, uncomplicated CAP treatment (previously healthy, no use of antibiotics in past 3 months)

7-10 days of:

1st line: Macrolide (clarithromycin, azithromycin)

2nd/3rd line: fluoroquinalone

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Outpatient CAP treatment for patient with underlying chronic disease or use of antimicrobials in past 3 months

7-10 days of:

1st line: Fluoroquinolone (Moxi 400mg, Levo 750mg, Gemi)
or

Alt 1st line: Macrolide (clarithro / azithro) + beta lactam (amoxicillin / augmentin / ceftriaxone / cefotaxime)

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Inpatient treatment CAP, non ICU

Consider coverage of S. pneumo AND Legionella

1st line: Fluoroquinolone (Moxi 400mg, Levo 750mg, Gemi)

Alt 1st line: Macrolide (azithro / clarithro) + beta lactam (ceftriaxone / cefotaxime)

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Inpatient treatment CAP in ICU

Beta Lactam (Cefotazime, Ceftriaxone, Ampicillin-sulbactam)
+
Fluroquinolone (Moxi 400mg, Levo750mg)
or (2nd line) Azithromycin

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Inpatient pen-allergic ICU CAP treatment

Fluoroquinolone + Aztreonam (monobactam)

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Treatment if pseudomonas is suspected agent:

Fluoroquinolone (Cipro / Levo)
+
Beta Lactam for pneumo/pseudo (Piperacillin / Cefepime / Imipenem / Miropenem

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Vaccine recommended for all patients 65 and older

PPSV23 AND PCV13

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Atypical CAP most commonly found in what populations

young adults, living in close proximity

college dorms
military
boarding schools

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Most common causes of Atypical CAP

1 - Mycoplasma pneumoniae

Chlamydia pneumoniae
Legionella sp. (air conditioning, humidifiers)

Moraxella sp.
Influenza A / B

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Clinical features Atypical CAP

Low grade fever

Persistent dry cough

Constitutional: malaise, myalgia, headache

“smouldering” illness

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Distinctive Mycoplasma findings

"Bullous myringitis" - reddened tympanic membrane Vesicular rash

Distinctive Legionella findings

Systemic illness: diarrhea, hyponatremia

Distinctive Chlamydia findings

Longer prodrome Sore throat, hoarseness

Atypical CAP Diagnostic Workup

H&P Dry cough that is not resolving CXR usually confirms infiltrates Routine labs usually not too bad (WBC, BMP, sputum) **Treatment usually based on clinical diagnosis alone**

Atypical CAP Treatment

** No Beta Lactams ** Choose Macrolide, Fluoroquinalone, Tetracycline ``` Azithro or Clarithromycin or Doxycycline (Mycoplasma, Legionella) ``` Tetracycline if Chlamydia suspected

Hospital acquired pneumonia (HAP) and VAP, distinctions

Clinical infection more than 48 hours after hospital admission ICU patients on ventilators at highest risk (VAP) - developed 47-72 hours after endotrachial intubation

Patients at risk for HCAP (Healthcare-associated pneumonia)

``` Within past 30 days: IV therapy Chemotherapy Wound care Dialysis ``` Within 90 days: Acute care hospitalization for 2+ days

Causative organisms for HAPs

S. Aureus and Gram Neg Bacilli: - Pseudomonas (*ICU*) - Klebsiella - E. coli - Enterobacter

Best Diagnostics for HAPs

**SPUTUM CULTURE** Blood Cultures Bronchoalveolar lavage - if can't obtain sputum culture

Early onset (<5 days) HAP treatment, no MDR risk factors

**Based on Culture and Sensitivity Results** Cetriaxone Levo Ampicillin-sulbactam x8 days

Late onset (>5 days) treatment, +MDR risk, HCAP

**Based on Culture and Sensitivity Results** Cipro or Levo Cefepime Ceftazidime Imipenem Miropenem Piperacillin Vancomycin Linezolid

Indication of a sputum culture / gram stain with ** mixed flora **

Aspiration pneumonia

Most common cause of bacterial pneumonia in HIV patients

Streptococcus pneumo

Most common "opportunistic infection" in HIV patients

Pneumocystis jiroveci

Treatment of choice for pneumonia in HIV patients

Bactrim (trimethroprim - sulfamethoxazole) **prophylaxis indicated in all patients w CD4 counts < 200 **

Of the very uncommon fungal pneumonia, which is most common causative agent

Histoplasma capsulatum

CXR indicative of Histoplasmosis

GRANULOMAS **confirm with bronchoalveolar lavage or biopsy ** or serologic testing

Tx Histoplamosis

Itraonazole (mild) Amphotercin B (severe)

Primary TB vs Progressive Primary TB vs Latent TB

Primary TB: 10% of persons infected w TB, immune system able to prevent progression. Form granulomas Progressive primary TB: 5% ppl fail to contain primary infection and progress to active TB Latent TB: 95% of ppl contain bacterium without becoming symptomatic. Not infectious, asymptomatic.

Clinical features TB

Dry cough, progressing to productive cough - with or without hemoptysis >> 3 weeks + ** Drenching night sweats, weight loss, Posttussive rales**

Primary TB Radiography

Homogenous infiltrates "Segmental atelectasis" (collapse of one or several segments of lung) Lung Cavitations Hilar/Paratracheal lymph swelling

Reactivation TB Radiography

**Apical fibrocavitary infiltrates**

Radiography findings in healed primary infection

Ghon complexes (calcified primary focus) Ranke complexes (Ghon + calcified hilar lymph node)

Tuberculin Skin Test (TST) PPD reported according to

DIAMETER of induration - NOT erythema Identifies but does not differentiate between active / latent!

Definitive diagnosis of TB

ID of M. tuberculosis via sputum cultures or DNA/RNA amplification

Histologic hallmark of TB

Biopsy revealing caseating granulomas (aka, necrotizing granulomas)

LTBI Treatment

Isoniazid (INH) for 9 months or Rifampin (RIF) for 4 months or RIF and Pyrazinamide (PZA) for 2 months - if contact w resistant strains

Active TB Tx

Isoniazid (INH) + RIF + PZA + Ethambutol (EMB) for 2 months + Additional 4 months mutlidrug treatment based on culture sensitivity results

Length of multi drug treatment of HIV patients w TB?

1 year

Prophylaxis TB treatment?

INH for 6-12 months

Inflammation of airways, characterized by cough

Bronchitis

>90% cases of acute bronchitis caused by

VIRUSES (including RSV) ** bacterial causes considered in patients w chronic lung diseases (S. pneumo, H. influenza, M. catarrhalis)

Is sputum color predictive of bacterial involvement for acute bronchitis?

Diagnostic studies for acute bronchitis

Generally none, unless need to differentiate bronchitis from pneumonia CXR negative in bronchitis

Treatment acute bronchitis

Supportive - unless exacerbation of chronic bronchitis>> >> 1st line: 2nd gen cephalosporin 2nd line: or 2nd gen macrolide or Bactrim

When are antibiotics indicated for acute bronchitis?

Elderly Underlying cardiopulmonary diseases and cough for +7-10 days Any immunocompromised patient

Inflammation of the bronchioles (airways <2mm diameter) Primarily illness of young children and infants

Acute bronchiolitis

Most common cause of Acute Bronchiolitis, and others

RSV Others: Parainfluenza Adenovirus Rhinovirus

Clinical features of respiratory distress in pediatrics w acute bronchiolitis

Nasal flaring Tachypnea Retractions

Diagnostic studies - acute bronchiolitis / RSV

CBC - usually normal CXR - normal but can show bronchial thickening / air trapping Nasal washing for RSV culture ** often done for infants **

Treatment / management of RSV

If present, consider hospitalization, esp premature infants + RIBAVARIN ``` Supportive measures: Antipyretics Nebulized albuterol IV fluids humidified O2 Chest physiotherapy? ```

HIB vaccine has decreased incidence of this in children, but can still be found in unimmunized adults or caused by Strep A

Acute epiglottitis

``` Sudden onset high fever Severe Dysphagia Drooling Muffled voice Posture compensation Respiratory Distress ```

Acute epiglottitis

Management of Acute Epiglottitis

Secure Airway Broad spectrum 2nd-3rd gen cephalosporins (Cefotaxime, Ceftriaxone) Dexaeathasone to reduce inflammation

Harsh, barking, cough Inspiratory stridor Aphonia infection with Parainflueza, RSV, other viruses

Croup

Diagnostic studies for Croup

PA (postanterior) Neck Film: Shows Steeple Sign (subglottic narrowing) **this differentiates croup from epiglottitis**

Management for Croup

Usually only supportive ** Hydration is very important** Corticosteroids Humidified O2 Nebulized epinephrine