L12 Bronchitis and Pneumonia Flashcards by Jeri Sheldon (AZ PA Mast 20)

most common cause of bacteria acute bronchitis

bordetella pertussis

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most acute bronchitis is

VIRAL

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presence of purulent sputum

NOT predictive of bacterial infection or response to antibiotics

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acute bronchitis physical exam

Rhonchi that clear with coughing

Negative for crackles/consolidation

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crackles aka

rales

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acute bronchitis is diagnosed

clinically

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Perform CXR for acute bronchitis

cough > 3 weeks or:

Fever (>38), tachypnea (>24), tachycardia (>100), consolidation (crackles, egophony, fremitus)

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codeine and acute bronchitis

avoid, potential for addiction, side effects

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when to give antibiotics for acute bronchitis

pertussis

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Bordetella pertussis

Whooping cough

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Name that pertussis phase:

URI+fever, 1-2 weeks

Phase 1: Catarrhal

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Name that pertussis phase:

coughing fits followed by classic whooping sound, post-tussive emesis, 2-6 weeks

Phase 2: Paroxysmal

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Name that pertussis phase:

Cough gradually resolves over weeks to months

Phase 3: Convalescent

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optimum timing for culture of pertussis

0-2 weeks after cough onset

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optimum timing for PCR of pertussis

0-4 weeks after cough onset

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optimum timing for serology of pertussis

2-8 weeks after cough onset

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if pertussis is suspected

begin empiric therapy while waiting for diagnostic confirmation

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why do we use antibiotics for pertussis if it has little effect on symptom resolution

it decreases transmission

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antibiotics used to treat pertussis

Azithromycin (500 mg PO followed by 250 mg x 4 days)
Clarithromycin (500 mg PO BID x7 days)
Erythromycin (500 mg PO QID x14 days)
TMP-SMX (DS PO BID x14 days)

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kids pertussis tx

admission, isolation, macrolid

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new recommendation for Tdap

adolescent booster

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other pertussis considerations

Abx prophylaxis for close contacts

Report to State Health Department

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incubation of pertussis is

up to 21 days

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Influenza clinical presentation

abrupt onset of:
fever
headache
myalgia
malaise

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when using Rapid influenza diagnostic test (RIDTs)

Negative does not reliably exclude influenza during periods of peak influenza activity

pneumonia results from

virulent organism, large inoculum, and/or impaired host defense

main way community acquired pneumonia is transmitted

aspiration from the oropharynx

pathophysiology of community acquired pneumonia

Proliferation of microbial pathogens at the alveolar level when the capacity of the alveolar macrophages to ingest or kill organisms is exceeded Alveolar macrophages initiate an inflammatory response

typical bacterial community acquired pneumonia

streptococcus pneumoniae

atypical bacterial community acquired pneumonia

mycoplasma pneumoniae

viral causes of pneumonia

** influenza ** RSV parainfluenza adenovirus

mixed bacterial viral community acquired pneumonia

20% of cases | more severe, longer hospitalization

Fungal community acquired pneumonia

is unusual in an immuncompetent

general community acquired pneumonia risk factors

``` asthma immunosuppression advanced age >70 alcoholism institutionalization ```

risk factors for pneumococcal community acquired pneumonia

``` Dementia seizures heart failure cerebrovascular disease alcoholism smoking COPD HIV+ ```

presetation of community acquired pneumonia

acute onset fever cough

atypical presentation of community acquired pneumonia in younger, healthy patients

subacute onset, viral prodome, nonproductive cough, low grade fever, HA, myalgia/athralgia, malaise, absence of pleurisy & rigors

Atypical presentation of community acquired pneumonia in elderly patients

*confusion*, weakness, failure to thrive, delirium, abdominal pain, tachypnea, N/V/D

signs of consolidation

dullness to percussion increased tactile fremitius bronchophony egophony

signs of community acquired pneumonia

``` fever tachypnea >24 breaths hypoxia tachycardia diaphoresis decreased/bronchial breath sounds crackles consolidation ```

bronchophony

spoken words are louder and clearer

egophony

spoken E sounds like A

CBC of community acquired pneumonia

leukocytosis with left shift

CXR of community acquired pneumonia

infiltrate on plain chest xray is the gold standard for diagnosis lobar consolidation interstitial infiltrates cavitation

when to test sputum or blood cultures

very ill or risk factors for unusual organisms

bacterial causes of community acquired pneumonia which show up on urine antigen tests

Legionella | S. pneumoniae

best predictor of a good outcome for community acquired pneumonia

right site of care

how long to treat community acquired pneumonia

at least 5 days

median time for community acquired pneumonia: fever to resolve cough and fatigue resolve return to work

3 days 14 days 6 days

who gets a follow up CXR for community acquired pneumonia | when to do it?

smokers >40 years old 7-12 weeks post treatment

uncomplicated means

previously healthy, no abx use in last 3 months

DOC for community acquired pneumonia

azithromycin 500 mg day 1 + 4 days 250 mg -OR- doxycylcine 100 mg BID 7-10 days

complicated means

``` recent abx use COPD liver/renal disease cancer DM CHD alcoholism asplenia immunosuppression ```

tx for outpatient complicated community acquired pneumonia

beta lactam plus macrolide -or- respiratory fluoroquinolone

complicated outpatient community acquired pneumonia beta lactam

amoxicillin-clavulanate 500 mg BID | in combination with a macrolide

complicated outpatient community acquired pneumonia macrolide

azithromycin in combination with a beta lactam dosing not given?

complicated outpatient community acquired pneumonia respiratory fluoroquinolone

levofloxacin 750 mg daily x5 days

inpatient community acquired pneumonia patients at risk for pseudomonas

``` alcoholism CF neutropenic fever recent intubation cancer organ failure septic shock ```

inpatient community acquired pneumonia patients at risk for MRSA

end stage renal disease IVDU prior abx use influenza

if an inpatient community acquired pneumonia patient isn't at risk for MRSA or pseudomonas, tx:

same as outpatient but FLUOROQUINOLONE preferred

when to end inpatient community acquired pneumonia treatment

``` minimum 5 days AND: afebrile 48-72 hours HR<100 RR <24 SBP > 90 mmHg supplemental O2 not needed ```

who gets pneumococcal vaccines

Patients >65 years old | Patients 19-64 at increased risk: cardiopulmonary disease, sickle cell, smokers, splenectomy, liver disease

nosocomial means

acquired in a hospital

hospital acquired pneumonia

pneumonia 48 hours+ after admission which did not appear to be incubating at time of admission

Ventilator acquired pneumonia

A type of hospital acquired pneumonia that develops more than 48-72 hours after endotracheal intubation

highest risk for hospital acquired pneumonia

ICU | mechanical ventilation

highest risk for hospital acquired pneumonia pseudomonas aeruginosa

ICU

how to diagnose hospital acquired pneumonia

CXR: new/progressive infiltrate + 2 of the following ``` Fever + purulent sputum → gram stain & culture + Leukocytosis ```

who to do a sputum culture and gram stain on in hospital acquired pneumonia

everyone

Pneumocystis jirovecii pneumonia was previously called

pneumocystis carinii: PCP

Pneumocystis jirovecii pneumonia is considered a

fungus

Associated with HIV+ and low CD4 count

Pneumocystis jirovecii pneumonia

Symptoms: Fever, nonproductive cough, progressive dyspnea, extra-pulmonary lesions

Pneumocystis jirovecii pneumonia

Risk factors for Pneumocystis jirovecii pneumonia in HIV, prophylaxis is indicated:

History of previous PCP CD4 < 200 Oropharyngeal thrush

preferred Pneumocystis jirovecii pneumonia treatment/prophylaxis

trimethoprim-sulfamethoxazole

alternate Pneumocystis jirovecii pneumonia treatments

TMP-dapson clindamycin-primaquine pentamidine steroids

Pneumocystis jirovecii pneumonia treatment with the best side effect profile

Pentamidine

alternative Pneumocystis jirovecii pneumonia prophylaxis

dapsone | aerosolized pentamidine

aspiration pneumonia is

Displacement of gastric contents to the lung causing injury & infection → gram negative anaerobes

aspiration pneumonia risk

Risk: post-operative state, neurologic compromise (CVA, parkinsons, ALS, sedation), anatomical defect or aberrancy

CXR: Right lower lobe infiltrate

aspiration pneumonia

4 equally acceptable Aspiration pneumonia treatments

Piperacillin/tazobactam Ampicillin/sulbactam Clindamycin Moxifloxacin