L12 Bronchitis and Pneumonia Flashcards
most common cause of bacteria acute bronchitis
bordetella pertussis
most acute bronchitis is
VIRAL
presence of purulent sputum
NOT predictive of bacterial infection or response to antibiotics
acute bronchitis physical exam
Rhonchi that clear with coughing
Negative for crackles/consolidation
crackles aka
rales
acute bronchitis is diagnosed
clinically
Perform CXR for acute bronchitis
cough > 3 weeks or:
Fever (>38), tachypnea (>24), tachycardia (>100), consolidation (crackles, egophony, fremitus)
codeine and acute bronchitis
avoid, potential for addiction, side effects
when to give antibiotics for acute bronchitis
pertussis
Bordetella pertussis
Whooping cough
Name that pertussis phase:
URI+fever, 1-2 weeks
Phase 1: Catarrhal
Name that pertussis phase:
coughing fits followed by classic whooping sound, post-tussive emesis, 2-6 weeks
Phase 2: Paroxysmal
Name that pertussis phase:
Cough gradually resolves over weeks to months
Phase 3: Convalescent
optimum timing for culture of pertussis
0-2 weeks after cough onset
optimum timing for PCR of pertussis
0-4 weeks after cough onset
optimum timing for serology of pertussis
2-8 weeks after cough onset
if pertussis is suspected
begin empiric therapy while waiting for diagnostic confirmation
why do we use antibiotics for pertussis if it has little effect on symptom resolution
it decreases transmission
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)
kids pertussis tx
admission, isolation, macrolid
new recommendation for Tdap
adolescent booster
other pertussis considerations
Abx prophylaxis for close contacts
Report to State Health Department
incubation of pertussis is
up to 21 days
Influenza clinical presentation
abrupt onset of: fever headache myalgia malaise
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
