Lecture 4 - Pneumonia Flashcards
The type of pneumonia diagnosed outside of the hospital in ambulatory patients who are not residents of nursing homes or other long term facilities
Community acquired pneumonia
What is healthcare acquired pneumonia?
When you acquire pneumonia from nonhospitalized patients with extensive healthcare
Example of HCAP
- IV therapy, wound care, IV chemo prior to 30 days
- residence in nursing homes or long term facilities
- hospitalization in an acute care facility for 2 or more days within the prior 90 days
- attendance in hemodialysis clinic within the prior 30 days
3 factors that distinguish HCAP from CAP
- difference infectious causes
- different abx susceptibility patterns
- poorer underlying health status putting patients at risk for more severe infections
What are distinguishing factors for HAP?
- develops more than 48 hrs after admission to the hospital
- FEVER
- purulent sputum
- new opacity on CXR
- leukocytosis (increased WBCs)
Some bugs that cause pneumonia for HAP and HCAP
- Escherichia coli
- klebsiella pneumoniae
- enterobacter
- pseudomonas aeruginosa
- acinetobacter
- staph aureas
- streptococcus
What is the bacteria that is Methicillin resistant and extremely difficult to treat in humans?
Staphylococcus aureus
What is an infection that is drug resistant in HCAP?
Streptococcus
Risk factors for CAP?
- advanced age
- ETOH/tobacco
- comorbid conditions (asthma, copd)
- immunosuppression
- malnutrition
- viral URI
- lung cancer
- previous episode of penumonia
What are some gram - bacteria etiologies?
-What is special about these etiologies
Streptococcus pneumonia (MAIN cause)
Staph. aureus (Seen in older adults and in younger patients recovering from influenza)
What are some gram + bacterial etiologies?
-What do these etiologies cause?
- pseudomonas aeruginosia (bronchiectaisis, CF, and the repeated use of abx courses or prolonged steroids and previous hospitalizations)
- klesbsiella pneumonia (COPD, DM, ETOH – red jelly sputum)
- haemophilus
- moraxella catarrhalis
Atypical pathogens
Mycoplasma pneumonia
Chlamydia pneumonia
Legionella pneumonia
Describe Legionella
- 2-9% of the cases
- sporadic infections or outbreaks
- stem from aerosal producing devices, showers, grocery store mist machine, cooling towers, decorative fountains
Describe M. Pneumonia
-transmitted person to person by infected respiratory droplets during close contact
Infection rates are highest in school aged children, military recruits, and college students
-fall and wanter
Describe Chlamydia Pneumonia
Very similar to M. pneumonia
Viral etiologies
- influenza
- RSV
- adenovirus
- Parainfluenza virus
How does the approach begin with a CAP patient
- begins with clinical evaluation
- followed by a CXR
Signs and symptoms of pneumonia
○ Fever. ○ Cough- with or w/o sputum. ○ Dyspnea. ○ Sweats/chills. ○ Chest discomfort. ○ Pleurisy. ○ Hemoptysis. ○ Headache. ○ Abdominal pain. ○ Anorexia. ○ Rust colored sputum-pneumococcal ○ Mental status change (in elderly pts)
What would you do on a PE exam for pneumonia pts?
○ Fever. ○ Tachypnea. ○ Decrease pulse O2. ○ Acutely ill patient. ○ Inspiratory crackles. ○ Dullness to percussion. ○ Egophony. ○ Whispering pectoriloquy. ○ Tactile fremitus. ○ Leukocytosis - with a left shift on CBC
Describe egophony
Over consolidated lung areas E is heard as A with your scope over abnormal lung tissue.
Describe tactile fremitus
- “99”
- Increased
- Palpable vibrations transmitted thru the bronchopulmonary tree to the chest wall as a patient is speaking
- dull when percussing
Describe whispered PECTORILOQUY
- Increase loudness of whispering noted during auscultation with a stethoscope
- Usually spoken words of a whispered volume by the patient would NOT be heard by auscultating a normal lung field.
What is consolidation?
Occurs when normally air filled lung tissue becomes engorged with fluid and puss and tissue
When should you order a CXR
-Should be obtained in patients with suspected pneumonia when possible.
What is the GOLD standard for CXRs
-Infiltrate on chest x-ray is the GOLD standard.
Why would you not obtain a specific culture of microbes when suspected pneumonia?
-Testing for microbial diagnosis is usually not performed in outpatients because empiric treatment is almost always successful.
Treatment of pneumonia
For previously healthy patients who have not taken
abx within the past 3 months:
- Macrolide – EX. ZPAK (general drug that fights bacteria)
- Doxycycline – Tetracycline (use for the atypical pathogens)
OR
Patients with a co morbid medical condition:
- Fluoroquinolone (broad spectrum antibiotics) – ex. Levaquin
- Macrolide plus a beta lactam (contain a beta lactams inhibit synthesis of the peptidoglycan layer) (5-7 days)
What is the recommended follow up process with pts with pneumonia?
- F/u with the patient in several days to be sure they are feeling better and there are no complications of pneumonia.
- Patients who do not respond after 48-72 hrs should be re evaluated. (patient should be responding!!)
- Fever and pulse O2 should improve in 3 days
- Cough and fatigue may take up to 14 days (or even a month) to improve.
- RTW 6 days.
Indications for hospitalization
- Ability to maintain oral intake
- Elderly patients
- Likelihood of compliance.
- Hx of substance abuse.
- Mental illness?
- Patient functional status.
- Living situation
What is the CURB 65 score?
A scale that determines the mortality of CAP to help determine inpatient vs. outpatient treatment
What does the CURB scale score on?
- Confusion
- Urea >7mmol/L ( 20 mg/dL)
- Resp rate >30 breath/min
- Blood pressure 65 years
CURB scale score results
0-1= outpatient
2 admitted
3 or more ICU
Diagnostic testing for microbial etiology
- Outpatient with CAP = routine diagnostic tests are optionsal
- Hosp patients w/specific indications should have blood cx and sputum gram stain
- patients with severe CAP requiring ICU = blood cd, urinary antigen test, and sputum cx
What are the only two bacteria you can order a urinary antigen test for?
Legionella and S. pneumonia (provide results in minutes)
What does the urinary antigen test for?
the urinary antigen test will basically identify the antigen on the surface of bacteria
Advantages of the urinary antigen test
- Most studies show these urinary antigen tests are more sensitive & specific than gram stain and culture of sputum
- Urine specimens are usually available in 30-40% of patients who cannot supply sputum.
- Results of urine antigen test are immediately available.
- Test remains valid after abx therapy.
Recommendations for pneumococcal urinary antigens in the follow circumstances
○ ICU admission. ○ Failure of outpatient abx. ○ Leukopenia. ○ ETOH. ○ Asplenia. ○ Pleural effusion. **THE PRESENCE OF A POSITIVE URINARY ANTIGEN IN A NON BACTERMIC PATIENT MAY BE HELPFUL FOR GUIDING THERAPY
When is a sputum sample necessary?
- ICU.
- Failure of outpatient abx therapy.
- Cavity lesions.
- Active ETOH use.
- Severe COPD.
- Positive urinary antigen test.
- Pleural effusion.
What is likely to indicate aspiration pneumonia?
A hx of coughing while eating or drinking
How is dysphasia confirmed?
Bedside swallowing test using fluids with varying volumes and consistencies
Most pneumonia arises how?
aspiration of micro organisms from the oral cavity or nasopharynx.
Predisposing conditions for aspiration pneumonia
- Reduced consciousness.
- Dysphagia from neurologic deficits.
- GERD (has to severely reflux)
- Mechanical disruption of the glottic closure due to tracheostomy, endotracheal intubation, bronchoscopy, upper endoscopy, and nasogastric feeding.
- Protracted vomiting.
- Large volume tube feed.
Signs that aspiration penumonia has involved anaerobic bacteria
- Absence of rigors (a sudden feeling of being cold and shivering, with a raise in temperature.
- Sputum that has a putrid odor.
- Periodontal disease.
- Indolent symptoms-slow to develop.
What is aspiration pneumonia usually do to?
Has usually been referred to an infection caused by less virulent bacteria primarily oral anaerobes and streptococci
What is the presentation of aspiration pneumonia similar to?
The presentation of bacterial aspiration pneumonia is similar to that of CAP.
What does the CXR reveal of asp pneumonia
- involvement of dependent pulmonary segments.
- lower lobes when aspiration occurs in the upright position
- superior segments of the lower lobes or posterior segment of the upper lobes when aspiration occurs in the recumbent position.
With the slow progression that characterizes infections involving anaerobes, many patients present later with complications characterized by
- Lung abscess-thick walled solitary cavity surrounded by consolidation.
- Empyema- purulent pleural fluid
Treatment of aspiration pneumonia
- Clindamycin: 1st line = covers aerobic and oral flora
- Augmentin: 2nd line = combination with a amoxil and acid
- Moxifloxacin = fluroquinilone
Prevention of asp pneumonia
- positioning
- dietary changes
- oral hygiene
- tube feeding have been proposed to prevent aspiration especially in older adults and stroke patients.
Most common pathogens associated with CAP with HIV
- strep pneumo
- H influenza
- p. aeurginosa
What do CAP w/ HIV present with
Fever chills cough SOB sputum
How do you treat someone with CAP w/ HIV
○ Obtain a chest x-ray, sputum cx, cbc, blood cx (bc they will need more aggressive tx)
Pulmonary complications of someone with HIV
Pneumocystis Carinii (jirovecii) Cryptococcus Toxoplasmosis Histoplasmosis TB
What is important in someone with fungal pneu?
History of travel!!!
What percentage do fungal infects account for in pneumonia?
Fungi account for only a small portion of community acquired and hospital acquired pneumonia.
How do fungal infections occur?
Fungal infection occurs following the inhalation of spores or by the reactivation of a latent infection.
Tx of fungal pneu
TX-Amphotericin B, flucanazole, itraconazole (All anti-fungal medications)
Endemic fungal pathogens
Histoplasma capsulatum
Coccidioides
Blastomyces Dermatitidis
Cryptococcus neoformans
cause infection in healthy hosts and in immunocompromised patients in defined geographic locations of the Americas and around the world.
Cryptococcus neoformans
Where are endemic fungi located?
prevalent in the Mississippi River Valley, the Southwestern U.S. & Northwestern New Mexico.
Cryptococcus
- Found in soil.
- In immunocompetent individuals, primary infections are asymptomatic and found on chest x-ray.
- Immunocompromised - fever, cough, sob.
- Workers or farmers with heavy exposure to bird, bat, or rodent droppings in endemic areas are predisposed to any of the endemic fungal pneumonias such as histoplasmosis.
Histoplasma
- Worldwide
- Midwestern states - Ohio & Mississippi River Valleys
- Flu like illness- fever, cough, chest pain that is pleuritic, sob leading to respiratory distress
COCCIDIOIDES
- Certain deserts of the western hemisphere.
- Southern Arizona, Central California, West Texas, Southwestern New Mexico.
- Found in alkaline, sandy soils and extreme temperatures.
- Unilateral infiltrate and ipsilateral hilar adenopathy.
Two opportunistic infections
- Candida species.
2. Aspergillus species
Conditions that predispose patients to an opportunistic infection
- Acute leukemia or lymphoma.
- Bone marrow transplant.
- AIDS
- Prolonged steroid therapy.
- Post splenectomy state.
- Solid organ transplant.
Leading cause of invasive pulmonary lung infection and death among patients who are neutropenic.
ASPERGILLOSIS
What does a CXR show for aspergillosis
pulmonary nodules surrounded by ground class opacity called the “halo sign”
What is diagnostic of acute bronchitis
-Cough > 5 days
-Typically no fever.
-Wheezing? Sputum?
-Caused by a virus (typically not bacterial)
o Influenza A & B
o Parainfluenza
o RSV
o Rhinovirus
o Coronavirus
PE of acute bronchitis
- NO CRACKLES that are heard with pneumonia
- rhonchi that may clear with coughing (rhonchi caused by blockage usually by secretions)
- fever (maybe have a low grade fever)
- Chest x-ray- clear.
- Airway hyper reactivity improves 4-6 weeks.
Treatment for acute bronchitis
TX: nsaids, otc? Albuterol (because they often act like an asthmatic)
