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Pulmonology > Lecture 4 - Pneumonia > Flashcards

Lecture 4 - Pneumonia Flashcards

1
Q

The type of pneumonia diagnosed outside of the hospital in ambulatory patients who are not residents of nursing homes or other long term facilities

A

Community acquired pneumonia

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2
Q

What is healthcare acquired pneumonia?

A

When you acquire pneumonia from nonhospitalized patients with extensive healthcare

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3
Q

Example of HCAP

A
  • 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
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4
Q

3 factors that distinguish HCAP from CAP

A
  • difference infectious causes
  • different abx susceptibility patterns
  • poorer underlying health status putting patients at risk for more severe infections
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5
Q

What are distinguishing factors for HAP?

A
  • develops more than 48 hrs after admission to the hospital
  • FEVER
  • purulent sputum
  • new opacity on CXR
  • leukocytosis (increased WBCs)
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6
Q

Some bugs that cause pneumonia for HAP and HCAP

A
  • Escherichia coli
  • klebsiella pneumoniae
  • enterobacter
  • pseudomonas aeruginosa
  • acinetobacter
  • staph aureas
  • streptococcus
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7
Q

What is the bacteria that is Methicillin resistant and extremely difficult to treat in humans?

A

Staphylococcus aureus

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8
Q

What is an infection that is drug resistant in HCAP?

A

Streptococcus

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9
Q

Risk factors for CAP?

A
  • advanced age
  • ETOH/tobacco
  • comorbid conditions (asthma, copd)
  • immunosuppression
  • malnutrition
  • viral URI
  • lung cancer
  • previous episode of penumonia
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10
Q

What are some gram - bacteria etiologies?

-What is special about these etiologies

A

Streptococcus pneumonia (MAIN cause)

Staph. aureus (Seen in older adults and in younger patients recovering from influenza)

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11
Q

What are some gram + bacterial etiologies?

-What do these etiologies cause?

A
  • 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
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12
Q

Atypical pathogens

A

Mycoplasma pneumonia
Chlamydia pneumonia
Legionella pneumonia

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13
Q

Describe Legionella

A
  • 2-9% of the cases
  • sporadic infections or outbreaks
  • stem from aerosal producing devices, showers, grocery store mist machine, cooling towers, decorative fountains
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14
Q

Describe M. Pneumonia

A

-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

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15
Q

Describe Chlamydia Pneumonia

A

Very similar to M. pneumonia

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16
Q

Viral etiologies

A
  • influenza
  • RSV
  • adenovirus
  • Parainfluenza virus
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17
Q

How does the approach begin with a CAP patient

A
  • begins with clinical evaluation

- followed by a CXR

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18
Q

Signs and symptoms of pneumonia

A 
○	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)
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19
Q

What would you do on a PE exam for pneumonia pts?

A 
○	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
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20
Q

Describe egophony

A

Over consolidated lung areas E is heard as A with your scope over abnormal lung tissue.

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21
Q

Describe tactile fremitus

A
  • “99”
  • Increased
  • Palpable vibrations transmitted thru the bronchopulmonary tree to the chest wall as a patient is speaking
  • dull when percussing
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22
Q

Describe whispered PECTORILOQUY

A
  • 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.
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23
Q

What is consolidation?

A

Occurs when normally air filled lung tissue becomes engorged with fluid and puss and tissue

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24
Q

When should you order a CXR

A

-Should be obtained in patients with suspected pneumonia when possible.

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25
Q

What is the GOLD standard for CXRs

A

-Infiltrate on chest x-ray is the GOLD standard.

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26
Q

Why would you not obtain a specific culture of microbes when suspected pneumonia?

A

-Testing for microbial diagnosis is usually not performed in outpatients because empiric treatment is almost always successful.

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27
Q

Treatment of pneumonia

A

For previously healthy patients who have not taken
abx within the past 3 months:

  1. Macrolide – EX. ZPAK (general drug that fights bacteria)
  2. Doxycycline – Tetracycline (use for the atypical pathogens)

OR

Patients with a co morbid medical condition:

  1. Fluoroquinolone (broad spectrum antibiotics) – ex. Levaquin
  2. Macrolide plus a beta lactam (contain a beta lactams inhibit synthesis of the peptidoglycan layer) (5-7 days)
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28
Q

What is the recommended follow up process with pts with pneumonia?

A
  • 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.
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29
Q

Indications for hospitalization

A
  • Ability to maintain oral intake
  • Elderly patients
  • Likelihood of compliance.
  • Hx of substance abuse.
  • Mental illness?
  • Patient functional status.
  • Living situation
30
Q

What is the CURB 65 score?

A

A scale that determines the mortality of CAP to help determine inpatient vs. outpatient treatment

31
Q

What does the CURB scale score on?

A
  • Confusion
  • Urea >7mmol/L ( 20 mg/dL)
  • Resp rate >30 breath/min
  • Blood pressure 65 years
32
Q

CURB scale score results

A

0-1= outpatient
2 admitted
3 or more ICU

33
Q

Diagnostic testing for microbial etiology

A
  • 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
34
Q

What are the only two bacteria you can order a urinary antigen test for?

A

Legionella and S. pneumonia (provide results in minutes)

35
Q

What does the urinary antigen test for?

A

the urinary antigen test will basically identify the antigen on the surface of bacteria

36
Q

Advantages of the urinary antigen test

A
  • 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.
37
Q

Recommendations for pneumococcal urinary antigens in the follow circumstances

A 
○	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
38
Q

When is a sputum sample necessary?

A
  • ICU.
  • Failure of outpatient abx therapy.
  • Cavity lesions.
  • Active ETOH use.
  • Severe COPD.
  • Positive urinary antigen test.
  • Pleural effusion.
39
Q

What is likely to indicate aspiration pneumonia?

A

A hx of coughing while eating or drinking

40
Q

How is dysphasia confirmed?

A

Bedside swallowing test using fluids with varying volumes and consistencies

41
Q

Most pneumonia arises how?

A

aspiration of micro organisms from the oral cavity or nasopharynx.

42
Q

Predisposing conditions for aspiration pneumonia

A
  • 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.
43
Q

Signs that aspiration penumonia has involved anaerobic bacteria

A
  • 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.
44
Q

What is aspiration pneumonia usually do to?

A

Has usually been referred to an infection caused by less virulent bacteria primarily oral anaerobes and streptococci

45
Q

What is the presentation of aspiration pneumonia similar to?

A

The presentation of bacterial aspiration pneumonia is similar to that of CAP.

46
Q

What does the CXR reveal of asp pneumonia

A
  • 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.
47
Q

With the slow progression that characterizes infections involving anaerobes, many patients present later with complications characterized by

A
  1. Lung abscess-thick walled solitary cavity surrounded by consolidation.
  2. Empyema- purulent pleural fluid
48
Q

Treatment of aspiration pneumonia

A
  • Clindamycin: 1st line = covers aerobic and oral flora
  • Augmentin: 2nd line = combination with a amoxil and acid
  • Moxifloxacin = fluroquinilone
49
Q

Prevention of asp pneumonia

A
  • positioning
  • dietary changes
  • oral hygiene
  • tube feeding have been proposed to prevent aspiration especially in older adults and stroke patients.
50
Q

Most common pathogens associated with CAP with HIV

A
  • strep pneumo
  • H influenza
  • p. aeurginosa
51
Q

What do CAP w/ HIV present with

A 
Fever
chills
cough
SOB
sputum
52
Q

How do you treat someone with CAP w/ HIV

A

○ Obtain a chest x-ray, sputum cx, cbc, blood cx (bc they will need more aggressive tx)

53
Q

Pulmonary complications of someone with HIV

A 
Pneumocystis Carinii (jirovecii)
Cryptococcus
Toxoplasmosis
Histoplasmosis
TB
54
Q

What is important in someone with fungal pneu?

A

History of travel!!!

55
Q

What percentage do fungal infects account for in pneumonia?

A

Fungi account for only a small portion of community acquired and hospital acquired pneumonia.

56
Q

How do fungal infections occur?

A

Fungal infection occurs following the inhalation of spores or by the reactivation of a latent infection.

57
Q

Tx of fungal pneu

A

TX-Amphotericin B, flucanazole, itraconazole (All anti-fungal medications)

58
Q

Endemic fungal pathogens

A

Histoplasma capsulatum
Coccidioides
Blastomyces Dermatitidis
Cryptococcus neoformans

59
Q

cause infection in healthy hosts and in immunocompromised patients in defined geographic locations of the Americas and around the world.

A

Cryptococcus neoformans

60
Q

Where are endemic fungi located?

A

prevalent in the Mississippi River Valley, the Southwestern U.S. & Northwestern New Mexico.

61
Q

Cryptococcus

A
  • 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.
62
Q

Histoplasma

A
  • Worldwide
  • Midwestern states - Ohio & Mississippi River Valleys
  • Flu like illness- fever, cough, chest pain that is pleuritic, sob leading to respiratory distress
63
Q

COCCIDIOIDES

A
  • 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.
64
Q

Two opportunistic infections

A
  1. Candida species.

2. Aspergillus species

65
Q

Conditions that predispose patients to an opportunistic infection

A
  • Acute leukemia or lymphoma.
  • Bone marrow transplant.
  • AIDS
  • Prolonged steroid therapy.
  • Post splenectomy state.
  • Solid organ transplant.
66
Q

Leading cause of invasive pulmonary lung infection and death among patients who are neutropenic.

A

ASPERGILLOSIS

67
Q

What does a CXR show for aspergillosis

A

pulmonary nodules surrounded by ground class opacity called the “halo sign”

68
Q

What is diagnostic of acute bronchitis

A

-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

69
Q

PE of acute bronchitis

A
  • 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.
70
Q

Treatment for acute bronchitis

A

TX: nsaids, otc? Albuterol (because they often act like an asthmatic)

Pulmonology (2 decks)

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