Lower respiratory infections Flashcards
- symptoms might be extremely variable
- no one finding will allow you to definitely diagnose pneumonia
- might be particularly difficult in the elderly
- sx: cough, fever, chills, pleuritic chest pain, wheezing, sputum prodcution, abdominal symptoms, tachycardia, tachypnea, SOB, DOE
Community acquired pneumonia
what are some historical elements of pneumonia that you should keep in mind?
- change in hydration status wiht complaints of orthostatis
- nausea, vomiting, vomiting triggered by coughing
- signs of pulmonary involvement (bacteremia-skin, arthritis, etc)
- aspiration potential
organisms include
- Streptococcus pneumonia
- haemophilus influenzae
- staphylococcus aureus
- gram negative bacteria
CXR: may be signs of pulmonary consolidation (dullness, increased fremitus, egophony, bronchial breath sounds and rales
Common presentation: chils, tachypnea, pleurtic chest pain, fever, consolidations, rigors
Typical pneumonia
Organism Include
- mycoplasma pneumoniae
- legionella species
- chlamydophila pneumoniae
- respiratory viruses (covid-19, influenza, adenovirus, RSV)
The common presentation might be a range of respiratory signs that are non-specific (non-productive cough, fever, dyspnea)
intrinsically resistant to all B-lactam agents
Atypical Pneumonia
What is some of the differences between typical and a typical pneumonia?
what are some clinical manifestations that are thought to be more common with legionella atypical pneumonia infection?
- diarrhea
- temperature > 39 degrees celcius
- neurologic change (confusion, etc)
what are other types of pneumonias?
- Viral pneumonias (influenza, respiratory synctial virus, adenovirus, parainfluenza virus, covid-19)
- fungal pneumonias
- pneumonitis (inflammation of lungs caused by chemicals, food, liquids, or foreign objects)- can lead to infectious pneumonia
Initial site of treatment for pneumonia states
- The PSI has been validated for predicting mortality, guidelines discuss using the PSI recommendations to assist identifying pts with CAP who may be candidates for outpaitent tx
- PSI not a good substitute for good clincial judgement
- first asess preexisting conditions that may compromise the safety of outpatient care
- outpatient tx is recommended for risk classes I, II, III
evaluation of pneumonia uses?
- History and physical exam
- chest X-ray (typical- lobar consolidation; atypical- interstitial infiltrates; virus- interstitial infiltrates)
Cannot accurately differentiate typical from atypical based on CXR alone
- Diagnosis of pneumonia if there is a new infiltrate when the clincial and microbiologic features are supportive
- recommended for all adults
- if not infiltrate found, dx of pneumonia questionable
- False negatives- too early, dehydration, neutropenia
Chest X-ray
When should you evaluate blood cultures?
make sure to get two cultures before antiobiotics
- advised in patients with severe community acquired pneumonia, chronic liver disease or neutropenia secondary to pneumonia, asplenia or complement deficiencies
what empirical antibiotic treatment of CAP should be used in patients with no comorbidities?
for previously healthy patients with No use of antimicrobial within the previous 3 months
- Use Amoxicillin 1 G PO TID X 7 DAYS
- or doxyclycline
- or a macrolide Azithromycin 250mg tablets 2 PO tabs today and 1 tab PO daily x 4 days)
know bolded
Empirical antibiotic treatment of CAP in a patient with comorbidities?
In the presence of comorbidities such as chronic heart, lung, liver or renal disease; DM; alcoholism, cancer, asplenia; immunocompromising conditons or drugs causing immunocompression; or use of antimicrobials within the previous 3 months
- respiratory fluroquinolone (strong rec)- levofloxacin, moxifloxacin…
- or B-lactam plus macrolide
empirical antibiotic treatment for pneumonia? (INPATIENT) non-ICU
USE:
- a respiratory fluoroquinolone
- or B-lactam plus a macrolide
what is the guideline for the duration of antibiotic therapy for patients with CAP?
patients with CAP should be treated for a minimum of 5 days, should be afrebrile for 48-72h and should have no more than 1 CAP-associated sign of clincial instability
- a longer duration of therapy may be needed if initial was not active against the identified pathogen or etc
what is considered clincal stability?
- temperature < 37.8
- heart rate < 100bpm
- respiratory rate < 24
- systolic > 90mmHg
- aterial oxygen > 90%
- ability to maintain oral intake
- normal mental status
how do you calculate the pneumonia mortality criteria?
Don’t need to know specific calc- just generality
CURB-65
- confusion
- uremia > 7mmol/1
- respiratory rate > 30/min
- blood pressure: SBP < 90mmHG
OR
- DBP < 60mmHg
- 65 years or older
Presence of each item contributes 1 point to the score
What is the microorganism?
- Single rigor or chills and rust colored sputum
- lobar pneumonia
- aka pneumococcal pneumonia
- pts typically affected: anyone, post splenectomy
- TX: Amoxicillin 1G TID
Strep Pneumoniae
What is the microorganism?
- hyponatremia
- vomitting and diarrhea
- relative bradycardia, confusion, LFT changes
- pts typically affected: exposure to “humid” environments (A/C units or stagnant water)
- tx: Fluoroquinolone or Azithromycin
legionella pneumoniae
What is the microorganism?
- Bilateral nodular infiltrates, empyema, or pulmonary abscess formation
- pts typically effected: IV drug use, post-influenza
- tx: Beta lactam +macrolide
staph aureus
What is the microorganism?
- bullous myringitis, cold agglutination +
- cobweb infiltrates,
- low grade fever and cough
- pts typically effected: Young adults, college students
mycoplasma pneumoniae
What is the microorganism?
- Productive cough
- green sputum
- pts typically effected: COPD, Post splenectomy, decreased immunities
- tx: Amoxicillin 1g TID
Haemophilis influenza
What is the microorganism?
- Current jelly sputum
- bulging fissure sign, lung necrosis possible if not treated appropriately
- Pts typically effected: Alcoholics, chronic illnesses and aspiration
- tx: 3rd or 4th cephalosporin or quinolone
Klebsiella pneumoniae
What is the microorganism?
- green sputum with abscess formation
- pts typically effected: ventilator pts and CF pts
- tx: fluroquinolone
pseduomonas aeruginosa
What is the microorganism?
- Foul smelling sputum
- periodontal infection
- pts typically effected: aspiration and neonates
- tx: beta lactam +beta lactamase inhibitor or clindamycin
anaerobic pneumonia
