lower respiratory infections part 2 Flashcards
what is the most common infectious cause of disease in the world
pneumonia
what is the definition of pneumonia
Pneumonia is defined as inflammation of the lung parenchyma which leads to consolidation of the affected part and a filling of the alveolar air spaces with exudate, inflammatory cells, and fibrin
what are the MCC of pneumonia
bacteria or viruses
what are other causes of pneumonia
inhalation of chemical
trauma to chest wall
infection by other agents
what is the pathophysiology of pneumonia
- infection of lung
- inflammatory response initiated
- alveolar edema + exudate formation
- alevoli & resp bronchioles fill w serous exudate, blood cells, fibrin and bacteria.
- consolidation of lung tissue
what 5 pathogens are more commonly found in health care acquired pneumonia
- Pseudomonas aeruginosa
- Staphylococcus aureus (including MRSA)
- Klebsiella pneumoniae
- Serratia marcescens
- Acinetobacter baumannii
How is pneumonia classified
- anatomic location
- mechanism of acquisition
- setting of acquisition
what is included in anatomic location
where in the lungs is it?
what is mechanism of acquisition
how did they get it? aspiration or ventilator associated
what is setting of acquisition
is it community acquired or nosocomial
what is a lobar pneumonia
acute exudative inflammation of an ENTIRE pulmonary lobe
what is the MCC of lobar pneumonia
Strep (95%)
what lobe is S. pneumo classically found in
RLL
this is because its location to the right main bronchus. therefore it is the most common
where does klebsiella tend to occur
upper lobes
(patients dirnk and then pass out prone… leading to upper lobe pnx)
where does legionella tend to occur
lower lung fields
how often is the right lung affected in pneumonia
2x as often as the left
how does lobular/bronchopneumonia appear on a CXR
patchy, with peribronchial thickening and poorly defined air-space opacities
what are the common pathogens for lobular/bronchopneumonia
S aureus
strep
H flu
klebsiella
p aurgionosa
what does lobular/bronchopneumonia lead to
Frequently lead to abscesses, cavitation, necrosis and pleural effusions
what are classifications of interstitial pneumonia
focal
diffuse
what does interstitial pneumonia result from
edema and inflammatory cellular infiltrate into the interstitial tissue of the lung and fibrosis
what is the cause of interstitial pneumonia
idiopathic
what is the pattern of interstitial pneumonia
bilateral, symmetric, diffuse.
how does interstitisal pneumonia present
Viral-like prodrome with nonproductive cough
Later - similar presentation to ARDS, so must rule this out
what type of pnuemonia is this
lobar
what type of pneumonia is this
bronchopneumonia
what pneumonia is this
bronchopneumonia
what pneumonia is this
lobar pneumonia
what pneumonia is this
interstitial pneumonia
what is this
right upper/right middle lobar pneumonia
what is this
she said you could argue bronchopneumonia but the ground glass appearance suggests more interstitial pneumonia
what is aspiration pneumonia
Pneumonia that develops after the inhalation of oropharyngeal secretions, gastric contents or colonized organisms
what does the location of aspiration pneumonia depend on
the position of the patient when the aspiration occurred
what is the MC site of infiltration in aspiration pneumonia
RLL
where would aspiration pneumonia present in a apatient who aspirated while lying in the left lateral decubitus position
left sided infiltrated
what is the MC site of aspiration pneumonia in alcoholics
RUL (aspiration in prone position)
what is the pathophysiology of aspiration pnemonia
Aspiration of gastric content or bacteria enter lung
Inflammatory response
Cavity extend to bronchus
Abscess become encapsulated
Tissues necrotize
Increase production of sputum
Purulent sputum
what is ventilator associated pneumonia
Pneumonia that develops 48 hours or longer after mechanical ventilation via ET tube or trach
how common is ventilator associated pneumonia
Complication of as many as 28% of ventilated patients and increases with length of ventilation; mortality is 27 - 76%
why is mortality rate so high in ventilator associated pneumonia
multidrug resistent gram negative bacteria is common
what are the MC pathogens in ventilator associated pneumonia.
Staph aureus (44%)
pseudomonas
acinetobactor
which pathogens are most associated with higher mortality rates in ventilator associated pneumonia
Pseudomonas and Acinetobacter
what is the pathophysiology of VAP
Endotracheal tube placed
Impaired natural protection/clearance system
Contamination/colonization with bacteria
Aspiration of microorganisms into the lungs directly through the ET tube or around the cuff
Lungs contaminated with microorganisms
ugh
what is considered CAP
Develops in the outpatient setting or within 48 hours of admission to a hospital
what is considered healthcare associated pneumonia (HCAP)
Pneumonia that develops within the first 48 hours of admission to the hospital, meaning it likely developed in an outpatient setting
what is considered hospital acquired pneumonia
Pneumonia that develops at least 48 hours after admission to a hospital
what is considered ventilator associated pneumonia
Pneumonia that develops more than 48 hours after endotracheal intubation or within 48 hours of extubation
what are risk factors for the development of CAP
Advanced age
Alcoholism
Tobacco use
Comorbid medical conditions, especially asthma or COPD
Immunosuppression
what are the MC bacterial causes of CAP
S pneumo - 2/3 of cases
Mycoplasma pneumonia
H flu
Klebsiella
S aureus
what are the common viruses assocaited with CAP
influenza
RSV
Parainfluenza
adenovirus
what is the sputum color for S pneumo
rust-colored sputum
what is the sputum color for pseudomonas, haemophilus and other pneumococci
green
what is the sputum color for klebsiella
red current-jelly sputum
what is the sputum color for anaerobic infection
foul-smelling or bad-tasting sputum
what are the MC symptoms of pneumonia. what are additional symptoms?
cough (productive)
fever - 80%
dyspnea - 45-70%
pleuritic CP - 30%
chills - 40-50%
HA
NVD
(theres more but these are the ones im doing)
What does a PE show in pneumonia
+ egophony
louder whispering pectoriloquy
dullness to percussion
pleural friction rub
rhonchi/rales/wheezes
fever
again there are more but im using these
what imaging is the gold standard for pneumonia
CXR with the presence of infiltrate
what lab tests should be done on CAP treated outpatient
none
what lab tests should be done on CAP treated inpatient
Sputum gram stain and culture
NP swab / PCR
Blood cultures
CBC
CMP
ABG (if hypoxemic)
How would you test for Spneumo and legionella in pneumonia
urinary antigen tests
what additional testing can be done in the assessment of pneumonia
- Influenza testing if suspected
- Urinary antigen tests for S pneumoniae and Legionella
- Thoracentesis with pleural fluid analysis, gram stain and culture
- Procalcitonin / CRP - Increased in bacterial infections and septic shock
- Bronchoscopy
what is used to determine whether a patient should be treated inpatient or outpatients
Pneumonia severity index (PSI)
CURB-65
at what PSI and CURB-65 indicates in patient treatment
PSI - 3
CURB-65 - 2
what is the CURB - 65 criteria
2 or more + = hospital
remember the number for uremia is >19! not 7.
what other factors may indicate the need for hsopitalization
- exacerbation of underlying disease
- other medical/psychosocial needs
- failure of outpatient therapy
How do you treat CAP outpatient
- antibiotics
- expectorants
- steroids (maybe)
- rest
how long should CAP outpatient stay on antibiotics?
at least 5-7 days and continued at least 48-72 hrs after pt is afebrile
what antibiotics are used to empirically treat CAP in a previously healthy pt with no comorbidities that has NOT been on antibiotics in the past 3 months
beta-lactam (amoxicillin)
or
macrolide (azithromycin or clarithromycin)
or
doxycycline
what is empiric treatment for outpatient CAP in a pt who has received ABX in the past 3 months or has a comorbidity
macrolide + beta lactam (rocephin)
or
levofloxacin or moxifloxacin (resp flouroquinolones)
what is the management for a non-ICU inpatient CAP
Levofloxacin or moxifloxacin
OR
azithromycin + beta lactam (rocephin)
How do you treat inpatient CAP that requires ICU placement
how do you prevent pneumonia
pneumococcal vaccine
oml plz no
yes. theres cards over this. just five it.
what are risk factors for hospital acquired pneumonia
what thre factors distinguish nosocomial pneumonia from CAP
(1) Different infectious causes
(2) higher incidence of drug resistant bacteria
(3) patients tend to be sicker = worse infections
what are s/s of HAP
similar to CAP but get worse
hemoptysis
hypoxemia
rigors
respiratory distress
Not all of them
what is the diagnostic evaluation for HAP
how do you manage HAP
- empiric ABX as soon as pnx is suspected
- start ABX tailored to culture once its back
- supportive care
what antibiotics are used for HAP when there is low-risk for multi drug resistent pathogens
ONE of the following
levofloxacin
pip/taz
cefepime
imipenem
meropenem
what is the antibiotic regimen for higher risk multi drug resistant pathogens DONT NEED ThIS JUST FLIP IT
- a. Cefepime or ceftazidime, plus
b. Imipenem/Cilastatin (Primaxin) or meropenem, plus
c. Piperacillin-Tazobactam (Zosyn) - a. Levofloxacin or ciprofloxacin, plus
b. Intravenous gentamicin, tobramycin, amikacin - COVERS MRSA
a. Intravenous vancomycin, or
b. Linezolid (Zyvox)
she said “yall dont have to memorize this chart. i just want yall to know, its a big deal!!!” thank tha lort
what are the key S/S for klebsiella pneumonia
red-currant jelly sputum
ground glass opacities on CT (100%)
what is the treatment for pneumonia cuased by staph pneumo
clindamycin or inpatient vanc
what is key s/s for mycoplasma pneumonia
bullous myringitis
nonproductive cough
CXR normal to patchy bilateral infiltrates
clear auscultation
what is treatment for mycoplasma pneumonia
macrolides or flouroquinolones
what is MCC of viral pnuemonia
influenza
what is the treatment for viral pnuemonia
supportive. unless influenza, treat within 48 hours
who is pneumocystis jiroveci MC in
HIV or immunocompromised pt
what is the presentation of a patient with Pneumocystis Jiroveci Pneumonia
immunocomp patient with cough and fever
what labs would you see in Pneumocystis Jiroveci Pneumonia
elevated LDH
elevated B D glucan level (indicated fungal infection)
CXR with diffuse bilateral interstitial infiltrates !!!! biggest thing
CT with HALLMARK ground glass opaciteis
what is treatment for Pneumocystis Jiroveci Pneumonia
ART initiated if not already
+
Bactrim
what are the MC pathogens in pneumonia with HIV
Pneumocystis jirovecii
Mycobacterium tuberculosis
Cryptococcus
Histoplasmosis
what are the MC pathogens in pneumonia with Transplant patients
Fungi :
* Aspergillosis, Cryptococcus, Histoplasmosis
Nocardia
CMV
what are the MC pathogens in pneumonia with neutropenic patients
Fungi (Aspergillosis)
Gram - bacteria
what are the MC pathogens in pneumonia with smokers
s pneumo
H flu
M cat
what is the MC pathogen in pneumonia with alcoholics
s pneumo
klebsiella
anaerobes
what is the MC pathogen in pneumonia with IVDU
s aureus
pneumocystitis
anaerobes
what is the MC pathogen in pneumonia with cystic fibrosis
pseudomonas
s aureus
what is the MC pathogen in pneumonia with deer mouse exposure
hantavirus
what is the MC pathogen in pneumonia with bat exposure
histoplasma
the MC pathogen in pneumonia with rat exposure
yersinia pestis
the MC pathogen in pneumonia with rabbit exposure
francisella tularensis
the MC pathogen in pneumonia with bird exposure
C Psittaci
cryptococcus
the MC pathogen in pneumonia with bioterrorism
bacillus anthracis
F tularensis
Y pestis
