Lower Respiratory Infections - Part 2- Exam 1 Flashcards
What is pneumonia defined as ? Leads to consolidation of the affected part and a filling of the alveolar air spaces with _______, ______ and _____. What are the 2 MC causes of pneumonia?
inflammation of the lung parenchyma
exudate, inflammatory cells and fibrin
bacteria and viruses
What is the pathophys behind pneumonia?
What are common strands of hospital acquired pneumonia? **What is the major one Olivia mentioned in lecture?
Pseudomonas aeruginosa
**Staphylococcus aureus (including MRSA)
Klebsiella pneumoniae
Serratia marcescens
Acinetobacter baumannii
**________ bacteria is known to cause painful cavitations and abscesses on the lungs. Is it usually hospital acquired or community acquired?
Staph aureus
hospital acquired
Is it more common to aspirate into the right or left lung? Why?
more common on the right
because it sits up higher aka its the first lung “tube” that the foreign substance comes across
How are pneumonias classified? 3 things
anatomic location (lobar, lobular/bronchial, intersititial)
mechanism of acquisition (ventilator- associated, aspiration)
setting of acquisition (Community acquired CAP or nosocomial)
watch this youtube video when you go back and study
https://www.youtube.com/watch?v=b8_83UDfbbU&t=7s
______ is the MC cause of bacterial pneumonia
streptococcus
**What lobe is S. pneumoniae classically found in?
Right Lower Lobe
**Klebsiella has a tendency to occur in the _____
upper lobes
**Legionella has a predilection for the ______
lower lung fields
What test can you order that will tell you if your pt has a strep or legionella infection?
urine
What are some common pathogens that cause patchy appearance, with peribronchial thickening and poorly defined air-space opacities on CXR. What does it usually lead to? **What is the major connection between ____ organism and PE finding of _____
S aureus, Strep species, H influenzae, Klebsiella, and P aeruginosa
leads to abscesses, cavitation, necrosis and pleural effusions
**Staph aureus leads to cavitation
What can interstitial pneumonia be classified as? What does it result from?
focal or diffuse
Results from edema and inflammatory cellular infiltrate into the interstitial tissue of the lung and fibrosis
What is the cause of interstitial pneumonia? What is the classic presentation? **What is the pattern?
Causes: typically unknown / “Idiopathic”
Viral-like prodrome with nonproductive cough
Bilateral, symmetric, diffuse pattern with “ground glass” appearance
If “ground glass” appearance is present on CXR need to think _____ as a cause
think viral cause
later interstitial pneumonia has a similar presentation to ______ so must rule this out
ARDS
Younger male in his 20’s, what is the typical classification of pneumonia? What is the MC organism?
lobar
95% pneumococcal
What kind of pneuomonia?
Central bronchi involved
Asymmetrical
Peribronchial cuffing
Extremes of age
Secondary, in sick
S aureus, Strep sp, P aeruginosa, Klebsiella, H flu
Patchy, basal, bilateral around small bronchi
Not limited by anatomic boundaries
bronchopneumonia
Ground glass appearance
Bilateral, symmetrical
What kind of pneumonia?
interstitial pneumonia
What is the difference between lobar and lobular pneumonia?
what is the location of the aspiration penumonia dependent on? What is the MC site of infiltration?
the position of the patient when the aspiration occurred
RLL because the right mainstem bronchus is more vertical
_____ most common aspiration pneumonia site with alcoholics who aspirate while in a prone position
Right Upper Lobe
What is the pathophys behind aspiration pneumonia?
When does ventilator associated pneumonia tend to show up? What is an important factor to remember? What is the abx of choice? What 2 bacteria strains are associated with higher mortality rates in VAP?
48 hours or longer after mechanical ventilation via ET tube or trach
Multidrug resistant gram negative bacteria
Cipro, Cefepime, Ceftazidime
Higher mortality rates with Pseudomonas and Acinetobacter
What is the pathophys behind VAP?
**What are the risk factors for developing MRSA VAP?
treatment in a unit in which more than 10-20% of Staph Aureus isolates are methicillin resistant
tx in a unit which the prevalence of MRSA is not known
Define community- acquired pneumonia.
Develops in the outpatient setting or within 48 hours of admission to a hospital
What would be considered a healthcare associated pneumonia?
assisted living facilty or rehab, aka hospital adjacent but not the hospital
What are the 5 risk factors for CAP?
Advanced age
Alcoholism
Tobacco use
Comorbid medical conditions, especially asthma or COPD
Immunosuppression
_____ are the MC causative pathogens for CAP. Which one is the cause of 2/3rd of cases?
**S pneumo - 2/3 of cases
Mycoplasma pneumonia
Haemophilus influenzae
Klebsiella
Staph aureus
**20 year old male pt with CAP, what is the most likely organism?
mycoplasma pneumonia
What 4 viruses are associated with CAP?
Influenza, RSV, Parainfluenza, and Adenovirus
Pt’s sputum is rust-colored, thinking ______ pathogen
S pneumoniae
Pt’s sputum is green, thinking ______ pathogen
Pseudomonas, Haemophilus and other pneumococci
Pt’s sputum is red currant-jelly like, thinking ______ pathogen
Klebsiella
Pt’s sputum is foul smelling or bad tasting, thinking ______ pathogen
Anaerobic infections
What will the PE look like on a pt with CAP?
Fever
Tachypnea (greater than 24)
Use of accessory respiratory muscles
Tachycardia or bradycardia
Central cyanosis
Altered mental status
Tracheal deviation
Lymphadenopathy
Adventitious breath sounds, such as rales/crackles, rhonchi, or wheezes
Dullness to percussion
Pleural friction rub -> rare but possible
**a pt with CAP, what will egophony sound like? Whispered pectoriloquy?
**normal “E” will sound like “A” due to consolidation
**Ask the patient to whisper a sequence of words such as “one-two-three,” and listen with a stethoscope. Normally, only faint sounds are heard. However, over areas of tissue abnormality, the whispered sounds will be clear and distinct.
What is the gold standard for dx CAP?
Presence of infiltrate on x-ray is the Gold Standard for diagnosis
T/F: CXR will help you determine the specific microbiologic cause of CAP
FALSE!! cannot tell pathogen cause on any chest imaging
If you suspect CAP can also order urinary antigen testing to look for _____ and _________. Can also order _______ to analysis the pleural fluid.
S pneumoniae and Legionella
thoracentesis
What is the first question you need to ask yourself when evaluating a pt with CAP?
In pt or out pt!!!
What is in pt vs out pt determined by for CAP?
Pneumonia Severity Index (PSI) and the CURB-65 in addition to the overall picture of the patient
What is the CURB 65 criteria? What score do you have to get in order to be treated in pt?
score 2+, need to tx in pt
2= hospital
3-5= ICU
What are 3 additional factors that would apply when determining if you should tx CAP in pt or out pt?
Exacerbations of underlying disease (such as heart failure) that would benefit from hospitalization.
Other medical or psychosocial needs (such as cognitive dysfunction, psychiatric disease, homelessness, drug abuse, lack of outpatient resources, or poor overall functional status).
Failure of outpatient therapy, including inability to maintain oral intake and medications.
What form(s) does ceftriaxone come in? PCN G?
IV only
IV only
What is the generic tx for out pt CAP?
abx that continue 48-72 hours after fever has subsided
Rest, hydration
Analgesics (acetaminophen or ibuprofen)
Expectorants
Steroids
A pt with CAP with no comorbidities/previously healthy; No risk factors for drug resistant S. pneumoniae; no Ab w/in past 3 mos. What is the tx?
Amoxicillin
OR
Azithromycin
OR
Doxy
**A pt with CAP that has received prior antibiotic treatment within the last 3 months or co-morbid conditions, what is the tx?
macrolide PLUS Beta-lactam
aka azithromycin plus amoxicillin
OR
Fluoroquinolone (Levo)
What is the tx for in pt CAP (not ICU)? Give both options
Respiratory Fluoroquinolone (Levo or Moxi)
OR
Beta-Lactam & Macrolide (Ceftriaxone plus azithromycin 500 mg IV!!)
What is the tx for CAP in the ICU, no PCN allergy?
Azithromycin PLUS Ceftriaxone
OR
Levo PLUS Ceftriaxone
What is the tx for CAP in the ICU, with PCN allergy?
Levo PLUS Aztreonam (to cover gram (-)
What is the prevention for pneumonia? Who is it indicated for?
pneumonia vaccines that decrease changes of getting SEVERE pneumonia!
indications:
65+ people
any chronic illness that increases the risk of CAP
When should immunocompromised people receive a second dose of pneumonia vaccine?
single revaccination 6 years after the first vaccination
Immunocompetent persons 65 years of age or older should receive a second dose of vaccine if the patient first received the vaccine _____ previously and was under _____ old at the time of vaccination
6 or more years
65 years
HIV pts are at the highest risk of what pathogen?
Pneumocystis jirovecii
transplant pts are at the highest risk of what pathogen? Need to avoid giving these pts _____
Fungi: Aspergillosis, Cryptococcus, Histoplasmosis
avoid giving steroids because fungi feed on steroids
neutropenic pts are at the highest risk of what pathogen?
Fungi (Aspergillosis)
Gram - bacteria
smokers are at the highest risk of what pathogen?
S pneumo, H flu, M cat
alcoholics are at the highest risk of what pathogen?
S pneumo, Klebsiella, anaerobes
intravenous drug users are at the highest risk of what pathogen?
S aureus, pneumocystis, anaerobes
cystic fibrosis are at the highest risk of what pathogen?
Pseudomonas, S aureus
deer mouse exposure are at the highest risk of what pathogen?
Hantavirus
**bat exposure are at the highest risk of what pathogen?
Histoplasma
rat exposure are at the highest risk of what pathogen?
yersinia pestis
rabbit exposure are at the highest risk of what pathogen?
Francisella tularensis
bird exposure are at the highest risk of what pathogen?
C psittaci, cryptococcus
bioterrorism is more likely to use what pathogens?
Bacillus anthracis, F tularensis, Y pestis
What are risk factors for HAP?
What are 3 factors that distinguish HAP from CAP?
1) Different infectious causes
(2) Different antibiotic susceptibility patterns, specifically, a higher incidence of drug resistance
(3) Different underlying health status of patients putting them at risk for more severe infections
What organisms are prevalent in HAP?
Streptococcus pneumoniae, often drug-resistant, in HCAP
Staphylococcus aureus, methicillin-sensitive (MSSA)
Staphylococcus aureus, methicillin-resistant (MRSA)
Klebsiella pneumoniae
Escherichia coli and Enterobacter species
Pseudomonas aeruginosa
Acinetobacter species
_____ should be initiated as soon as HAP is suspected
Empiric antibiotics - IV!!
HAP with a low risk of multi-drug resistant pathogens, what is the tx?
IV levo
OR
IV Pip/Taz
OR
IV Cefepime
HAP with a high risk of multi-drug resistant pathogen, what is the tx?
If you suspect MRSA in HAP need to add on either ______ or _______
IV Vanc
OR
linezolid
What type of pathogen is Klebsiella Pneumoniae? Where is it normally found? What pt population is it strongly associated with?
Enterobacteriaceae genus
Gram negative bacilli
normal in mouth and intestine
alcoholics
**What does the sputum look like in Klebsiella Pneumoniae? What are some common CT findings?
**Currant jelly sputum
Ground glass opacities (100%)
Alveolar consolidation
Intralobular reticular opacities
Pleural effusions
What type of pathogen is staphylococcal pneumonia? Where does it normally found?
Gram positive cocci in clumps
skin or nares
What type of pathogen may follow a viral pneumonia (such as influenza) or right sided endocarditis with a PE?
staph pneumonia
What does the CXR look like on a pt with staph pneumonia? What is the tx?
CXR reveals extensive disease with empyema, pleural effusions, and multiple areas of infiltrate
Clindamycin or inpatient IV vancomycin
What type of pathogen is most prevalent in patients with COPD, laryngeal cancer, immunosuppressed patients, nursing home patients, or others at risk for aspiration pneumonia?
staph pneumonia
Describe mycoplasma pneumonia as a pathogen. **What is the typical pt population?
The smallest free living organism
Lack a cell wall
Adhere to host cells, with affinity to respiratory cells, causing a parasitic relationship on the target cell
younger male pts (think military base in the fall/winter because it is transfered via respiratory droplets in close contact situations)
What does a CXR look like for mycoplasma pneumonia? What will the pt sound like?
CXR normal to patchy bilateral lower lobe infiltrates (consolidated pneumonia is RARE)
Chest may be normal on auscultation
How do you dx mycoplasma pneumonia? What is the tx?
NP swab; IgM titers
macrolides (azithromycin) or fluoroquinolones
What are the common sources of viral pneumonia? Which one is MC? How do you dx? What is the tx?
Influenza- MC, adenovirus, parainfluenza, RSV, HMNV
NP swab
CXR
O2, rest, fluids, antipyretics, analgesics, IVF
Tapered toward the particular virus
Prophylaxis for influenza only
aka supportive care
What will the CXR look like in viral pneumonia?
diffuse and non-specific
Describe pneumocystis jiroveci as a pathogen. What dz is it associated with?
Unicellular
Classified as a fungal pneumonia
HIV when CD4 counts drops below 200
What will a CXR look like in Pneumocystis Jiroveci Pneumonia? CT?
CXR - diffuse, bilateral interstitial infiltrates
CT scan - Hallmark ground glass opacities (all the whited out areas in the CT scan are the pneumonia)
**What is the tx for Pneumocystis Jiroveci Pneumonia?
ART and Trimethoprim-sulfamethoxazole (Bactrim)
What tests would you order and what would you expect to find with a pt who has Pneumocystis Jiroveci Pneumonia?
Elevated LDH
Elevated Beta-D-glucan level (used to detect invasive fungal infections)
Detection of the organism in respiratory specimens
