- used for severe cases - gram + diplococci = strep. pneumoniae - cluster of gram + cocci = staph. aureus - gram - coccobacilli = H. influenzae - gram - dipplococci = M. catarrhalis - plump gram - rods = Klebsiella pneumoniae - thin gram - rods = pseudomonas aeruginosa

- generally expectorated sputum - reserved for severe cases (hospitalized) - try to obtain BEFORE ABX so still get high yield of gram stain and culture - will present with normal flora a lot of the time

- legionella pneumophila - mycoplasma penumoniae - chlamydophila pneumoniae

- abrupt onset - unilateral well-defined infiltrate - significant fever, chills, sweats, dyspnea - purulent sputum production - primary pulmonary symptoms: pleuritic chest pain

LRTIs Flashcards by Michelle Hui

what are common causes for pneumonia?

aspiration of upper airway microbiota
inhalation of aerosolized material
metastatic seeding from the blood to the lung (rare; surgery, trauma, catheterization)

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what are some clinical signs of pneumonia?

RR > 30
HR > 100
temp > 100
also
purulent sputum, leukocytosis, decrease O2

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signs and symptoms of pneumonia?

cough
sputum production
dyspnea
fever and chills
hemoptysis (blood in sputum)
pleuritic chest pain
tachypnea
tachycardia
diminished breath sounds
egophony (E sounds like A)
increased WBC

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pneumonia on a CXR?

uni=lobe and middle lung infection with lower lobe infiltrates (most common)

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gram stain

used for severe cases
gram + diplococci = strep. pneumoniae
cluster of gram + cocci = staph. aureus
gram - coccobacilli = H. influenzae
gram - dipplococci = M. catarrhalis
plump gram - rods = Klebsiella pneumoniae
thin gram - rods = pseudomonas aeruginosa

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what color is the gram stain for gram NEGATIVE bacteria?

PINK (gram positive = PURPLE)

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sputum culture

generally expectorated sputum
reserved for severe cases (hospitalized)
try to obtain BEFORE ABX so still get high yield of gram stain and culture
will present with normal flora a lot of the time

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what are some other diagnostic tests?

BAL (bronchoalveolar lavage)
blood cultures (admitted and severe)
procalcitonin (only in severe/sepsis)
O2 saturation
urinary antigen testing (pneumococcal and legionella)
viral panel

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CURB-65

another test, get a certain score

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community-acquired pneumonia

no exposure to the healthcare system

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hospital-acquired pneumonia

pneumonia not incubating at time of hospital admission and occurring ≥ 48 hours AFTER admission
- can also include patients coming from the community who have received IB ABXs within 90 days of admission

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ventilator=associated pneumonia

pneumonia occurring > 48 hours after endotracheal intubation

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what is the most common pathogen for pneumonia regardless of CAP, HAP, or VAP?

Streptococcus pneumoniae

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atypical pathogens

legionella pneumophila
mycoplasma penumoniae
chlamydophila pneumoniae

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what are some characteristics of pneumonia caused by legionella pneumophila?

mild to rapidly progressing pneumonia
- water exposure
- males > females
- smokers

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how to treat pneumonia caused by legionella pneumophila?

fluoroquinolone
azithromycin

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typical pneumonia

abrupt onset
unilateral well-defined infiltrate
significant fever, chills, sweats, dyspnea
purulent sputum production
primary pulmonary symptoms: pleuritic chest pain

atypical pneumonia

gradual onset
diffuse infiltrates, ground-glass appearance
mild fever, mild dyspnea
dry cough
extrapulmonary symptoms common: myalgias, diarrhea, abdominal pain

outpatient treatment of CAP for someone who was previously healthy with no risk factors for drug resistance

PO amoxicillin
PO doxycycline (alternative)
PO macrolide (azithro and clarithromycin ONLY)

comorbidities

age < 2 or > 65
beta-lactam within prior 3 months
alcohol abuse
immunosuppression
exposure to daycare
cancer
chronic respiratory disease

outpatient treatment of CAP for someone with comorbidities

PO amoxicillin/clavulanate OR cephalosporin (cefpodox, cefdinirm cefurox) PLUS macrolide (azithro or clarithro)
PO respiratory quinolone (levo, moxifloxacin) IF ALLERGY or RESISTANCE HX

inpatient treatment of NON-SEVERE CAP

IV Beta-Lactam (ampicillin/sulbactam, ceftriaxone) PLUS macrolide OR respiratory fluoroquinolone

inpatient treatment of SEVERE CAP

IV Beta-lActam PLUS Macrolide OR
IV Beta-Lactam PLUS respiratory fluoroquinolone
give anti-MRSA or anti-pseudomonal IF prior respiratory cultures

duration of ABXs for CAP

treat for a MINIMUM of 5 days (generally 7 days/1 week)
- patients should be afebrile for 48-72 hours

what are some pretreatment tests

- blood cultures and expectorated sputum samples for gram stains and culture should be sent for all patients with anti-MRSA or anti-pseudomonal ABX orders - patients with SEVERE CAP should have urinary antigen test for legionella and strep pneumoniae

antibiotic assessments

- check for allergies!! - check for QTc prolongation (quinolones and azithromycin can both prolong the ATc)

what are some signs and symptoms of HAP

- same as CAP but more SEVERE - respiratory complications more common - SIRS(systemic inflammatory response syndrome)/Sepsis more common

how should we treat patients if HAP or VAP are suspected (all disease severity)

if there is late onset (≥5 days) OR risk factors for MDR pathogens, prior ABX, colonization, hospitalization, or chronic care, immunosuppression/therapy -> use BROAD spectrum initial ABX therapy for MDR pathogens if not, just use limited-spectrum initial ABX therapy

what are some potential pathogens for VAP and what are some recommended ABXs?

- streptococcus pneumoniae - H. influenzae - MSSA -> ceftriaxone OR levofloxacin, moxifloxacin, OR ampicillin/sulbactam, OR ertapenem

recommended ABX therapy for VAP?

- ceftriaxone OR - levo, moxi OR - amp/sul OR - ertapenem

when should we empirically cover for pseudomonas?

- prior IV ABX use within previous 90 days - severe presentation (septic shock, need for ventilator support) - previous infection/colonization - immunosuppression

how should we empirically cover for pseudomonas?

- ONE anti-pseudomonal ABX

pseudomonas ABX recommendations

- piperacillin/tazobactam - cefepime - ceftazidime - imipenem, meropenem (reserved due to potency) - aztreonam (reserved for alternate combinations - ciprofloxacin (reserve for PO availability, renal considerations) - levofloxacin (limited data; reserve for only moderate infections or less) - aminoglycosides - colistin, polymixin B (last resort)

what are some targeted treatments?

CULTURES - HAP: patients treated should have a sputum sample obtained noninvasively, then BAL if possible - VAP: noninvasive sampling of semi-quantitative cultures preferred over invasive sampling of quantitative cultures

noninvasive sampling

endotracheal aspiration

invasive sampling

BAL

duration of ABX therapy

7 day duration for both HAP and VAP regardless of pathogen!

CAP treatment for healthy patients

oral monotherapy with amoxicillin (or macrolide or doxycycline)

CAP treatment for patients with comorbidities

oral combo therapy with beta-lactam (only amox/clav) + macrolide -> OR respiratory quinolone (levo, moxi if allergy or resistance hx)

inpatient CAP treatment

IV therapy; combo (BL + MAC or BL + FQ)

treatment for HAP/VAP

combo therapy -> anti-MRSA or pseudomonal agent (1 BL - cefepime, pip/tazo, most carbapendems) - duration 7 days