Module 4 - Pneumonia

Question 1

• Community Acquired Pneumonia

Answer 1

• sudden onset
• productive cough
• pleuritic chest pain (worsens with deep breathing, movement, cough) and often an audible friction rub expiratory and inspiratory
• pulmonary CONSOLIDATION
• high fever
  > ELDERLY
  - CONFUSION
  - LOWER TEMP
  - MORE CHEST AND RIB PAIN
  - FATIGUE

Question 2

• Case Study John

Answer 2

Diagnosed with influenza A
Likely organisms:
- strep pna (gram +)
> high fever, shaking, chills, pleuritic cp, cough,
copious production of rusty appearing purulent
sputum
> pleurisy and para pneumonic effusions common
- mycoplasma pna
- haemophilus flu (gram -) usually in smokers (same sx but sputum not rust colored)
- chlamydia pna
- respiratory viruses

if they are a smoker make sure you have - coverage to cover h.flu

Question 3

• Pulmonary Consolidation

Answer 3

replacement of air in alveoli with drainage

• INCREASED TACTILE FREMITUS
• DULLNESS TO PERCUSSION
• RALE OR CRACKLES (late inspiration)
• BRONCHIAL BREATH SOUNDS (over normal areas which are usually vesicular
• EGOPHONY (positive voice sounds)
• dense = dullness

Question 4

• Antibiotic Treatment

Answer 4

PREVIOUSLY HEALTHY WITH NO RISK FACTORS FOR DRSP
- BETA LACTAM AS MONOTHERAPY OR IN COMBO
> high dose amoxicillin 1000mg TID x 5 days or
> high dose augmentin ER 2000/125mg BID x 5days
- If used in combo with one of the following
> Macrolides
- azithromycin 500mg 1 day, then 250mg qd x
4day
- clarithromycin 500mg BID x 5 days
> Doxycycline 100mg BID x 5 days

PCN Allergy
- 3rd generation cephalosporins (and should be used in combo with a macrolide or doxy)??)
- cefpodoxime 200mg BID

Question 5

• Treatment for DRSP
  preferred

Answer 5

• Macrolides x 5 days
  - azithromycin 500mg 1 day, then 250mg qd x
  4day
  - clarithromycin 500mg BID x 5 days
• PLUS A BETA LACTAM x 5 days
  - augmentin 1000mg BID
• Alternative to macrolide is doxy 100mg bid x 5 days

PCN Allergy:
- Cefpodoxime 200mg BID x 5 days

Question 6

• Treatment for DRSP
  fluoroquinolones

Answer 6

Respiratory Fluoroquinolones should be used LAST
- risk of tendon rupture (esp if with corticosteroids)
- also associated with QT prolongation and peripheral neuropathy

• moxifloxacin 400mg daily
• levofloxacin 750mg daily
• gemifloxacin 320mg daily
  x 5 days

Question 7

• Drug Induced Long QT Interval

Answer 7

• disturbance in ventricular repolarization
  > ion channels and proteins
  > normal 470-480
• can be inherited, acquired, or med s/e
• causes cardiac arrest with torsades
• LGTS >500ms or an increase of 60ms from the patients baseline QTc

remember this when prescribing fluorquinolones (floxacin)

Question 8

• Risk factors for QT Prolongation and Torsades De Points

Answer 8

look at slide
hypomagnesia
hypokalemia
hypocalcemia
diuretic use
brady
use of more than one qtc prolong

Question 9

• CURB-65

Answer 9

tool to decide who gets hospitalized
Confusion
Urea > 7
RR > 30
BP < 90/60 (either)
Age > 65

0-1 outpatient
2 prob hospital
3-5 def hospital

Question 10

• CXR

Answer 10

recommended in all patients to document infiltrate’s and consolidation

TB often has cavitation

RESOLUTION: CXR 4-6 weeks after treatment especially if they have risk factors for malignancy

Question 11

• Who Gets Follow Up CXR?

Answer 11

(typically does resolve on cxr for 6-8weeks)

• Elderly patients >60
• smoking history
• immunosuppression
• more virulent pathogen (gram -)
• underlying chronic diseases
• persistent symptoms > 8 week s
• initial unusual findings

high risk patients should have follow up in 4-6 weeks especially if they have risk factors for malignancy
3% of all pna is malignant