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WI-18 Pulmonary > PI 1 > Flashcards

PI 1 Flashcards

1
Q

classification of PNA

A

causative pathogenic organism

anatomic/radiologic location

acquisition

setting occur

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2
Q

why do we classify PNA

A

direct Abx therapy and determine risk of exposure to MDR organisms

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3
Q

PNA epidemiology

A

2nd mMC cause of hospital acq. infection,

MC in winter months and colder climates

mc in elderly and high mortality rate in very old

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4
Q

PNA pathogenesis

A

inflammation of lung parenchyma causing filling of the air spaces with exudates, inflammatory cells and fibrin = CONSOLIDATION

host defense mechanisms are defective or overwhelmed

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5
Q

how to organisms enter the lower respiratory tract

A

inhalation
aspiration
hematogenous spread

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6
Q

classification mechanisms of bacterial mechanisms

A

community acquired PNA (CAP)

healthcare associated PNA (HCAP)

hospital and ventilator associated PNA (HAP/VAP)

aspiration PNA

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7
Q

CAP

A

develops outside the hospital or care facility OR

within 48 hrs of admission to hospital

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8
Q

CAP in pts just admitted who has NOT

A

been hospitalized >2 days in last 90 days

significant healthcare contact (including HD, wound care, chemo, or IV ABX)

has not resided in >14 days in an extended care facility (ECF, SNF)

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9
Q

HCAP

A

non hospitalized patient or develops before 48hrs of hospitalization in pt with extensive healthcare contact

(IV therapy, HD, wound care, chemo in 30 days, residence in nursing home or long term care facility >14 days, hospitalization 2+ days)

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10
Q

HAP

A

occurs 48 hours+ after admission and did not appear to be incubating at time of admission

noscicomial PNA

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11
Q

VAP

A

HAP that develops more than 48-72 hrs following endotracheal ventilation

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12
Q

who is at risk of MDR pathogens?

A

ABX in preceding 90 days

current hospitalizations (>5 days)

high freq. ABX in community or specific unit

immunsuppressed

presence of risk factors/ family members

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13
Q

CAP bacterial pathogens

typical

A

Streptococcal app

H. Flu

Moraxella catarrhalis

s. aureus

MAY be anaerobes and gram neg

cause the TYPICAL symptoms of CAP

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14
Q

atypical CAP pathogens

A

infectious agents that cause “walking PNA”

Mycoplasma pan, legionella, chlamydia pneumo, chlamydophilia psittaci

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15
Q

adult CAP microbiology

A

bacterial (70-80)
Atypical (10-20)
viral (10-20)

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16
Q

typical pathogens Gram +

A

strep pneumonia

staph aureus

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17
Q

strep pneumonia

A

MC bacterial cause of CAP

rates are decreasing due to vaccination

rust colored sputum

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18
Q

staph areus

A

mc in groups of pt (post-flu, abx tx, HD, IVDA, pulmonary dx_

MRSA CAN cause cavitation

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19
Q

typical pathogens Gram -

A

H. flu

moraxella catarrali

klebsiella pneumoniae

psuedomonas aeruginosa

gram 0 bacilli

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20
Q

h. flu

A

cause of PNA in elder and underlying lung dz

routine immunization decreased prevalence

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21
Q

moraxella catarrali

A

gram - diplococcus

more common in COPD, PCM, neutropenia, and malignancy

often a copathogen

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22
Q

klebsiella pneumoniae

A

common in COPD, DM, and chronic alcohol abuse

causes necrotizing PNA with jelly sputum

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23
Q

Pseudomonas aeruginosa

A

only in certain groups of pts :

underlying lung dz
repeated courses of Abx 
DM 
prolonged glucocorticoids, immunodeficiency
recent ventilation
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24
Q

gram negative bacilli

A

E. coli, enterobacter, serrate, proteus

uncommon

causes severe PNA and req. intensive care unit

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25
Q

atypical CAP organisms

A

can’t be gram stained or cultured in standard media

mycoplasma species
legionella 
chlamydophila psittaci 
chlamydophilia pneumoniae 
chlamydophilia trachomatis
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26
Q

mycoplasma species

A

atypical

15% of CAP

transmitted by respiratory droplets

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27
Q

legionella

A

atypical

fresh water (contamination of water systems/aerosols)

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28
Q

two forms of legionella illness

A

pontiac fever (virus presentation, malaise, fevers HA, benign)

frank PNA (aggressive, high mortality)

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29
Q

chlamydophila psittaci

A

causes ornithosis

ass. with handling of birds

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30
Q

chlamydophilia pneumoniae

A

causes mild PNA or bronchitis in teens/young adults

older adults may have more severe, repeated infxn

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31
Q

chlamydophilia trachomatis

A

STI/PID and cause of PNA in infants and young children

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32
Q

uncommon CAP etiologies

A

francisella tularensis

coxiella burnetii

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33
Q

francisella tularensis

A

tularemia or rabbit fever

suspected in hx of rodent exposure

may be bioterrorism

TYPICAL PNA

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34
Q

coxiella burnetii

A

causes Q fever

suspected in hx of exposure to domestic animals

ATYPICAL presentation

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35
Q

classic CAP presentation

A

rigors

AMS, hyponatramia, diarrhea, other GI symptoms

rust colored sputum

red jelly sputum

foul smelling sputum

green sputum

exposure to animal vectors

exposure to overcrowded conditions

exposures to contained air or water

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36
Q

suspect what type of PNA:

AMS, hyponatramia, diarrhea, other GI symptoms

A

legionella

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37
Q

what type of PNA:
rust colored sputum

red jelly sputum

foul smelling sputum

green sputum

A

rust: pneumococcal

red jelly: klebsiella

green: pseudomonas, haemophilus, pneumococcal

foul smelling: anaerobic

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38
Q

what type of PNA:

exposure to animal vectors

exposure to overcrowded conditions

exposures to contained air or water

A

birds - C. psittaci

rabbits/rodents - F tularensis, Y pestis

cats, cattle, sheep, goats - C burnetii, B anthracis

crowded conditions: S pneumonia, mycoplasma, chlamydophilia, mycobacterium

water: legionella

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39
Q

clinical picture of atypical PNA

A

teens and young adults

preceded by pharyngitis or URI

onset is gradual, heralded by HA, malaise, dry cough, GI symptoms, low grade fever, chills

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40
Q

tests in PNA diagnosis

A

CBC
CXR
blood cultures
sputum gram stain

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41
Q

bacterial factors that facilitate PNA

A 
obstructive lesions
COPD
tobacco use 
repeat ABX 
dysphagia/aspiration 
periodontal dz
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42
Q

what is considered health care contact?

A
  1. IV therapy, HD wound care, chemotherapy (30 days)
  2. nursing home or long term care facility >14 days
  3. hospitalization for 2+ days in prior 90 days
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43
Q

why are GN pathogens causing PNA more severe

A

endotoxins released have high likelihood to cause sepsis or DIC

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44
Q

typical CAP presentation

pt characteristics

A

65+ with co-morbidities:

COPD/pulmonary dz
DM/CKD
Cardiac DZ

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45
Q

typical CAP presentation

symptoms

A 
accessory muscle use
cough (productive/colored) 
dyspnea 
pleuritic CP 
high fever (>101, chills, hypothermia) 
malaise, anorexia, fatigue
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46
Q

typical CAP presentation

signs and exam findings

A

tachypnea, tachycardia, decrease bp

dull to percussion, e->a changes

rales or crackles

increased tactile fremitus

wheezing

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47
Q

benefit of hospitalization

A

observe patient
access to modalities
IV ABX
ensures compliance

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48
Q

drawbacks to hospitalization/alternatives

A

could get sicker
expensive, time off

alternative would be f/u in 24hrs

49
Q

more likely to hospitalization if pt:

A

comorbidities
physical exam findings (HoTN, tacky, AMS, temp)

labs (uncontrolled DM, hypoxia, dehydration)

imaging

50
Q

CURB-65

A 
Confusion 
Urea (>20) 
Respiratory rate (>30 bpm) 
Blood pressure (HoTN) 
Age >65

1= outpatient, 2-3 = inpatient, 3+ = ICU

51
Q

PORT/PSI

A

more comprehensive scoring system allows risk stratification to determine which pts req. hospitalization

52
Q

empiric tx of CAP

healthy pt, no ABX exposure

A
  1. MACROLIDE (preferred, azithromycin, clarithromycin)

2. Doxycycline

53
Q

who gets a macrolide in empiric tx of CAP

A

pts with no comorbidiites and low levels of strep pneumonia resistance

Pack, clarithromycin or doxxy if macrolide allergic

54
Q

empiric tx of CAP

comorbid/recent ABX

A
  1. Respiratory quinolone mono therapy (levoquin, cipro)

2. Beta lactam + macrolide

55
Q

what doesn’t work for empiric tx of CAP

A

PCN, E-mycin, TMP-SMX

pneumococcal resistance

56
Q

how long do PNA pts get ABX

A

5 days output

57
Q

die effects of macrolide

A

QT prolongation
increased LFTs
Warfarin interaction
GI upset

58
Q

augmentin side effects

A

GI upset
C Diff risk

PREG SAFE

59
Q

Fluroquinalones side effects

A 
tendon rupture 
C diff 
QT prolongation 
CNS disturbance 
CKD dose adjust 
photosensitivity
60
Q

telemetry inpatient CAP tx

A
  1. B-lactam + macrolide
    (ceftriaxone - CKD Ok, Cefotaxime, + Azithro.)
  2. Fluoroquinolone mono therapy
61
Q

inpatient CAP tx pseudomonas risk

A

Zosyn
Primaxin
Cefepina
Cetazidime

PLUS fluoro

62
Q

telemetry inpatient CAP tx

ca-MRSA risk

A

empiric tx with vancomycin

63
Q

who to consider severe ca-MRSA

A

admission to ICU for septic shock/mechanical vent

necrotizing cavitation

Empyemas

GPC clusters on stain

64
Q

who is at risk for ca-MRSA

A 
ESRD 
IVDA
MSM
prisoners
recent flu illness, recent ABX
65
Q

supportive CAP tx

A 
IV hydration, diuretics 
nutrition 
pulmonary toiling 
respiratory tx
pain meds
supplemental o2
antipyritics
66
Q

clinical course of pNA

A

pneumo defervesce in 48-72 hrs

symptoms may take longer (cough 8 days, crackles 3 weeks)

dont change ABX in first 72 hrs

67
Q

when i sPNA tx refractory to another regimen

A

TB, viral/fungal PNA

effusion or atelectasis

must do non-contrast CT

68
Q

when to change ABX from IV to PO

A

patient is healthy for 24hrs, one dose after that

69
Q

prevention of CAP

A

seasonal flu vaccine

pneumococcal vaccine

70
Q

pneumococcal vaccine

A

routine use in adults >64 and children 2+ with significant comorbdities

revaccinate in 5 yrs

71
Q

list the 2 pneumococcal vaccines

A

conjugate vax (PCV13) - chiffren <5, adults 65+, children >6 with risks

PPSV23- adults 65+, others with risk

72
Q

Noscocomial PNA

typically caused by

A

gram negative bacilli aspirated from GI

MAY be S. pneumococcal and S. aureus

73
Q

pathogenesis of HAP/VAP

A

colonization of pathogens

aspiration to lower tract

due to immunocompromised its, with direct access to lung (vent, catheters), no coughing

74
Q

s/s of HAP/VAP

A

non-specific

fevers (mild), leukocytosis, AMS, new cough, infiltrates on CR

75
Q

diagnosing HAP/VAP

A

clinical

easy to collect sputum in ventilated patients but NOT ALL infiltrates are PNA

76
Q

T or F ALL infiltrates are PNA

A

FALSE

77
Q

tx of HAP

mild

A

3rd gen cephalosporins
beta lactam
respiratory fluoroquinalones

  • NO MRSA, Psedomondas cvg
78
Q

tx of severe HAP/VAP

A

broad coverage x 7 days

amino glycoside or fluoroquinolone + Zosyn, Cefepime, Carbapenem

79
Q

fulminant PNA

A

immunocompromised

secondary to bacterial pathogens

80
Q

immunocompromised insidious PNA

A

viral cause

gunwale, protozoan, mycobacteria

81
Q

management of immunocompromised

A

aggressive empiric therapy

early invasive testing (bronchoscopy) to consider severe disease and if patients fail to improve

82
Q

flu presents as

A

myalgia/malaise, body pain

sudden/abrupt onset of symps

high fever, n/v, dry cough, sore throat

no specific finding

83
Q

major complication of the flu

A

development of pneumonia

84
Q

groups at high risk for flu complications

A

chronic cardio dz, pulmonary illness

DM, liver, renal dz, immunosuppressed

residents of nursing homes or chronic care

50+

85
Q

Primary influenza PNA

A

flu virus directly infects lungs

severe PNA, but rare

86
Q

primary flu PNA

symptoms

A

peristent, increasing flu symptoms

high fever
dyspnea

cyanosis

87
Q

secondary bacterial pneumonia

A

25% of flu deaths

virus causes epithelium of trachea and bronchioles to decrease size

lose cilia and increase bacterial load = secondary PNA

88
Q

common secondary PNA pathogens

A

destruction of bronchioles causes infection

strep pneumo (increased adherence and invasion)

caMRSA

H Flu

89
Q

clinical presentation

secondary bacterial pneumonia

A

exacerbation of fever and respiratory symptoms

after initial improvement in symptoms of acute influenza the pt relapses with higher fevers, cough, production of purulent sputum and pulmonary infiltrates

90
Q

tx of secondary bacterial pneumonia

A

vancomycin (cMRSA coverage)

91
Q

leading cause of viral lower respiratory infections in infants

A

RSV

92
Q

RSV epidemiology

A

can be deadly in infants and young children

common in winter, males more likely to be hospitalize

children ages 2-8 months

more severe in those with f/h of asthma, congenital heart dz, chronic lung dz, prematurity and multiple gestations

93
Q

s/s of RSV

A

URI symptoms (progresses over 1-2 days) to fever (<101)

cough, wheezing, rales, retractions and cyanosis

secondary infection due to RSV uncommon except AOM

94
Q

RSV tx

A

supportive treatment (O2, bronchodilators, and vaporized epinephrine)

95
Q

RSV prophylaxis

A

high risk infants

humanized monoclonal anti-RSV Ab during RSV season

96
Q

fungal PNA

A

suspected if pt has immunocompromised or PNA

can mimic acute CAP, but also indolent course and cavitation possible

difficult to isolate

97
Q

common fungal pneumonias

A

aspergillus

cryptococcus

98
Q

aspergillus

A

classical in neutropenic its and on multiple Abx

also common in old pt with COPD on steroids

99
Q

cryptoccocus

A

ubiquitous

causes clinically significant dz in immunocomplrimised

100
Q

less common fungal dzs

A

histoplasmosis
blastomycosis
coccidomycosis

101
Q

pneumocystis pneumonia

A

MC opportunistic infection in HIV

gradual onset over weeks to months

102
Q

PCP symptoms

A

fever, non-productive to somewhat productive cough

progressive dyspnea with severe hypoxemia

103
Q

aspiration PNA

A

often unseen, common during sleep

may cause acute worsening of asthma, chemical pneumonitis, airway obstruction, pulmonary infection

causes dz in dependent lung zones

104
Q

who is at risk aspiration PNA

A 
dysphagia (stroke) 
drugs/alcohol
sleep apnea 
seizures, anesthesia 
vomiting/GERD
105
Q

aspiration PNA dz development

A

quick respiratory distress development, fever, cyanosis, tachypnea/tachycardia, wheezing, hypoxia, and cough, may be productive

liken develop ARDS

106
Q

aspiration PNA caused by which organisms

A

staph, strep, anaerobes

esp. in pts swallowing issue, poor hygiene, dysphagia/stroke, alcoholics

107
Q

aspiration PNA pt presentation

A

insidious process, presentation present with advanced dz

low grade fever, smelly/productive cough, dyspnea

108
Q

aspiration PNA tx

A

must include cvg for CAP, anaerobes

Unasyn, or Augmentin (not severly ill) Clinda can be used x 7 days

pleural effusion = toracentesis

cavitary dz = longer course

109
Q

complications of PNA

A

respiratory failure

parapneumonic pleural effusion

empyema

bacteremia

lung abscess

110
Q

paraneumonic effusions

A

exudates caused by increased in fluid during PNA

form when resorptive capacity of pleural space

111
Q

paraneumonic effusions

uncomplicated (stage I)

A

small, resolves with approtriope ABx

no bacterial in fluid space

lots of fluid may be tx with toracentesis

112
Q

parapneumonic effusions

complicated

A

bacterial and neutrophil invasion of pleural space

deposition of fibrin cause location and lung entrapment

tx as if empyema is present (no pus)

113
Q

empyema

A

stage III parapneumonic effusions

Pus in pleural space

req. drainage

114
Q

tx of empyema

A

complete fluid drainage
sterilization of cavity
adequate lung expansion

115
Q

lung abscess

A

necrosis of tissue with fibrous vanity caused by bacterial and fungal infection

indolent course of fever, night sweats weight loss and cough

116
Q

mc source of lung abscess

A

complication of aspiration pneumonia (7-14 days later, weeks to frank abscess)

117
Q

pathophysiology of lung abscess

A

free. caused by anaerobes from gingiva

mc in its at risk for aspiration - alcoholics pts with poor hygiene, chronic dz bc PERIODONTAL DZ impaired swallowing or pulmonary defense mechanisms

118
Q

making dx lung abscess

A

CXR reveals cavitary lung lesion +/- air fluid level

CT scan w/contrast = Study of Choice

other cavitary dzs considered

119
Q

lung abscess tx

A

3+ weeks Abx IV

Empiric therapy with Unazyn or carbapenem

Augmentin ok orally

most of time - sx not required

percutaneous abscess draining or resection reserved for its who don’t respond to management

WI-18 Pulmonary (11 decks)

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