PNA

Question 1

Common Typical pathogens PNA?

And five uncommon but that you should think of

Answer 1

peds: S. pneumo

0 comorbidities: S. pneumo, M, peumo, C. Pneumo
Viruses \

With risk factors or hospitalized also think of Group A Strep and Legionella

PJP
TB
FLu
Toxo
Mac

Question 2

Risk Factors for PNA

Answer 2

• Elderly
• PMHx: Asthma, COPD; CHF, CRF, Liver Failure; DM, HIV; Alcoholism, Smoking
• Meds: Steroid use, recent (<3 month) antibiotic use
• Tobacco Smoking, Alcoholism
• Hospitalization in < 3 mo

Question 3

clinical ftx PNA

Answer 3

2 or more ssx:
fever/childs/cough/sputum, new cough, dyspnea, sweats/wt loss
+ ausc findings < AE
+ opacity on CXR

Question 4

What specific measurements would you order with suspected PNA?

Answer 4

temp >37.8
tachypnea >25
spo02
Bp: HTN

Question 5

Peds ssx:

Answer 5

increased RR, temp >38, indrawing/grunting, tracheal tugs, nasal flaring
Same aus. findings: < AE

Question 6

What inx do your order for outpatient PNA?

Answer 6

CXR - AP/Lateral
* labs typically not rq

And don’t do the x-ray or diagnose PNA if they have normal vitals and a normal physical because <0.4% chance of it being pneumonia at that point

Question 7

Treatment course/timeline for PNA?

Answer 7

Empiric 5days, or 7-14 days
respond within 72 hrs
discontinue abx if afebrile 48-72 hrs
tx for antiviral with influenza

Question 8

Outpatient CAP txt in healthy adult: First line txt? 2nd line txt?

Answer 8

First Line:
•	Amoxicillin 
Second Line:
•	Macrolide (Azithromycin, Clarithromycin) 
•	Doxycycline

Question 9

follow up PNA

Answer 9

no-repeat CXR in adults with resolved CAP 5-7 days

-repeat in 6wks if extensive/comorbities

Question 10

How to prevent PNA?

Answer 10

handwash
smoking cessation
avoid env. tobacco
immunize: flu, pneumococcal 13 then 23 in high risk

Question 11

Hospitalized common pathogens for PNA

Answer 11

S. pneumo, M. Pneumo, C. Pneumo
H. Influenza, S. Aureus, M. Catarrhalis, Enterobactereae
Group A strep, Legionella

Question 12

Name 5 signs of consolidation on auscultatory exam in suspected PNA

Answer 12

• Decreased breath sounds
• Increased tactile fremitus
• Dullness to percussion
• Diminished air entry
• Bronchial Breath Sounds
• Whisper pectoriloquy
• Pleural rub
• Crackles
• Egophony (E -> A)

Question 13

Outpatient CAP txt in adult with modifiers/co morbidities or LTC : First line txt? 2nd line txt?

And outpatient CAP Txt in adults with no co morbidities 1st and second line

Answer 13

First Line:
• Beta-lactam (Amoxicillin, Amox / Clavulanate, Cefuroxime, Cefprozil)
PLUS
• Macrolide (Azithromycin, Clarithromycin) OR Doxycycline
OR
Second Line:
• Fluroquinolone (Moxifloxacin, Gemifloxacin, Levofloxacin)–Not first line because partially treats TB

No co-morbidities

1. Amox
2. Doxy, or azithro, or clarithromycin

Question 14

First line and second line txt for CAP requiring hospitalization?

Answer 14

• Ceftriaxone
PLUS
• Macrolide (Azithromycin, Clarithromycin)
OR
• Fluroquinolone (Levofloxacin, Moxifloxacin)

Try to avoid the fluroquinolones because they are quite big guns and they also partially treat TB

Question 15

First line treatment for PNA in children 3mo - 5 yrs

Answer 15

Likely Viral so often don’t need ax.

First Line:
• Amoxicillin 80 mg / kg / d
• Amoxicillin / Clavulanate 80 mg / kg / d
• Clarithromycin 15 mg / kg / d
• Azithromycin 10 mg / kg / d x 1, then 5 mg / kg / d x 4 d

Question 16

First line treatment for PNA in children 5 - 18 yrs

Answer 16

First Line:
Amoxicillin (per choose wisely)
•	Clarithromycin 15 mg / kg / d
•	Azithromycin 10 mg / kg / d x 1, then 5 mg / kg / d x 4 d
•	Doxycycline 2-4 mg / kg / d

Question 17

What to do if someone has a normal CXR and failed first line treatment for pneumonia

Answer 17

Serial x-rays
Test for things like PJP, Flu, Toxo, MAC, TB

Test for HIV, Hep C and Hep B because you should always test for those together

Question 18

List four things to consider when prescribing an antibiotic for pneumonia

Answer 18

1. Allergies
2. Interactions
   ie are they on warfarin
   Are they old and on an ACE (THen avoid Septra)
3. Aspiration coverage necessary or not (Would give amox clav or clinda)
4. COPD?

Question 19

How do we gauge severity

Answer 19

Pneumonia Severity Index (not CURB 65 anymore) 
Considered Demographics (age and LTC), co morbidities, physical exam and labs and imaging

Question 20

What treatment other than abx. could you potentially offer someone with pneumonia

Answer 20

Fluids
O2
Ventolin (no inhaled steroid) 
ANTIVIRAL with the abx. if they are influenza positive (so you should test)
Oseltamivir

Question 21

When do you need blood cultures

Answer 21

Vitals unstable/quite sick. Otherwise don’t order sputum or blood cultures

Question 22

When do you get a follow up x-ray to ensure consolidation is gone

Answer 22

You don’t if symptoms have resolved. No longer recommended

Question 23

When do you want to consider covering with a cephalosporin like ceftriaxone

Answer 23

Aspiration

Hospitalized