PNEUMONIA

Question 1

Risk Factors for Pathogens Resistant to Usual Therapy for CAP.

• Hospitalization 2 or more days in previous 90 days
• Use of antibiotics in previous 90 days
• Immunosuppresion
• Nonambulatory status
• Tube feedings
• Gastric acid suppression
• Severe COPD or bronchiectasis

Answer 1

Multidrug-resistant gram-negative bacteria and MRSA

Question 2

Risk Factors for Pathogens Resistant to Usual Therapy for CAP.

• Cavity infiltrate or necrosis
• Gross hemptysis
• Erythematous rash
• Concurrent influenza
• Young, previously healthy status
• Summer-month onset

Answer 2

CA-MRSA

Question 3

Risk Factors for Pathogens Resistant to Usual Therapy for CAP.

• Hospitalization 2 or more days in previous 90 days
• Use of antibiotics in previous 90 days
• Chronic hemodialysis in previous 30 days
• Documented prior MRSA colonization
• Congestive heart failure
• Gastric acid suppression

Answer 3

Nosocomial MRSA

Question 4

Mechanical Factors of CAP

Answer 4

• hair and turbinates of the nares
• branching architecture of the tracheobronchial tree
• gag and cough reflex
• normal flora adhering to mucosal cells of the oropharynx

Question 5

Microorganisms access to the lower respiratory tract by:

Answer 5

– microaspiration from the oropharynx
– small-volume aspiration occurs frequently during sleep
– hematogenous spread
– contiguous extension from an infected pleural or mediastinal space

Question 6

When the capacity of the alveolar macrophages to ingest or kill the microorganisms is exceeded this become manifested.

Answer 6

clinical pneumonia

Question 7

Host inflammatory response trigger the clinical syndrome of pneumonia

– release of inflammatory mediators (IL6 and TNF)

Answer 7

fever

Question 8

host inflammatory response trigger the clinical syndrome of pneumonia

• chemokines (IL 8 and GCSF) -> release of neutrophils

Answer 8

peripheral leukocytosis and increased purulent secretions

Question 9

Host inflammatory response trigger the clinical syndrome of pneumonia

• Inflammatory mediators released by macrophages and the newly recruited neutrophils

Answer 9

alveolar capillary leak

Question 10

Host inflammatory response trigger the clinical syndrome of pneumonia

• erythrocytes cross the alveolar–capillary membrane

Answer 10

hemoptysis

Question 11

Host inflammatory response trigger the clinical syndrome of pneumonia

• capillary leak

Answer 11

radiographic infiltrate and rales

Question 12

Host inflammatory response trigger the clinical syndrome of pneumonia

• alveolar filling

Answer 12

hypoxemia

Question 13

Host inflammatory response trigger the clinical syndrome of pneumonia

• increased respiratory drive in the systemic inflammatory response syndrome

Answer 13

respiratory alkalosis

Question 14

– presence of erythrocytes in the cellular intra-alveolar exudate
– neutrophil influx is more important with regard to host defense
– bacteria are occasionally seen in pathologic specimens collected during this phase

Answer 14

Red hepatization phase

Question 15

– no new erythrocytes are extravasating, and those already present have been lysed and degraded
– neutrophil is the predominant cell, fibrin deposition is abundant, and bacteria have disappeared
– corresponds with successful containment of the infection and improvement in gas exchange

Answer 15

Gray hepatization

Question 16

• presence of a proteinaceous exudate—and often of bacteria—in the alveoli

Answer 16

Edema

Question 17

– macrophage reappears as the dominant cell type in the alveolar space
– debris of neutrophils, bacteria, and fibrin has been cleared, as has the inflammatory
response

Answer 17

Resolution

Question 18

Most common etiology of CAP

Answer 18

Streptococcus pneumoniae

Question 19

Atypical pathogens

Answer 19

– Mycoplasma pneumoniae,
– Chlamydia pneumoniae
– Legionella species
– respiratory viruses

Question 20

• play a significant role only when an episode of aspiration has occurred days to weeks before presentation for pneumonia
• Risk factors: unprotected airway (in patients with alcohol or drug overdose or a seizure disorder) and significant gingivitis

Answer 20

Anaerobes

Question 21

Clinical Manifestation of CAP involving palpitation.

Answer 21

increased or decreased tactile fremitus

Question 22

Clinical Manifestation of CAP involving percussion.

Answer 22

dull to flat

Question 23

Clinical Manifestation of CAP involving auscultation

Answer 23

crackles, bronchial breath sounds, and possibly a pleural friction rub

Question 24

In chest x-ray of CAP, pneumatoceles suggest infection with

Answer 24

S. aureus

Question 25

In chest x-ray of CAP, upper-lobe cavitating lesion suggest

Answer 25

tuberculosis

Question 26

Adequate sputum sample for Gram Stain and Sputum Culture of CAP

Answer 26

>25 neutrophils and <10 squamous epithelial cells per LPF

Question 27

For CAP patient’s admitted to the ICU and intubated, a ______ has a high yield on culture

Answer 27

deep suction aspirate or bronchoalveolar lavage sample

Question 28

Most frequently isolated pathogen in Blood Culture for CAP

Answer 28

S. Pneumoniae

Question 29

No longer considered de rigueur for all hospitalized CAP patients

Answer 29

BLOOD CULTURES

Question 30

■ Test for Legionella pneumophila detects only serogroup 1 ■ Legionella urine antigen test: 70% sensitivity and 99% specificity ■ Pneumococcal urine antigen test: 70% sensitivity > 90% specificity

Answer 30

URINARY ANTIGEN TESTS

Question 31

- Tests amplify a microorganism’s DNA or RNA. - Detect the nucleic acid of Legionella species, M. pneumoniae, C. pneumoniae, and mycobacteria - Increased bacterial load documented in whole blood by this test is associated with an increased risk of septic shock, the need for mechanical ventilator, and death

Answer 31

POLYMERASE CHAIN REACTION

Question 32

has become the standard for diagnosis of respiratory | viral infection

Answer 32

PCR of nasopharyngeal swabs

Question 33

■ Fourfold rise in specific IgM antibody titer between acute- and convalescent-phase serum samples ■ Fallen out of favor because of the time required to obtain a final result

Answer 33

SEROLOGY

Question 34

– identification of worsening disease or treatment failure

Answer 34

C reactive protein

Question 35

– distinguishing bacterial from viral infection – determining the need for antibacterial therapy – deciding when to discontinue treatment

Answer 35

Procalcitonin

Question 36

Acquired by direct DNA incorporation and remodeling resulting from contact with closely related oral commensal bacteria, by the process of natural transformation, or by mutation of certain genes

Answer 36

S. Pneumoniae Antibiotic Resistance

Question 37

minimal inhibitory concentration (MIC) cutoffs for penicillin in S. pneumoniae pneumonia:

Answer 37

■ ≤2 µg/mL for susceptible ■ >2–4 µg/mL for intermediate ■ ≥8 µg/mL for resistant

Question 38

Risk factors for penicillin-resistant pneumococcal infection for S. pneumoniae:

Answer 38

- antimicrobial therapy, - age of <2 years or >65 years, - attendance at day-care centers, - recent hospitalization, and - HIV infection

Question 39

Methicillin resistance in S. aureus is determined by the ____, which encodes for resistance to all β-lactam drugs

Answer 39

mecA gene

Question 40

____ resistance to macrolides is increasing as a result of binding-site mutation in domain V of 23S rRNA

Answer 40

Mycoplasma

Question 41

____species are typically resis- tant to cephalosporins, and the drugs of choice for use against these organisms are usually fluoroquinolones or carbapenems.

Answer 41

Gram-negative Bacilli | – Enterobacter

Question 42

Initial Tx Strategies for Outpx with CAP STATUS: No comorbidities or risk factors for antibiotic resistance

Answer 42

Combination Therapy: Amoxicilin + macrolide or doxycycline or Monotherapy: Doxycycline or macrolide

Question 43

Initial Tx Strategies for Outpx with CAP STATUS: With comorbidities w/ or w/o risk factors for antibiotic resistance

Answer 43

Combination Therapy: amoxicilin/clavulanate or sephalosporin + either macrolide or doxycycline or Monotherapy with a respiratory fluoroquinolone

Question 44

Initial Tx for Inpx w/ or w/o risk factors for infection w/ MRSA or P. aeuroginosa DISEASE SEVERITY, RISK STATUS: Non-severe No risk factors

Answer 44

Beta lactam + macrolide or respiratory fluoroquinoline

Question 45

Initial Tx for Inpx w/ or w/o risk factors for infection w/ MRSA or P. aeuroginosa DISEASE SEVERITY, RISK STATUS: Nonsevere Prior respiratory isolation

Answer 45

Add coverage for MRSA

Question 46

Initial Tx for Inpx w/ or w/o risk factors for infection w/ MRSA or P. aeuroginosa DISEASE SEVERITY, RISK STATUS: Nonsevere Recent hospitalization, antibiotic tx w/ or w/o LV

Answer 46

Add coverage for MRSA only if cultures are positive

Question 47

Initial Tx for Inpx w/ or w/o risk factors for infection w/ MRSA or P. aeuroginosa DISEASE SEVERITY, RISK STATUS: SEVERE No risk factors

Answer 47

Beta lactam + macrolide or beta lactam + respiratory fluoroquinolone

Question 48

Initial Tx for Inpx w/ or w/o risk factors for infection w/ MRSA or P. aeuroginosa DISEASE SEVERITY, RISK STATUS: SEVERE Prior respiratory isolation

Answer 48

Add coverage for MRSA

Question 49

Initial Tx for Inpx w/ or w/o risk factors for infection w/ MRSA or P. aeuroginosa DISEASE SEVERITY, RISK STATUS: SEVERE Recent hospitalization, antibiotic tx w/ or w/o LV

Answer 49

Add coverage for MRSA