Pneumonia

Question 1

Making the dx

Answer 1

• Infiltrate on CXR

- S/s: fever, dyspnea, cough, sputum production

Question 2

Severe CAP

Answer 2

found in patients with either: one major criterion or three or more minor criteria

Question 3

CAP Minor criteria

Answer 3

RR >/=30, PaFIO2 ratio
= 250, multilobular infiltrates, AMS, uremia, leukopenia, thrombocytopenia, hypothermia, or hypotension requiring fluid resuscitation

Question 4

CAP Major Criteria

Answer 4

septic shock requiring vasopressors or respiratory failure requiring mechanical ventilation

Question 5

Assessment findings

Answer 5

• Tachypnea
• Increased work of breathing
• Adventitious breath sounds
• —rales/crackles & rhonci
• Tactile fremitus
• Egophony
• Dullness on percussion
• CXR: pulmonary opacities

Question 6

Imaging studies

Answer 6

-Chest X-Ray
—AP & Lateral preferred
—Lobar consolidations
—Interstitial infiltrates
Cavitations
—CT may be indicated
Immunocompromised pts

Question 7

Dx Criteria

Answer 7

• Gram stain, sputum/tracheal secretion cultures & blood cultures
• -DO NOT collect routinely
• Do collect in:
• –Severe CAP
• –Empiric treatment for MRSA or Pseudomonas
• —Previous infection with MRSA or Pseudomonas
• –Hospitalized and antibiotics within 90 days

Question 8

CAP Traditional Pathogens

Answer 8

• Streptococcus pneumoniae** most common
• Haemophilus influenzae
• Moraxella catarrhalis
• Staphylococcus aureus (MRSA uncommon cause of CAP)
• Enterobacter including Klebsiella or E. Coli
• Mycoplasma pnuemoniae (atypical bacteria)
• Legionella species (atypical)
• Chlamydia pneumoniae (atypical)
• Aspiration
• Viral

Question 9

Atypical Bacteria

Answer 9

means intrinsic resistance to beta-lactams and inability to be visualized on GS or Cx using traditional techniques

Question 10

CAP Outpatient tx w/ no

comorbidities or risk of pseudomonas or MRSA

Answer 10

Amoxicillin
Doxycycline
Macrolide

Question 11

CAP Outpatient Tx w/ comorbidities

Answer 11

Combination therapy of:
Amox/clav or cephalosporin AND macrolide or doxy
OR monotherapy with respiratory FQ
–Cephalosporins, 3rd gen: ceftriaxone, cefpodoxime, cefditoren
–Resp FQ: levaquin, moxifloxacin, gemifloxacin

Question 12

CAP Inpatient Tx Non-severe
Tx for 5 days but ensure improving on therapy and afebrile for 48 hours before stopping abx. Extending beyond 7 days does not add benefit

Answer 12

-Beta-lactam + macrolide or respiratory FQ
IF prior history of:
-MRSA: add MRSA coverage & obtain swab to de-escalate
-Pseudomonas: add coverage and obtain cultures
-Recent hospitalization & risk for MSRA: obtain cultures but refrain from MRSA coverage unless cx +
-Recent hospitalization & risk for pseudomonas: cx but initiate coverage

Question 13

CAP inpatient Tx severe

Answer 13

-Beta-lactam + macrolide OR beta-lactam + FQ
IF prior history of:
-MRSA: add MRSA & obtain swab to de-escalate
-Pseudomonas: add coverage and obtain cultures
-Recent hospitalization & risk for MSRA: obtain cultures & add coverage
-Recent hospitalization & risk for pseudomonas: cx but initiate coverage
—Steroids Recommended against use Unless refractory septic shock per sepsis guidelines

Question 14

Non-infectious illnesses that mimic CAP or can co-occur with CAP (pulm infiltrate & cough)

Answer 14

• Pulmonary edema / CHF
• PE
• Pulmonary hemorrhage
• Atelectasis
• Aspiration / chemical -pneumonitis
• Drug reactions
• Lung Ca
• Vasculitis
• Bronchiectasis exacerbation
• ILD exacerbation

Question 15

Vaccinations

Answer 15

• Pneumococcal
• –Pneumovax 23 (PPSV23) for all >65
• –Prevnar 13 (PCV13) no longer recommended for all, but shared decision making if they do not have immunocompromising condition, CSF leak, cochlear implant who have not received PCV13 previously
• –Give 1 year before PPSV23 if it is given
• Influenza

Question 16

HAP/VAP Pathogens

Answer 16

Gram negative bacilli 
--Pseudomonas 
--E. coli 
--Klebsiella 
--Enterobacter
--Acinetobacter
Gram positive cocci
-Staph Aureus, including MRSA
-Streptococcus pneumonia

Question 17

Early onset, no risk factors for MDR pathogens

Tx for HAP/VAP

Answer 17

• Cephalosporins
• Fluoroquinolone
• Beta-lactatam/beta-lactatmase inhibitor
• Carbapenem

Question 18

Late onset, risk factors for MDR: Tx for HAP/VAP

Answer 18

• MRSA / pseudomonal coverage
• MRSA coverage with Vancomycin
• Double coverage for gram negatives
• Antipseudomonal cephalosporin, carbapenem or penicillin / beta-lactam, FQ or aminoglycoside
• 7 day course at least