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Pneumonia Flashcards

1
Q

What is pneumonia?

A

acute infection of the lung parenchyma

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2
Q

What is the most common cause of death due to infection?

A

pneumonia

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3
Q

What are the risk factors for pneumonia?

A

alcohol abuse
immunocompromised
lung disease
institutionalization
age >70

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4
Q

How does infection for pneumonia occur?

A

inhalation of airborne particles
-ex: TB, influenza, Legionella
aspiration of oropharyngeal secretions
-silent aspiration happens all the time
-most common cause
hematogenous spread

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5
Q

How do gross aspirations occur?

A

changes in consciousness
-alcoholics, drug abuse, seizures, respiratory arrest

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6
Q

Describe respiratory defences.

A

preventing foreign material from entering lungs:
-hairs lining nasal passages
-ciliated cells
-mucous production
-salivary enzymes
present in lung tissue:
-macrophages
-PMNs
-antibodies
ANY DEFECT CAN COMPROMISE HOST TO INVADING PATHOGENS

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7
Q

True or false: our lungs are normally incoluated with microorganisms from URT and inhaled aersols but pneumonia rarely occurs

A

true

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8
Q

What happens when there is a host defect in their respiratory defences?

A

lung being exposed to increased amount of microorganisms for sufficient period to cause inflammatory changes

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9
Q

Which organisms are responsible for community acquired pneumonia?

A

streptococcus pneumoniae (30-60%)
haemophilus influenzae (2-20%)
staphylococcus aureus (1-5%)
mycoplasma pneumoniae (5-10%, 17-37% in young + healthy)
chlamydia pneumoniae (4-6%)
legionella-uncommon in SK
viral (2-15%, likely higher)

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10
Q

Which organism is likely to cause pneumonia in a young, and healthy individual?

A

mycoplasma pneumoniae

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11
Q

Which organism is likely to cause pneumonia in someone with COPD or a smoker?

A

haemophilus influenzae

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12
Q

Which organism represents the “atypical” of pneumonia? What is the main difference?

A

mycoplasma pneumonia
hits both lobes of lung, S. pneumonia only hits one

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13
Q

True or false: you can differentiate between M. pneumonia and S. pneumonia being the cause of pneumonia through an X-ray

A

false

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14
Q

Which organisms are the likely cause of hospital acquired pneumonia?

A

klebsiella pneumoniae
E coli
enterobacter
proteus
pseudomonas aeruginosa
staph aureus (higher than CA)
anaerobes
s. pneumoniae

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15
Q

Which organisms represent 60% of hospital acquired pneumonia?

A

klebsiella pneumonia
proteus
E. coli
enterobacter

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16
Q

Which host factors can influence the causative organism of pneumonia?

A

heart, lung disease, DM
recent antibiotics (within last 3 months)
aspiration, cystic fibrosis
COPD

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17
Q

Which illnesses are most commonly associated with recurrent pneumonia?

A

COPD
heart failure

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18
Q

What are patient factors that can modify the causative organism of pneumonia?

A

heart, lung disease, DM
recent antibiotics (within last 3 months)
aspiration, cystic fibrosis

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19
Q

Which illnesses are most commonly associated with recurrent pneumonias?

A

COPD
heart failure

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20
Q

What are the signs and symptoms of pneumonia?

A

fever (may be high [>39C] or low grade)
chills
dyspnea
cough (productive or non-productive)
rust colored sputum or hemoptysis
pleuritic chest pain (stabbing)
other nonspecific symptoms (aches, fatigue, loss of appetite)
ABRUPT ONSET

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21
Q

What is the clinical presentation of pneumonia during a physical exam?

A

tachypnea
tachycardia
dullness to percussion
diminished breath sounds over affected area
inspiratory crackles

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22
Q

What can laboratory findings help determine for pneumonia?

A

low oxygen saturation
elevated WBC
sputum sample-may reveal PMNs and causative organism

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23
Q

Where does the difficulty lie with diagnosing pneumonia?

A

distinguishing bacterial from viral
if bacterial, which micro-organism

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24
Q

What is the issue with using sputum specimens to diagnose pneumonia?

A

difficult in children
normal flora always present=sample often contaminated

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25
When are sputum specimens used to diagnose pneumonia?
not recommend for CAP for inpatients with severe disease or suspected MRSA or P.aeruginosa
26
When are blood cultures used for diagnosing pneumonia?
not routinely recommended unless severe CAP or empirically treated for MRSA or P.aeruginosa
27
What are the many tools that are used in diagnosing pneumonia?
sputum specimen blood culture pleural fluid can be cultured serology WBC chest x-ray other (oxygen saturation or arterial blood gases)
28
What is required to make a diagnosis of pneumonia?
chest x-ray
29
What should a normal chest x-ray look like?
lots of black in the rib cage (black=air)
30
What is the pneumonia severity score used for?
predict the risk of death from pneumonia for anyone over the age of 50 -algorithm used to determine if a patient should be admitted to hospital
31
Even if the pneumonia severity score says a patient can be treated as an outpatient, what else must this patient be able to do if they are to be treated as an outpatient?
take oral fluids and antibiotics comply with outpatient care carry out activities of daily living
32
What are the goals of therapy for treating pneumonia?
eradicate the microorganism resolve signs and symptoms reduce risk of complications and hospitalizations reduce risk of adverse effects minimize the development of antimicrobial resistance
33
What are the general treatment measures for pneumonia?
bed rest hydration nutrition analgesic/antipyretics oxygen for hypoxemia (not CAP) cough suppression (better at night, not ideal to suppress) drainage of empyema/abscess
34
What is the mainstay of therapy for pneumonia?
antibiotics -should be initiated promptly, as soon as diagnosis is confirmed -appropriate antimicrobial samples should be obtained but should not delay antibiotics
35
What are the top three pathogens for pneumonia?
streptococcus pneumoniae haemophilus influenzae mycoplasma pneumoniae
36
What are the reasons for the attraction of fluoroquinolones? What is the main issue?
potent and broad spectrum activity good kinetics (OD dosing) issue: resistance (reserve quinolones)
37
What is first line treatment for CAP (adult mild to moderate, no comorbidities & no risk factors for MRSA or P.aeruginosa)? List the dosing.
amoxicillin 1000mg TID doxycycline 100mg BID clarithromycin 500mg BID or 1000mg OD azithromycin 500mg first day, then 250mg x 4 days OR 500mg OD x 3 days *macrolides only if local pneumococcal resistance is <25%*
38
What are the resistance rates in Saskatoon of strep pneumoniae to macrolides?
outpatient: 19% inpatient: 21% blood isolates: 43% (few isolates)
39
What are risk factors for MRSA or P.aeruginosa?
prior respiratory isolation of MRSA or P. aeruginosa OR recent hospitalization AND receipt of parenteral antibiotics in last 90 days
40
What are the co-morbidities that should be kept in mind when choosing an antibiotic for pneumonia?
chronic heart, lung, liver, or renal disease diabetes mellitus alcoholism malignancies asplenia
41
What are the choices of antibiotics for pneumonia when the patient has comorbidities but not risk for MRSA or P. aeruginosa? List the dosing.
amoxiclav 500/125mg TID or 875/125mg BID cefuroxime axetil 500mg BID cefprozil 500mg ANY ONE BETA-LACTAM AGENT LISTED ABOVE PLUS: clarithromycin, azithromycin, or doxycyline OR monotherapy with: levofloxacin 750mg OD x 5 days moxifloxacin 400mg OD
42
In regions with high rates (>25%) macrolide resistant S.pneumoniae, what should be considered for treatment?
consider alternative agent including in those with no comorbidities
43
What is the duration of therapy for outpatient tx of CAP?
5 days providing clinical stability is reached
44
True or false: in moderate severity CAP there was no difference between beta-lactam alone, macrolide and beta-lactam and fluoroquinolone therapy
true
45
What should be taken into consideration when a pathogen has been identified?
adjust therapy based on sensitivity results choose agent that is most effective or has the most evidence has fewest adverse effects convenience/lowest cost
46
How long does it take most patients to reach clinical stability? What is clinical stability?
48-72hr resolution of vital sign abnormalities -HR, RR, BP, oxygen saturation, temp
47
What are some outpatient cases of pneumonia that require longer treatment?
S. aureus or Ps. aeruginosa: 7 days longer if complications
48
What percent of the population has colonization of S. pneumoniae at any given time?
25% often follows a viral URTI
49
What is a characteristic symptom of pneumonia caused by S. pneumoniae?
one shaking chill followed by a high temperature pleuritic chest pain and headache are common
50
Which group of patients are at risk from pneumonia caused by S. pneumoniae?
spleenic dysfunction or asplenia diabetes renal disease cardio-pulmonary disease
51
What are the choices of antibiotics for pneumonia caused by S. pneumoniae? List the dosing.
pencillin G: 5-10 M units/d IV or IM oral penicillin V or amoxicillin alt: cefazolin or erythromycin or FQ
52
What is the cause of penicillin resistance for S. pneumoniae?
reduced affinity for PBP or change in amount of PBP present
53
What is the treatment of pneumonia caused by PRSP?
low level resistance: penicillin IV (high dose) OR amoxicillin (high dose) OR cefuroxime high level resistance: penicillin G 2MU IV q6h OR cefotaxime OR ceftriaxone OR resp. FQ
54
Which patients see higher levels of pneumonia caused by S. aureus?
debilitated patients cystic fibrosis
55
What can S. aureus release?
enzymes and endotoxins which lead to empyema and abscess
56
What is the treatment of pneumonia caused by MSSA?
cloxacillin: 8-12g/d IV (up to 2g q4h) alt: cefazolin, clindamycin, or vancomycin
57
What is the treatment of pneumonia caused by MRSA?
vancomycin linezolid tigecycline
58
Which group of patients tend to see higher levels of pneumonia caused by H. influenza?
COPD kids elderly can follow URTI
59
What is the treatment of pneumonia caused by non-BL producing H. influenzae?
ampicillin 6-8g/day IV (given q6h) amoxicillin 3g/d po
60
What is the treatment of pneumonia caused by BL producing H. influenzae?
amoxiclav 2nd gen cephalosporin (cefuroxime) 3rd gen cephalosporin (cefotaxime or ceftriaxone) FQ azithromycin clarithromycin doxycycline
61
Which organisms colonize the URT of hospitalized patients?
aerobic gram negative rods
62
What are the options for empiric therapy of a hospitalized patient with pneumonia?
3rd gen cephalosporin carbapenem piperacillin/tazobactam
63
Which patients tend to have higher incidence of pneumonia caused by Ps. aeruginosa?
underlying lung damage cystic fibrosis
64
What are some symptoms of pneumonia caused by Ps. aeruginosa?
fever chills cough green sputum with characteristic smell
65
Which FQ has adequate activity against pseudomonas?
ciprofloxacin
66
What is the treatment of pneumonia caused by Ps. aeruginosa?
piperacillin/tazobactam + cipro or AMG ceftazidime + cipro or AMG ciprofloxacin + AMG cefepime + cipro or AMG meropenem + cipro or AMG
67
How do the symptoms of pneumonia caused by mycoplasma pneumoniae tend to appear?
symptoms appear more viral in nature: -congestion, sore throat, chest pain, cough, etc
68
What are the triad of symptoms for mycoplasma pneumoniae?
maculopapular rash arthritis pneumonia
69
What is the treatment for pneumonia caused by M. pneumoniae?
erythromycin 250mg QID (or any macrolide) OR doxycycline alt: FQ
70
What is the morphology of Legionella pneumophilia?
aerobic gn rod
71
What is the incubation period of Legionella pneumophilia?
up to 10 days
72
What are the common symptoms of an infection by Legionella pneumophilia?
fever chills malaise myalgia headache cough GI problems
73
True or false: Legionella pneumophilia is common in SK
false
74
What is the treatment for Legionella pneumophilia?
azithromycin alt: resp FQ rifampin may be added
75
What is the morphology of chlamydophilia pneumoniae?
obligate intracellular gn
76
What are the symptoms of an infection by chlamydophilia pneumoniae?
low grade fever nonproductive cough normal WBC may report pharyngitis and hoarseness in prior weeks
77
What is the treatment for pneumonia caused by chlamydophilia pneumoniae?
doxycyline or macrolide alt: FQ
78
What may occur from aspiration pneumonia?
atelectasis hemorrhage pulmonary edema some patients develop secondary bacterial pneumonia due to decreased defenses
79
How long does it take patients to improve within onset of effective antibiotics?
2 days
80
True or false: chest x-ray resolution takes a while
true 3 weeks in young healthy adults up to 12 weeks in elderly or in those with complicated infection
81
What can be used as indicators of efficacy in pneumonia treatment?
decreased cough, dyspnea, and RR decreased fever decreased sputum production improved oxygenation normalization of WBC
82
What are the reasons for treatment failure of pneumonia?
non-adherence complication, spread of infection superinfection misdiagnosis of non-infectious causes
83
What are other considerations for a monitoring plan in pneumonia?
duration of therapy route of administration should patient be hospitalized adherence other drug therapy required (ex: antiypyretics) non-drug therapy
84
What are the pneumococcal vaccines?
23 valent polysaccharide 13 valent polysaccharide
85
Who should receive the 23 valent polysaccharide vaccines?
anyone over 65 patients with risk factors (COPD, HF, alcoholism, diabetes)

PHAR152 (21 decks)

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