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PHAR 152* > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

Describe pneumonia?

A

Acute infection of the lung parenchyma
most common cause of death due to infectin

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2
Q

In what group of people is the mortality rate higher?

A

Higher in infants - elderly - debiliated patients

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3
Q

What are the risk factors for pneumonia?

A

Alcohol abuse
Immunosuppression
lung disease
institutionalization
Age > 70

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4
Q

How does pneumonia occur?

A

1- inhalation of airborne particles
2- Aspiration of oropharyngeal material (silent or goss)
3- Hematogenous spread (S.aureus)

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5
Q

What is the most common pathogenisis of pneumonia?

A

B aspiration of oropharyngaeal material

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6
Q

Explain the respiratory defence system

A
  • Hairs lining nasal passages, ciliated
    cells, mucous production, salivary
    enzymes — all prevent foreign material
    from entering lungs
  • Have macrophages in the alveoli, PMNs, antibodies
    and complement present in lung tissues
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7
Q

True or false.
Most of the defects in the respiratory system can compromise the host defence.

A

False
All of them

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8
Q

What is epiglottal and cough reflexes affected by?

A

Alcohol
Anesthetics
Pain
Impaired consciousness
Seizures
NG tube

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9
Q

what is Tracheobranchial secretions and mucociliary transport is affected by?

A

Alcohol
smoke
anesthetics
narcotics
lung disease
viruses
OXYGEN LEVELS

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10
Q

What does a defect in the host defence lead to ?

A

Lung being exposed to increased amount of micro-organisms for sufficient period to cause inflammatory changes

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11
Q

What is the most common microorganism that causes pneumonia?(bacterial version)

A

streptococcus pneumonia

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12
Q

What is the most common microorganism in people with COPD?

A

Haemophilus influenzae

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13
Q

What is the most common microorganism causing pneumonia in young people?

A

Mycoplasma pneumoniae

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14
Q

What ist the number one cause of pneumonia in a hospital microorganism ?

A

Klebsiella pneumoniae

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15
Q

What are two conditions that are commonly associated with recurrent pneumonia?

A

COPD and HF

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16
Q

What is the most common microorganism that causes pneumonia in cystic fibrosis?

A

S. aerues

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17
Q

What are the signs and symptoms of pneumonia?

A

Abrupt onset of fever, chills, dyspnea, cough
Rust colored sputum or hemoptysis
Pleuritic chest pain (stabbing pain)
Other non-specific sx

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18
Q

What is the clinical presentation of pneumonia?

A

Tachypnea
Tachycardia
Dullness to percussion (should have a hollow sound)
Diminished breath sounds over affected area
Inspiratory crackles

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19
Q

What test is needed to diagnose penumonia?

A

Chest X-ray

look for pulmonary infiltrates or consolidation

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20
Q

What are the two algorithms used to determine if a pt should be admitted to the hospital?

A

Pneumonia severity index (PSI) - Tool of choice
CURB-65 - simpler to use, but fewer parameters

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21
Q

What are the laboratory findings of pneumonia?

A

low O2 saturations
elevated WBC
sputum sample - reveal PMNs and the causative org

one third to one half of pt report URTI preceding pneumonia

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22
Q

How to diagnose using a sputum specimen?

A

The pt needs to expectorate the deep sputum
Bronchoscopy, transtracheal aspirate, biopsy (mainly for in patients)
The normal flora will always be present, so the sample is often contaminated
Gram stain and C&S

Sputum not needed in outpatients
Inpatients - we suspect MRSA or P. aeruginosa

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23
Q

What are the other samples that we can use to diagnose

A

Blood cultures
Cultured pleural fluid
Serology (takes 4 weeks tho)
WBC
Chest x-ray - we want black. Black = air
Other - Oxygenation

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24
Q

What can be used to diagnose pneumonia?

A

Physical exam
Signs and symptoms
Chest x-ray

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25
Q

What else must patients be able to do aside from the severity score saying that patients can be treated as an outpatient?

A

Take oral fluids and antibiotics
Comply with outpatient care
carry out activities of daily living

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26
Q

What are the goals of therapy for penumonia?

A

Eradicate the microorg
Resolve signs and sx
Reduce risk of complications and hospitalization
Reduce risk of adverse events
Minimize the development of antimicrobial resistance

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27
Q

What are the general tx measures for pneumonia?

A

Bed rest
hydration
nutrition (labored breathing takes alot of energy and burns calories)
analgesics/antipyretics
O2 for hypoxemia
cough suppression (cough keeping pt up at night)
drainage of empyema/abscess

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28
Q

True of false; if admitted to hospital, mortality rates increase if tx is delayed for more than 8 hours?

A

True

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29
Q

What are the main pathogens of pneumonia?

A

Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae

30
Q

What are ABs that cover the three main pathogens of pneumonia?

A

Azithromycin (worried about R)
Levofloxacin (worried about R)

31
Q

What is said about fluoroquinolones as an empiric AB?

A

We should reserve them, use as a2nd line option when DOC doesn’t work
Attractive - Potent and broad spectrum with good kinetics for po
Problem - resistance (esp with gram -ves)

32
Q

What is the tx of mild to moderate CAP in adults with no comorbidities and no risk factors for MRSA or P. aeruginosa?

A

Amoxicillin 1000 TID
Doxycycline 100mg BID
Clarithromycin 500 BID or 1000mg OD
Azithromycin 500mg day 1, then 250mg for 4 days OR 500mg daily for 3d

*macrolides only if local pneumococcal resistance is less than 25%

33
Q

What are the risk factors for MRSA or P.aeruginosa?

A

Prior respiratory isolation or MRSA or P. aeruginosa or recent hospitalization AND receipt of parenteral AB in last 90d

34
Q

What are the comorbidities for pneumonia tx?

A

chronic heart, lung , liver, or renal disease
diabetes mellitus, alcoholism, malignancies, asplenia

AB within the last 3mo - consider switching types if significant exposure to a particular ab class

35
Q

What are the AB for adults with comorbidities, but no risk factors for MRSA or P. aeru ?

A

Amoxicillin/clavulanate 500mg/125 mg TID or 875mg/125 mg BID
Cefuroxime axetil 500mg BID
Cefprozil 500mg BID

any one beta-lactam above PLUS clarithromycin, azithromycin, or doxy
OR
monotherapy with:
Levofloxacin 750 mg OD for 5d
Moxifloxacin 400 mg OD

36
Q

What to do for CAP in regions with high rates (25%+) macrolide resistance

A

Consider alternative agent including those with no comorbidities
Duration of 7-14 days. there is good evidence for short therapy duration too
Minimum of 5 days, be afebrile for 48-72 hr and otherwise clinically stable (azithro 3d)

37
Q

What is clinically stable?

A

Good resp rate
Good HR

38
Q

What are the general guidelines when the pathogen is identified?

A

Adjust therapy based on the sensitivity results
Choose the agent that is most effective or has the most evidence
Has the fewest adverse effects
Convenience and lowest cost should be considered

39
Q

What is the duration of therapy for outpatients tx with CAP

A

5d providing clinical stability is reached (most pt reach it in 48-72hrs)
Ability to east and normal mentation

40
Q

What is the duration of tx for Staph aureus of Ps. aeruginosa?

A

7d

41
Q

What is the main characteristic of Streptococcus pneumoniae infxn?

A

once shaking chill followed by by high temperature
- the chill is v. intense

pleuritic chest pain and headache are also common

42
Q

Who are the patients at risk with S. pneumoniae?

A

Those with splenic dysfxn or asplenia, DM, renal disease, cardio-pulmonary disease

43
Q

What is the tx for strep penumoniae?

A

Pen G 5-10M units/d IV or IM
Oral penicillin V or amoxicillin

Alternative: If allergic - cefazolin erythromycin or FQ

44
Q

What is the tx for Pen R strep pneumoniae?

A

Low lvl R - Penicillin IV (HD) or amoxicillin (HD) or cefuroxime
High level R - Pen G 2MU IV q6h or cefotaxime or ceftriaxone or resp. FQ

When the pt is afebrile for 2-3d can switch to oral therapy

45
Q

What is the main cause of penicillin resistance?

A

Reduced affinity for PBP or change in the amount of PBP present (higher dose to flood the receptors)

46
Q

Where is staph aureus more common in? what can the org do?

A

Debilitated patients (lung disease) and cystic fibrosis patients

Can release enzymes and endotoxins which lead to empyema and abscess

47
Q

What are the AB active against Staph aureus?

A

Cloxacillin - Yes, but not for MRSA
Clindamycin - MRSA and MSSA
TMP/SMX - MSSA or MRSA
Vancomycin - always works

48
Q

What is the treatment for MSSA and MRSA staph aureus?

A

Cloxacillin 8-12 g/d IV (up to 2g q4h)

Alternate: cefazolin, clindamycin or vancomycin

MRSA -> vancomycin, linezolid, tigecycline

49
Q

How long does it take to see a response in staph aureus after AB tx?

A

May take up to 3 weeks to see a response
Cont. tx for 14-21d

50
Q

What type of pt does haemophilus influenzae mainly target?

A

COPD pt
Kids more common
COPD
Elderly

51
Q

What are the AB tx for H. influenzae (non B-lactamase and B-lactamase)?

A

Non: Ampicillin 6 -8 g/d IV q6h or amoxicillin 3g/d po

B-lactamase:
amox/clav or 2nd gen ceph or 3rd gen ceph or FQ or azithro or clarithro or doxy

52
Q

What is the empirical tx for aerobic gram -ve rods?

A

3rd gen ceph
carbapenem
piperacillin/tazobactam

53
Q

Who does Ps. aeruginosa primarily target? What are the signs and sx? What may occur?

A

Pt with underlying lung damage or in CF
Fever chills, cough, green sputum with characteristic smell
Can prod necrotizing process in alveolar tissue

54
Q

What is the tx for Ps. aeru?

A

piperacillin/tazobactam + cipro or AMG (tobramycin)
ceftazidime + cipro or AMG
Ciprofloxacin + AMG
Cefepime + cipro or AMG
Meropenem + cipro or AMG

Only FQ that has activity is CIPRO

55
Q

What is the tx for mycoplasma pneumoniae? And how does it present?

A

More viral sx
Congestion sore throat, chest pain, cough
triad of sx - maculopapular rash, arthritis, pneumonia

Erythromycin 2540mg QID or doxy

Alternate: FQ

56
Q

Explain Legionella peneumophilia?

A

Aerobic gram -ve
Rare in SK
Loves H20 - Contaminates hot water plumbing, air conditioners, sprinklers, fountains
Seen in smoker, males (50-600, alcohol use
Spreads by inhaled water droplets
incubation period of up to 10d
Fever, chills, malaise, myalgia, headache, cough, GI probs
Diagnosed by antibody titers or anitbody detection

57
Q

What is the tx for legionella pneumophilia?

A

Azithromycin
Alt: respiratory FQ

Rifampin may be added

58
Q

What is the tx of Chlamydophila pneumonaie? What do you see in these infxns?

A

Low grade fever, nonprod cough, normal WBC

Doxycycline or macrolide
Alt: FQ

59
Q

What is aspiration pneumonia?

A

Pt aspirating gastric contents -> may cause pneumonitis (lung inflammation)

Aspirated secretions creates a shift of fluid into the involved lung area, every pt will experience change in breathing, can get rapid hypoxia and shock following the massive fluid shifts

60
Q

What else can patients experience with aspiration pneumonia?

A

Atelectasis, hemorrhage, and pulmonary edema

Some may also develop secondary bacterial pneumonia from decreased defenses

61
Q

How can you determine a secondary infxn? (tests)

A

New onset of fever
Change on x-ray
increased WBC
Prescence of bacteria

62
Q

When do CAP patients improve after starting ABs? Discuss x-ray resolution as well

A

Within 2 days
Mainly feature a decrease in temp and WBC

Chest x-ray takes longer - 3weeks in young healthy adults, up to 12 weeks in elderly or those with complicated infxn
- follow up x-ray not routinely recommended

63
Q

What are some indicators that are useful for monitoring drug efficacy in pneumonia?

A

Subjective response within 3 days

Objective response:
Decreased cough, dypnea, respiratory rate, fever, sputum production
Improved oxygenation (indicator for alveolar function)
Normalization of WBCs (decreased immune response)

64
Q

What are some reasons why drug therapy for pneumonia can fail?

A

Non-adherence
Complication
Spread of infection
Superinfection (concurrent or subsequent infections)
Misdiagnosis of non-infectious causes

65
Q

What are some indicators for drug toxicity?

A

Insert answer

66
Q

What are some other monitoring considerations?

A

Duration of therapy
Route of administration
Should patient be hospitalized
Adherence
Other drug therapy required
Non-drug therapy

67
Q

Who benefits the most from influenza vaccines in reducing pneumonia?

A

Those at risk of influenza complications (old age, smokers, etc)

Household contacts of high risk people

Anyone

68
Q

What pneumococcal vaccines are available in Saskatchewan?

A

23 valent polysaccharide vaccine:
65+ and patients with risk factors (COPD, HF, alcoholism, diabetes, etc)

13 valent polysaccharide-protein conjugate vaccine:
Only certain risk groups are covered in Saskatchewan

69
Q

What is the advantage of a polysaccharide-protein conjugate vaccine vs. a polysaccharide vaccine?

A

Polysaccharide vaccines do not evoke a strong immune response in young children, hence this drug is generally given to older adults

70
Q

What is strain replacement?

A

Vaccines that cover x number of strains, reduce the prevalence of those strains, but other strains can take over and increase their share in the types of causative pathogens

71
Q

Does the COVID-19 vaccine pose a concern for subsequent pneumonia?

A

Yes, there is a possibility for secondary infection

PHAR 152* (16 decks)

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