Pneumonia Flashcards
Risk Factors
Alcohol abuse
Immunosuppression
Lung disease
Institutionalization
Age > 70
CAP Organisms
- Strep Pneumonaie –> Most common
- Haemophilus Influenzae
- Staph Aereus
- Mycoplasma Pneumonaie –> Young helathy
- Chlamydia Pneumonaie
- Legionella –> Uncommon
- Viral
Penumonaie Atypicals
- Mycoplasma Pneumaie
- Both lobes of Lung
- Chlamydia Pneumonaie
- Legionella
Hospital Acquired Organisms
GRAM NEG Organism
Klebsiella pneumoniae
E coli
Enterobacter species
Proteus species
Pseudomonas aeruginosa
Staph aureus
Anaerobes
Strep pneumoniae
What conditions for recurring pneumona?
COPD and HF
Others –> Cystic Fibrosis, recent antibitocs (last 3 months)
Pneumonaie Symptoms (Abrupt)
Fever (may be high [>39°C] or low grade
Chills
Dyspnea
Cough(productive or non-productive)
Rust colored sputum or hemoptysis
Pleuritic chest pain (described as stabbing)
Other nonspecific sx
Physical Exam Symptoms
Tachypnea
Tachycardia
Dullness to percussion (palpate the lungs) lugs should be filled with air, so should sound hollow dullness if fluid/mucus there
Diminished breath sounds over affected area
Inspiratory crackles
Clinical Presentation
- Chest X-ray
- Low O2 stauration
- Elvated WBC
- Sputum Sample
Diagnosis of Pneumona
Physical exam
Signs and symptoms
Chest x-ray
Diagnosis Challenges
- Viral or BActerial
- Which microorganisms
Sputum Specimen Use and Challanges. When to use?
Normal flora always present so sample often contaminated (looking for a predominant organism)
- Atypicals won’t stain
- Use when suspect MRSA or P. Aeuroginosa
Blood Culture Use
Can be positive in patients with CAP but not routinely recommended unless severe CAP or empirically treated for MRSA or P. aeruginosa
Pleural Fluid Test
- Can be cultured
Serology
> 4 fold rise in antibody titre (for specific pathogen such as M. pneumoniae
- Conducted only 4 weeks apart
What is required for pneumona diagnosis?
- Chext X-ray
Even if a patient can be treated as outpatient, they must be able to….
- take oral fluids
- comply with outpatient care
- carry out activities of daily living
Goals of Therapy for Pneumonae
Eradicate the micro-organism
Resolve signs and symptoms
Reduce risk of complications and hospitalization
Reduce risk of adverse events
Minimize the development of antimicrobial resistance
Antibiotic Tx For Pneumonae Should be Started When
- SHould be initiated promptly
- Appropriate microbial smaples should be obtaines, but should not delay antibiotics
- If viral, stop antibiotics
Pathogens to Cover when TX
- Strep Pneumonaie
- Haemophilus Influenzae
- Mycoplasma Pneumonaie
Should fluorquinones be used?
- NO
- Broad spectrum –> Leads to more resistance
CAP TX First Line No Comorbities and No risk for MRSA and P. Aeruginosa
Amoxicillin 1000mg tid (covers strep pnemoanie, hamophilus influenza (if a non-beta-lactmase producer, no coverage of mycoplasma pneumonaie however resolves on its own)
Doxycycline 100 mg BID (may be 200 mg for first dose, then 100 mg afterwards)
First Line MAcrolides USage and Dosage
- If pneumonnococo resistance is less than 25%
Clarithromycin 500 mg BID or 1000 mg Ex. Release OD
Azithromycin 500mg first day, then 250mg x 4 days OR 500mg daily x 3 days
Risk Factors for MRSA and P. Aeuriginosa
Prior respiratory isolation of MRSA or P. aeruginosa or recent hospitalization AND receipt of parenteral antibiotics in last 90 days
Comorbities Examples
chronic heart, lung, liver or renal disease, diabetes mellitus, alcoholism, malignancies, asplenia
Antibiotic within last 3 months (switch if large exposure to one class)
Comorbities and No Risk for MRSA or P. Aeruginosa
Amoxicillin/clavulanate 500mg/125mg tid or 875mg /125 mg bid
Cefuroxime axetil 500mg bid
Cefprozil 500mg bid
Any one beta-lactam agent above plus…
Clarithromycin, azithromycin or doxycycline
OR monotherapy with
Levofloxacin 750 mg once daily for 5 days
Moxifloxacin 400mg once daily
Duration of Tx
7-14 days
Min 5 days, be afebrile for 48-72hrs and otherwise clinically stable (exception: azithro 3 days)
5 DAYS –> CLINICAL STABILITY IS REACHED (HR, RR, OXYGEN SATURATION AND TEMP ARE NORMAL)
If staph aereus or Ps. Aeuriginosa duration of tx
- 7 days
Tx of Strep. Pneumonaie
Penicillin G – 5 to 10 M units/d IV or IM
Oral Penicillin V or amoxicillin (often used if strep pneumonaie)
Alt: cefazolin or erythromycin (resistance) or FQ
Strep Pneumonaie Charcateristically SYmptom
one shaking chill followed by a high temperature
Strep pneumonaie penicllin resistance is often due to….
reduced affinity for PBP or change in amount of PBP present
Penicillin resistant Strep. Pneumonaie. Route of Admin switch?
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
When patient is afebrile for 2-3 days can switch to oral therapy
Staph Aereus seen when, more common in, and result….
Increased incidence following influenza epidemics
More common in debilitated patients and CF
Can release enzymes and endotoxins which lead to empyema and abscess
MSSA TX
Cloxacillin 8 to 12 g/d IV (up to 2g q4h)
Alt: cefazolin, clindamycin or vancomycin
MRSA TX, Duration, and Length of TX
Vancomycin, linezolid, (tigecycline – little evidence for pneumonaie )
May take up to 3 weeks to see a response
Continue treatment for 14 to 21 days
