Pneumonia Flashcards
1
Q
Risk factors for infection with MRSA and P. aeruginosa
A
- Prior isolation of the organism
- Hospitalization and treatment with an antibiotic in the previous 90 days
2
Q
Aspiration pneumonia accounts for _____ of CAP cases
A
5-15%
3
Q
The result of the proliferation of microbial pathogens at the alveolar level and the host’s response to them.
A
Pneumonia
4
Q
3 factors that determines the constitution of the lung microbiota
A
- Microbial entry into the lungs
- Microbial elimination
- Regional growth conditions for bacteria (pH, oxygen tension, temperature)
5
Q
Pneumonia: IL6 & TNF
A
fever
6
Q
Pneumonia: IL8 & GSF
A
increase in local neutrophils
7
Q
Cardiovascular events associated with pneumonia
A
- Congestive heart failure
- Arrhythmia
- Myocardial infarction
- Stroke
may be acute, or who occurrence may extend to at least 1 year
8
Q
Mechanisms of cardiovascular events in pneumonia
A
- Increased myocardial load
- Destabilization of atherosclerotic plaques by inflammation
9
Q
Stage of Pneumonia: proteinaceaous exudate, and often bacteria in the alveoli
A
Edema
10
Q
Stage of Pneumonia: Erythrocytes in the intraalveolar exudate
A
Red Hepatization
11
Q
Stage of Pneumonia: Lysis of erythrocytes, Neutrophil is the predominant cell, fibrin deposition as abundant, bacteria has disappeared
A
Gray hepatization
12
Q
Stage of Pneumonia: corresponds to successful containment of infection and improvement of gas exchange
A
Gray hepatization
13
Q
Stage of Pneumonia: macrophage reappears as dominant stage
A
Resolution
14
Q
Common pattern in nosocomial pneumonia
A
Bronchopneumonia
15
Q
Common patten in Bacterial CAP
A
Lobar pattern
16
Q
Typical bacterial pathogens
A
S. pneumoniae
Haemophilus influenzae
S. aureus (in selected patients)
Gram negative bacilli (K. pneumoniae,P. aeruginosa)
17
Q
Atypical bacterial pathogens
A
M. pneumoniae
C. pneumoniae
Legionella species
Respiratory Viruses
18
Q
___ cannot be cultures on standard media or seen on GS
A
Atypical organisms
19
Q
Atypical organisms typically resistant to all beta lactams, and require treatment with
A
Macrolide
Fluoroquinolone
Tetracycline
20
Q
____ of CAP cases are polymicrobial
A
10-15%
21
Q
Known to complicate influenza virus infection
A
Staphylococcus aureus
22
Q
Mortality patient of CAP patients treated as outpatient
A
<5%
23
Q
Mortality rate of hospitalized CAP patients
A
12-40%
24
Q
18% of hospitalized CAP patients are readmitted within _______
A
1 month of discharge
25
Risk factors for Community Acquired Pneumonia
1. Alcoholism
2. Asthma
3. Immunosuppression
4. Institutionalization
4. Age >70 years old
26
Factors increasing likelihood of pneumonia in the elderly
1. Decreased cough reflex
2. Decreased gag reflex
3. Reduce antibody and toll-like receptors
27
Risk factors for **Pneumococcal** pneumonia
1. Dementia
2. Seizure disorders
3. Heart failure
4. Cerebrovascular disease
5. Alcoholism
6. Tobacco smoking
7. Chronic obstructive pulmonary disease
8. HIV infection
28
Common type of pneumonia in patients with **skin colonization/infection**
CA-MRSA
29
Infection with _______ usually tend to infect patients who have **recently been hospitalized**, given **antibiotics**, who have co-morbidites
Enterobacteriaceae
30
Common etiology in patients with severe structural lung disease
P. aeruginosa
31
Risk factors for **Legionella infection**
1. Diabetes
2. Hematologic malignancy
3. Cancer
4. Severe renal disease
5. HIV infection
6. Smoking
7. Male gender
8. Recent hotel stay/trip on a cruise ship
32
Possible pathogen for **Alcoholism**
Streptococcus pneumoniae
Oral anaerobes
Klebsiella pneumoniae
Acinetobacter spp.
Mycobacterium tuberculosis
33
Possible pathogen for **COPD and/or Smoking**
Haemophilus influenzae
Pseudomonas aeruginosa
Legionella spp.
S. pneumoniae
Moraxella catarrhalis
Chlamydia pneumoniae
34
Possible pathogen for **Structural lung disease**
P. aeruginosa
Burkholderia cepacia
Staphylococcus aureus
35
Possible pathogen for **Dementia, stroke, decreased level of consciousness**
Oral anaerobes
Gram-negative enteric bacteria
36
Possible pathogen for **Lung Abscess**
CA-MRSA
Oral anaerobes
Endemic fungi
M. tuberculosis
Atypical mycobacteria
37
Possible pathogen for **travel to Ohio or St. Lawrence river valley**
Histoplasma capsulatum
38
Possible pathogen for**travel to southwestern USA**
Hantavirus
Coccidioides spp
39
Possible pathogen for **travel to Southeast Asia**
Burkholderia pseudomallei
Avian influenza virus
40
Possible pathogen for **stay in hotel or cruise ship in previous 2 weeks**
Legionella sp
41
Possible pathogen for **local influenza activity**
Influenza virus
S. pneumoniae
S. aureus
42
Possible pathogen for **exposure to infected humans**
SARS CoV-2
43
Possible pathogen for **Exposure to birds**
H, capsulatum
Chlamydia psittaci
44
Possible pathogen for **Exposure to rabbits**
Francisella tularensis
45
Possible pathogen for **Exposure to sheeps, goats, parturient cats**
Coxiella burnetti
46
Clinical finding suggestive of **Necrotizing pneumonia**
Gross hemoptysis
47
_______ of patients has GI symptoms
20%
48
Possible **initial symptom** of CAP in the **elderly**
New-onset or worsening **CONFUSION**
49
Sensitivity and Specificity of **Physical Exam** on CAP
Sensitivity: 58%
Specificity: 67%
50
Chest Xray: **Pneumatoceles**
Staphylococcus aureus
51
Chest Xray: **Upper-lobe cavitation**
Tuberculosis
52
Test used to ensure **suitability** of specimen for culture
**Sputum gram stain**
Neutrophils >25
Squamous epithelial cells <10
53
Sputum CS, positive yield
≤50%
54
Sputum GSCS recommended in
Hospitalized patients
55
Only ______ of hospitalized CAP is **positive in Blood CS**
5-14%
56
Most common pathogen isolated in Blood CS of CAP patients
S. pneumoniae
57
Indications for Blood CS in CAP
1. High Risk/Severe CAP
2. Neutropenia secondary to CAP
3. Asplenia
4. Complement deficiencies
5. Chronic liver disease
6. Risk for MRSA or P. aeruginosa
58
Test that can detect antigen even after the initiation of **appropriate antibiotic therapy**
**Urinary Antigen test**
Reserved for Severe cases
59
Etiologic agent where Serology can be helpful
Coxiella burnetii
60
Standard for diagnosis of Respiratory Viral Infections
Polymerase chain reaction
61
PSI score needing admission
Class III and above
62
CURB-65 score needing ICU admission
≥3
22% Mortality rate
63
Criteria of CURB 65
**C**onfusion
**U**rea >7 mmol/L
**R**R ≥30 cpm
**B**P: Systolic ≤90, Diastolic ≤60
**65** Age ≥65
64
**Minor** Criteria for SEVERE CAP
**3 out of 9**
Respiratory rate ≥30 breaths/min
PaO2/Fio2 ratio ≤250
Multilobar infiltrates
Confusion/disorientation
Uremia (BUN level ≥20 mg/dL)
Leukopenia (WBC count <4000 cells/μL)
Thrombocytopenia (platelet count <100,000 cells/μL)
Hypothermia (core temperature <36°C)
Hypotension requiring aggressive fluid resuscitation
65
Risk factors for **penicillin-resistant pneumococcal infection**
1. Recent antimicrobial therapy
2. Age of <2 or >65 years
3. Attendance at a **day-care center**
4. Recent hospitalization
5. HIV infection.
66
Macrolide resistance: **target site modification**
Ribosomal methylation in 23S rRNA encoded by the **ermB gene** results in **high-level resistance**
40%
Higher level resistance
67
**Major** Criteria for SEVERE CAP
Respiratory failure requiring invasive mechanical ventilation
Septic shock requiring vasopressors
68
Pneumococcal resistance to Beta-Lactams
(1) **direct DNA incorporation** and remodeling of **penicillin-binding proteins** through contact with closely related oral commensal bacteria (e.g., viridans group streptococci)
(2) the process of **natural transformation**
(3) **mutation** of certain genes
69
Fluoroquinolones: **mutations in gyrA**
Topoisomerase II
70
Macrolide resistance: **efflux mechanism**
Encoded by the **mef gene (M phenotype)** is usually associated with **low-level resistance**
60%
Lower level resistance
71
**TRUE OR FALSE**
Macrolide should can be used as empirical monotherapy in CAP.
FALSE
72
Fluoroquinolones: **mutations in parC genes**
Topoisomerase IV
73
Isolates resistant to ______ are considered MDR
≥3
74
**Most important risk factor** for antibiotic-resistant pneumococcal infection is ___
Use of a **specific antibiotic** within the previous 3 months.
75
Resistance in MRSA is determined by
**mecA gene** which encodes for resistance to all β-lactam drugs
76
Superantigens released by CA-MRSA
Enterotoxins B and C
Panton-Valentine Leukocidin
77
Mycoplasma resistance to macrolides is increasing as a result of ____
**Binding-site mutation** in domain V of 23S rRNA
78
Enterobacter species are typically resistant to cephalosporins, and the drugs of choice for use against these organisms are usually ____ (2)
Fluoroquinolones
Carbapenems
79
Indications for Routine coverage for Anaerobes
1. Poor dentition
2. Lung abscess
3. Necrotizing pneumonia
80
First line therapy CAP: **Outpatient, No comorbidities/RF**
**Combination therapy**
Amoxicillin 1g TID
+
Macrolide or Doxycycline
OR
Monotherapy with Doxycycline (100 mg BID)
81
First line therapy CAP: **Outpatient, with Comorbidities +/- RF**
**Combination therapy**
Amoxicillin/Clavulanate or Cephalosporin
+
Macrolide or Doxycycline
OR
Monotherapy with Respiratory Fluoroquinolone
82
First line therapy CAP: **Inpatient, NON-SEVERE, No RF**
IV Beta-lactam + Macrolide
OR
Respiratory Fluoroquinolone
(Levofloxacin, Moxifloxacin, Gemifloxacin)
83
First line therapy CAP: **Inpatient, NON-SEVERE, Prior respiratory isolation**
IV Beta-lactam + Macrolide
OR
Respiratory Fluoroquinolone
(Levofloxacin, Moxifloxacin, Gemifloxacin)
**PLUS coverage for MRSA or P. aeruginosa**
84
First line therapy CAP: **Inpatient, NON-SEVERE, Recent hospitalization**
V Beta-lactam + Macrolide
OR
Respiratory Fluoroquinolone
(Levofloxacin, Moxifloxacin, Gemifloxacin)
**PLUS coverage for MRSA or P. aeruginosa ONLY IF CULTURES ARE POSITIVE**
85
First line therapy CAP: **Inpatient, SEVERE, NO RF**
IV Beta-lactam + Macrolide
OR
IV Beta-lactam + Respiratory Fluoroquinolone
86
First line therapy CAP: **Inpatient, SEVERE, Prior respiratory isolation, recent hospitalization**
IV Beta-lactam + Macrolide
OR
IV Beta-lactam + Respiratory Fluoroquinolone
**PLUS coverage for MRSA or P. aeruginosa**
87
**More robust risk factor** than recent hospitalization and exposure to parenteral antibiotics.
Prior isolation of MRSA or P. aeruginosa
88
Preferred first-line treatment for MRSA
**Linezolid**
Inhibits exotoxin and better drug penetration
89
Duration of treatment for Uncomplicated CAP
5 days
90
Drainage needed if Pleural studies results are?
1. pH <7.2
2. glucose level of <2.2 mmol/L
3. lactate dehydrogenase concentration of >1000 U/L
4. bacteria are seen or cultured
91
Resolution: **fever and leukocytosis**
2-4 days
92
Resolution: **chest radiographic abnormalities**
4-12 weeks
93
**Full recovery** of young patient with no comorbidities in CAP
2 weeks
94
Main preventive measure for CAP
Vaccination
95
T-cell dependent antigen, resulting in long term immunologic memory
PCV13 vaccine
96
Once a ventilated patient is transferred to a chronic-care facility or to home, the incidence of pneumonia drops significantly, especially in the absence of other risk factors for pneumonia. However, in chronic ventilator units, ________ becomes a significant issue
purulent tracheobronchitis
97
Three factors are critical in the pathogenesis of VAP
1. Colonization of the oropharynx with pathogenic microorganisms
2. Aspiration of these organisms from the oropharynx into the lower respiratory tract
3. Compromise of normal host defense mechanisms.
98
Most obvious risk factor for VAP
endotracheal tube
99
Most important risk factors for VAP
1. Antibiotic selection pressure
2. Cross-infection from other infected/colonized patients or contaminated equipment
3. Severe systemic illness
4. Malnutrition
100
In VAP: Major risk factor for infection with MRSA and ESBL-positive patients
Frequent use of Beta-Lactam (eg Cephalosporins)
101
In VAP: ________can develop resistance to all routinely used antibiotics, and, **even if initially sensitive**, isolates may develop resistance during treatment.
P. aeruginosa
102
In VAP: Etiologic agents that are **intrinsically resistant** to many of the empirical antibiotic regimens employed
1. Acinetobacter species
2. Stenotrophomonas maltophilia
3. Burkholderia cepacia
103
In VAP: The major difference from CAP is the markedly lower incidence of atypical pathogens in VAP; the exception is _______
Legionella
104
The **standard recommendation** for patients with risk factors for MDR infection and a **high mortality risk** is for **three antibiotics**: ____
Two directed at P. aeruginosa
One directed at MRSA
105
In VAP: Therapy for **carbapenem-resistant Enterobacteriaceae** can consist of ____
1. Ceftazidime–avibactam
2. Imipenem–relebactam
3. Meropenem– vaborbactam
106
In VAP: Therapy for organisms that **produce metallo-β-lactamases** can be treated with : ____
1. Ceftazidime–avibactam
2. Cefiderocol
107
**TRUE OR FALSE**
In VAP: A negative tracheal-aspirate culture or growth below the threshold for quantitative cultures of samples obtained before any antibiotic change strongly suggests that **antibiotics should be discontinued** or that an alternative diagnosis should be pursued.
TRUE
108
Apart from death, the major complication of VAP is ___
Prolongation of Mechanical Ventilation
109
VAP crude mortality rate
50-70%
110
Marker for patient whose immune system is so compromised that death is almost inevitable
Stenotrophomonas maltophilia
111
Most important preventive intervention for VAP is ___
Avoid intubation or Minimize its duration
112
VAP Treatment: **NO RISK FACTORS FOR RESISTANT GRAM-NEGATIVE PATHOGEN**
Piperacillin- tazobactam (4.5 g IV q6h)
Cefepime (2 g IV q8h)
Levofloxacin (750 mg IV q24h)
113
VAP Treatment: **RISK FACTORS FOR RESISTANT GRAM-NEGATIVE PATHOGEN**
**Choose One**
Piperacillin-tazobactam (4.5 g IV q6h)
Cefepime (2 g IV q8h)
Ceftazidime (2 g IV q8h)
Imipenem (500 mg IV q6h)
Meropenem (1 g IV q8h)
**PLUS (Choose One)**
Amikacin (15–20 mg/kg IV q24h)
Gentamicin (5–7 mg/kg IV q24h)
Tobramycin (5–7 mg/kg IV q24h)
Ciprofloxacin (400 mg IV q8h)
Levofloxacin (750 mg IV q24h)
Colistin (loading dose of 5 mg/kg IV followed by maintenance doses of 2.5 mg × [1.5 × CrCl + 30] IV q12h)
Polymyxin B (2.5–3.0 mg/kg per day IV in 2 divided doses)
114
VAP Treatment: **Risk Factors for MRSA**
ADD:
Linezolid (600 mg IV q12h) or
Adjusted-dose vancomycin (trough level, 15–20 mg/dL)
115
In VAP, preventive measure for: **Elimination of normal flora, overgrowth by pathogenic bacteria**
Avoidance of prolonged antibiotic courses; consider oral chlorhexidine
116
In VAP, preventive measure for: **Large-volume oropharyngeal aspiration around time of intubation**
Short course of prophylactic antibiotics for comatose patients
117
In VAP, preventive measure for: **Gastroesophageal reflux**
Postpyloric enteral feeding with orally placed feeding tube
Avoidance of high gastric residuals
Prokinetic agents
118
In VAP, preventive measure for: **Cross-infection from other colonized patients**
Hand washing, especially with alcohol- based hand rub
Intensive infection control education; isolation
Proper cleaning of reusable equipment
119
In VAP, preventive measure for: **Bacterial overgrowth of stomach**
Avoidance of prophylactic agents
that raise gastric pH
Selective decontamination of digestive tract with non-absorbable antibiotics
120
In VAP, preventive measure for: **Large-volume aspiration Ventilator circuit humidification**
Endotracheal intubation
Rapid- sequence intubation technique
Avoidance of sedation
Decompression of small-bowel obstruction
Change ventilator circuits only when soiled and with new patient
Drain ventilator circuit condensate away from patient
Replace heat moisture exchanger every 5–7 days or if soiled or malfunctioning
121
In VAP, preventive measure for: **Endotracheal intubation**
Noninvasive ventilation
122
In VAP, preventive measure for: **Prolonged duration of ventilation**
Daily awakening from sedation
Weaning protocols
123
In VAP, preventive measure for: **Secretions pooled above endotracheal tube**
Head of bed elevated
Continuous aspiration of subglottic secretions with specialized endotracheal tube
Avoidance of reintubation
Minimization of sedation and patient transport
Prophylactic PEEPc of 5–8 cm
124
In VAP, preventive measure for: **Altered lower respiratory host defenses**
Tight glycemic control
Lowering of hemoglobin transfusion threshold
125
In HAP, ____ are common, because of greater risk of macroaspiration and lower oxygen tension in the lower respiratory tract
Anaerobes
126
**TRUE OR FALSE**
In HAP, the lower frequency of MDR pathogens allows monotherapy in a larger proportion of cases of HAP than of VAP.
TRUE
127
Initial symptom of CAP in elderly
New or worsening *CONFUSION*
128
In CAP: CT scan of the chest is requested for
1. Suspected loculated pleural effusion
2. Suspected cavitary cases
3. Post-obstructive pneumonia caused by tumor or foreign body
129
Predominant pathogens in VAP, if it develops within 7 days of admission
**Non-MDR pathogens**
S. pneumoniae
Other Streptococcus
H. influenzae
MSSA
Antibiotic-sensitive Enterobacteriaceae
130
Adversely affects the immune response in VAP
Hyperglycemia
Frequent Transfusions
131
Threshold for quantitave-culture approach
**Proximal:** 10^6 CFU/mL
**Distal:** 10^3 CFU/mL
132
Failure to improve, VAP: **MRSA**
40% failure rate if treated with standard dose of vancomycin
133
Failure to improve, VAP: **Pseudomonas**
40-50% failure rate, no matter what regimen is started
134
Ways to decrease treatment failure in VAP
1. Optimized beta-lactam dosing
2. Prolonged or Continuous infusion therapy
