Pneumonia Flashcards by Darian Oldham

What pneumonia is associated with no recent hospitalization and lacking health care associated risk factors?

Community required pneumonia (CAP)

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What type of pneumonia results from aspiration of oropharyngeal or gastric contents?

Aspiration pneumonia

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What type of pneumonia occurs >48-72 hours after endotracheal intubation?

Ventilator-associated pneumonia (VAP)

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What type of pneumonia occurs >48 hours after hospital admission?

Hospital acquired pneumonia (HAP)

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What type of pneumonia results from Any patient who was hospitalized for >2 days in the last 90 days, Resided in nursing home or long-term care facility, Received recent IV antibiotic, chemotherapy or wound care within past 30 days, or is a Patient on hemodialysis?

Healthcare-associated pneumonia (HCAP)

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What is the leading cause of death due to infection?

CAP

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What are the microorganisms that are most associated with bacterial pneumonia?

Streptococcus pneumoniae most common pathogen
Mycoplasma pneumoniae- 2nd most common cause
Haemophilus influenzae- colonization increases in patients with COPD and cystic fibrosis
Moraxella catarrhalis a more common cause in young children and elderly
Community acquired methicillin resistant staphylococcus aureus-associated with necrotizing and more severe forms of CAP

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What are the viral causes of pneumonia?

Often cause of CAP in children
RSV, influenza A, parainfluenza
Much less common in adults
Influenza A+B, adenoviruses, and even more less common others; rhinovirus, enterovirus, varicella zoster, herpes simplex.

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What is the most common cause of CAP?

S. pneumoniae most common cause
Drug resistant S. pneumoniae (DRSP)
Strains resistant to at least 3 drugs
Becoming more and more common

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What are the risk factors for drug resistance S. pneumonaie?

Age < 2 years or > 65 years
Antibiotic therapy within previous 3 months
Alcoholism
Medical comorbidities
Immunospupression

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What are the risk factors for CA-MRSA?

Cavitary Pneumonia
Lung necrosis
Rapidly increasing pleural effusion
Gross hemoptysis
Neutropenia
Concurrent infection
Erythematous skin rash 
Previously healthy
Summer season
Prior conjugate pneumococcal vaccination

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What are the risk factors associated with aspiration pneumonia?

Dysphagia
Stroke, seizures, alcoholics, and aging
Change in oropharyngeal colonization
Oral/dental disease, poor hydiene, tube feedings, medications
Gastroesophageal reflux
May allow gram (-) bacilli to colonize gastric contents
Decreased host defenses
Impaired mucus production or cilia function, decreased immunoglobulin in secretions, altered cough reflex

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What are the oral contents that cause aspiration pneumonia?

Variety of anaerobes

Bacteroides spp., Fusobacterium spp,. Prevotella spp. and anaerobic gram cocci

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What are the gastric contents that cause aspiration pneumonia?

Gram (-) bacilli and S. auerus

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What is the 2nd most common nosocomial infection in the US?

Hospital acquired pneumonia

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HAP accounts for ______ of all ICU infections and _____ of the antibiotics used

HAP accounts for 25% of all ICU infections and >50% of the antibiotics used

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What are the risk factors for HAP?

-Intubation and mechanical ventilation
-Aspiration– Risk of aspiration increased in ICU patients
-Oropharyngeal colonization– Affected by antibiotics, and poor infection control measures
-Hyperglycemia–Directly and indirectly promote infections, Inhibit phagocytosis, provides nutrients for the bacteria

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VAP occurs in ______% of all intubated patients

9-27

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VAP are the highest in the 1st _____ days of intubation

5 days

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VAP has the highest mortality in?

bacteremia caused by Pseudomonas and Acinetobacter
medical rather than surgical illness
treatment with ineffective antibiotic therapy

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What is the etiology for pneumonia?

Aerobic Gram-negative bacteria
Ps. aeruginosa
E. coli
K. pneumonia
Acinetobacter sp.

Gram-positive bacteria
S. aureus (MRSA)

Anaerobes: very rare

What are the sx of pneumonia?

Cough, SOB, difficulty breathing

Fever, fatigue, headaches, myalgia, mental status change; confusion, lethargy, and disorientation

What are the signs of pneumonia?

Fever, sustained or intermittent, cyanosis and use of accessory muscles, breath sounds may be diminished, rhales or rhonci may be heard

What are the factors associated with poor prognosis/severe illness?

RR > 30 breaths/min
DBP < 60 mmHg
SBP < 90 mmHg
HR > 125 bpm
Temp < 35C or > 40C

Chest-X ray
Multilobar infiltrates
Rapid progression infiltrates
Pleural effusion
Necrotizing pneumonia

What is used to diagnosis pneumonia?

--Chest X-ray should reveal infiltrates --O2 saturation should be over 90% --CBC, elevated or drop in WBC, differential should show a predominance of neutrophils --Sputum gram stain may or may not show a predominance of on organism Not obtained in outpatient setting --Blood cultures MUST be obtained in all patients hospitalized with pneumonia In CAP blood cultures are positive 1-20% of the time

What are the diagnostic considerations for pneumonia?

PCR- being used more to detect DNA of respiratory pathogen Potential for more rapid diagnosis Allows more rapid pathogen targeted therapy ``` Urinary Antigens (DFA) Used to diagnose L. pneumophila ```

PSI class I has a 30-d mortality Risk of what? and where is the site of care?

0.4% 30day mortality risk | Outpatient

PSI class II has a 30-d mortality Risk of what? and where is the site of care?

0.7% 30day mortality risk | Outpatient

PSI class III has a 30-d mortality Risk of what? and where is the site of care?

2.8% 30day mortality risk | Clinical judgement

PSI class IV has a 30-d mortality Risk of what? and where is the site of care?

8.5% 30day mortality risk | Inpatient

PSI class V has a 30-d mortality Risk of what? and where is the site of care?

31.1% 30day mortality risk | Inpatient-ICU

What is the severity of assessment?

``` Confusion, Uremia, Respiratory Rate, Blood Pressure (CURB-65) Score 0-5, 1 point for each of the following: Confusion BUN > 7 mmol/L (19.6 mg/dL) RR > 30 SBP < 90 mmHg or DBP < 60 mmHg Age > 65 years 2 points; consider hospital admission >3 points; consider ICU admission ```

HAP/VAp chest xray should reveal what?

``` A new infiltrate plus two of the following: Temp > 38 C (100.4 F) Leukocytosis or leukopenia Purulent secretions Cultures identifying pathogen ```

What should the initial treatment for pneumonia be?

Empiric

What is empiric therapy guided by to treat pneumonia?

``` Type of pneumonia Severity of pneumonia (ICU vs. non-ICU) Time of onset Specific risk factors Patient factors ```

If you are worried about MRSA what should be added to treatment?

Vancomycin or linezolid

What is used to treat the healthy outpatient according to the CAP IDSA empiric treatment guidelines?

Macrolide or Doxycycline

What is used to treat the outpatients at risk for DRSP according to the CAP IDSA empiric treatment guidelines?

Respiratory Fluoroquinolone Or Beta-lactam + Macrolide

What is used to treat the inpatient, non-ICU according to the CAP IDSA empiric treatment guidelines?

Respiratory Fluoroquinolone Or Beta-lactam + Macrolide

What is used to treat the inpatient ICU according to the CAP IDSA empiric treatment guidelines?

Beta-lactam + azithromycin Or Beta-lactam + respiratory flouroquinolone

What is the JC/CMS recommendations for non-icu patients?

Beta-lactam +macrolide OR Antipneumococcal quinolone OR Beta-lactam + doxycycline or Tigecycline montherapy or Macrolide monotherapy

What is the JC/CMS recommendations for ICU patients?

Macrolide and Beta-lactam * or antipneumococcal/antipsuedomonal Beta-Lactam OR Antipneumococcal quinolone OR Antipseudomonal quinolone + Beta-lactam or antipneumococcal/antipseudomonal beta lactam OR Antipneumococcal/antipseudomonal beta-lactam + aminoglycoside + either antipneumococcal quinolone or macrolide

What is the treatment for CAP?

If able to identify organism target therapy (24-72h after admission) Duration of therapy 5-7 days - -Minimum 5 days until patients are afebrile for 48-72 hours - -Longer for S. auerus or Pseudomonas When clinically stable switch to po If admitted discharge patients when --Vital signs and Oxygen status are stable and no unresolved comorbidities

What is the treatment for oral contents aspiration pneumonia?

PCN G, ampicillin/sulbactam, and clindamycin all cover typical pathogens

What is the treatment for oral and gastric treatment aspiration pneumonia?

Ampicillin/sulbactam, amoxicillin/clavulante piperacillin/tazobactam

What are HAP treatment considerations?

``` Dynamic ICUs are important reservoirs Prior antibiotic therapy Broad spectrum antibiotics Key concerns are: MRSA, Pseudomonas aeruginosa, Acinetobacter spp., and Stenotrophomonas maltophilia ```

What is the HAP treatment?

Early onset (< 5 days) most frequent pathogens S. pneumoniae, H. influenzae, MSSA, and enteric gram (-) bacilli 3rd generation cephalosporin +macrolide or Respiratory fluoroquinolone

What are the risk factors for MDR?

Antimicrobial therapy in preceding 90 days Current hospitalization of 5 days or more High frequency of antibiotic resistance in the community or in the specific hospital unit Presence of risk factors for HCAP: Hospitalization for >2 days in the preceding 90 days Residence in a nursing home or extended care facility Home infusion therapy (including antibiotics) Chronic dialysis within 30 days Home wound care Family member with multidrug-resistant pathogen Immunosuppressive disease and/or therapy

What do you treat early onset VAP and no risk for MDR?

``` Cefotaxime 2 g IV q 8H or Ceftriaxone 2 g IV q 24H or Ampicillin/Sulbactam 3 g IV q 8H or Antipneumococcal fluoroquinolone Plus Vancomycin or linezolid (if high rates of MRSA) ```

What are the pathogens associated with VAP?

S.aureus, S. pneumoniae, H. influenzae, gram-negative Enterobacteriaceae