Pneumonia Flashcards
What pneumonia is associated with no recent hospitalization and lacking health care associated risk factors?
Community required pneumonia (CAP)
What type of pneumonia results from aspiration of oropharyngeal or gastric contents?
Aspiration pneumonia
What type of pneumonia occurs >48-72 hours after endotracheal intubation?
Ventilator-associated pneumonia (VAP)
What type of pneumonia occurs >48 hours after hospital admission?
Hospital acquired pneumonia (HAP)
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)
What is the leading cause of death due to infection?
CAP
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
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.
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
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
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
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
What are the oral contents that cause aspiration pneumonia?
Variety of anaerobes
Bacteroides spp., Fusobacterium spp,. Prevotella spp. and anaerobic gram cocci
What are the gastric contents that cause aspiration pneumonia?
Gram (-) bacilli and S. auerus
What is the 2nd most common nosocomial infection in the US?
Hospital acquired pneumonia
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
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
VAP occurs in ______% of all intubated patients
9-27
VAP are the highest in the 1st _____ days of intubation
5 days
VAP has the highest mortality in?
bacteremia caused by Pseudomonas and Acinetobacter
medical rather than surgical illness
treatment with ineffective antibiotic therapy
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
