Pneumonia

Question 1

what is the most common lethal nosocomial infection?

Answer 1

HAP

Question 2

development of pneumonia rest upon the balance between ____ and _____

Answer 2

exposure; host defenses

Question 3

common failures of lung defense

Answer 3

viral infection, cigarette smoking, COPD, medications

Question 4

severe failures of lung defense

Answer 4

AIDS, immunosuppressives, malignancy, endotracheal tubes

Question 5

the most common aspiration event is?

Answer 5

microaspiration of pathogens colonizing the oropharynx

Question 6

in additional to aspiration, name two more routes of pneumonia infection

Answer 6

inhalation, hematogenous

Question 7

three step process for evaluation of CAP

Answer 7

1. establish diagnosis of pneumonia, 2. attempt to identify pathogen, 3. assess severity of illness

Question 8

when the clinical picture suggests pneumonia, what is the most important test to do?

Answer 8

CXR; establishes presence of pneumonia, rules out other diseases, assesses severity, distribution, and complications

Question 9

most common etiologies of all severities of CAP

Answer 9

strep pneumo; h flu

Question 10

common etiologies of severe (ICU) pneumonia

Answer 10

strep pneumo, h flu, legionella, gram neg bacilli, staph aureus

Question 11

a precise diagnosis of the pathogen is found in about ___% of cases

Answer 11

50%

Question 12

downsides to sputum gram stains are?

Answer 12

high false+ and false- rates

Question 13

downside to blood cultures is that they are?

Answer 13

specific, but not sensitive

Question 14

urinary antigen is useful for?

Answer 14

legionella (serotype 1)

Question 15

serologic tests may be used to detect?

Answer 15

chlamydia and mycoplasma

Question 16

gram stain & culture are useful when?

Answer 16

large # of bacteria with single morphology, many PMNs and minimal epithelial cells, abx have not been started

Question 17

organisms that cannot be detected on a gram stain/culture

Answer 17

legionella, mycoplasma, chlamydia (the atypicals)

Question 18

upper lobe cavitary infiltrate suggests?

Answer 18

TB

Question 19

name 3 mortality risk assessments

Answer 19

PORT Prediction Rule, CURB-65, Practical Severity Assessment (no blood test)

Question 20

name 3 biomarkers that may guide therapy or give a sense of course

Answer 20

procalcitonin, cortisol, CRP

Question 21

high procalcitonin is a sign that the pneumonia may be of ____ origin

Answer 21

bacterial

Question 22

empiric therapy is determined based on these 4 groups of severity

Answer 22

1. healthy outpatient, 2. outpatient at risk for DRSP, 3. inpatient (non-ICU), 4. ICU

Question 23

healthy outpatients will receive?

Answer 23

macrolide or doxycycline

Question 24

outpatients at risk and non-ICU inpatients both receive?

Answer 24

respiratory fluoroquinolone OR beta lactam + macrolide

Question 25

ICU patients receive?

Answer 25

beta lactam + Z-pac OR beta-lactam + fluoroquinolone

Question 26

in patients who do not show a response to ABX within 24-48 hours (~13%), consider?

Answer 26

wrong dx, wrong abx, host failure, bronchoscopy, look for empyema, abscess, dissemination, acute MI

Question 27

median duration of fever on appropriate therapy is?

Answer 27

about 3 days

Question 28

how long does it take for the CXR to clear?

Answer 28

weeks

Question 29

what % of hospitalized pts acquire HAP, and what is the mortality?

Answer 29

1%, 33%

Question 30

risk factors for HAP

Answer 30

IV/urinary cath, endotracheal intubation, contaminated resp devices, poor hand washing, comorbid illness

Question 31

diagnostic signs of HAP

Answer 31

fever, leukocytosis, increase resp secretions, new/worsening infiltrates

Question 32

HAP may be difficult to distinguish from?

Answer 32

CHF, PE, pulm hemorrhage, ARDS

Question 33

common pathogens for HAP

Answer 33

gram neg bacilli, MRSA, anaerobes, often polymicrobial

Question 34

pneumonia in the immunocompromised host - what determines likely pathogen?

Answer 34

underlying immune deficit

Question 35

neutropenia post chemo increases risk of?

Answer 35

bacteria, aspergillus, candida

Question 36

splenectomy increases risk of?

Answer 36

encapsulated organisms

Question 37

HIV increases risk of?

Answer 37

fungi, mycobacteria, viruses (CMV, EBV), and bacteria

Question 38

important pathogens: AIDS with CD4 >500

Answer 38

tuberculosis, bacteria

Question 39

impotant pathogens: AIDS with CD4 <200

Answer 39

pneumocystic jirovecii

Question 40

important pathogens: AIDS with CD4 <50

Answer 40

non-TB mycobacteria

Question 41

what is the most likely diagnosis in a symptomatic HIV+ patient with an abnormal CXR?

Answer 41

bacterial pneumonia

Question 42

clinical presentation of PCP

Answer 42

dyspnea, dry cough, fever with insidious onset; diffuse infiltrates; hypoxemia

Question 43

diagnosis of PCP

Answer 43

sputum positive for fungi with silver stain

Question 44

what should be added to the PCP tx when significant hypoxemia is present?

Answer 44

corticosteroids

Question 45

histoplasma & coccidiodes usually cause _________ in HIV

Answer 45

disseminated dz (reactivation or primary)

Question 46

risk factors for invasive aspergillosis in HIV pt

Answer 46

end-stage disease, concomitant neutropenia, marijuana

Question 47

cryptococcus neoformans is more likely to cause _____ in an AIDS patient, but can also cause pneumonia

Answer 47

meningitis