Pneumonia Flashcards
what is CAP?
Not recently hospitalized and lacking healthcare associated risk factors
what is HAP?
Pneumonia that occurs >48 hours after hospital admission
what is VAP?
Pneumonia that arises > 48-72 hours after endotracheal intubation
what is HCAP? 4
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
Patient on hemodialysis
what is the most common etiology of bacterial pneumonia?
Streptococcus pneumoniae
what is the 2nd most common cause of bacterial pneumonia?
Mycoplasma pneumoniae
what causes colonization increases in patients with COPD and cystic fibrosis
Haemophilus influenzae
what is a more common cause in young children and elderly
Moraxella catarrhalis
what is the most common cause of CAp in children?
Viral-RSV, influenza A, parainfluenza
what is DRSP? to how many drugs?
Drug resistant S. pneumoniae (DRSP)
Strains resistant to at least 3 drugs
Becoming more and more common
what are risk factors of DSRP?
Age < 2 years or > 65 years Antibiotic therapy within previous 3 months Alcoholism Medical comorbidities Immunospupression
what are risk factors of CA-MRSA? 10
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 risk factors for aspiration pneumonia?
Dysphagia, change in oropharyngeal colonization, GERD, decreased host defenses, oral contents, gastric contents
what causes dysphagia?
Stroke, seizures, alcoholics, and aging
what causes Change in oropharyngeal colonization
Oral/dental disease, poor hydiene, tube feedings, medications
what may GER cause
May allow gram (-) bacilli to colonize gastric contents
what can decreased host defenses cause?
Impaired mucus production or cilia function, decreased immunoglobulin in secretions, altered cough reflex
what anaerobes may be found in oral contents?
Bacteroides spp., Fusobacterium spp,. Prevotella spp. and anaerobic gram cocci
what microbes may be in gastric contents?
Gram (-) bacilli and S. auerus
what is the 2nd most common nosocomial infection in the US
HAP
what are 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
what is the etiology of pneumonia? 5
-Aerobic Gram-negative bacteria Ps. aeruginosa E. coli K. pneumonia Acinetobacter sp. -Gram-positive bacteria S. aureus (MRSA) Anaerobes: very rare
what is the symptoms 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 does the chest xray of pneumonia show?
Multilobar infiltrates
Rapid progression infiltrates
Pleural effusion
Necrotizing pneumonia
How do you Dx pneumonia? 3
Chest Xray should reveal infiltrates
O2 saturation should be over 90%
CBC, elevated or drop in WBC, differential should show a predominance of neutrophils
what are 2 additional things that need to be done in hospitalized patients with pneumonia before you diagnose?
Sputum gram stain may or may not show a predominance of on organism
Blood cultures MUST be obtained in all patients hospitalized with pneumonia
what is CURB65?
how to know where to place them…
Confusion, Uremia, Respiratory Rate, Blood Pressure over 65.
2 points; consider hospital admission
>3 points; consider ICU admission
what criteria must be met to dx HAP/VAP?
Chest X-ray should reveal a new infiltrate plus two of the following: Temp > 38 C (100.4 F) Leukocytosis or leukopenia Purulent secretions Cultures identifying pathogen
73 year old woman presents to your clinic complaining of difficultly breathing and shortness of breath. PE reveals decreased breath sounds on left side compared to the right, and rales in the left lower lobe. Temp 37.4C, RR 20, BP 110/76. Chest X ray: lower left lobe infiltrates. O2 saturation 92%.
what does she have?
what pathogen
what else should you know?
CAP - strep pneumo - where did she come from
48 yo male admitted s/p MVA, intubated at scene. SICU day #9, the nurse notes thick green sputum upon tracheal aspiration.
V.S.:T 101.5oF O2Sat 90% on 3L O2 P.E.:difficult to assess lung WBC:16,000 / mm3 X-Ray: LLL infiltrates what is the pathogen?
MRSA
Empirical treatment for CAP - health outpt?
Macrolide or Doxycycline
Empirical treatment for CAP - outpt at risk for DRSP
Respiratory Fluoroquinolone
Or
Beta-lactam + Macrolide
Empirical treatment for CAP - inpt nonICU - 1st is for IDSA 2nd is JCCMS
Respiratory Fluoroquinolone
Or
Beta-lactam + Macrolide
Antipneumococcal quinolone OR
Beta-lactam + doxycycline or Tigecycline montherapy or Macrolide monotherapy
Empirical treatment for CAP - inpt ICU - 1st is for IDSA 2nd is JCCMS
Beta-lactam + azithromycin
Or
Beta-lactam + respiratory fluoroquinolone
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
Respiratory Fluoroquinolone
: Levofloxacin, moxifloxacin, gemifloxacin
Beta-lactam (Inpatient)
Ceftriaxone, cefotaxime, ampicillin/sulbactam
CA-MRSA treatment options
Vancomycin or Linezolid
Antipneumococcal/antipseudomonal beta-lactam
Cefepime, Imipnem, meropenem,
piperacillin/tazobactam
Antipneumococcal quinolone
cipro or levo
you are able to ID organism how long after admission?
24-72hrs
what is the duration of therapy?
Duration of therapy 5-7 days
Minimum 5 days until patients are afebrile for 48-72 hours
when should therapy be longer?
Longer for S. auerus or Pseudomonas
when clinical able…
switch to PO
when can you d/c pts?
Vital signs and Oxygen status are stable and no unresolved comorbidities
how do you treat Aspiration of oral contents pneumonia?
PCN G, ampicillin/sulbactam, and clindamycin all cover typical pathogens
how do you treat aspiration of oral and gastric contents pneumonia?
Ampicillin/sulbactam, amoxicillin/clavulante piperacillin/tazobactam
what are the key concerns for HAP
MRSA, Pseudomonas aeruginosa, Acinetobacter spp., and Stenotrophomonas maltophilia
if onset within 5 days of admission what pathogens caused HAP
S. pneumoniae, H. influenzae, MSSA, and enteric gram (-) bacilli
how do you treat early onset HAP?
3rd generation cephalosporin +macrolide
or
Respiratory fluoroquinolone
what are risk factors for multidrug resistant? lots…
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
how do you treat MDR?
Antipsuedomonal cephalosporin (Cefepime, ceftrazidime)
OR
Antipseudomonal carbapenem (imipenem or meropenem)
Or
Beta-lactam/Beta-lactamase inh (Piperacillin/ tazobactam)
Antispeudomonal fluoroquinolone (cpirofloxacin or levofloxacin)
Or
Aminoglycoside (amikacin, gentamicin or tobramycin)
Vancomycin
Or
Linezolid
how do you treat VAP?
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 pathogens of VAP
S.aureus, S. pneumoniae, H. influenzae, gram-negative Enterobacteriaceae
