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Pulmonology > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

community acquired pneumonia (CAP)

A

-Dx outside of hospital or within 48 hours after admission*:
-Has not:
-been hospitalized in acute care hospital for ≥ 2 days within 90 days of infection
-resided in a long-term care facility
-received IV antibiotics, chemo, or wound care within 30 days prior to infection
-attended a hospital or hemodialysis clinic

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2
Q

CAP: pulmonary defense mechanisms

A

-cough reflex
-mucociliary clearance system
-immune responses

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3
Q

CAP occurs when…

A

-Defect in one or more of normal host defense mechanisms OR
-Very large infectious inoculums (large load) OR
-Highly virulent pathogen overwhelms the host (large strength)

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4
Q

stats on CAP

A

-> 4.5 million outpatient/ER visits per yr in US
-Highest in extremes of age
-Men > women
-AA > Caucasians
-Most deadly infectious disease in US
-In top 10 leading cause of death in US:
-10-12 % among hospitalized patients
-< 1% for patients who do not require hospitalization

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5
Q

risk factors for increased morbidity and mortality from CAP

A

-Advanced age
-Alcoholism
-Comorbid medical conditions
-Altered mental status- aspirate more
-Respiratory rate ≥ 30 breaths/min- tachypneic
-Hypotension
-BUN > 30 mg/dL

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6
Q

CAP: atypical vs typical pathogens

A

-Bacteria MC
-Traditionally: “typical” and “atypical” agents -> not used anymore but you may hear it still
-1. “Typical” organisms:
-s. pneumoniae*** (MC for immune competent and compromised!), Haemophilus influenzae, Staphylococcus aureus, Group A streptococci, Moraxella catarrhalis, anaerobes, and aerobic gram-negative bacteria
-2. “Atypical” organisms:
-mycoplasma pneumoniae (mc), Legionella spp, Chlamydophila (formerly Chlamydia) pneumoniae, and C. psittaci
-atypical - usually in young healthy adults, non productive cough and self limited! (walking)

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7
Q

CAP: bacteria vs viral

A

-MC bacterial pathogen in CAP:
S pneumoniae (less due to vaccination) -> immunocompetent or compromised
-Other common bacterial pathogens include:
-H influenzae (COPD), Mycoplasma pneumoniae, Chlamydia pneumoniae, S aureus, Neisseria meningitidis, M catarrhalis, Klebsiella pneumoniae (EtoH), other gram-negative rods, and Legionella species
-Common viral causes of CAP:
-Influenza A and B viruses, severe SARS-CoV-2, Other coronaviruses, Rhinoviruses, Parainfluenza viruses, Adenoviruses. Respiratory syncytial virus, Human metapneumovirus, Human bocaviruses

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8
Q

diff pathogens and the disease assoc

A

-s. pneumoniae- MC
-Klebsiella pneumoniae (EtoH)- red brown color sputum
-H influenzae (COPD)
-histoplasma capsulatum- bird or bat droppings
-chlamydophilia- birds
-legionella- hotel or cruise ship -> lives in air vents
-staph aureus- injection drug use

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9
Q

CAP: symptoms

A

-Acute or subacute onset of fever, cough +/- sputum production, and dyspnea
-tachypnea
-Other common symptoms:
-Rigors
-Sweats
-Chills
-Chest discomfort/pleurisy
-Hemoptysis
-Fatigue
-Myalgias
-Anorexia, headache, and abdominal pain

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10
Q

CAP: physical exam

A

-Fever or hypothermia
-Tachypnea, tachycardia, and mild arterial oxygen desaturation
-dull rather than resonant
-more vibration in area of consolidation- 99 test
-Chest examination:
-Altered breath sounds and rales
-+/- Dullness to percussion
-Egophany (E to A changes)

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11
Q

lung sounds

A

-rhonci is normally heard everywhere
-rales are normally found in a specific spot
-tactile fremitus- use ball of hand or side of hand -> say 99 ->
-increased fremitus with pneumonia/fluid over an area of consolidation
-hyperresonce- COPD
-dullness- fluid, pneumonia
-crackles- blowing bubbles in water
-CHF- crackles on both sides
-egophony- E sounds like A in pneumonia (with consolidation
-whispered pectoriloquy- ask pt to whisper -> if you hear it clearer or loud sounds suggest consolidation

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12
Q

CAP: diff dx

A

-URI
-Reactive airway diseases
-Bronchitis
-CHF
-Lung cancer (bronchoalveolar cell)
-Pulmonary vasculitis
-Pulmonary thromboembolic disease with infarct
-Atelectasis

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13
Q

acute bronchitis vs pneumonia

A

-ACUTE BRONCHITIS:
-inflamed, red, large, airways
-mucus in airway
-often virus
-open alveoli
-normal/low fever
-acute persistent cough
-lack of signs of lung consolidation
-recent or concurrent URI
-PNEUMONIA:
-inflamed, red, small and large airways (bronchopneumonia)
-often bacterial
-pus, mucus, and fluid filled alveoli -> consolidations (crackles, rhonchi, egophony)
-acute cough
-dyspnea
-fever
-tachycardia, decrease O2 sat

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14
Q

CAP: labs: sputum

A

-never do sputum on outpt
-sputum- gram stain and culture should be attempted in all pts requiring hospitalization
-before antibiotics are initiated except in antibiotic failure
-sputum induction- do when cant provide expectorated sputum samples OR may have P jiroveci or Mycobacterium tuberculosis pneumonia
-other techniques:
-transtracheal aspiration
-fiberoptic bronchoscopy
-transthoracic needle aspiration

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15
Q

CAP: hospitalized pt labs

A

-Pre-antibiotic blood cultures
-Arterial blood gases
-CBC with differential
-Chemistry panel
-Procalcitonin
-Urinary antigen assays
-Respiratory panel (see pdf)

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16
Q

CAP: chest radiography

A

-CONFIRMS dx, detect associated lung disease
-severity and response to therapy
-patchy airspace infiltrates to lobar consolidation with air bronchograms (alveoli filled with gunk) to diffuse alveolar or interstitial infiltration (widespread)
-+/- pleural effusions* and cavitation (gunk + pus) -> + -> CT sometimes if complicated
-f/u x-ray would be 6 weeks later rather than 2 -> delay
-see PP images

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17
Q

CAP: thoracentesis with pleural fluid analysis

A

-Performed on most pts with pleural effusions (inpatient)
-Assists in dx of the etiologic agent
-Gram stain and cultures
-Glucose
-Lactate dehydrogenase (LDH)
-Total protein levels
-Leukocyte count with differential
-pH determination

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18
Q

pneumonia severity index (PSI)

A

-IRL eyeball it
-when to send pt inpatient:
-septic shock or respiratory failure -> inpatient
-vomiting, cant keep food down -> inpatient
-noncompliant, mental illness -> inpatient
-<92% O2 sat or less than baseline -> inpatient
-if ALL no -> PSI
->50 -> class 2-5
-<50, neoplastic disease, HF, CVD, renal disease, liver disease -> class 2-5
-<50, no cormib, BUT AMS, pulse > 125, RR >30, BP < 90, temp <35 or > 40 -> class 2-5
-if all no -> class 1
-increase class increase mortality

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19
Q

outpt setting, empiric tx of CAP

A

-1. Healthy w/o comorbidities or risk factors for antibiotic-resistant pathogens:
-Amoxicillin 1 gram 3x daily* OR
-Doxycycline 100 mg 2x daily OR
-Macrolide (azithromycin or clarithromycin) only in areas with macrolide resistance < 25% (dont really do)

-2. Adults with comorbidities:
-Combination therapy:
-Amoxicillin/clavulanate (augmentin) OR a cephalosporin (cefpodoxime or cefuroxime) AND a macrolide (azithromycin or clarithromycin) OR Doxycycline
-Monotherapy- Fluoroquinolone (levofloxacin or gemifloxacin)

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20
Q

comorbid conditions: CAP

A

-chronic heart, lung, liver, or kidney disease
-diabetes mellitus
-alcohol use disorder
-malignancy
-asplenia
-immunosuppressant conditions or
-use of immunosuppressive drugs
-or use of antibiotics within the previous 3 months

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21
Q

inpatient adults with non-severe CAP tx

A

-w/o risk factors for MRSA orP. aeruginosa:
-Combination therapy-
Beta-lactam (ampicillin+sulbactam, cefotaxime, ceftriaxone or ceftaroline) AND a macrolide (azithromycin or clarithromycin) OR

-Monotherapy - Respiratory fluoroquinolone (levofloxacin or moxifloxacin)
-*can use combo above if ICU tx

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22
Q

aspiration pneumonia- pathogen and tx

A

-primarily anaerobes and streptococci
-tx- augmentin or clindamycin as first line therapy (bc anarobes)

23
Q

CAP: prevention

A

-Polyvalent pneumococcal vaccine- prevents strep pneumonia
-Influenza vaccine
-COVID vaccine
-RSV vaccine
-Smoking cessation

24
Q

hospital acquired pneumonia

A

-Defined as pneumonia developing more than 48 hours after admission
-2nd MC hospital acquired infection
-Leading cause of death due to nosocomial infection
-Mortality rate 15-30%
-Highest-risk ICU patients on vent
-Microaspiration of organisms that have colonized the oropharyngeal tract and GI tract

25
Q

HAP: risks

A

-Pharyngeal colonization:
-Instrumentation: ng/et tubes
-Contamination: hands/equipment
-Broad-spectrum antibiotics- Drug-resistant organisms
-Patient factors- Malnutrition, age, altered consciousness, swallowing disorders, and underlying pulmonary and systemic diseases

26
Q

HAP: pathogens

A

-MC organisms (nosocomial pneumonia):
-Aerobic gram neg: P. aeruginosa, Enterobacter, K. pneumoniae, and E. coli
-Aerobic gram positive: S. Aureus, MRSA, Streptococcus
-Uncommon causes:
-Mycobacteria, fungi, chlamydiae, viruses, rickettsiae, and protozoal organisms

-Organisms in VAP (ventilator associated pneumonia):
-S. aureus, P. aeruginosa, Klebsiella species, Enterobacter species

27
Q

HAP: symptoms and signs

A

-nonspecific
-One or more clinical findings:
-Fever
-Leukocytosis
-Purulent sputum
-New or progressive pulmonary infiltrate on cxr typically are present most patients
-Other findings include those listed for CAP

28
Q

HAP: diff dx

A

-CHF
-Atelectasis
-Aspiration
-ARDS
-Pulmonary thromboembolism
-Pulmonary hemorrhage
-Drug reactions

29
Q

HAP: labs

A

-Blood cultures: + in 20%
-Arterial blood gas or pulse oximetry
-CBC and chemistry
-Thoracentesis*- if there is fluid def do to identify bug
-Gram stains and cultures of sputum
-Endotracheal aspiration and fiberoptic bronchoscopy
-Nasal MRSA Swab

30
Q

HAP: chest x-ray

A

-Nonspecific
-often Patchy airspace infiltrates OR
-Lobar consolidation with air bronchograms OR
-Diffuse alveolar or interstitial infiltrates
-+/- pleural effusions or cavitation

31
Q

empiric antimicrobial agents for VAP and HAP

A

-Empiric tx options for MRSA- vancomycin (15 mg/kg every 12 hours), or linezolid (600 mg every 12 hours)
-Empiric tx forPseudomonas aeruginosa- piperacillin-tazobactam (4.5 g every 6 hours), cefepime (2 g every 8 hours), ceftazidime (2 g every 8 hours), aztreonam (2 g every 8 hours), meropenem (1 g every 8 hours) or imipenem (500 mg every 6 hours)
-after results of sputum, blood, and pleural fluid cultures -> switch to narrow spectrum
-can give both
-usually 7 day course

32
Q

HAP: duration

A

-2016 Infectious Diseases Society of America(IDSA)/AmericanThoracic Society (ATS):
-Guidelines recommend a 7 day course of antimicrobial therapy rather than longer duration regardless of the pathogen
-Shorter or longer duration may be indicated depending on rate of improvement of clinical, radiologic, and laboratory parameters

33
Q

HIV disease and bacterial pneumonia

A

-Bacterial pn is common in HIV ds
-Direct relation between CD4 count and incidence of bacterial pneumonia
-Recurrent bacterial pn is an AIDS defining condition
-similar presentation to immunocompetent pts -> abrupt onset of fever, productive cough, chills, pleuritic cp
-high WBC
-bacteremia common
-lower CD4 worser off

34
Q

HIV disease pneumonia diff dx and work up

A

-TB, Pneumocystis jiroveci, viral pneumonia (COVID, influenza)
-WORK UP:
-CBC with diff
-Blood cultures
-Urinary antigen testing, COVID, Flu, TB (if appropriate)
-Chest radiograph: MC finding: Segmental or lobar consolidation
-Sputum examination
-Thoracentesis- if inpatient

35
Q

HIV disease pn: tx and prevention

A

-Outpatient: same as CAP
-Inpatient:
-General medial ward: Same as CAP
-ICU: Same as CAP
-Nosocomial pn: Empiric pseudomonas coverage should be included

-Prevention-vaccines and keep CD4 count up

36
Q

HIV disease and pneumocystis jiroveci pneumonia

A

-Pneumocystis jiroveci pneumonia is one of MC opportunistic infection associated with AIDS
-anyone who is immunosuppressed can have high association too
-Also seen in cancer pts, severe malnutrition, immunosuppressive or radiation therapy
-Currently recognized as a fungus BUT tx is antibiotics
-Transmission airborne
-believed to lay dormant

37
Q

Pneumocystis jiroveci Pneumonia symptoms

A

-nonspecific
-May be difficult to diagnose
-Fever, dry cough, tachypnea, SOB
-Presentation ranges from fever and no respiratory symptoms to frank respiratory distress
-pt can look fine and become decompensated from simply walking across room

38
Q

Pneumocystis jiroveci Pneumonia
physical findings

A

-can be disproportionate to the degree of illness and radiologic findings
-fever (over 80%)
-tachypnea (60%)
-crackles and rhonchi (50% normal chest examination) !
-may present with spontaneous pneumothorax
-oral thrush common
-Without treatment -> rapid deterioration -> death

39
Q

pneumocystis jiroveci Pneumonia diff dx

A

-Bacterial pneumonia
-Tuberculosis
-Coccidioidomycosis
-Histoplasmosis
-Cytomegalovirus
-Kaposi sarcoma
-Lymphoma
-Pulmonary embolism

40
Q

pneumocystis jiroveci Pneumonia labs

A

-LDH
-CD4
-ABG
-O2 Sat
-Induced sputum:
-Demonstrate cysts
-If negative and suspicion high: bronchoscopy- Bronchoalveolar lavage or transbronchial lung bx (not often)

41
Q

pneumocystis jiroveci Pneumonia imaging

A

-chest radiograph- diffuse, bilateral, interstitial***, or alveolar infiltrates
-ground glass appearance
-apical infiltrates- aerosolized pentamidine prophylaxis
-normal chest radiographs 25%

-computed tomography (HRCT) has high sensitivity for PCP among HIV+ pts ->
-presence of patchy or nodular ground glass attenuation is suggestive NOT dx
-negative scan makes the dx of PCP highly unlikely
-see PP images

42
Q

pneumocystis jiroveci Pneumonia: sputum

A

-you dx* PCP with induced sputum!!
-no culture bc this is fungus
-Induced Sputum- collected after having pt inhale irritant -> deep cough that collects secretion from bottom of lung
-PCR testing*
-Wright-Giemsa stain or direct fluorescence antibody (DFA) test of induced sputum
-If sputum negative, can do:
-bronchoscopy- Bronchoalveolar lavage then PCR of fluid
-Tissue bx
-Endotracheal aspirate
-Unlikely diagnosis if:
-Normal DLCO (diffusing capacity)*
-Normal high-resolution CT scan of the chest- NO ground glass
-CD4 count > 250 cells/mcL within 2 months prior

43
Q

PCP tx and prophylaxis

A

-TMP-SMX- Bactrim

44
Q

when to prophylax PCP

A

-Prophylaxis for Pneumocystis pneumonia:
-CD4 counts < 200 cells/mcL
-CD4 percentage below 14%
-Oral candidiasis (ignore this)
-Prior PCP

45
Q

pt in nrothern arizona and S&S of pneumonia. afebrile, non toxic, bilateral upper lobe infiltrates. whats the best tx

A

-itraconzole
-northern arizona (SW area)- tends to be fungal
-infiltrates can point to fungal

46
Q

hemorrhagic necrotizing consolidation pneumonia

A

-klebsiella pneumonia
-blood sloughing - red brown
-currant jelly

47
Q

thick, blood tinged sputum, fever, alcoholism, diabetes, infiltrates, what would you give him first

A

-monotherapy- fluoroquinolone- levo
-bc diabetes and alcoholic comorbitities

48
Q

farmer from SW, rodent feces, fever, non productive cough, diffuse crackles. most likely pathogen

A

-rodent feces -> hantavirus pneumonia
-strep pneumonia tends to be consolidated -> not diffuse everywhere

49
Q

most common pathogen that causes atypical pneumonia

A

-mycoplasma pneumonia- IS THE MORE COMMON ONE
-chlamydia penumoniae

50
Q

diffuse expiratory wheeze with decreased sounds to right lower lung fields, WBC is high, chest x-ray shows dense consolidation with buldging fissures, whats the most likely pathogen

A

-legionella pneumonphila- causes bulding fissures

51
Q

cave exploration on Ohio river, x-ray reveals focal consolidation, you suspect histoplasmosis pneumonia, what do you give

A

-Itraconazole

52
Q

pneumocystosis jiroveci in HIV pt

A

-hazy
-diffuse interstitial infiltration
-ground glass

53
Q

mc acquired bacterial pathogen in nosocomial pneumonia

A

-pseudomonas aeurginosa
-staph aureus

Pulmonology (19 decks)

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