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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 associated

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

-CBC with differential
-Pre-antibiotic blood cultures
-Chemistry panel + Respiratory panel
-ABG: assess O2 + acid base status
-Procalcitonin: differentiate bacterial from viral infections
-Urinary antigen assays: help with pathogen identification

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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
HAP: risks
-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
HAP: pathogens
-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
HAP: symptoms and signs
-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
HAP: diff dx
-CHF -Atelectasis -Aspiration -ARDS -Pulmonary thromboembolism -Pulmonary hemorrhage -Drug reactions
29
HAP: labs
-sputum sample: -Gram stains and cultures of sputum -Endotracheal aspiration and fiberoptic bronchoscopy -Blood cultures: + in 20% -ABG or pulse oximetry -CBC and chemistry -Thoracentesis*- if there is fluid def do to identify bug -Nasal MRSA Swab
30
HAP: chest x-ray
-Nonspecific -often Patchy airspace infiltrates OR -Lobar consolidation with air bronchograms OR -Diffuse alveolar or interstitial infiltrates -+/- pleural effusions or cavitation
31
empiric antimicrobial agents for VAP and HAP
-Empiric tx options for MRSA- IV vancomycin (15 mg/kg every 12 hours) -Empiric tx for Pseudomonas aeruginosa: piperacillin-tazobactam (4.5 g every 6 hours; Beta-Lactam abx) -after results of sputum, blood, and pleural fluid cultures -> switch to narrow spectrum -can give both -usually 7 day course
32
HAP:abx duration
-2016 Infectious Diseases Society of America(IDSA)/American Thoracic 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
HIV disease and bacterial pneumonia
-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
34
HIV disease pneumonia diff dx and work up
-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
HIV disease pn: tx and prevention
-Outpatient: same as CAP-> amoxicillin/doxy (no comorbid); fluoroquinolone OR augmentin + azithromycin -Inpatient: -General medial ward: Same as CAP -> fluoroquinolone OR beta lactam + azithromycin -ICU: Same as CAP -Nosocomial pn: Empiric pseudomonas coverage should be included -Prevention-vaccines and keep CD4 count up
36
HIV disease and pneumocystis jiroveci pneumonia
-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
Pneumocystis jiroveci Pneumonia symptoms
-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
Pneumocystis jiroveci Pneumonia physical findings
-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
pneumocystis jiroveci Pneumonia diff dx
-Bacterial pneumonia -Tuberculosis -Coccidioidomycosis -Histoplasmosis -Cytomegalovirus -Kaposi sarcoma -Lymphoma -Pulmonary embolism
40
pneumocystis jiroveci Pneumonia labs
-LDH -CD4 -ABG -O2 Sat -Induced sputum: -Demonstrate cysts -If negative and suspicion high: bronchoscopy- Bronchoalveolar lavage or transbronchial lung bx (not often)
41
pneumocystis jiroveci Pneumonia imaging
**-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
pneumocystis jiroveci Pneumonia: sputum
-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
PCP tx and prophylaxis
-TMP-SMX- Bactrim
44
when to prophylax PCP
-Prophylaxis for Pneumocystis pneumonia: -CD4 counts < 200 cells/mcL -CD4 percentage below 14% -Oral candidiasis (ignore this) -Prior PCP
45
pt in nrothern arizona and S&S of pneumonia. afebrile, non toxic, bilateral upper lobe infiltrates. whats the best tx
-itraconzole -northern arizona (SW area)- tends to be fungal -infiltrates can point to fungal
46
hemorrhagic necrotizing consolidation pneumonia
klebsiella pneumonia -blood sloughing - red brown -currant jelly
47
thick, blood tinged sputum, fever, alcoholism, diabetes, infiltrates, what would you give him first
-monotherapy- fluoroquinolone- levo -bc diabetes and alcoholic comorbitities
48
farmer from SW, rodent feces, fever, non productive cough, diffuse crackles. most likely pathogen
-rodent feces -> hantavirus pneumonia -strep pneumonia tends to be consolidated -> not diffuse everywhere
49
most common pathogen that causes atypical pneumonia
-mycoplasma pneumonia- IS THE MORE COMMON ONE -chlamydia penumoniae
50
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
-legionella pneumonphila- causes bulding fissures
51
cave exploration on Ohio river, x-ray reveals focal consolidation, you suspect histoplasmosis pneumonia, what do you give
-Itraconazole
52
pneumocystosis jiroveci in HIV pt
-hazy -diffuse interstitial infiltration -ground glass
53
mc acquired bacterial pathogen in nosocomial pneumonia
-pseudomonas aeurginosa -staph aureus
54
HIV Bacterial Pneumonia presentation/ S+ S
-similar presentation to immunocompetent pts: -abrupt onset of fever, productive cough, chills, pleuritic cp -high WBC -bacteremia common -lower CD4 worser off

Pulmonary (23 decks)

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