Pneumonia Flashcards
community acquired pneumonia (CAP)
-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
CAP: pulmonary defense mechanisms
-cough reflex
-mucociliary clearance system
-immune responses
CAP occurs when…
-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)
stats on CAP
-> 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
risk factors for increased morbidity and mortality from CAP
-Advanced age
-Alcoholism
-Comorbid medical conditions
-Altered mental status- aspirate more
-Respiratory rate ≥ 30 breaths/min- tachypneic
-Hypotension
-BUN > 30 mg/dL
CAP: atypical vs typical pathogens
-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)
CAP: bacteria vs viral
-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
diff pathogens and the disease associated
-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
CAP: symptoms
-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
CAP: physical exam
-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)
lung sounds
-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
CAP: diff dx
-URI
-Reactive airway diseases
-Bronchitis
-CHF
-Lung cancer (bronchoalveolar cell)
-Pulmonary vasculitis
-Pulmonary thromboembolic disease with infarct
-Atelectasis
acute bronchitis vs pneumonia
-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
CAP: labs: sputum
-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
CAP: hospitalized pt labs
-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
CAP: chest radiography
-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
CAP: thoracentesis with pleural fluid analysis
-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
pneumonia severity index (PSI)
-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
outpt setting, empiric tx of CAP
-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)
comorbid conditions: CAP
-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
inpatient adults with non-severe CAP tx
-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
