Pneumonia Flashcards
pneumonia overview
infection of the pulmonary parenchyma
proliferation of microbial pathogens
Host response depends on mechanical factors.
Compromised mechanical factors
cough and gag reflexes
protection for aspiration
pneumonia classification
- CAP
- HAP
- VAP
- HCAP (IV therapy, HD)
CAP community aquired PNA
8th leading cause of death in the US
80% treated as OP , 20 % as inpatient
mortality rate:
outpatient < 5%
inpatient 12-40%
no one cause of death from infection > 65 years
18% of hospitalized CAP readmitted in 1 month
risk factors
alcoholism, asthma ,immune suppression , institutionalization, > 70 yrs
CAP organisms
Potential etiologic agents:
bacteria, fungi , virueses and protozoa
newly identified pathogens
metapneumovirus, coronaviruses, Middle East resp syndrome, CA -MRSA
streptococcus pneumoniae is the most common
consider other organisms if risk factors of severity of illness
viruses responsible for large proportion
influenza,parainfluenaz and RSV
10-15 % are polymicrobial
combination of typical and atypical pathogens
MRSA was reported as a primary agent of CPAP
MRSA spread from hospital setting to community
a distinct strain of MRSA in the community
able to infect healthy individual
CAP organisms of concern
Pneumococcal pneumonia:
Risk factors , dementia, seizure disorder, CHF, CVA, tobacco smoking or COPD
CA-MRSA
skin colonization or current infection
Enterobacteriaceae
risk factor :
Recent hospitalization, antibiotic therapy, alcoholism, HF, or renal failure
Pseudomonas aeruginosa
Risk factor:
Bronchiectasis, cystic fibrosis, or severe COPD
legionella pneumophila:
diabetes, hematological malignancy, renal disease, HIV, smoking, male gender, and recent hotel stay or ship cruise
CAP risk factor for early deteioration
multilobular infiltrates
hypoxemia
acidosis
mental confusion
tachypnea
hypoalbuminemia
neutropenia
thrombocytopenia
hyponatremia
hypoglycemia
CAP complications
septic shock and organ failure
cardiovascular compromise
due to inflammation and procoagulant activity
AMI, CHF arrhythmias
concerning the elderly
90% of ACS within the first week
new onset of CHF extends up to one year
CAP diagnosis
what is etiology
chest radiograph
sputum and gram stain
blood cultures
urine antigen test
legionella and pneumococcal
polymerase chain reaction (PCR)
legionella , mycoplasma , chlamydia
CPR and PCT
identification of worseinig disease
treatment failure
PCT distinguishes bacterial vs viral
need foe discontinue treatment
CURB 65
C- confusion 1
U- urea > 7 1
R RR > 30 1
B SPB < 90
DBP < 60 1
65 age > 65 1
CAP treatment
Non- ICUi:
resp fluorquinolone (moxiflocin or Levofloxacin
beta lactam ( rocephin ) plus macrolide ( Azithromycin)
ICU:
Beta-lactam plus azithromycin or fluoroquinolone
-Pseudomonas concideration:
antipeudomonal beta lactam ( zosyn or cefepime ) plus floroquinolone
- antipseudomonal beta-lactam plus aminoglycoside
( tobramycin) plus azithromycin
-antipseudomonal beta-lactam plus aminoglycoside plus antipneumoccal fluoroquinolone ( maxi or Levo)
CA- MRSA
zyvox or vancomycin plus ( clindamycin)
Duration of treatment:
uncomplicated 5 D
complicated consider extension
CAP treatment
hydration
oxygen support
pressor support
ventilation
steroids
Aspiration pneumonia
Risk factors:
unprotected airway
elderly
decreased cough, and gag reflexes, reduced antibodies
polymicrobial oropharyngeal flora
aerobic and anaerobic
anaerobes
abscess, empyema, and parapneumonic effusions
Treatment plan:
ceftriaxone 1 gram IV QD
levofoxacin 750 IV QD + /- flagyl 500 po IV Q 8
ampicillin/sulbactam 3 G IV Q 6 or clindamycin 600mg IV Q 8
aspiration PNA-related lung abscess
Zosyn pharmacy to dose
ventilator-associated pneumonia
The community rate of VAP
ventilated was> 30 days. 70%
VAP > 48 hours after intubation
mortality 50-70%
underlying disease plays a role
etiology of VAP
MDR and non-MDR bacterial pathogen
NON-MDR like CAP
lower incidence of atypical
except for legionella
three factors to the pathogenesis of VAP
colonization of the oropharynx
aspiration of these organisms
compromise of the normal host defense
HAP overview
HAP > 48 hours
higher frequency of non-MDR pathogens
higher rate of monotherapy
more common pathogen
anaerobes
due to macroaspiration
management
simular to
VAP
VAP risk factors:
endotracheal tube
prolonged intubation
bypass normal mechanical factors
preventing macroaspiraiton
microaspiration can occur
oropharynx flora replaced by pathogenic microorganisms
- glycocalyx biofilm
-protect bacteria
-risk for inoculation
immunoparylysis :
Corresponds with VAP
Antibiotic selection pressure:
Poses the greatest risk
cross infections
contaminated equipment
malnutrition
VAP orginisms
MDRI pathogens vary from hospital to hospital
pseudomonas aeruginosa and MRSA
less common pathogens
fungal and viral
severely immunocompromised
multi drug-resistant pathogens
pseudomonas aeruigonsa
MRSA
Aniebocter SUPP
ESBL strains
Legionella pneumophila
aspergillus
Burkholderia cepacia
