1. High Rate: Migration of microbiota into Lower Respiratory Tract 2. Low Rate: Elimination of microbiota from Lower Respiratory Tract 3. High Rate: Reproduction of microbiota from Lower Respiratory Tract

Pneumonia Flashcards by Kevin Tea

Signs of Infection

Inflammation
Redness
Heat
Pus

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Systemic Signs/Symptoms of Infection

Fever, increased HR, RR
Increased WBC
Site specific aches

Severely Ill
- Septic Shock, Hypotension, Unconscious

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Pneumonia

High Rate: Migration of microbiota into Lower Respiratory Tract
Low Rate: Elimination of microbiota from Lower Respiratory Tract
High Rate: Reproduction of microbiota from Lower Respiratory Tract

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Community Acquired Pneumonia

Acute infection of the pulmonary parenchyma

Has two of the following
- Fever > 37.8°C
- Hypothermia
- Rigors
- Sweats
- Change in respiratory secretions
- Dyspnea
- Discomfort

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Streptococcus Pneumoniae

The most common cause of CAP

Specifically patients with
- Spleen dysfunction
- Chronic cardiopulmonary disease
- Diabetes
- Renal disease
- HIV

Causes Lobar Pneumoniae
- Localized to one lobe

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What bacteria pathogen causes Lobar Pneumoniae

Streptococcus Pneumoniae

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Risk Factors for Resistant S. Pneumoniae

Antibacterial Use:
- Beta-Lactams, Macrolide, Quinolones,

Older than 65 yrs old

Exposure to children from daycare

Alcoholism

Immunosuppression

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Mycoplasma Pneumoniae

Affects multiple lobes

Symptoms:
- Gradual onset of fever, headache, and malaise

Non-Pulmonary Symptoms:
- Nausea, Vomiting, Skin Rashes

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Chlamydia Pneumoniae

Fever and headache common

Young Adults:
- Mild respiratory symptoms
- Gradual Onset

Incomplete immunity, reinfection in older adults is common

Older Adult:
- Severe pneumonia in older adults

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Haemophilus Influenzae

Co-pathogen in elderly
- Causes pneumonia in patients with co-morbid disease

Symptoms:
- COPD Patients: Bronchopneumonia or Acute Exacerbation
- Acute Lobar Pneumonia: Cough, Fever, Chest Pain

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Pneumonia
- Diagnosis

Gold Standard: Chest X-Ray
- To demonstrate pulmonary infiltrates that are consistient with pneumonia

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Pneumonia
- Physical Findigns

Elevated RR
Fever
O2 Saturation
Diminished Air Entry
Abnormal Breath Sounds

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Risk Assessment (With Lab Values)
- To determine if patient needs hospitalization

C: Confusion
U: Uremia (BUN > 7 mmol/L)
R: Respiration Rate (RR>30)
B: Blood Pressure (Systolic < 90, Diastolic < 60)
65: Older than 65 years old

0-1 = Outpatient
2 = Inpatient
≥3 ICU

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Risk Assessment (No Lab Values)
- To determine if patient needs hospitalization

C: Confusion
R: Respiratory Rate (RR > 30)
B: Blood Pressure (Systolic < 90, Diastolic < 60)
65: Older than 65 years old

0 = Low risk of death, does not need hospital admission
1-2 = Increased risk of death, hospitalization should be required
≥3 = High risk of death, urgent hospitalization

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Pneumonia
- Prevention

Vaccinations (Pneumococcal, Influenza, COVID, RSV)
Reduce aspiration risk
Handwashing
Smoking Cessation
Rehabilitation programs
Comorbidities management

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Pneumonia
- Comorbidities

Smoking
Diabetes
Alcoholism
Chronic Heart/Lung/Liver/Renal disease
Immunosuppressive
Malnutrition

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Community Based Pneumonia - Outpatient
- Mild Treatment

CRB65 Score of 0
CURB65 Score of 0-1

Amoxicillin (Covers S. Pneumoniae)
+
Doxycycline (Covers M. Pneumoniae and C. Pneumoniae)

Alternative:
- Azithromycin
- Clarithromycin

Community Based Pneumonia - Outpatient
- Moderate Treatment

CRB65 Score of 1-2
CURB65 Score of 2

Amox or Amox/Clav

Plus (If CRB65 = 2 OR If CRB65 = 1 + Comorbidities)
- Doxycycline (If MRSA coverage is required) - Azithromycin
- Clarithromycin

Community Based Pneumonia - Hospitalized
- Non-Severe (Moderate) Treatment

Ceftriaxone

Plus (If CRB65 = 2 OR CRB65 = 1 + Comorbidities)
- Doxycycline
- Azithromycin
- Clarithromycin

Alternative: Levofloxacin

Community Based Pneumonia - Hospitalized
- ICU / Severe Treatment

Ceftriaxone + Azithromycin

Community Based Pneumonia - Hospitalized
- ICU / Severe Treatment
- P. Aeruginosa suspected

If colonization/recent infection with P. Aeruginosa
- Piperacillin-Tazobactam + Azithromycin

Community Based Pneumonia - Hospitalized
- ICU / Severe Treatment
- Ceftriaxone Allergy

Levofloxacin
- *Note mono therapy with quinolones may not be enough in severe

Community Based Pneumonia - Hospitalized
- ICU / Severe Treatment
- MRSA Suspected

Ceftriaxone
+
Vancomycin OR Linezolid

Pneumonia
- Monitoring

Temperature below 37.8
Respiratory Rate below 24
Systolic BP above 90
O2 Saturation above 90%

Ability to oral intake
Mental Status

Pneumonia - Follow Up (Symptom Resolution/Reduction)

1 Week: Fever 4 Week: Chest Pain and Sputum 6 Weeks: Cough and Breathlessness 3 Months: Most symptoms (Fatigue may still be present) 6 Months: Back to normal

Pneumonia - Follow Up (X Ray)

X-Ray at 6 weeks in patients with either: - Extensive Pneumonia - Smoker - Alcoholism - COPD - More than 5% weight loss in past month - Older than 50 years old

Nursing Home-Acquired Pneumonia - Diagnosis

Chest X-Ray Tachypnea - RR greater than 25 = Increased mortality - RR greater than 40 = Transfer to hospital Plus two of the following: - Fever greater than 37.8 or greater than 1.1 of baseline - New productive cough - Crackles, wheeze - Pleuritic chest pain

Nursing Home-Acquired Pneumonia - Treatment

Same as CAP with Comorbidities Should cover: - S. Pneumoniae - C. Pneumoniae - H. Influenzae - S. Aureus - Enterobacterales

Hospital Acquired Pneumoniae - Treatment Late Onset

More than 4 days in hospital Treat for Enterobacterales - Ceftriaxone OR - Levofloxacin Can add Gentamycin if needed for resistant bacteria

Hospital Acquired Pneumoniae - Treatment Early Onset

Less than 4 days in hospital Treat the same as Community Acquired Hospitalized: - Ceftriaxone + Doxycycline | Azithromycin | Clarithromycin

Hospital Acquired Pneumoniae - Define Late Onset + Risk Factors

More than 4 days in hospital + one of the following: - Prior broad spectrum antibiotics (less than 3 months ago) - Structural lung disease - Immunosuppressed

Hospital Acquired Pneumoniae - Treatment Late Onset + Risk Factors

Piperacillin/Tazobactam OR Imipenem OR Meropenem + Tobramycin If MRSA suspected add: - Vancomycin or - Linezolid

Ventilator Associated Pneumonia - Treatment Early Onset and/or No Risk Factors

Ceftriaxone OR Levofloxacin If MRSA suspected add: - Vancomycin or - Linezolid

Ventilator Associated Pneumonia - Treatment Late Onset and/or Risk Factors

Piperacillin/Tazobactam OR Imipenem OR Meropenem + Tobramycin OR Ciprofloxacin If MRSA suspected add: - Vancomycin or - Linezolid

Ventilator Associated Pneumonia - Prevention

- Elevate head of bed by 30° - Mouth care - Hand hygiene of health care workers

Risk Factors for Gut Anaerobes

- Poor hand hygiene - Severe periodontal disease - Putrid sputum

Community Acquired Aspiration Pneumonia - Treatment Without risk factors for Gut Anaerobes

Ceftriaxone OR Levofloxacin

Community Acquired Aspiration Pneumonia - Treatment With risk factors for Gut Anaerobes

Amox/Clav OR Ceftriaxone + Metronidazole Alternative: - Levofloxacin + Metronidazole

Hospital Acquired Aspiration Pneumonia - Treatment Mild-Moderate

Amox/Clav Or Ceftriaxone + Metronidazole

Hospital Acquired Aspiration Pneumonia - Treatment Severe/ICU

Piperacillin/Tazobactam Or Meropenum

Acute Bronchitis - Symptoms

Cough - No fever - No tachypnea - No tachycardia

Acute Bronchitis - Treatment

Increased humidity Smoking cessation Can use, but, not too useful - Antitussive (Only treats symptoms) - Bronchodilators (Shouldn't use too often) Do not use: - Corticosteroids - Expectorants