Pneumonia Flashcards
Describe the general pathophysiology of pneumonia?
Increased # of microbial pathogens @ alveolar level
Host’s inability to fight off said pathogens
How do pathogens gain access to the pulmonary cavity to cause pneumonia?
Aspiration from oropharynx = MOST COMMON
Inhaled as contaminated droplets
Hematogenous spread = rare
Extension from infected pleural or mediastinal space
What are the defense mechanisms of the respiratory system?
Hairs/turbinates of nares
Branch architecture of tracheobronchal tree –> traps particles in lining
Mucociliary clearance
Local antibacterial factors
Gag reflex
Cough mechanism
Normal flora of the oropharynx
Body’s Immune Response
When will pneumonia occur?
When 1 or more of the bodies defense mechanisms fail
Large Infectious inoculum/virulent pathogen overwhelms immune response
What are the immune responses that triggers the clinical syndrome of pneumonia and what are their symptoms?
Alveolar capillary leak = infiltrate/rales
Alveolar filling = hypoexmia
Leakage of erythrocytes = hemoptysis
What is CAP?
Community Aquired Pneumonia
What is the epidemiology of CAP?
8th most common cause of death in the US –> 25% = hospitalized
4 - 5 million cases/year –> 12/1000
Most common cause of death from infectious disease
Which populations have the highest incidence of CAP?
Extremes of ages: very young and very old
12-18/1000 60 yo
What are the mortality rates of CAP?
Out patient = < 1%
In patient = 10 - 12%
1 year mortality of patents > 65 = 40%
What is the presentation of CAP dependent on?
Progression
Severity
What are the classic signs/symptoms of CAP?
Acute or subacute cough w/ or w/o sputum
Dyspnea
Fever
Chills
Sweats
Chest pain (esp. plueritic) w/ deep breath
Hemoptysis
GI complains = 20% have n/v and/or diarrhea
Fatigue
Head Ache
Myalgias (body Aches)
What is the etiology of CAP?
Strep. pneumonia = MOST common
H. Influenza
S. aureus
In pts w/ a Hx of aspiration, abscess formation, empyemas or parapneumonic effusions, what is the most common cause of CAP?
Anaerobes
In pts w/ a Hx of alcohol abuse, what is the most common cause of CAP?
Klebsiella pneumonia, Strep pneumonia
What are the signs/symptoms of CAP caused by Klebsiella pneumonia?
Necrosis
Hemorrhage
Sputum looks like currant jelly
What is the most common cause of CAP in a pt w/ a Hx of aspiration?
Pseudomonas aeroginose
What are the common risk factors/comorbidities of pneumonia (14)?
Alcoholism
Asthma/COPD
Immunosupression –> chronic steroid use
Institutionalism
> 70
Smoking = STRONGEST RISK FACTOR IN NON ELDERLY/NON IMMUNOCOMPROMISED
increase chance 2-4x
Dementia
Seizure disorder
Cerebrovascular dz
HIV
Structural lung DZ
Introvenous Drug Abuser
Gastric Acid Suppression Therapy
Short duration H+ inhibitors
What would you expect to see on physical exam of a pt w/ pneumonia?
Fever
Tachypnea
Tachycardia
Hypoxia
Increased tactile fremitus (increased chest wall vibration near infection)
Egophony over infected area (E sounds like A)
Altered breath sounds
Crackles
Ronchi
Bronchial breath sounds
Dullness to percussion over infection
When treating an outpatient CAP, should you culture for a specific pathogen?
Not at first
What test do you perform on EVERYONE w/ pneumonia?
Chest X-ray = Classic Exam
What would you expect to see on a chest x-ray of a pt w/ pneumonia?
Patchy airspace infiltrates
Lobar consolidation
Diffuse alveolar/interstitial infiltrates
may or may not see pleural effusion
When would you do a CT scan on a pt suspected of having pneumonia?
Severe cases
Unresolving cases
Complicated Cases
When do you do a follow Chest X-Ray for a pt w/ pneumonia?
At least 6 weeks (otherwise won’t see a difference in X-ray)
What are the Ddx for CAP?
Acute bronchitis
COPD exacerbation
CHF
Lung Cancer
Pulmonary Embolism
Atelectasis
Pulmonary Vasculitis
When would you admit a pt for pneumonia?
Pneumonia Severity Index
CURB-65 criteria
Outpatient treatment failed
Exacerbation of underlying disease
Complications
Hypoxemia
Pleural effusion
Sepsis
Other medical/psychosocial needs
Cognitive dysfunction
Homelessness
Drug abuse
Lack of outpatient resources
How would you treat out patient pneumonia?
Antibiotics 5 - 10 days
Treat empirically to cover most likely pathogens (based on acuity, risk factors, local antibiotic resistance)
Don’t wait for culture results to start!
What is your first line antibiotic to treat outpatient CAP in a healthy pt w/ no antibiotic use in the last 3 months?
Macrolide:
erythromycin
clarithromycin
azithromycin
What is your second line antibiotic to treat outpatient CAP in a healthy pt w/ no antibiotic use in the last 3 months?
Doxycycline
What is your first line antibiotic to treat outpatient CAP in a pt with a comorbidity or has had antibiotic treatment in the last 3 months?
Respiratory Fluoroquinolones:
Levofloxacin
Moxifloxacin
Gemifloxacin
Beta-lactam antibiotics:
Amoxacillin/Augmentin + macrolide
What are the complications associated w/ pneumonia?
Respiratory failure
Shock
Multi-organ failure
Coagulopathy
Exacerbation of comorbidity -> COPD/chronic bronchitis
Metastatic (spread) infection (10% of bacterial pneumonia) –> meningitis, pericarditis, peritonitis, parapneumonic effusion, empyema
Pulmonary embolism w/ infarction
Acute MI
Acute respiratory distress syndrome (ARDS)
Which types of patient will get a full diagnostic work-up for pneumonia?
ALL inpatients
Pt w/ weird presentation
Public health concerns
In a pt w/ a Hx of COPD, what are the most common causes of CAP?
H. influenza
Moraxella catarrhalis
S. pneumonia
In a pt w/ a Hx of Cystic Fibrosis (CF) what are the most common causes of CAP?
Pseudomonas species
In Young adults what is the most common cause of CAP?
Atypicals:
Mycoplasma
Chlamydia
If a pt were to have gotten pneumonia from shitty air conditioning, what is the most common pathogen?
Legionella pneu.
In pts w/ suffering from leukemia/lymphoma what are the most common cause of CAP?
Fungus
In pts w/ a Hx of IV drug abuse, what is the most common causes of CAP?
Hematogenous spread of S. auerus ( (+) MRSA)
In a pt post CVA (stroke) aspiration, what is the most common cause of pneumonia?
Oral flora (including S. pneumonia)
In a pt post influenza, what is the most common cause of pneumonia?
S. pneumonia
S. aureus
In children < 1 yo, what is the most common cause of pneumonia?
RSV (respiratory syncytial virus)
In children > 2 yo, what is the most common cause of pneumonia?
Parainfluenza virus
What is the atypical pneumonia presentation?
Low grade fever
Mild pulmonary symptoms = non productive cough
Myalgias
Fatigue
No lobar consolidation
Small increases in WBCs
**Pt looks better than symptoms/CXR suggest
What is the cause of atypical pneumonia?
Mycoplasma pneumonia = MORE common in young
Chlamydia pneumonia = most common in out patient (10% CAP); younger population
Legionella spp. = most common inpatient
Exposure to contaminated H2O drops
from cooling and ventilation system
Nursing Homes
Rehab Facilities
Moraxella species
Viruses
Influenza/RSV = most common
Adenovirus
What are the signs and symptoms in elderly patients?
Subtle!
Cognitive impairment or change in mental status
Anorexia
Functional Decline
Falls
Weight Loss
Slight increase in respiratory rate
What are the labs for inpatient treatment?
Point of care diagnostic testing (POC)
Pre-antibiotic sputum cultures
Blood cultures
ABG (arterial blood gas) if hypoxic
CBC w/ differential
CMP
HIV testing in any pt who is at risk
When is POC diagnostic testing done and why is it done?
Usually ER
Helps in broadening Abx coverage in pts being hospitalized
What is included in POC?
Sputum gram stain
Urinary antigen tests for Legionella species/S. pneumonia
Rapid antigen testing for influenza (nasal swab)
When is it most important to do sputum cultures and blood cultures?
PRIOR to starting Abx
How are the blood cultures done?
2 sets from 2 separate needle sticks @ 2 different sites
Why is it important to do POC, Pre-antibiotic sputum tests, and blood cultures?
Allows the adjustment of Abx coverage based on results
How would you treat inpatient, non-ICU patients?
Respiratory Fluoroquinolone PO/IV
Beta lactam (ceftriaxone/cefotaxime) + macrolide (clarithromycin/azithromycin)
Hydration
Room air if O2 sat is > 90%; supplemental O2 if sat is < 90%
What is the treatment for inpatient ICU patients?
IV Macrolide
IV Respiratory fluoroquinolone + anti-pseudomonal B-lactam
How do you prevent CAP?
Annual influenza vaccine (6 mo (+))
Polyvalent pneumococcal vaccine
What does the polyvalent pneumococcal vaccine do?
Potential to prevent
Less severity
Which patients are recommended to get the pneumococcal vaccine?
> 65 yo
Hx of chronic illness
What are the follow up recommendations for outpatient CAP?
2 - 3 days if no improvement (sooner if worse)
In an otherwise healthy pt when will fever/leukocytosis resolve?
2 - 4 days
How long will the physical findings of CAP persist?
Much longer (fatigue/cough)
CXR won’t clear for 4 - 12 weeks depending on pt age/underlying lung dz
What are the follow up recommendations for inpatient CAP?
Discharge once conditions are stable
Repeat CXR in 4 - 6 wks
When would you consider an underlying neoplasm?
If relapse/recurrence occurs (particularly in same segment of lung)
What is HCAP?
Health Care-Associated Pneumonia
virulent/drug resistance pathogens (MDR)
What are the factors responsible for the development of HCAP?
Widespread use of potent Abx
Early transfer of pts out of acute care hospital to homes/lower acuity facilities
Increased use of outpatient IV Tx
Aging population
More extensive immunomodulatory therapy
What are the risk factors for HCAP?
Abx therapy in past 90 days
Acute care hospitalization for at least 2 days in the last 90 days
Residence in nursing home or extended care facility
Home infusion therapy w/in past 30 days
Home wound care
Family member w/ infection involving MDR pathogen
Immunosuppresive disease or immunosuppresive therapy
What is the definition of HAP?
Caused by organisms that colonize ill patients, staff and equipment, producing clinical infx more than 48 hours after admission to the hospital or other health care facility and excludes any infection present at the time of admissio
What is the epidemiology of HAP?
ICU pts @ increased risk
2nd most common cause of hospital acquired infection
Leading cause of death d/t infection
Mortality = 20 - 50%
What is VAP?
Ventilator Associated Pneumonia
“Pneumonia that has developed more than 48 hours following endotracheal intubation and mechanical ventilation”
What is important about VAP?
Higher mortality rate
What are the risk factors for VAP?
Endotracheal tube (microaspiration)
Cross infection from other infected/colonized patients
Contaminated Equipment
Malnutrition
What are the common organisms that cause HCAP/HAP/VAP
S. pneumonia - often drug resistant in HCAP
S. aureus (MSSA/MRSA)
Pseudomonas aeruginosa
Klbsiella
E. coli
Enterobacter
VRE (Vancomycin resistant enterococci)
What is the most likely pathogen in the ICU?
Pseudomonas aeruginosa
Which of the organisms that cause HCAP/HAP/VAP carries the worst prognosis?
Pseudomonas aeruginosa
What are the common signs/symptoms of HCAP/HAP?
Similar to CAP but may be nonspecific
2+ clinical findings (fever, purulent sputum, leukocytosis) in setting of new or progressive pulmonary opacity on Chest X-Ray is highly suggestive of pneumonia
What are the clinical signs/symptoms of VAP?
Fever
Leukocytosis
Increase in respiratory secretions
Pulmonary consolidation on physical exam
New or changing infiltrate on CXR
Tachypnea
Tachycardia
Worsening oxygenation = hypoxia
Increased minute ventilation
What is the most important thing in diagnosing VAP?
Physical Exam, patients can’t talk
What is the Ddx of HCAP/HAP/VAP
CHF
Atelectasis
Aspiration
ARDS
Pulmonary Embolism
Pulmonary Hemorrhage
Drug Reactions
What are diagnostic tests of HCAP/HAP/VAP?
Gram stain
Sputum culture
Blood culture (2 different sites)
WBC
ABG
Pulse Ox
Thoracentesis in pts w/ pleural effusion (culture)
CXR
Endotracheal aspiration cultures (VAP)
Procalcitonin levels
What would you expect the WBC findings to be in a pt with HCAP/HAP/VAP?
Elevated
Increased Bands
Why are the procalcitonin levels checked in a pt who you’re trying to diagnose w/ HCAP/HAP/VAP?
Studies show can help to distinguish bacterial pneumonia from noninfectious causes of fever w/ pulmonary infiltrates in hospitalized pts
What is the treatment of HCAP/HAP/VAP?
Start empirical therapy
Tailor when cultures come back
When do anaerobic pneumonia and lung abscesses happen?
Secondary to aspiration
What are the risk factors for aspiration (and therefore anaerobic pneumonia/lung abscess)
Decreased LOC d/t drug or ETOH use
Siezure
General anesthesia
CNS disease
Esophageal disease
Tracheal or NG tubes
Periodontal diseases/poor dental hygiene (increases chances fo anaerobic infection)
Which part of the lungs infected is the most likely by anaerobic pneumonia and lung abscesses?
Posterior segments of upper lobes
Superior/basilar segments of lower lobes
**body position @ time of aspiration determines which lung zone are affected
Describe the onset of anaerobic pneumonia and lung abscess?
Insidious –> gradual and harmful
What kinds of complications may accompany anaerobic pneumonia and lung abscess?
Abscess
Empyema
Necrotizing pneumonia
**because onset is gradual but harmful
What is the cause of anaerobic pneumonia and lung abscesses?
Multiple anaerobes typically present
Can also have aerobic bacteria
Prevotella melaninogenica
Peptostreptococus
Fusobacterium nucleatum
Bacteroides species
What is the clinical presentation of anaerobic pneumonia and lung abscess?
Fever
Weight Loss
Malaise
COUGH w/ FOUL-SMELLING PURULENT SPUTUM (don’t have to have cough)
Dentition = poor
What diagnostic tests are done to diagnose anaerobic pneumonia and lung abcess?
Labs
CXR
What types of labs are done and how are they done?
Sputum culture
BUT must be obtained by transthoracic aspiration, thoracentesis or bronchoscopy
**Expectorated sputum cultures contaiminated w/ mouth flora
** rarely indicated b/c pts usually respond well to empiric therapy
What would you expect to see on a CXR in a pt with anaerobic pneumonia and lung abscess?
Lung Abscess
Empyema
Thick walled solitary cavity surrounded by consolidation
Air fluid level usually present
Necrotizing pneumonia
In addition to CXR what do you want to do in a pt w/ anaerobic pneumonia and lung abscess?
Ultra sound (helps located fluid/reveal loculations)
What does necrotizing pneumonia look like on a CXR?
Multiple areas of cabiation w/ in an area of consolidation
What is the treatment of anaerobic pneumonia?
Clindamycin OR
Amoxicillin-clavulanate OR
Penicillin G + metronidazole
What is the treatment of empyema/lung abscess?
Clindamycin OR
Amoxicillin-clavulanate OR
Penicillin G + metronidazole
AND
Drainage –> tube thoracostomy or open pleural drainage (NEED TO DO THIS!!)
What is one of the most frequent complication of HIV?
Pneumonia
What is one of the 3 most common AIDS defining illnesses?
Recurrent bacterial pneumonia
What are the most common causes of pneumonia in a pt w/ AIDS?
Streptococcus
Haemophilus
Pseudomonas
TB
Pneumocystis jiroveci (PCP)
What is the epidemiology of Pneumocystis pneumonia (PCP)?
decreaed incidence d/t prophylaxis and improved treatment of HIV/AIDS
MOST COMMON CAUSE of pneumonia in pts w/ HIV in US
50% occur in pts unaware that they have HIV
Increased risk if pt has previous bout of PCP, those who have CD4+ T cell count < 200/uL
What should all pts w/ CD4+ T cell counts < 200 do?
Be on prophylaxis
Vaccinate w/ pneumocci vaccine
What are the signs/symptoms of HIV related pneumonia?
Nonspecific symptoms
Fever
Cough
SOB
Unexplained weight loss
Severity of symptoms can vary significantly
Hypoxia = severe
What diagnostic testing is done in pts suspected of HIV related pneumonia?
Definitive diagnosis REQUIRES organism in sputum sample
CXR
CT Scan
What would you expect CXR of HIV related pneumonia to look like?
Normal (5 - 10%)
Diffuse/perihilar infiltrates = most characteristic
Ground glass appearance** (test question)
What would you see in the CT Scan of HIV related pneumonia?
Patchy ground glass appearance
What is the STANDARD treatment of PCP?
Trimethoprim/Sulfamethoxazole = Bactrim
What would you add if you pt who has PCP is hypoxic?
Steroids
What happens if PCP is untreated?
100% mortality rate
How long is PCP treatment?
21 days
Prophylaxis w/ Bactrim or Dapsone in all pts w/ CD4 count < 200 or hx of PCP
What is the cause of tuberculosis pneumonia?
Mycobacterium tuberculosis
How is tuberculosis spread?
Airborn droplets
What is the epidemiology of tuberculosis pneumonia?
World’s most widespread and deadly illness
3 million ppl die/yr worldwide
Estimated 15 million infected in US
Increased drug resistance (have to treat w/ multi drugs for longer)
Which populations have the greatest occurrence of Tuberculosis?
HIV (+)
Foreign born
Disadvantaged populations –> malnourished, homeless, living in overcrowded/substandard housing
What would you see with primary tuberculosis?
Clinically/radiographically silted
May lie dormant for years –> decades
T cells/macrophages contain the infection in granulomas but don’t eradicate it from the body
What is primary progressive TB?
5% of primary tuberculosis cases
immune response = inadequate
pulmonary/constitutional symptoms develop
What is latent tuberculosis infection?
Pt doesn’t have active disease
Can’t transmit to others
What is secondary tuberculosis?
Reactivation of the disease
When does secondary tuberculosis occur?
When host’s immune system is impaired
Develop in 10% of pts that have latent TB infection who haven’t been given preventive therapy
When is there increased risk of reactivation (secondary tuberculosis)?
Immunosuppression –> HIV, immunosuppressive Tx
Gastrectomy
Silicosis
Diabetes Mellatus
What are the signs/symptoms of tuberculosis pneumonia?
Chronic cough = MOST COMMON PULMONARY SYMPTOM
(initially dry –> productive; blood streaked sputum)
Slow progressive constitutional symptoms = classic
Anorexia
Weight Loss
Fever
Night Sweats
Pt Looks ill/malnourished
Auscultation can be normal OR post-tussive apical rales
What are the labs that are done for a pt suspected to have tuberculosis pneumonia?
Culture or ID bacteria by PCR (need 3 consecutive morning sputum samples)
Fiberoptic bronchoscopy (if sputum smear = (-); and you suspect TB)
Transbronchial lung biopsy
What do CXR look like in a pt w/ tuberculosis pneumonia?
Ghon = calcified primary focus –> healed primary TB
Ranke = calcified primary focus/calcified hilar lymph nodes –> healed primary TB
Small homogenous infiltrates
Hilar/parathracheal lymph node enlargement
Segmental atelectasis
Pleural effusion
Cavitation may be seen w/ progressive primary TB
What kind of test can you do to ID pts who have been infected w/ TB?
Tuberculin Skin Test –> Mantoux Test/PPD
What is the problem with the Tuberculin Skin/ PPD Test?
Doesn’t distinguish between active and latent infection
Describe the method of the tuberculin skin/ PPD test?
0.1 mL of purified protein derivative (PPD) contain 5 tuberculin units injected intradermally on forearm
Transverse width in mm of induration (elevation) @ site of injection is measured w/in 48 - 72 hrs
What are considered a (+) tuberculin skin test/ PPD?
> /= 15 mm in person w/o risk factors
> /= 10 mm for recent immigrants, IVDU, lab personnel, residents/employees in high risk setting, person w/ medical conditions that increase risk of TB, children < 4 or infant, child, or adolescent exposed to high risk adults
> /= 5 mm for HIV (+) pts, recent contacts of individual w/ active TB, person w/ CXR indicative of TB, pts w/ organ transplants, other immunosuppressed pts
How long after TB infection does it take for a (+) Tuberculin skin test/PPD test?
2 - 10 weeks
What can give a false positive tuberculin skin test/PPD test?
Pts who have been vaccinated against TB w/ BCG
BCG = bacillus calmette-guerin (foregin vaccine)
What are the treatment goals against pulmonary tuberculosis?
Eliminate all tubercle bacilli from individual
Prevent morbidity/death while avoiding emergence of drug resistance
Who do you need to report any suspected/confirmed cases of TB?
Local/State Public Health
What is the major cause of treatment failure?
Non-adherence –> continued transmission and drug resistance
Which 4 drugs are the first line drugs against pulmonary tuberculosis?
Isoniazid
Rifampin
Pyrazinamide
Ethambutol
What is a side effect of isoniazid?
Neuropathy
What should be given with isoniazid?
Vitamin B6
Who should be give vitamin B6 w/ isoniazid?
Alcoholics
Malnourished
Pregnant/lactating women
Pts w/ CRF
Pts w/ Diabetes Mellitus
Pts w/ HIV
Describe the treatment of tuberculosis pneumonia in a HIV (-) patient?
6 - 9 month regimen
1st phase (first 2 months) –> bacilli is killed, symptoms resolve, pt = noninfectious
2nd phase (4 - 7 months) –> continuation/sterilizing to eliminate persisting mycobacteria and prevent relapse
During the first phase of treatment for tuberculosis pneumonia in a HIV (-) pt which drugs are given?
4 drug therapy:
Isoniazid
Rifampin
Pyrazinamide
Ethambutol
During the 2nd phase of treatment for tuberculosis pneumonia in a HIV (-) pt which drugs are given?
at least 4 months of:
Isoniazid
Rifampin
What is the treatment of tuberculosis pneumonia in HIV (+) pt?
Similar to HIV (-) but longer duration
**important to monitor drug interactions
Requires specialists in management of TB and HIV
Direct observation therapy to confirm adherance
B6 supplementation
What is the treatment of latent tuberculosis?
Isoniazid x 9 months
Rifampin and pyrazinamide x 2 month = usually treatment of choice b/c of length
Rifampin x 4 months
When would you treat for latent tuberculosis?
(+) mantoux and high risk
if pt had close contact w/ active disease –> repeat PPD if initial test = (-) (b/c takes 2 - 10 wks before you can have (+) ppd test)
