Pneumonia

Question 1

Factors that increase risk for pneumonia:

Answer 1

1) More pathogens are aspirated than the immune system can handle
2) The immune system cannot handle the pathogens will
3) A combination of 1 and 2

Question 2

Pneumonia signs and symptoms:

Answer 2

Cough, fever, and dyspnea are common. Tachypnea, hypertension, or hypotension, pleurisy, chills, rigors, and myalgias can occur.
Physical exam reveals CRACKLES, asymmetrical dullness, egophony, whispered pectoriloquy, enhanced vocal fremitus, wheezes, and rhonchi.
An INFILTRATE on X-ray is the cardinal finding of pneumonia. A chest X-ray is required to diagnose pneumonia.
It is reasonable, but not necessary, to obtain a sputum sample for gram stain.
It is difficult to diagnose pneumonia in the old and frail, and their inability to mount an effective immune response renders them unable to mount an effective immune response. Have a low threshold for suspecting pneumonia in these patients.

Question 3

Community acquired pneumonia (CAP) organisms:

Answer 3

S. pneumoniae, mycoplasma, chlamydophila and influenza. Legionella can cause severe CAP. (S. pneumoniae and H. flu cause “typical” pneumonia, mycoplasma and chlamydophila cause “atypical” pneumonia).

Question 4

Aspiration pneumonia organisms:

Answer 4

Polymicrobial, often due to oral anaerobes.

Question 5

Healthcare associated pneumonia (HAP) and sicker outpatient organisms:

Answer 5

Staph aureus (including MRSA) and gram-negative rods.

Question 6

Ventilator-associated pneumonia (VAP):

Answer 6

Pseudomonas

Question 7

Approach to pneumonia treatment:

Answer 7

Start by giving antibiotics to treat epidemiologically-likely organisms, and then narrow the antibiotic spectrum to the sole identified pathogen, when appropriate.

Question 8

Treatment for MILD community-acquired pneumonia:

Answer 8

Coverage against typicals (S. pneumoniae) and atypicals (mycoplasma). Treat with AZITHROMYCIN or DOXYCYCLINE. Both drugs can be overcome by resistant strep strains.

Question 9

Treatment for MODERATE community-acquired pneumonia:

Answer 9

CEFTRIAXONE (covers S. pneumoniae, GNRs) and AZITHROMYCIN (covers atypicals). Levofloxacin or moxifloxacin are also acceptable.

Question 10

Treatment for SEVERE community-acquired pneumonia:

Answer 10

VANCOMYCIN (for MRSA), CEFTRIAXONE, and AZITHROMYCIN.

Question 11

Treatment for hospital-acquired pneumonia:

Answer 11

VANCOMYCIN and CEFTRIAXONE. Atypicals are uncommon.

Question 12

Treatment for ventilator-acquired pneumonia:

Answer 12

VANCOMYCIN and PIPERACILLIN-TAZOBACTAM (Zosyn), or VANCOMYCIN and CEFTAZIDIME.

Question 13

Pneumonia prevention:

Answer 13

Vaccination against pathogens (pneumococcal vaccine for the very young and very old).
Controlling TB.
Treating the underlying cause of pneumonia susceptibility.

Question 14

With suspected pneumonia, always remember to ask about:

Answer 14

1) TB risk factors
2) Travel history
3) Animal exposure (Q fever, Cryptococcus, etc.)
4) Activity risk factors in immunocompromised patients (gardening, construction sites, etc.)

Question 15

Pneumococcal vaccinations:

Answer 15

7-valent conjugate polysaccharide vaccine for children (less T-cell immunity requires the use of a conjugate vaccine)
23-valent polysaccharide vaccine for adults
(better T-cell immunity in adults)