Pneumonia

Question 1

What is the definition of community acquired pneumonia

Answer 1

Occurs before hospitalization or within 48 hours of hospital admission

Question 2

The common pathogens involved in community acquired pneumonia are H. influenzae, staph aureus, klebsiella, mycoplasma, chlamydia, legionella, chlamydia psittaci and coxiella burnetii. What are the associations for H. influenzae, staph aureus, and klebsiella

Answer 2

H. Influenzae = COPD
Staph aereus = recent influenza
Klebsiella = alcoholism, diabetes

Question 3

The common pathogens involved in community acquired pneumonia are H. influenzae, staph aureus, klebsiella, mycoplasma, chlamydia, legionella, chlamydia psittaci and coxiella burnetii. What are the associations for mycoplasma, chlamidya, and legionella

Answer 3

1. ) Mycoplasma - young people
2. ) Chlamidya - hoarseness
3. ) legionella - contaminated water sources, air conditioning

Question 4

The common pathogens involved in community acquired pneumonia are H. influenzae, staph aureus, klebsiella, mycoplasma, chlamydia, legionella, chlamydia psittaci and coxiella burnetii. What are the associations of chlamydia psittaci and coxiella burnetii

Answer 4

1. ) Chlamydia psittaci: Birds

2. ) Coxiella burnetii: Animals at time of giving birth, veternarians, farmers

Question 5

What are the most common symptoms of pneumonia

Answer 5

Fever and cough most common

Severe infections have dyspnea. You know its severe if abnormalities of vital signs of mental status. Dullness to percussion is found if there is an effusion

Bronchial breath sounds/egophony: If there is consolidation of air spaces

Chills or rigors are a sign of bacteremia

Chest pain that is pleuritic

Question 6

What is the difference between bronchitis and pneumonia

Answer 6

Pneumonia has dyspnea, high fever, and an abnormal chest X-ray

Question 7

What are the associations of klebsiella pneumonia, anaerobes, mycoplasma pneumonia, legionella, and pneumocystis

Answer 7

Klebsiella: Hemopytisis because necrotizing (currant jelly sputum)

Anaerobes: Foul smelling sputum
Mycoplasma: Dry cough with bullous myringitis
Legionella: GI symptoms and CNS symptoms
Pneumocystis: Aids with cd4 less than 200

Question 8

Which infections cause dry cough and why do they cause dry cough

Answer 8

They cause dry cough because they infect the interstitium more

This includes mycoplasma, chlamidya (atypicals), viruses, coxiella (farmers) and pneumocystis (AIDS)

Will see bilateral interstitial infiltrates instead of consolidation

Question 9

What is the best initial diagnostic test and the order of tests for pneumonia

Answer 9

Best initial: Chest X-ray

Next do sputum gram stain and sputum culture, even though doesnt work 50% of times

Also, atypical organisms (the ones with dry cough) infect cells intracellularly and go into interstitium and will not be seen in sputum cultures

Blood cultures only positive 15% of times but will be more from strep pneumo

Question 10

When is a sputum gram stain allowed to be used

Answer 10

When more than 25 WBC and less than 10 epithelial cells

Question 11

If pneumonia is severe, then you can elect to do a thoracentesis or bronchoscopy. What is the purpose of each

Answer 11

1. ) Thoracentesis is used to analyze pleural effusion and see if empyema is present if diagnosis unclear. If LDH above 60% of serum and protein above 50%, then it is infected and should be drained with chest tube
2. ) Bronchscoyp: Only if ICU, or if pneumocystis where therapy is critical and must figure this shit out

Question 12

Treatment for pneumonia depends on whether you have the gram stain, and we need to decide outpatient and inpatient treatment. What is the criteria and classifications of outpatient treatment

Answer 12

Outpatient
Previously healthy in last 3 months and mild symptoms = macrolide or doxycycline

Comorbities or abx in last 3 months = fluoroquinolone

Question 13

Treatment for pneumonia depends on whether you have the gram stain, and we need to decide outpatient and inpatient treatment. What is the criteria and classifications of inpatient therapy

Answer 13

Just either fluoroquinolone or ceftriaxone + azithromycin

Question 14

What is the criteria for admitting a patient with peumonia

Answer 14

Severe disease: Hypotension, respiratory rate > 30, pO2 less than 60, and more

Question 15

What vaccine should everyone above the age of 65 be given

Answer 15

Pneumococcal vaccine

Other reasons: Functional/anatomic asplenia, hematologic malignancy, immunosuppression

Do not give to healthcare workers

Question 16

What is the definition of hospital acquired pneumonia

Answer 16

Pneumonia developing more than 48 hours after admission

More likely gram negative bacilli such as E. Coli or pseudomonas

Question 17

What is the treatment for hospital acquired pneumonia

Answer 17

Because it is gram negative bacilli, macrolides are not the treatment anymore. Instead, give antipseudomonal and other medications

Antipseudomonal: Cefepime or piperacillin/tazobactam or carbapenems

Question 18

Ventilator associated pneumonia is when you have a mechnical ventilation that interferes with mucociliary clearance of respiratory tract such as ability to cough. What are some hints to suggest that this is what is going on

Answer 18

Fever, new infiltrate, and purulent secretions coming out of endotracheal tube

Question 19

In VAP, sputum culture is completely useless. What are diagnostic tests in order of accuracy and invaseness

Answer 19

1. ) Tracheal aspirate using suction catheter
2. ) Bronchoalveolar lavage: Bronchoscope placed deep into lungs where there should not be organisms, can contaminate - modify with protected brush specimen to avoid contamination from nasopharynx
3. ) Video assisted thoracoscopy: Using scope through chest wall and getting biopsy (like endoscopy)
4. ) Open lung biopsy - most accurate

Question 20

What is the treatment for ventilator associated pneumonia

Answer 20

Combine 3 drugs

Cephalosporin or penicillin or carbapenem (same as HAP) + aminoglycoside or fluoroquinolone (not in HAP) + vanco or linezolid (incase meth resistant staph) However, if specific etiology is known, change abx treatment towards that

Question 21

How does aspiration pneumonia happen and what can it lead to

Answer 21

It happens when someone is lying flat, someone aspirates with poor dentition and this can lead to abscess

Stroke, seizures, intoxication, and endotracheal intubation can also result in aspiration

They will have a large volume sputum that is foul smelling because of anaerobes

Question 22

What is the diagnostic test used for aspiration pneumonia

Answer 22

Initial: Chest X-ray - shows cavity with air fluid level

Most accurate: Lung biopsy

Question 23

What is the treatment for abscess from aspiration pneumonia

Answer 23

Clindamycin or penicillin

Question 24

What is pneumocysti pneumonia, what is the most likely presentation on exam

Answer 24

PCP - P. Jiroveci that occurs exclusively in AIDS patients with CD4 counts

Question 25

What is the initial test for pneumocystis pneumonia, and the best test

Answer 25

Best initial test: CXR showing bilateral INTERSTITIAL infiltrates/arterial blood gas showing increased A-a gradient (however, could be other interstitial processes as well)

Best test: Bronchoalveolar lavage

Stain positive means no further testing for sputum

LDH levels are always elevated, so if they’re not then this is not the answer

Question 26

What is the treatment for PCP

Answer 26

TMP/SMX for treatment and prophylaxis

Steroids decreases mortality if PCP is severe, as in pO2 less than 70 and A-a gradient above 35

If toxicity (neutropenic or rash), switch to clindamycin/primaquine (unless G6PD deficiency) or pentamidine

Question 27

What are prophylaxis treatments for PCP

Answer 27

1.) TMP/SMXIf rash/neutropenia, switch to atovoquone or dapsone

You can stop drugs if cells go above 200