Pneumonia Flashcards
What are the types of pneumonia based on how it is acquired?
CAP (community-acquired pneumonia): not recently hospitalized and without healthcare associated risk factors
Aspiration: from aspiration of GI content
HAP (hospital acquired pneumonia): acquired more than 48 hours after hospitalization
VAP (ventilator associated pneumonia): acquired more than 48-72 hours after endotracheal intubation
HCAP (healthcare associated pneumonia): if was hospitalized for more than 2 days in the last 90 days, lives in nursing home/long-term care, recent IV therapy or wound care in last 30 days, or on hemodialysis
What is the most common pathogen in CAP? Is it different in children?
(what are the possible pathogens)
Streptococcus pneumoniae is the most common cause of CAP, Mycoplasma pneumoniae is second
Moraxella catarrhalis is more common cause in young children and elderly
But VIRAL is the common cause of CAP in children (RSV, parainfluenza, influenza A)… while less common in adults (influenza A+B, adenovirus…and even less common rhinovirus, enterovirus, varicella zoster, herpes simplex)
- H. influenzae colonization risk higher in COPD and cystic fibrosis patients
- MRSA is associated with necrotizing and more severe forms of CAP
What are the risk factors for obtaining drug resistant S. pneumoniae (DRSP) CAP?
DRSP means strains resistant to 3+ drugs
S. pneumoniae is the most common cause
Risk factors: younger than 2 or older than 65, antibiotic therapy in last 3 months, alcoholism, medical comorbidities, immunosuppression
What are the risk factors that the patient might have CA-MRSA?
Cavitary pneumonia, lung necrosis, rapidly increasing lung effusion
Gross hemoptysis
Neutropenia, concurrent infection
Erythematous skin rash
Summer season, previously healthy, prior conjugate pneumococcal vaccination (rules out S. pneumo cause)
What are risk factors for aspiration and how might aspirations lead to pneumonia infections?
Aspiration risk factors: conditions that cause Dysphagia (stroke, seizure, alcoholism, aging), changed Oropharyngeal colonization (poor hygiene, meds, disease, tube feeding),
Reflux that allows gram-negative bacilli to colonize gastric content
Decreased host defense (impaired mucus or cilia function, decreased immunoglobulin, altered cough reflex)
Oral content has anaerobic variety (Bacteroides spp., Fusobacterium spp, Prevotella etc.)
Gastric content could be overrun by gram-negative bacilli and S. aureus
What is the 2nd most common nosocomial/hospital-acquired infection in the US?
HAP, more common with increasing age
Risk factors: intubation and mechanical ventilation, aspiration, oropharyngeal colonization, hyperglycemia (inhibits phagocytosis and feeds bacteria)
When is risk of VAP highest? What species cause the highest rate of death?
VAP highest risk in 1st FIVE days of intubation (decreases onward)
Highest mortality due to bacteremia from Pseudomonas and Acinetobacter (both need high coverage treatment, resistant), medical illness rather than surgical, ineffective antibiotic therapy
*Cause is rarely from anaerobes
Causes can be gram-negative aerobic (Ps. aeruginosa, E. coli, K. pneumonia, Acinetobacter sp.) or gram-positive (S.aureus/MRSA)
What are the signs and symptoms of pneumonia? As the patient is admitted, what vitals indicated poor prognosis?
Symptoms:
cough, SOB, dyspnea
constitutional (fever, fatigue, myalgia)
neuro (mental status change, confusion, lethargy, disorentation)
Signs: FEVER (sustained or intermittent)
Pulm. (cyanosis, using accessory muscles, diminished breath sounds, rales or rhonchi)
Vitals associated with poor prognosis: RR 30+, BP under 90/60, HR 125+, temp under 35C or over 40C
What diagnostic tests should be performed for suspected pneumonia? What might indicate severity/poor prognosis?
O2 sat (should be over 90%)
CBC (shows high or low WBC with neutrophilia)
Sputum gram stain (not done in outpatient setting)
Blood culture REQUIRED in all pneumonia-hospitalized patients (best to get two sets and before treatment)
Chest X-ray supportive of diagnosis if reveals infiltrates…
Can also consider PCR to detect pathogen DNA allowing for more rapid diagnosis/targeted therapy, or urinary antigens (DFA) for diagnosing Legionella pneumophila
*Poor prognosis based on X-ray findings of:
multilobar or rapid progression infiltrates, pleural effusion, necrotizating
How is pneumonia severity determined/classified and how does this impact how the patient receives care?
Using Pneumonia Severity Index (5 categories based on 30 day mortality)
or
CURB-65
1 point each given based on confusion, uremia (BUN above 7mmol/L), respiration (30+), blood pressure (below 90/60), age (above 65)
Predicts WHERE patient receives care:
PSI = I-II outpatient, III clinical judgement, IV inpatient, V ICU
or
CURB-65 = 2 points consider hospitalization, 3+ points consider ICU
How can a chest-xray indicate HAP/VAP along with clinical signs?
Chest-xray shows NEW infiltrate with at least TWO of the following:
Temp above 38C/100.4F
Leukocytosis or Leukopenia
Purulent secretion
Culture identifies pathogen (definitely should get blood culture, sputum culture should be obtained before Abx)
In general, how is initial treatment for pneumonia guided?
Initial treatment is EMPIRICAL…so based on history before cultures return
(guide by pneumonia type and severity, onset, specific risk factors and patient factors)
Keep in mind LOCAL resistance patterns
What are the empiric treatment guidelines for CAP (using IDSA guideline)?
Healthy Outpatient = Macrolide OR Doxycycline
Outpatient at risk for DRSP or for Inpatient non-ICU = Respiratory Fluoroquinalone OR Beta-Lactam and Macrolide
Inpatient ICU = Beta-lactam and Azithromycin OR Beta-lactam and Respiratory fluoroquinalone
- Respiratory Fluoroquinalone i.e. Levofloxacin, Moxifloxacin, Gemifloxacin
- Beta-lactam (inpatient) i.e. Ceftriaxone, Cefotaxime, Ampicillin/Sulbactam
- For CA-MRSA can use Vancomycin or Linezolid
What are the empiric treatment guidelines for CAP (using JC/CMS guideline)?
Distinguishes Non-ICU from ICU patients
Options for Non-ICU = Beta-lactam and Macrolide… or Antipneumococcal Quinalone… or Beta-lactam and doxycycline, Tigecycline monotherapy, Macrolide monotherapy
Options for ICU = Macrolide with beta-lactam or specifically antipneumococcal/antipseudomal Beta-lactam… or Antipneumococcal quinalone, Antipseudomonal quinalone with Beta-lactam or specifically antipneumococcal/antipseudomonal Beta-lactam… or antipneumococcal/antipseudomonal Beta-lactam with aminoglycoside with either antipneumococcal Quinalone or Macrolide
- Beta-lactam i.e. Ceftriaxone, Cefotaxime, Unasyn
- Antipneumococcal/Antipseudomonal Beta-lactam i.e. Cefepime, Imipenem, Meropenem, Piperacillin/Tazobactam
- Antipneumococcal Quinalone i.e. Ciprofloxacin or Levofloxacin
What is the general duration of therapy for pneumonia i.e. when can they be discharged for hospital?
Try to identify organism targeted therapy within 24-72 hours after admission
Therapy for 5-7 days, at minimum 5 days until no fever for 48-72 hours
Use oral meds when clinically stable
Discharge patient when vital signs and O2 status is stable and no comorbitidies are unresolved
