Pneumonia Flashcards by Charles Cabus

CURB-65 Criteria. (Harrison’s 19th edition, pp 806)

Confusion
Urea > 7mmol/L
RR >/= 30 cpm
Blood pressure < or = 90/60
Age >/= 65 yo

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Pathologic phases of pneumonia. (Harrison’s 19th edition, pp 804)

Edema
Red hepatization
Gray hepatization
Resolution

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Most common organism in community-acquired pneumonia. (Harrison’s 19th edition, pp 804)

Streptococcus pneumoniae

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Criteria for adequate sputum sample for culture. (Harrison’s 19th edition, pp 806)

> 25 Neutrophils per low-power field

< 10 squamous epithelial cells per low-power field

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Most frequently isolated pathogen in blood cultures. (Harrison’s 19th edition, pp 806)

Streptococcus pneumoniae

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Most important risk factor for antibiotic-resistant pneumococcal infection. (Harrison’s 19th edition, pp 806)

Use of a specific antibiotic within the previous 3 months

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Treatment for outpatients with community-acquired pneumonia who are previously healthy and no antibiotics use in the past 3 months. (Harrison’s 19th edition, pp 808)

Macrolide OR Doxycycline
Clarithromycin 500mg PO BID
Azithromycin 500mg PO x 1 dose then 250mg PO OD
Doxycycline 100mg PO BID

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Indication for Chest tube insertion in patients with parapneumonic pleural effusion. (Harrison’s 19th edition, pp 809)

pH < 7
Glucose level < 2.2mmol/L
Lactate dehydrogenase > 1000U/L
(+) bacteria seen or cultured

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Most obvious risk factor for Ventillator-associated pneumonia. (Harrison’s 19th edition, pp 810)

Endotracheal tube

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Mechanical factors in host defense for pneumonia. (Harrison’s 19th edition, pp 804)

Hairs and turbinates
Branching architecture of the tracheobronchial tree
Mucociliary clearance
Local antibacterial factors
Gag reflex
Cough mechanism
Normal flora

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Treatment for outpatients with community-acquired pneumonia who have comorbidities or antibiotics in past 3 months. (Harrison’s 19th edition, pp 808)

Fluroquinolone OR B-Lactam + macrolide
Moxifloxacin 400 mg PO OD
Gemifloxacin 320mg PO OD
Levofloxacin 750mg PO OD
Amoxicillin 1gm PO TID
Co-amoxiclav 2gm PO BID
Ceftriaxone 1-2gm/IV OD
Cefpodoxime 200mg PO BID
Cefuroxime 500mg PO BID

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In pneumonia, the percent yield from blood cultures when samples are collected before antibiotic therapy. (Harrison’s 19th edition, pp 806)

Low (5-14%)

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In pneumonia, which Legionella pneumophila serogroup/s can be detect with a legionella antigen test in the urine? (Harrison’s 19th edition, pp 806)

Serogroup 1 only (sensitivity 90%, specificity 99%)

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Sensitivity and Specificity for pneumococcal urine antigen test to diagnosed Pneumococcal pneumonia. (Harrison’s 19th edition, pp 806)

sensitivity 80%

specificity >90%

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Yield of positive cultures from sputum samples. (Harrison’s 19th edition, pp 806)

Highly variable (< or = 50%, even in cases of proven bacteremic pneumococcal pneumonia)

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Access point of microorganisms to the lower respiratory tract. (Harrison’s 19th edition, pp 804)

Aspiration from the oropharynx
Inhaled as contaminated droplets
Hematogenous spread – rarely (from tricuspid endocarditis)
Contiguous extension – rarely (from an infected pleural or mediastinal space)

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Most common access (pathophysiology) of pneumonia. (Harrison’s 19th edition, pp 804)

Aspiration from oropharynx

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Initial presentation of elderly patients with pneumonia. (Harrison’s 19th edition, pp 805)

New-onset or worsening confusion and few other manifestations

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Clinical manifestation of pneumonia if the pleura is involved. (Harrison’s 19th edition, pp 805)

Pleuritic chest pain

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Physical findings of patients with pneumonia. (Harrison’s 19th edition, pp 805)

Vary with the degree of pulmonary consolidation and presence/absence of pleural effusion
Increase RR and use of accessory muscles – common
Palpation – increased (consolidation) or decreased (effusion) tactile fremitus
Percussion – dull to flat
Auscultation – Crackles, bronchial breath sounds and pleural friction rub

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In pneumonia, gross hemoptysis is suggestive of? (Harrison’s 19th edition, pp 805)

CA-MRSA

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Empirical antibiotic treatment of health care-associated pneumonia. (Harrison’s 19th edition, pp 812)

B-lactam + gram neg coverage + gram pos coverage
Ceftazidime 2gm/IV Q8, Cefepime 2gm/IV Q8-12, Piptazo 4.5gm/IV Q6, Imipinem 500/IV Q6 or 1gm/IV Q8, meropenem 1gm/IV Q8
+
Gentamicin or tobramycin 7mg/kg/IV Q24, amikacin 20mg/kg/IV Q24, Ciprofloxacin 400mg/IV Q8, Levofloxacin 750mg/IV Q24
+
Linezolid 600mg/IV Q12
Vancomycin 15mg/kg Q12

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Prevention strategies for VAP. (Harrison’s 19th edition, pp 813)

Avoidance of intubation
Decrease duration of MV
Avoidance of prolonged antibiotic courses
Short course of prophylactic antibiotics for comatose patients
Head elevation 30-45O
Prophylactic agents that raise gastric pH
Oropharyngeal and bowel flora decontamination
Tight glycemic control

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Microorganisms in CAP that are intrinsically resistant to beta lactam agent. (Harrison’s 19th edition, pp 804)

Atypical organisms

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Typical organisms in community-acquired pneumonia. (Harrison’s 19th edition, pp 804)

``` Streptococcus pneumoniae Haemophilus influenza Staphylococcus aureus Klebsiella pneumoniae Pseudomonas aeruginosa ```

Atypical organisms in community-acquired pneumonia. (Harrison’s 19th edition, pp 804)

Mycoplasma pneumoniae Chlamydia pneumoniae Legionella species Respiratory viruses (influenza, adenoviruses, RSV and HMPV)

Treatment for atypical organisms in CAP. (Harrison’s 19th edition, pp 804)

Macrolide Fluoroquinolone Tetracycline

Phase of pneumonia that is characterized by predominance of neutrophils, abundant fibrin deposition, and disappearance of bacteria and corresponds with successful containment of the infection and improvement in gas exchange. (Harrison’s 19th edition, pp 804)

Gray hepatization

Phase of pneumonia that is characterized by the presence of a proteinaceous exudate (often bacteria) in the aveoli. (Harrison’s 19th edition, pp 804)

Edema

Phase of pneumonia that is characterized by the presence of erythrocytes in the cellular intraalveolar exudates but neutrophil influx is more important with regard to host defense and bacteria is usually seen in pathologic specimens collected during this phase. (Harrison’s 19th edition, pp 804)

Red hepatization

Phase of pneumonia that is characterized as reappearance of macrophage as the dominant cell type in the alveolar space, and the debris of neutrophils, bacteria, and fibrin has been cleared, as has the inflammatory response. (Harrison’s 19th edition, pp 804)

Resolution

Phase of pneumonia that is characterized by no new erythrocytes extravasating and those already present have been lysed and degraded. (Harrison’s 19th edition, pp 804)

Gray hepatization

Predominant cell in each phase of pneumonia. (Harrison’s 19th edition, pp 804)

Edema – proteinaceous exudates (often bacteria) Red hepatization – erythrocytes Gray hepatization – neutrophils Resolution – macrophages

In pneumonia, fever and leukocytosis usually resolve within? (Harrison’s 19th edition, pp 809)

2-4 days

In pneumonia, physical findings may persist longer than? (Harrison’s 19th edition, pp 809)

2-4 days

The possibility of this underlying condition should be considered if relapse or recurrence of pneumonia is documented particularly on the same segment. (Harrison’s 19th edition, pp 809)

Neoplasm

In pneumonia, chest radiographic abnormalities should resolve within? (Harrison’s 19th edition, pp 809)

4-12 weeks

Recommended follow-up radiograph for hospitalized patient with pneumonia. (Harrison’s 19th edition, pp 809)

4-6 weeks

Radiographic results that suggest an S. aureus etiology of pneumonia. (Harrison’s 19th edition, pp 805)

Pneumatoceles

Radiographic results that suggests tuberculosis. (Harrison’s 19th edition, pp 805)

Upper-lobe cavitating lesion

Epidemiologic factors suggesting a possible Pseudomonas aeruginosa etiology of community acquired pneumonia. (Harrison’s 19th edition, pp 805)

COPD Smoking Structural lung disease

Epidemiologic factors suggesting a possible Klebsiella pneumoniae or acinetobacter etiology of community acquired pneumonia. (Harrison’s 19th edition, pp 805)

Alcoholism

Epidemiologic factors suggesting a possible Oral anaerobes etiology of community acquired pneumonia. (Harrison’s 19th edition, pp 805)

``` Alcoholism Dementia Stroke Decrease level of consciousness Lung abscess ```

Empirical antibiotic treatment of community-acquired pneumonia if Pseudomonas is a consideration. (Harrison’s 19th edition, pp 808)

Antipseudomonal B-lactam + fluroquinolone Antipseudomonal B-lactam + aminoglycoside + azithromycin Antipseudomonal B-lactam + aminoglycoside + fluoroquinolone Piperacillin-tazobactam 4.5gm IV Q6, Cefepime 1-2gm IV Q12, Imipinem 500 IV Q6, Meropenem Q8 Ciprofloxacin 400mg IV Q12, Levofloxacin 750mg IV Q24 Amikacin 15mg/kg Q24, Tobramycin 1.7mg/kg Q24

In ventilator associated pneumonia, what is the diagnostic threshold for a quantitative endotracheal aspirate? (Harrison’s 19th edition, pp 811)

10^6 cfu/mL

In ventilator associated pneumonia, what is the diagnostic threshold for a protected specimen brush method? (Harrison’s 19th edition, pp 811)

10^3 cfu/mL

Drug of choice for bacteria producing extended spectrum beta lactamases (ESBL). (Harrison’s 19th edition, pp 807)

Fluoroquinolone | Carbapenems

Potential etiologic MDR pathogens of ventilator-associated pneumonia. (Harrison’s 19th edition, pp 809)

``` Pseudomonas Aeruginosa MRSA Acinetobacter spp Antibiotic-resistant Enterobacteriaceae (Enterobacter spp, ESBL-positive strains, klebsiella spp) Legionella pneumophila Burkholderia cepacia Aspergillus spp ```

Potential etiologic non-MDR pathogens of ventilator-associated pneumonia. (Harrison’s 19th edition, pp 809)

``` Streptococcus pneumonia Other streptococcus spp Haemophilus influenza MSSA Antibiotic-sensitive Enterobacteriaceae (E. Coli, K. pneumoniae, Proteus, Enterobacter spp, Serratia marcescens) ```

Non infectious conditions that may mimic pneumonia. (Harrison’s 19th edition, pp 808)

``` Pulmonary edema Pulmonary embolism Lung carcinoma Radiation Hypersensitivity pneumonitis Connective tissue disease ```

Main preventive measure for CAP. (Harrison’s 19th edition, pp 808)

Vaccination

Clinical conditions associated with MRSA as the likely pathogen in health care-associated pneumonia. (Harrison’s 19th edition, pp 803)

Hospitalization for >/= 48hrs Hospitalization for>/= 2 days in the prior 3 months Nursing home or extended-care-facility residence Chronic dialysis Home infusion therapy Home wound care Family member with MDR infection

Clinical conditions associated with Pseudomonas aeruginosa as the likely pathogen in health care-associated pneumonia. (Harrison’s 19th edition, pp 803)

Hospitalization for >/= 48hrs Hospitalization for>/= 2 days in the prior 3 months Nursing home or extended-care-facility residence Antibiotic therapy in preceding 3 months

Clinical conditions associated with Acinetobacter as the likely pathogen in health care-associated pneumonia. (Harrison’s 19th edition, pp 803)

Hospitalization for >/= 48hrs Hospitalization for>/= 2 days in the prior 3 months Nursing home or extended-care-facility residence

Clinical conditions associated with MDR Enterobacteriaceae as the likely pathogen in health care-associated pneumonia. (Harrison’s 19th edition, pp 803)

Hospitalization for >/= 48hrs Hospitalization for>/= 2 days in the prior 3 months Nursing home or extended-care-facility residence Antibiotic therapy in preceding 3 months Family member with MDR infection

Microbiological causes of CAP in outpatients. (Harrison’s 19th edition, pp 804)

``` Streptococcus pneumoniae Mycoplasma pneumoniae Haemophilus influenzae Chlamydia pneumoniae Respiratory viruses ```

Microbiological causes of CAP in Non ICU hospitalized patients. (Harrison’s 19th edition, pp 804)

``` Streptococcus pneumoniae Mycoplasma pneumoniae Haemophilus influenzae Chlamydia pneumoniae Respiratory viruses Legionella spp ```

Microbiological causes of CAP in ICU hospitalized patients. (Harrison’s 19th edition, pp 804)

``` Streptococcus pneumoniae Haemophilus influenzae Legionella spp Staphylococcus aureus Gram-negative bacilli ```

Possible pathogen of a patient with CAP who stayed in hotel or on cruise ship in previous 2 weeks. (Harrison’s 19th edition, pp 805)

Legionella spp

Risk factors for early deterioration in CAP. (Harrison’s 19th edition, pp 807)

``` Multilobar infiltrates Severe hypoxemia (arterial saturation < 90%) Severe acidosis (pH < 7.3) Mental confusion Severe tachypnea (>30cpm) Hypoalbuminemia Neutropenia Thrombocytopenia Hyponatremia Hypoglycemia ```