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Clinical Medicine II > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

Pneumonia Definition

A

Inflammatory condition of the lung affecting predominantly the <b>alveoli</b>

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2
Q

Pathophysiology of Pneumonia (HINT: 3)

A

<b>1. Micro-aspiration of organism</b>
-Inhale contaminated droplets that make it down to your alveoli

<b>2. Defect in host defense system</b> -I.e. Sick

<b>3. Virulence of the organism</b>

  • Certain organisms have components to them that make it easier to penetrate
  • I.e. Mycobacterium
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3
Q

what causes the consolidation/whiteness on x-ray seen with pneumonia?

A

leaking capillaries & edema of the alveoli

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4
Q

what is the most common cause of mortality in the US?

A

pneumonia and influenza combined

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5
Q

what is the #1 cause of CAP overall?

A

Bacterial pneumonia

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6
Q

what is the #1 cause of pneumonia <5 y/o?

A

viral pneumonia

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7
Q

what is the #1 cause of sepsis?

A

CAP

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8
Q

pneumonia classifications (HINT: 5)

A
  1. Community acquired pneumonia (CAP)
  2. Healthcare Associated Pneumonia (HCAP)
  3. Hospital Acquired Pneumonia (HAP) - Nosocomial
  4. Ventilator Acquired Pneumonia (VAP)
  5. Aspiration Pneumonia
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9
Q

what is the definition of community acquired pneumonia (CAP)?

A

Non-hospitalized patient <b>without</b> extensive health care contact

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10
Q

what is the definition of Healthcare Associated Pneumonia (HCAP)?

A

a. **Non-hospitalized patient with extensive healthcare contact
i. someone that is getting a lot of care for health problems and then get pneumonia

b. **Hospitalized in an acute care setting ≥48 hours last 90 days – BIGGEST ONE
i. patient is discharged, comes back and has pneumonia

c. **Resides in nursing homes or long term care facilities
d. IV therapy, chemotherapy or wound care ≤30 days
e. Attended hospital or hemodialysis clinic ≤30 days

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11
Q

what is the definition of Hospital Acquired Pneumonia (HAP) - Nosocomial?

A

a. Pneumonia Acquired while hospitalized after ≥48 hours
i. In hospital for 2 days for something else before developing pneumonia

b. Early onset <5 days vs Late onset >5days

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12
Q

what is the definition of Ventilator Acquired Pneumonia (VAP)?

A

48-72 hours after endotracheal intubation

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13
Q

what is the definition of Aspiration Pneumonia?

A

a. Relatively large amount of material from the stomach or mouth entering the lungs
i. Someone who lacks a gag reflex – vomited or aspirated small amount repeatedly that becomes large amount in lungs
ii. Someone that vomited into their lungs

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14
Q

CAP etiologies?

A

Bacterial, Viral, Fungal, Parasites

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15
Q

what is the most common cause of CAP in healthy individuals?

A

Bacterial

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16
Q

what are the bacterial typical organisms and atypical organisms that cause CAP?

A

Typical Organisms:
<b>-**Strep Pneumoniae #1 – most common cause of CAP</b>
-H. Influenzae

Atypical Organisms:
<b>-M. Pneumoniae #2</b> (College communities, military communities)
-C. Pneumoniae

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17
Q

what is the #1 bacterial cause of CAP?

A

Strep Pneumoniae

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18
Q

what is the #2 cause of bacterial pneumonia?

A

M. Pneumoniae (college communities, miliary communities)

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19
Q

what is the 2nd most common cause of CAP in healthy individuals?

A

influenza

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20
Q

what are the common viral causes of CAP?

A

<b>Influenza - #1 cause in adults</b>

RSV - common in children
Adenovirus - common in children
Rhinovirus

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21
Q

what is the #1 cause of CAP in adults?

A

influenza

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22
Q

if an adult develops pneumonia secondary to influenza, what may they have a co-infection of?

A

staph aureus

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23
Q

what are CAP risk factors?

A

Tobacco use
<b>-ETOH abuse (micro-aspiration)
-Altered LOC - stroke, seizures, alcohol abuse, opioid abuse
-Age - 65 y/o
-Pulmonary disease (COPD, CF, bronchiectasis)
-Immunosuppression diseases and agents (chemo, systemic corticosteroids, organ transplant)</b>
-Congenital heart disease
-Malnutrition
-Sickle cell disease

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24
Q

what are the symtpoms of pneumonia?

A 
<b>-Fever (80%)***</b>
<b>-cough (+/- productive)</b>
-chills
-pleuritic pain (from coughin)
-hemoptysis - common for TB
-infants/children -> poor feeding restless
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25
Q

Signs/PE findings for pneumonia

A 
<b>-Fever</b>
-Rales/Crackles
-Tachypnea
<b>-Decrease breath sounds</b>
-Asymmetric breath sounds
-Expiratory wheezing
-Hypoxemia
-Tachycardia
-Hypotension
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26
Q

Mycoplasma pneumoniae typical manifestations & patient characteristics

A

<b>Typical Manifestations:</b>

  • low grade fever
  • cough
  • bullous myringitis (cyst on TM)
  • erythema multiforme

<b>Patient Characteristics:</b>

  • school age >5yo
  • adolescents
  • young adults
  • college students
  • military recruits
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27
Q

Legionella Pneumoniae typical manifestations and patient characteristics

A

<b><i>DOESN’T DISCRIMINATE WITH SEASONS (CAN PRESENT IN THE SUMMER)</i></b>

<b>Typical Manifestatins:</b>

  • diarrhea
  • abdominal pain
  • sore throat
  • congestion
  • cough
  • hyponatremia

<b>Patient Characteristics:</b>

  • air conditioning
  • aerosolized water
  • hot tubs
  • cruises
  • recent travel
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28
Q

Chlamydia pneumonia typical manifestations

A

<b>Typical Manifestations:</b>

  • longer prodrome
  • sore throat
  • hoarseness
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29
Q

Strep. Pneumoniae Typical Manifestations & Patient Characteristics

A

<b>Typical Manifestations:</b>

  • single rigor
  • rust colored sputum

<b>Patient Characteristics:</b>
-EVERYONE

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30
Q

Klebseilla pneumoniae typical manifestations & patient characteristics

A

<b>Typical Manifestations:</b>
-currant jelly sputum

<b>Patient Characteristics:</b>
-chronic illness (i.e. alcoholics, COPD)

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31
Q

H. Influenza Pneumonia Patient characteristics

A

chronic pulmonary (i.e. COPD, CF, bronchiectasis)

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32
Q

Pseudomonas pneumonia patient characteristics

A
  • HCAP
  • CF
  • immunosuppressed
  • late stage COPD
  • bronchiectasis
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33
Q

Pneumonia Dx Tools

A

<b>1. Clinical Evaluation</b>

  1. Chest X-Ray (PA/Lateral)</b>
  2. CT scan chest w/out contrast
  3. Sputum Induction
  4. Blood cultures
  5. Microbiological testing
  6. Additional labs
    - last 5 you won’t always do - just complement dx of pneumonia
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34
Q

why is clinical evaulation as a dx tool for pneumonia challenging?

A

b/c there are no constellation of sx’s or signs that accurately predict CAP >50%

Sensitivity and Specificity of clinical evaluation for pneumonia is <50%

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35
Q

how does M. Pneumoniae present?

A

abrupt onset, myalgia, abdominal pain, otitis media, rash, conjunctivitis, sore throat

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36
Q

how does influenza present and how do other viral causes of pneumonia present?

A

influenza - URI or flu-like symptoms rapid onset

other viral - URI sx’s slow in onset; diffuse change in breath sounds

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37
Q

sputum color examples for S. pneumonia, atypical organisms, klebsiella

A
  • S. pneumoniae – rust color
  • Atypical organism – non-productive, scant or watery
  • Klebsiella – hemoptysis of currant jelly
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38
Q

what is the gold standard for diagnosis of pneumonia?

A

CXR

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39
Q

what is required for the dx of pneumonia?

A

In addition to a constellation of suggestive clinical features, <b>a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting microbiological data</b>, is required for the diagnosis of pneumonia

40
Q

CXR Finding Examples for Pneumonia

A

<b>Lobar</b> - single lobe or segment/pattern - common w/strep pneumo

<b>Interstitial & peribronchial</b> - viral pneumonia; PCP
-increased vasculature & patchiness in upper lobes of bronchi

41
Q

CT scan of chest as pneumonia dx tool

A 
<b>-High sensitivity</b>
-Expensive
-High radiation exposure
<b>-Utilize if will change treatment plan</b>
-Often not done
-Without IV contrast
42
Q

sputum induction as pneumonia dx tool

A

-Culture and Gram Stain
-Good Sample = <10-25 epithelial cells per low-power field, + neutrophils
<b>-Limited utility d/t technical and patient issues
-Best done in morning</b>

43
Q

what are the criteria for expectorated sputum specimens in hospitalized patients for pneumonia?

A

<b>-admitted to the ICU</b>

  • cavitary lesion on imaging
  • immunocompromised host</b>
  • abx failure
  • active ETOH abuse
  • severe COPD or lung disease
  • epidemic pneumonia
  • pathogen of clinical or epidemiological interest
44
Q

do all patients with pneumonia get blood cultures?

A

NO!

45
Q

blood cultures as pneumonia dx tool

A

-Sterile technique, obtained from 2-3 different sites (straight stick)
<b>-Prior to antibiotic administration
-Most common isolate in CAP is S. pneumoniae</b>

46
Q

criteria of when to obtain blood cultures & sputum for pneumonia

A
  • ***ICU admission/severe CAP

- ***Cavitary lesion on x-ray

47
Q

types of microbiological testing for pneumonia dx

A

urine antigen test (UAT)
influenza antigen
multiplex PCR
serology

48
Q

urine antigen test for pneumonia (organisms? Pros/cons?)

A

Organisms: S. pneumoniae; Legionella

Pros: simple, good sensitivity, detects after abx admin, may stay pos for weeks

Cons: cost, inability to perform susceptibility testing, detects only Legionella Type 1, unsure if will change abx management

49
Q

influenza antigen test for pneumonia (organisms? Pros/cons?)

A

Organisms: influenza A & B

Pros: decr antibiotic agents; identify for epidemilogical purpose; high specificity

Cons: cost; high rate of false negatives; low sensitivity; not superior to physician judgement

50
Q

Multiplex PCR test for pnuemonia (Organisms? Pros/cons?)

A

Organisms: M pneumoniae; C. Pneumoniae; B. Pertussis; 14 viruses (e.g. influenza, RSV)

Pros: rapid quick detection

Cons: requires lab; high rate of false positive; expense and availability

51
Q

Serology test for pneumonia (Organisms? Pros/cons?)

A

Organisms: C. pneumoniae; M. pneumoniae; Legionella

Pros: standard for dx

Cons: not practical; must compare an acute phase vs. convalescent serology; positive serology may confer present or past infection

52
Q

what is a good predictor for sepsis?

A

Lactic acid
-if very high then admit pt to ICU and start sepsis protocol

-additional lab for pneumonia dx

53
Q

what are additional labs to dx pneumonia?

A
  • CBC w/diff
  • Basic Metabolic Panel or Comprehensive Metabolic Panel
  • Lactic Acid (good predictor for sepsis)
  • CRP
  • Pro-Calcitonin
54
Q

pneumonia guide to dx testing for <b>outpatients</b>

A
  • Clinical Diagnosis
  • CXR
  • Organism testing only if will impact epidemiological or Abx management
55
Q

pneumonia guide to dx testing for <b>inpatients</b>

A
  • CXR
  • CBC w/diff, BMP or CMP
  • +/- CRP, Sed Rate or Lactic Acid
56
Q

pneumonia guide to dx for <b>ICU patients</b>

A

<b>GETTING EVERYTHING!!!</b>

  • CXR
  • Blood Cultures
  • UAT legionella and Pneumococcal
  • Sputum
  • CBC w/diff, BMP or CMP, Lactic Acid
  • +/- CRP or Sed Rate
57
Q

If patient has CAP & was previoulsy healthy & no use of abx w/in previous 3 months, how do you empirically treat their CAP?

A

Macrolide (azitrhomycin; clarithromycin; erythromycin) x 5 days

<b>-OR-</b>

Doxycycline x 5 days

58
Q

If patient has CAP & has comorbidities or use of abx w/in previous 3 months or in region with high DRSP, how do you empirically treat their CAP?

A

-Respiratory fluoroquinolone (moxifloxacin; levofloxacin) x 5 days

<b>-OR-</b>

-Beta-lactam (amoxicillin, augmentin, cefpodoxime, cefuroxime) – all BID, except amox is TID

<b>PLUS</b> Macrolide/Doxycycline PO – add macrolide/doxy to cover atypicals

59
Q

Inpatient, Non-ICU CAP txt - empiric txt?

A

-Respiratory fluoroquinolone (moxifloxacin; levofloxacin) IV +/- Glucocorticoid therapy

<b>-OR-</b>

Anti-pneumococcal beta-lactam (ceftriaxone, Unasyn) IV

<b>PLUS</b> Macrolide/Doxycycline IV (see above) +/- Glucocorticoid therapy

60
Q

what tools can you use to supplement your decision on whether to admit or not admit a patient for CAP?

A
  • Pneumonia Severity Index (PSI)
  • CURB-65
  • CRB-65 – not widely used
  • SMART-COP
61
Q

what does the pneumonia severity index (PSI) measure?

A

it’s a prognostic tool - measures likelihood of death in 30 days

  • decision aid for risk stratification pts w/CAP
  • measures low mortality risk @ 30 days
62
Q

what are the pros/cons of pneumonia severity index (PSI)?

A

<b>Pros:</b> only decision tool that has safety and efficacy demonstrated in randomized trial

<b>Cons:</b> difficult to remember all 20 points; require database to input; must have ABG; fails to account for social factors or underlying lung disease

63
Q

what does the CURB-65 score measure? criteria? pros/cons?

A

severity illness tool

<b>Criteria:</b>

  • Confusion
  • Urea ≥19mg/dL
  • Respiratory rate ≥30
  • BP <90mmHg systolic
  • Age ≥65 yo

<b>Pros:</b> easy algorithm to remember; outcome similar to PSI

<b>Cons:</b> may not recognize those requiring admission as well as PSI; doesn’t account for comorbidities & NH residents

64
Q

what does SMART-COP measure? Criteria? Pros/cons?

A

prognostic tool to predict which pts require intensive care & need for intensive respiratory or vasopressor support

Criteria: Systolic BP, Multilobar infiltrate, Albumin level, RR, Tachycardia, Confusion, Oxygen level, arterial Ph

Pros: superior to CURB-65 & PSI for predicting need for mechanical ventilation or need for inotropes

Cons: sensitivity decreases substantially in pts <50 y.o/use w/caution in this age group; no online calculator

65
Q

when do you transition pt from IV to oral abx therapy when treating CAP? & what do class of abx do you transition them to?

A
  • Clinical improvement and afebrile after 48 hours

- Transition to similar class and complete treatment total 5-7 days

66
Q

when should a pts fever improve for CAP in terms of follow-up instructions?

A

fever should improve w/in 72 hours

67
Q

when should pts call office for outpatient CAP txt follow-up instruction?

A

Call the office if symptoms are not improving in 48-72 hours

<b>-OR-</b>

PCP should contact patient 48-72 hours to assess

68
Q

what should you advise your patient about their symptoms for outpatient CAP txt follow-up instructions?

A

Advise symptoms may continue beyond treatment

-Persistence of symptoms not an indication to extend course of antibiotic therapy as long as there was a clinical response

69
Q

are routine follow-up CXRs indicated for follow-up for CAP?

A

No, routine follow-up CXR <b>NOT</b> indicated if improved clinically

  • Small group of patients who may have indication, if so, done 7-12 weeks out
  • Infiltrates can take 30 days to improve so if do repeat CXR, infiltrates will still be there
  • Cough can last for 2-3 weeks
70
Q

how can you prevent pneumonia?

A
  • Smoking Cessation
  • Screen for influenza vaccine status (October – March)
  • Screen for pneumococcal vaccine status

At risk population

  • > 65 y/o
  • Comorbidities or smoking
71
Q

what bacteria are associated with HAP/VAP <b>early onset < 5 days?</b>

A
  • Strep pneumoniae
  • Haemophillus influenza
  • Methicillin-sensitive S. Aureus
  • Gram Negative Bacilli (e.coli, klebsiella pneumoniae, enterobacter sp., proteus sp.)
72
Q

what bacteria are associated with HAP/VAP <b>late onset >5 days & HCAP?</b>

A

all bacteria associated with HAP/VAP early onset < 5days
(Strep pneumoniae, Haemophillus influenza, MSSA, Gram Negative Bacilli -e.coli, klebsiella pneumoniae, enterobacter sp., proteus sp.) <b>PLUS</b>

Pseudomonas, Acinetobacter, MRSA

73
Q

what is the txt for HAP/VAP early onset?

A

Ceftriazone 1-2g IV

<b>-or-</b>

Levofloxacin 750mg IV/PO

<b>-or-</b>

Ampicillin/Sulbactam (Unasyn) 1.5-3g (IV); Amoxicillin/Clavulanic acid 875mg BID (PO)

74
Q

what is the treatment for HAP/VAP late onset & HCAP?

A 
Cefepime IV
<b>-or-</b>
Ceftazadime
<b>-or-</b>
Meropenem IV
<b>-or-</b>
Piperacillin/Tazobactam (IV)
<b>-or-</b>
Levofloxacin (IV)

<b>PLUS</b>
Vancomycin (IV) or Linezolid (PO)

75
Q

if concerned that pt has MDR or is dying, how do you treat them for HAP/VAP & HCAP?

A 
Cefepime IV
<b>-or-</b>
Ceftazime
<b>-or-</b>
Meropenem IV

<b>PLUS</b>

Levofloxacin or aminoglycosides

<b>PLUS</b>

Vancomycin

76
Q

what are the risk factors for multi-drug resistant pathogens of pneumonia?

A
  • Antimicrobial therapy in preceding 90 days
  • Current Hospitalization >5 days
  • High frequency of antibiotics resistance in the community or specific hospital unit
  • Presence of risk factors for HCAP
77
Q

what is aspiration pneumonia?

A
  • Relatively large amount of material from the stomach or mouth entering the lungs
  • Infection by less virulent bacteria <b>(primarily anaerobes)</b>
78
Q

what are the risk factors for aspiration pneumonia?

A
  • Altered LOC – e.g. opiate addict that’s out for a long period time
  • Dysphagia
  • Neurological Disorder
  • Mechanical Disruption – e.g. intubation
  • Misc. – e.g., protracted vomiting, general debility, gastroparesis, ileus
79
Q

what type of hx will a pt with aspiration pneumonia have?

A

<b>Clinical history of aspiration</b> or condition concerning for aspiration

80
Q

what are the signs/symptoms of aspiration pneumonia?

A

<b>-Gastric content/inert fluids aspiration:</b> abrupt onset of hypoxemia, +/- fever, signs of pulmonary edema diffuse crackles, rales

<b>-Bacterial aspiration:</b> typically evolves slowly

81
Q

how do you dx aspiration pneumonia?

A
  • hx

- CXR

82
Q

how do you treat gastric content/inert fluids aspiration?

A

<b>-Supportive IVF, +/- ventilator support, +/- Glucocorticoids</b>

<i>-Sometimes this develops a superimposed infection which then administer abx</i> (Clindamycin IV or Flagyl + Amoxicilin x 7-10 days)

83
Q

how do you treat bacterial aspiration pneumonia?

A

Clindamycin IV or Flagyl + Amoxicilin x 7-10 days

84
Q

what is a type of opportunistic pneumonia? what must a pts CD4 count be below for them to be at risk for this?

A

Pneumocystis Jirovecii (PCP) - fungi

CD4 count < 200 cells/mcL

85
Q

what is the most common opportunistic infection associated with AIDS/HIV?

A

PCP pneumonia

86
Q

since when has there been a dramatic decrease in PCP pneumonia cases?

A

since onset of ART therapy & ppx therapy b/c mostly AIDS/HIV pts get PCP pneumonia

87
Q

what are the risk factors for PCP pneumonia?

A
  • Advanced Immunosuppression
  • Previous PCP
  • Oral thrush
  • Recurrent pneumonia
  • High plasma RNA
88
Q

what are the sx’s for PCP pneumonia?

A

<b>NON-SPECIFIC SX’S!!!</b>

  • Gradual in onset – days to weeks</b>
  • Fever
  • Cough (non-productive)
  • Dyspnea
  • Fatigue
  • Weight loss
89
Q

signs of PCP pneumonia

A
  • Fever
  • Tachypnea
  • Crackles
  • Rhonchi
  • Thrush
  • Hypoxemia
90
Q

Lab Diagnostics for PCP Pneumonia

A

<b>-CD4 count < 200 cells/mcL
-ABG – Alveolar-arterial oxygen gradient widened</b>
(measure the A-A gradiant – the wider it is, the higher the risk)
-LDH
-1-3-beta-d-glucagon levels
-Induced sputum – Microscopy with gram stain of induced sputum (can’t get culture on PCP; done as hospitalist)

91
Q

imaging diagnostics for PCP pneumonia

A

<b>-Chest x-ray – Diffuse bilateral interstitial or alveolar infiltrates</b>

  • CT scan – ground glass appearance (VERY SENSITIVE TEST)</b>
  • Gallium Citrate scanning
  • Diffuse Lung Capacity (DLCO) - If decreased highly unlikely
92
Q

what is mild PCP pneumonia disease and how do you treat it?

A

<b>Mild Disease:</b> A-A gradient <35mmHg; partial pressure arterial oxygenation >70mmHg

<b>Txt:</b> TMP-SMX PO

93
Q

what is moderate PCP pneumonia disease and how do you treat it?

A

<b>Moderate Disease:</b> A-A gradient 35-45mmHg; partial pressure arterial oxygenation 60-70mmHg

<b>Txt:</b> TMP-SMX IV/PO -PLUS- PO Adjunctive Corticosteroids (Prednisone 60mg)

94
Q

what is severe PCP pneumonia disease and how do you treat it?

A

<b>Severe Disease:</b> A-A gradient >45; partial pressure arterial oxygenation < 70mmH

<b>Txt:</b> TMP-SMX IV PLUS Adjunctive Corticosteroids IV (Methylprednisolone)

-will get transitioned to oral if you can stabilize them

95
Q

Indications for antimicrobial ppx in HIV pts for PCP Pneumonia?

A
  • CD4 count < 200 cells/microL
  • Oropharyngeal candidiasis
  • CD4 count percentage < 14%
  • CD4 cell count b/w 200-250 cells/microL when frequent monitoring is not possible
96
Q

Abx options for PCP ppx

A

<b>-TMP-SMX SS (single strength) QD or DS (double strength) 3x/weekly</b>
-TMP-SMX DS QD – (if CD4 count < 100 cells/microL)

Alternatives for sulfa allergies:

  • Dapsone
  • Atovaquone
  • Aerosolized Pentamidine – less effective

*D/C ppx if on continued ART with undetectable viral load and a rise in CD4 >200 cells/microL for three months

Clinical Medicine II (10 decks)

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