Pneumonia Flashcards
1
Q
Pneumonia Definition
A
Inflammatory condition of the lung affecting predominantly the <b>alveoli</b>
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
3
Q
what causes the consolidation/whiteness on x-ray seen with pneumonia?
A
leaking capillaries & edema of the alveoli
4
Q
what is the most common cause of mortality in the US?
A
pneumonia and influenza combined
5
Q
what is the #1 cause of CAP overall?
A
Bacterial pneumonia
6
Q
what is the #1 cause of pneumonia <5 y/o?
A
viral pneumonia
7
Q
what is the #1 cause of sepsis?
A
CAP
8
Q
pneumonia classifications (HINT: 5)
A
- Community acquired pneumonia (CAP)
- Healthcare Associated Pneumonia (HCAP)
- Hospital Acquired Pneumonia (HAP) - Nosocomial
- Ventilator Acquired Pneumonia (VAP)
- Aspiration Pneumonia
9
Q
what is the definition of community acquired pneumonia (CAP)?
A
Non-hospitalized patient <b>without</b> extensive health care contact
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
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
12
Q
what is the definition of Ventilator Acquired Pneumonia (VAP)?
A
48-72 hours after endotracheal intubation
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
14
Q
CAP etiologies?
A
Bacterial, Viral, Fungal, Parasites
15
Q
what is the most common cause of CAP in healthy individuals?
A
Bacterial
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
17
Q
what is the #1 bacterial cause of CAP?
A
Strep Pneumoniae
18
Q
what is the #2 cause of bacterial pneumonia?
A
M. Pneumoniae (college communities, miliary communities)
19
Q
what is the 2nd most common cause of CAP in healthy individuals?
A
influenza
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
21
Q
what is the #1 cause of CAP in adults?
A
influenza
22
Q
if an adult develops pneumonia secondary to influenza, what may they have a co-infection of?
A
staph aureus
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
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
25
Signs/PE findings for pneumonia
```
-Fever
-Rales/Crackles
-Tachypnea
-Decrease breath sounds
-Asymmetric breath sounds
-Expiratory wheezing
-Hypoxemia
-Tachycardia
-Hypotension
```
26
Mycoplasma pneumoniae typical manifestations & patient characteristics
Typical Manifestations:
- low grade fever
- cough
- bullous myringitis (cyst on TM)
- erythema multiforme
Patient Characteristics:
- school age >5yo
- adolescents
- young adults
- college students
- military recruits
27
Legionella Pneumoniae typical manifestations and patient characteristics
DOESN'T DISCRIMINATE WITH SEASONS (CAN PRESENT IN THE SUMMER)
Typical Manifestatins:
- diarrhea
- abdominal pain
- sore throat
- congestion
- cough
- hyponatremia
Patient Characteristics:
- air conditioning
- aerosolized water
- hot tubs
- cruises
- recent travel
28
Chlamydia pneumonia typical manifestations
Typical Manifestations:
- longer prodrome
- sore throat
- hoarseness
29
Strep. Pneumoniae Typical Manifestations & Patient Characteristics
Typical Manifestations:
- single rigor
- rust colored sputum
Patient Characteristics:
-EVERYONE
30
Klebseilla pneumoniae typical manifestations & patient characteristics
Typical Manifestations:
-currant jelly sputum
Patient Characteristics:
-chronic illness (i.e. alcoholics, COPD)
31
H. Influenza Pneumonia Patient characteristics
chronic pulmonary (i.e. COPD, CF, bronchiectasis)
32
Pseudomonas pneumonia patient characteristics
- HCAP
- CF
- immunosuppressed
- late stage COPD
- bronchiectasis
33
Pneumonia Dx Tools
1. Clinical Evaluation
2. Chest X-Ray (PA/Lateral)
3. CT scan chest w/out contrast
4. Sputum Induction
5. Blood cultures
6. Microbiological testing
7. Additional labs
- last 5 you won't always do - just complement dx of pneumonia
34
why is clinical evaulation as a dx tool for pneumonia challenging?
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%
35
how does M. Pneumoniae present?
abrupt onset, myalgia, abdominal pain, otitis media, rash, conjunctivitis, sore throat
36
how does influenza present and how do other viral causes of pneumonia present?
influenza - URI or flu-like symptoms rapid onset
other viral - URI sx's slow in onset; diffuse change in breath sounds
37
sputum color examples for S. pneumonia, atypical organisms, klebsiella
- S. pneumoniae – rust color
- Atypical organism – non-productive, scant or watery
- Klebsiella – hemoptysis of currant jelly
38
what is the gold standard for diagnosis of pneumonia?
CXR
39
what is required for the dx of pneumonia?
In addition to a constellation of suggestive clinical features, a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting microbiological data, is required for the diagnosis of pneumonia
40
CXR Finding Examples for Pneumonia
Lobar - single lobe or segment/pattern - common w/strep pneumo
Interstitial & peribronchial - viral pneumonia; PCP
-increased vasculature & patchiness in upper lobes of bronchi
41
CT scan of chest as pneumonia dx tool
```
-High sensitivity
-Expensive
-High radiation exposure
-Utilize if will change treatment plan
-Often not done
-Without IV contrast
```
42
sputum induction as pneumonia dx tool
-Culture and Gram Stain
-Good Sample = <10-25 epithelial cells per low-power field, + neutrophils
-Limited utility d/t technical and patient issues
-Best done in morning
43
what are the criteria for expectorated sputum specimens in hospitalized patients for pneumonia?
-admitted to the ICU
- cavitary lesion on imaging
- immunocompromised host
- abx failure
- active ETOH abuse
- severe COPD or lung disease
- epidemic pneumonia
- pathogen of clinical or epidemiological interest
44
do all patients with pneumonia get blood cultures?
NO!
45
blood cultures as pneumonia dx tool
-Sterile technique, obtained from 2-3 different sites (straight stick)
-Prior to antibiotic administration
-Most common isolate in CAP is S. pneumoniae
46
criteria of when to obtain blood cultures & sputum for pneumonia
- ***ICU admission/severe CAP
| - ***Cavitary lesion on x-ray
47
types of microbiological testing for pneumonia dx
urine antigen test (UAT)
influenza antigen
multiplex PCR
serology
48
urine antigen test for pneumonia (organisms? Pros/cons?)
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
influenza antigen test for pneumonia (organisms? Pros/cons?)
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
Multiplex PCR test for pnuemonia (Organisms? Pros/cons?)
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
Serology test for pneumonia (Organisms? Pros/cons?)
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
what is a good predictor for sepsis?
Lactic acid
-if very high then admit pt to ICU and start sepsis protocol
-additional lab for pneumonia dx
53
what are additional labs to dx pneumonia?
- CBC w/diff
- Basic Metabolic Panel or Comprehensive Metabolic Panel
- Lactic Acid (good predictor for sepsis)
- CRP
- Pro-Calcitonin
54
pneumonia guide to dx testing for outpatients
- Clinical Diagnosis
- CXR
- Organism testing only if will impact epidemiological or Abx management
55
pneumonia guide to dx testing for inpatients
- CXR
- CBC w/diff, BMP or CMP
- +/- CRP, Sed Rate or Lactic Acid
56
pneumonia guide to dx for ICU patients
GETTING EVERYTHING!!!
- CXR
- Blood Cultures
- UAT legionella and Pneumococcal
- Sputum
- CBC w/diff, BMP or CMP, Lactic Acid
- +/- CRP or Sed Rate
57
If patient has CAP & was previoulsy healthy & no use of abx w/in previous 3 months, how do you empirically treat their CAP?
Macrolide (azitrhomycin; clarithromycin; erythromycin) x 5 days
-OR-
Doxycycline x 5 days
58
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?
-Respiratory fluoroquinolone (moxifloxacin; levofloxacin) x 5 days
-OR-
-Beta-lactam (amoxicillin, augmentin, cefpodoxime, cefuroxime) – all BID, except amox is TID
PLUS Macrolide/Doxycycline PO – add macrolide/doxy to cover atypicals
59
Inpatient, Non-ICU CAP txt - empiric txt?
-Respiratory fluoroquinolone (moxifloxacin; levofloxacin) IV +/- Glucocorticoid therapy
-OR-
Anti-pneumococcal beta-lactam (ceftriaxone, Unasyn) IV
PLUS Macrolide/Doxycycline IV (see above) +/- Glucocorticoid therapy
60
what tools can you use to supplement your decision on whether to admit or not admit a patient for CAP?
- Pneumonia Severity Index (PSI)
- CURB-65
- CRB-65 – not widely used
- SMART-COP
61
what does the pneumonia severity index (PSI) measure?
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
what are the pros/cons of pneumonia severity index (PSI)?
Pros: only decision tool that has safety and efficacy demonstrated in randomized trial
Cons: difficult to remember all 20 points; require database to input; must have ABG; fails to account for social factors or underlying lung disease
63
what does the CURB-65 score measure? criteria? pros/cons?
severity illness tool
Criteria:
- Confusion
- Urea ≥19mg/dL
- Respiratory rate ≥30
- BP <90mmHg systolic
- Age ≥65 yo
Pros: easy algorithm to remember; outcome similar to PSI
Cons: may not recognize those requiring admission as well as PSI; doesn't account for comorbidities & NH residents
64
what does SMART-COP measure? Criteria? Pros/cons?
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
when do you transition pt from IV to oral abx therapy when treating CAP? & what do class of abx do you transition them to?
- Clinical improvement and afebrile after 48 hours
| - Transition to similar class and complete treatment total 5-7 days
66
when should a pts fever improve for CAP in terms of follow-up instructions?
fever should improve w/in 72 hours
67
when should pts call office for outpatient CAP txt follow-up instruction?
Call the office if symptoms are not improving in 48-72 hours
-OR-
PCP should contact patient 48-72 hours to assess
68
what should you advise your patient about their symptoms for outpatient CAP txt follow-up instructions?
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
are routine follow-up CXRs indicated for follow-up for CAP?
No, routine follow-up CXR NOT 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
how can you prevent pneumonia?
- Smoking Cessation
- Screen for influenza vaccine status (October – March)
- Screen for pneumococcal vaccine status
At risk population
- >65 y/o
- Comorbidities or smoking
71
what bacteria are associated with HAP/VAP early onset < 5 days?
- Strep pneumoniae
- Haemophillus influenza
- Methicillin-sensitive S. Aureus
- Gram Negative Bacilli (e.coli, klebsiella pneumoniae, enterobacter sp., proteus sp.)
72
what bacteria are associated with HAP/VAP late onset >5 days & HCAP?
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.) PLUS
Pseudomonas, Acinetobacter, MRSA
73
what is the txt for HAP/VAP early onset?
Ceftriazone 1-2g IV
-or-
Levofloxacin 750mg IV/PO
-or-
Ampicillin/Sulbactam (Unasyn) 1.5-3g (IV); Amoxicillin/Clavulanic acid 875mg BID (PO)
74
what is the treatment for HAP/VAP late onset & HCAP?
```
Cefepime IV
-or-
Ceftazadime
-or-
Meropenem IV
-or-
Piperacillin/Tazobactam (IV)
-or-
Levofloxacin (IV)
```
PLUS
Vancomycin (IV) or Linezolid (PO)
75
if concerned that pt has MDR or is dying, how do you treat them for HAP/VAP & HCAP?
```
Cefepime IV
-or-
Ceftazime
-or-
Meropenem IV
```
PLUS
Levofloxacin or aminoglycosides
PLUS
Vancomycin
76
what are the risk factors for multi-drug resistant pathogens of pneumonia?
- 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
what is aspiration pneumonia?
- Relatively large amount of material from the stomach or mouth entering the lungs
- Infection by less virulent bacteria (primarily anaerobes)
78
what are the risk factors for aspiration pneumonia?
- 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
what type of hx will a pt with aspiration pneumonia have?
Clinical history of aspiration or condition concerning for aspiration
80
what are the signs/symptoms of aspiration pneumonia?
-Gastric content/inert fluids aspiration: abrupt onset of hypoxemia, +/- fever, signs of pulmonary edema diffuse crackles, rales
-Bacterial aspiration: typically evolves slowly
81
how do you dx aspiration pneumonia?
- hx
| - CXR
82
how do you treat gastric content/inert fluids aspiration?
-Supportive IVF, +/- ventilator support, +/- Glucocorticoids
-Sometimes this develops a superimposed infection which then administer abx (Clindamycin IV or Flagyl + Amoxicilin x 7-10 days)
83
how do you treat bacterial aspiration pneumonia?
Clindamycin IV or Flagyl + Amoxicilin x 7-10 days
84
what is a type of opportunistic pneumonia? what must a pts CD4 count be below for them to be at risk for this?
Pneumocystis Jirovecii (PCP) - fungi
CD4 count < 200 cells/mcL
85
what is the most common opportunistic infection associated with AIDS/HIV?
PCP pneumonia
86
since when has there been a dramatic decrease in PCP pneumonia cases?
since onset of ART therapy & ppx therapy b/c mostly AIDS/HIV pts get PCP pneumonia
87
what are the risk factors for PCP pneumonia?
- Advanced Immunosuppression
- Previous PCP
- Oral thrush
- Recurrent pneumonia
- High plasma RNA
88
what are the sx's for PCP pneumonia?
NON-SPECIFIC SX’S!!!
- Gradual in onset – days to weeks
- Fever
- Cough (non-productive)
- Dyspnea
- Fatigue
- Weight loss
89
signs of PCP pneumonia
- Fever
- Tachypnea
- Crackles
- Rhonchi
- Thrush
- Hypoxemia
90
Lab Diagnostics for PCP Pneumonia
-CD4 count < 200 cells/mcL
-ABG – Alveolar-arterial oxygen gradient widened
(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
imaging diagnostics for PCP pneumonia
-Chest x-ray – Diffuse bilateral interstitial or alveolar infiltrates
- CT scan – ground glass appearance (VERY SENSITIVE TEST)
- Gallium Citrate scanning
- Diffuse Lung Capacity (DLCO) - If decreased highly unlikely
92
what is mild PCP pneumonia disease and how do you treat it?
Mild Disease: A-A gradient <35mmHg; partial pressure arterial oxygenation >70mmHg
Txt: TMP-SMX PO
93
what is moderate PCP pneumonia disease and how do you treat it?
Moderate Disease: A-A gradient 35-45mmHg; partial pressure arterial oxygenation 60-70mmHg
Txt: TMP-SMX IV/PO -PLUS- PO Adjunctive Corticosteroids (Prednisone 60mg)
94
what is severe PCP pneumonia disease and how do you treat it?
Severe Disease: A-A gradient >45; partial pressure arterial oxygenation < 70mmH
Txt: TMP-SMX IV PLUS Adjunctive Corticosteroids IV (Methylprednisolone)
-will get transitioned to oral if you can stabilize them
95
Indications for antimicrobial ppx in HIV pts for PCP Pneumonia?
- 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
Abx options for PCP ppx
-TMP-SMX SS (single strength) QD or DS (double strength) 3x/weekly
-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
