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Pulmonary > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

What is opportunistic pneumonia?

A

Pneumonia which occurs because of a deficiency in the patient’s immune response

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2
Q

What is a humoral immune deficiency?

A

Congenital (agammaglobulinemia)

Acquired (chronic lymphocytic leukemia)

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3
Q

What is a cell-mediated immune deficiency?

A

*HIV (risk of opportunistic infections correlates inversely with CD4 cell count)
Corticosteroid therapy
Lymphoma & treatment, sarcoidosis
Transplantation
Congenital (e.g. severe combined immunodeficiency, di George’s syndrome)

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4
Q

What is a granulocyte immune deficiency?

A

Number (neutropenia, e.g. post chemotherapy)

Function (usually congenital)

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5
Q

What are some non-specific causes of reduced immunity?

A

malnutrition, aging, diabetes, alcoholism

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6
Q

How does chronic lymphocytic leukemia impair immune system?

A

Chronic lymphocytic leukemia (CLL) is associated with functional inability to respond to humoral antigens

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7
Q

What is the most common humoral immunity deficiency?

A

IgA deficiency, most common, is variable, often asymptomatic or mild

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8
Q

What is IgG deficiency associated with?

A

May be associated with recurrent otitis, sinus infection, bacterial pulmonary infections, often with encapsulated organisms

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9
Q

What is the management protocol for humoral deficiency?

A

Immune globulin replacement for IgG deficiency
Early treatment of infection
Antimicrobial prophylaxis
Stem cell transplant in selected circumstances

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10
Q

What causes pneumonia in HiV patients?

A

M. tuberculosis, *Streptococcus pneumoniae (may occur at any CD4 count, but risk increases with declining CD4)

Pneumocystis jiroveci : Risk largely limited to CD4 count < 200/ml

Miscellaneous: Nocardia, Cryptococcus, Endemic fungi (histoplasmosis, coccidioidomycosis)

Non-infectious: Kaposi’s sarcoma, lymphocytic interstitial pneumonitis

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11
Q

What investigations would be appropriate for HIV patient with respiratory issues?

A

Sputum (coughed or induced) examination

  • Gram stain, C&S
  • Special stains: Acid fast, fungal, pneumocystis

Ancillary tests:
Arterial blood gases
LDH (sensitive, not specific in pneumocystis)

CT chest

Bronchoscopy (lavage 95% sensitive in pneumocystis)

Empiric therapy (e.g. for pneumocystis) in selected circumstances, ie when highly typical

Open lung biopsy (rare)

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12
Q

Why does infections occur after a transplant?

A

Depends on degree of immune suppressive therapy

kidney < heart or liver < lung or intestine < allogeneic stem cell

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13
Q

For transplants, the risk of opportunistic infections causing pneumonia depend on?

A

the organ transplanted
depends on timing
- first few weeks common bacteria predominate
- 4 weeks to 6 months, CMV
depends on donor and recipient infection status
depends on prophylaxis the patient is taking

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14
Q

How to prevent infections in transplant patients?

A

Pre-transplant assessment, e.g. CMV status (also of donor).

Pneumocystis prophylaxis with trimethoprim/sulfamethoxazole

Enhanced surveillance and pre-emptive early treatment or prophylaxis (CMV)

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15
Q

What is the risk of infection in neutropenics (ie. acute myelocytic leukemia)?

A

Risk of infections increases sharply below absolute neutrophil count of 0.5 and with duration of neutropenia

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16
Q

T or F: majority of febrile neutropenia is accompanied by pulmonary infiltrate

A

F

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17
Q

What is the differential diagnosis of pulmonary infiltrate ?

A

radiation pneumonitis, drug toxicity, hemorrhage, edema etc. as well as infections

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18
Q

T or F: pulmonary infiltrate with fungal infections have high mortality

A

T

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19
Q

What organism infect neutropenics?

A

Early: gram positive & gram negative bacteria

Later, often after prolonged antibiotics: fungi e.g. Aspergillus, less commonly Mucor

Many common agents of community acquired pneumonia, eg Mycoplasma rare in this setting.

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20
Q

What can you consider for treatment in neutropenics?

A

cytokine therapy—granulocyte stimulating factor to correct neutropenia

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21
Q

How to prevent pneumonia in neutropenics?

A

Minimize period of neutropenia

Aggressive clinical surveillance

Antibacterial/antifungal prophylaxis depending on specific type of therapy and local epidemiology of opportunistic infections

22
Q

What is hospital-acquired pneumonia?

A

Pneumonia acquired after (as a complication of) admission to hospital

23
Q

What is VAP?

A

ventilator-associated pressure

24
Q

What is the pathophysiology of nosocomial pneumonia?

A

Altered oral flora in sick and hospitalized patients

  • -> from GI reflux or upper airway flora or hospital flora
  • -> biofilm in Endotracheal tube
  • -> Increased risk of/decreased defense against aspiration
25
Q

What are some risk factors for nosocomial pneumonia?

A

Neurologic disease or altered consciousness
Age
Functional status
Lung disease, smoking history
Severity of underlying illness
Time (risk is cumulative, but daily risk decreases with time).
Surgery, type of surgery
Position (sitting reduces aspiration risk)
Endotracheal intubation
Antacid therapy
Transmission by HCW’s; failure to handwash

26
Q

What is the microbial etiologies of nosocomial pneumonia?

A

Coliforms (E. coli etc.)
Staphylococcus aureus including MRSA
Pseudomonas especially in ICU, after antibiotics
Acinetobacter, Stenotrophomonas
Other (Legionella endemic in some hospitals)
RSV epidemics common in Pediatrics

27
Q

How to diagnose nosocomial pneumonia?

A

New radiologic infiltrate & compatible clinical features, e.g. fever, ↑ wbc, hypoxia, ↑ respiratory secretions

28
Q

What is the treatment/investigations approach for nosocomial pneumonia?

A

A) Empiric broad spectrum therapy based on “best guess”, local epidemiology and upper airway gram stain and cultures OR
B) Guidance based on respiratory specimen obtained non-invasively with semi-quantitative culture OR
C) “Invasive”diagnosis: bronchoscopy with sheathed brushes or quantitative bronchoalveolar lavage

29
Q

What is the treatment for nosocomial pneumonia?

A 
Early and mild: 
“respiratory” fluoroquinolone
3rd generation cephalosporin
Late or severe:
Piperacillin/tazobactam or carbapenem
				Plus
Vancomycin if evidence or likelihood of MRSA
Duration: Usual recommendation: 7 days depending on clinical/radiologic response.
30
Q

How to prevent nosocomial infections?

A

Recognize patients @ risk (decreased level of consciousness, altered swallowing, gastro-esophageal reflux)
Minimize aspiration risk
Position, feeding, airway management
Hand washing

Oral care
Semirecumbent position
Limit antacid use
Enteral feeding
Hand washing
Minimize intubation; use non-invasive ventilation, oral tube preferred to nasal
Adequate pressure in ET tube cuff
Prevent gastric overdistention
Scheduled drainage of condensation from circuits
31
Q

What is pneumonia?

A

Inflammation of the lung, usually of infectious etiology

–> Lung parenchyma inflammation/injury +/- filling of alveolar spaces with inflammatory gunk (consolidation)

32
Q

Can infection to lower tract occur as a result of aspiration?

A

Yes

33
Q

What does the development CAP signify?

A

The development of CAP indicates either a defect in host defenses (local and/or global), exposure to an overwhelming inoculum, or a particularly virulent microorganism

34
Q

What are symptoms of pneumonia?

A 
Fever
Dyspnea 
Cough
Sputum production
Pleuritic chest pain
Mental status changes
35
Q

What are signs of pneumonia?

A

Toxic appearance
Increased temperature
Increased respiratory rate/heart rate [most sensitive sign]
In severe cases respiratory failure & septic shock
Asymmetric movement of chest wall
Increased tactile fremitus
Dullness to percussion
Bronchial breath sounds on auscultation
Crackles, wheezes, egophony, whispering pectoriloquay
+/- signs of a “parapneumonic effusion”

36
Q

What is essential for the diagnosis of CAP?

A

CHEST XRAY:
Posterior-anterior and lateral views
If pleural effusion is present, do a lateral decubitus view with the involved side down

BUT CT has higher sensitivity and specificity

37
Q

T or F: bacterial culture and CBC is always done for CAP

A

F:
Testing for a microbial diagnosis is usually not performed in outpatients because empiric treatment is almost always successful.HAPs do not need the bloodwork.

38
Q

What microorganism is most likely associated with CAP?

A

Bacteria are the most common cause of CAP:

  • “Typical” organisms include S. pneumoniae, H. influenzae, S. aureus, Group A strep, M. catarrhalis, anaerobes, and aerobic gram-negative bacteria
  • “Atypical” refers to pneumonia caused by Legionella spp, M. pneumoniae, C. pneumoniae, and C. psittaci
39
Q

What virus is the predominant agent for CAP

A

Influenza

40
Q

How to manage pneumonia?

A 
(c) ABC
O2 to keep SpO2 > 90%; wean if > 95%
IV fluids (early goal directed therapy)
Lab work, septic workup (sputum, blood, +/- urine, +/- CSF) 
PA and Lateral CXR
\+/- CT, Bronchoscopy
\+/- Isolation precaution
41
Q

What kind of antibiotic is given for pneumonia?

A

Initial antibiotic selection for pneumonia is almost always empiric; if/when a likely organism is identified, focus antimicrobials accordingly

  • no comorbidity: macrolide OR doxycycline
  • comorbidity: fluoroquinolone OR beta-lactam + macrolide
42
Q

What is Pneumonia Severity Index/Fine Score?

A

Score to determine if patient should be admitted to the hospital:
Class I/II- Outpatient treatment
Class III- Clinical Judgement
Class IV/V- Hospitalize

43
Q

Who with CAP should be screened?

A

Most patients under 50 with CAP should be screened for HIV infection and IgG deficiency

44
Q

What are some risk factors for pneumonia?

A 
Alterations in the level of consciousness
Smoking tobacco 
Alcohol consumption 
Malnutrition
Being elderly
Cystic fibrosis 
Bronchiectasis 
Chronic obstructive pulmonary disease (COPD) 
Previous episode of pneumonia
Immunocompromised
45
Q

What are some bacterial virulence factor for N. meningitidis and S.pneumoniae?

A

produce proteases that can split secretory IgA

46
Q

Which organism can shear off cilia [virulence factor]?

A

Mycoplasma pneumoniae

47
Q

Whats the virulence factor of Chlamydophila pneumoniae ?

A

ciliostatic factor

48
Q

Which organisms are resistant to phagocytosis?

A

Mycobacterium spp, Nocardia spp, and Legionella spp

49
Q

What is inlfuenza virus’ virulence?

A

Influenza virus markedly reduces tracheal mucus velocity within hours of onset of infection and for up to 12 weeks postinfection

50
Q

What is a missed cause of pneumonia in immunocompromised?

A

Pneumocystis jirovecii

51
Q

What is PSI?

A

Pneumonia Severity Index

Pneumonia Severity Index for Adult CAP estimates mortality for adult patients with community-acquired pneumonia.

Pulmonary (25 decks)

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