Pneumonia and Pleural effusions Flashcards
Pneumonia:
Inflammation of the lungs with consolidation or interstitial lung infiltrates
Most often categorized according to the causative organism
6th leading cause of death in US:
pneumonia
most common S/S of PNA:
Cough Fever Pleuritic chest pain Dyspnea Sputum production Rales/crackles on lung exam Increased tactile fremitus if consolidation Decreased tactile fremitus if effusion
Causative organisms bacterial, viral, fungal
Bacterial PNA:
-mucopurulent sputum
Viral or atypical organism PNA:
scant or watery sputum
PNA most common diagnostic tools:
-often have leukocytosis with left shift
-History and clinical Exam
CXR
Pulse oximetry
Routine lab testing – CBC, BMP, LFTs
Sputum gram stain and culture
Blood culture
ABG (arterial blood gas)
Thoracentesis if pleural effusion present
Most basic PNA workups:
Clinical exam
CXR
(Pulse oximetry)
PNA workup:
Patient stable, looks toxic, fever, dyspnea:
Start empiric antibiotic treatment
Obtain labs
Blood culture
Obtain a sputum sample, stain and culture
May add an ABG (hospital setting)
Thoracentesis if effusion found on CXR, ideally in an inpatient setting
Tx of PNA
- bacterial: antibiotics
- Viral: supportive/anti-virals
- Fungal: anti-fungals
- Pleural effusion: thoracentesis
types of PNA
Community acquired pneumonia Hospital acquired pneumonia Ventilator associated Aspiration pneumonia Mycoplasma/atypical Fungal PCP
CAP definition:
an acute infection of the pulmonary parenchyma in a patient who has acquired the infection in the community, as distinguished from hospital-acquired (nosocomial) pneumonia.
most common cause of CAP:
Streptococcus pneumoniae is the most common cause of community-acquired bacterial pneumonia worldwide
CAP general info:
The overall rate of community-acquired pneumonia (CAP) in adults is approximately 5.16 to 6.11 cases per 1000 persons per year; the rate of CAP increases with increasing age
There is seasonal variation, with more cases occurring during the winter months
The rates of pneumonia:
Men>Women
African American > Caucasians
Determining whether to tx at home or admit use what score:
CURB-65
typical bacterial CAP pathogens:
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis
3 pathogens account for approximately 85% of CAP cases.
antibiotic choice of CAP:
Outpatient typically treated for 7-10 days of oral antibiotics with close follow up Culture results?
Most patients with CAP who are admitted to the hospital are treated with intravenous medications initially and then complete a 12-day oral course of therapy for a total of 14 days of combined intravenous and oral therapy.
when to use Pneumovax:
Two types of pneumococcal vaccine one that covers 23 serotypes and a new one covering an additional 13 serotypes
All patients ≥65 years: ACIP recommends routine vaccination with both PPSV23 (23-valent pneumococcal polysaccharide vaccine) and PCV13 (13-valent pneumococcal conjugate vaccine)
For those whom an additional dose of PPSV23 is indicated, this subsequent PPSV23 dose should be given 6-12 months after PCV13 and ≥5 yr after the most recent dose of PPSV23
HAP
Hospital-acquired (or nosocomial) pneumonia (HAP) is pneumonia that occurs 48 hours or more after admission and did not appear to be incubating at the time of admission.
VAP
Ventilator-associated pneumonia (VAP) is a type of HAP that develops more than 48 to 72 hours after endotracheal intubation.
HCAP
Healthcare-associated pneumonia (HCAP) is defined as pneumonia that occurs in a non-hospitalized patient with extensive healthcare contact, as defined by one or more of the following:
- Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days
- Residence in a nursing home or other long-term care facility
- Hospitalization in an acute care hospital for two or more days within the prior 90 days
- Attendance at a hospital or hemodialysis clinic within the prior 30 days
QUESTION: Why is it so important to do a good history and find out if a patient has one of these types of pneumonias versus community acquired pneumonia?
Multi-drug resistance!!!
For example, the definition of multidrug resistance in gram-negative bacilli, which are an important cause of HAP, VAP, and HCAP, is variably defined as resistance to at least two, three, four, or eight of the antibiotics typically used to treat infections with these organisms
Extensively drug-resistant (XDR) gram-negative bacilli are defined by resistance to all commonly used systemic antibiotics except colistin, tigecycline, and aminoglycosides.
Awareness of local resistance patterns is critical for decisions regarding empiric therapy for HAP, VAP, and HCAP.
HAP epidemiology:
Most cases that are diagnosed within 5 days of admission are due to sensitive bacteria, unless the patient was exposed to antibiotics within the last 90 days.
Patients with HAP diagnosed after 5 days typically have pneumonia due to a resistant bacteria.
The crude mortality for HAP may be as high as 30% to 70%, but many patients die of their underlying disease rather than HAP itself.
Attributable mortality is about 10%. (due to PNA bug itself)
