Pneumonia - clinical approach Flashcards
2 places where you can catch pneumonia?
- community (MC)
- hospital (acute care & long-term acute care)
nosocomial (hospital)
Key clue in history that suggests pneumonia?
pleuritic CP
cough, sputum, dyspnea, fever, malaise
What is pneumonia?
infection in alveoli
(terminal bronchioles)
physical exam findings of pneumonia (4)
- crackles (alveoli opening during inspiration)
- bronchial breath sounds
- egophony (only in pneumonia)
- dullness to percussion
(alveoli should always be open)
Where can you evaluate alveoli on CXR?
between the ribs
Patterns of pneumonia are categorized by which features?
- density
- location
bronchopneumonia involves which areas?
patchy over entire lung (air spaces)
lobar is just a lobe
define cavitary pneumonia
wall surrounding infection
key finding on CXR that suggests empyema
meniscus of fluid
What causes CAP in healthy hosts?
lung microbiome dysbiosis
(62% of patients don’t have a microbe that can be isolated)
CAP in host w/co-morbidities have which predisposing factors
different microbes within their lungs
3 step approach to tx pneumonia
- normal host or co-morbidities?
- risk factors for MRSA or pseudomonas?
- exposures?
rule in/out influenza, COVID-19
co-mordities that predispose to pneumonia (5)
- age>65
- chronic diz
- asplenia/immunosuppressed
- smoking, alcohol
- recent abx
CAP initial tx
normal host
amoxicillin or doxycylcine
(z-pac not used b/c pneumococcal is resistant)
CAP w/co-morbidities initial tx
beta-lactam + z-pac
(z-pac used here bc it is broader spectrum due to co-morbidities)
CAP w/co-morbidities initial tx in patients w/penicillin allergy
fluoroquinolone
(they are over used and there is now resistance)
when would you do dx testing for pneumonia?
- if they have COVID or flu
- sick enough to be admitted
only if tthe results will change management
major risk factors for MRSA/pseudomonas (R-GNB)
(step 2 in determining pneumonia tx)
- prior colonization or infection w/one of these organism
- hospitalization < 3 months + received IV abx
colonization means bacteria is there, but no diz
Which patients are at risk for MSRA/psudeomonas (R-GNB)
step 2 evaluation
- bronchiectasis
- CF
- COPD
- repeated abx or steroid use
Which 6 exposures pre-dispose to pneumonia?
step 3 in tx assessment
- farm animals
- cats/dogs
- birds
- camels
- rodens
- human: Covid, virus, tb
Which geographic regions pre-dispose to fungal pneumonia?
step 3 in tx assessment
SW: coccidioidomycosis
NE: blastomyces
SE: histoplasma
must ask patients where they have been the last 6 months
How do you know if a patient needs inpatient care?
- medical issues
- common sense issues: socioeconomic determinants
can they care for themselves?
clinical prediction rules used for pneumonia (2)
- Pneumonia severity index (PSI)
- CRB-65 (+O2 sat)
bedside
What is included in the CRB-65 assessment?
- Confusion
- RR >30/min
- BP < 90mmHG
- 65 > 65
- O2 < 92%
(0= outpatient, 1-2 = inpatient, 3-4 = ICU)
MUST use clinical judgement, look at social determinants
8 lab dx tests (POC) for pneumonia
- Rapid Niral NAATs (Ag detection)
- sputum stain & culture
- blood culture
- UA (pneumococcal or legionella)
- Nasal PCR
- Serology (retrospective)
- Procalcitonin
- Multi-plex PCR
use only if they have been admitted
What is procalcitonin used for in pneumonia patients?
tial end of pneumonia, to decide when to stop abx
positive correlation w/bacterial pneumonia
Multi-plex PCR will miss which causative microbe of pneumonia?
coccioides
Initial therapy for CAP inpatient ward w/co-morbidities
B-
- IV abx
- add MRSA coverage if needed
- sub B-lactame for pseudomonas coverage
**once they’ve been admitted, you can test to de-escalate abx use by day
