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Pulmonary > Pneumonia PREmidterm > Flashcards

Pneumonia PREmidterm Flashcards

1
Q

community acquired pneumonia (CAP)

A

-Dx outside of hospital or within 48 hours after admission*:

  • Not have been hospitalized > 2 days within 90 days of infection
  • Not have resided in long-term care facility
  • Not have received IV antibiotics, chemotherapy, or wound care within 30 days prior to current infection
  • Not have attended a hospital or hemodialysis clinic
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2
Q

CAP occurs when…

A

Defect in at least one host defense mechanism:
-cough reflex
-mucociliary clearance system
-immune responses

Very large infectious inoculum
Highly virulent pathogen overwhelms host

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3
Q

risk factors for increased morbidity and mortality from CAP

A

-Alcoholism
-Comorbid medical conditions
-Altered mental status- aspirate more
-Respiratory rate ≥ 30 breaths/min- tachypneic
-Hypotension
-BUN > 30 mg/dL

Pneumonia occurs more in
- Extremes of ages
- Men > women
- Black > white

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4
Q

CAP: pathogens

A

MC = S. pneumoniae***
Alcoholism + red brown colored sputum = Klebseila pneumoniae
COPD- Haemophilus Influenzae
Lung Abscess-Oral Anaerobes
HIV early- S. pneumoniae
HIV late: Pneumocystis jiroveci
Hotel/cruise: Legionella

-histoplasma capsulatum- bird or bat droppings
-chlamydophilia- birds
-staph aureus- injection drug use

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5
Q

CAP: symptoms

A

-Acute or subacute onset of fever, dyspnea, cough +/- sputum production
-tachypnea

-Other common symptoms:
-Rigors
-Sweats
-Chills
-Chest discomfort/pleurisy
-Hemoptysis
-Fatigue
-Myalgias
-Anorexia, headache, and abdominal pain

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6
Q

CAP: physical exam

A

Fever or hypothermia*

Abnormal vital signs:
-Tachypnea, tachycardia, and mild arterial oxygen desaturation

Chest Exam: signs of consolidation
-Altered breath sounds +/- rales (clicking/bubbling sound)
- Dullness with percussion
- Egophony

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7
Q

Sputum labs gram stain and cutlure should be attempted in all patients who..

A

Requiring hospitalization
-Before antibiotics are initiated except in antibiotic failure

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8
Q

Sputum Induction would be used in what populaions?

A

-P jiroveci or Mycobacterium tuberculosis pneumonia
or cant provide expectorated sputum

Other Technique:
Transtracheal Aspiration
Fiberoptic bronchoscopy
Transthoracic needle aspiration

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9
Q

CAP: hospitalized pt labs

A

-CBC with differential
-Pre-antibiotic blood cultures
-Chemistry panel + Respiratory panel
-ABG: assess O2 + acid base status
-Procalcitonin: differentiate bacterial from viral infections
-Urinary antigen assays: help with pathogen identification

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10
Q

CAP: chest radiography

A

CXR to confirm diagnosis !!!

Also used to assess severity, pleural effusion, and plan therapy

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11
Q

outpt setting, empiric tx of CAP

A

Healthy with No Risk Factors (Class I/II):a
-Amoxicillin OR
-Doxycycline

Adults with comorbidities:
- Augmentin AND Azithromycin
- Cephalosporin AND Azithromycin
- Monotherapy (Fluoroquinolone): Levofloxacin OR Gemifloxacin

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12
Q

comorbid conditions: CAP

A

-chronic heart, lung, liver, or kidney disease
-diabetes mellitus
-alcohol use disorder
-malignancy
-asplenia
-immunosuppressant conditions or
-use of immunosuppressive drugs
-or use of antibiotics within the previous 3 months

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13
Q

inpatient adults with non-severe CAP tx

A

Without risk of MRSA or P. aeruginosa and non-severe CAP
- Beta-Lactam (Ceftraxione) AND Azithromycin
- Respiratory Levofloxacin

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14
Q

aspiration pneumonia- pathogen and tx

A

Tx:
- Augmentin or Clindamycin (risk of C. Diff)

Bacteria:
- anaerobes and streptococci

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15
Q

CAP: prevention

A

Vaccinate + stop smoking

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16
Q

hospital acquired pneumonia def

A

Definition: Pneumonia acquired > 48 hours after admission
- Microaspiration of pathogen that has colonized oropharyngeal tracy and GI tract

17
Q

HAP: risks

A

-Pharyngeal colonization:
-Instrumentation: ng/et tubes; VENTILATION
-Contamination: hands/equipment
-Broad-spectrum antibiotics- Drug-resistant organisms
-Patient factors- Malnutrition, age, altered consciousness, swallowing disorders, and underlying pulmonary and systemic diseases

18
Q

HAP: MC organisms

A

Aerobic gram neg:
-P. aeruginosa*
- Enterobacter*
- K. pneumoniae
- E. coli
Aerobic gram positive:
- S. Aureus
- MRSA
- Streptococcus

19
Q

Empiric antimicrobial agents for VAP and HAP: MRSA + Psuedomonas aeruginosa

A

Empirical tx MRSA
- IV vancomycin

Empiric tx for Pseudomonas aeruginosa:
- piperacillin-tazobactam (Beta-Lactam)

After results of sputum, blood, and pleural fluid cultures -> switch to narrow spectrum
-can give both
-usually 7 day course

20
Q

HIV disease and bacterial pneumonia

A

-Bacterial pn is common in HIV ds
-Direct relation between CD4 count and incidence of bacterial pneumonia
-Recurrent bacterial pn is an AIDS defining condition

21
Q

HIV bacterial pneumonia sx

A

abrupt onset
same presentation as immune competent - fever, productive cough, chest pain
- high wbc

22
Q

HIV disease pn: tx and prevention

A

Outpatient: same as CAP with comorbidities
- Augmentin AND Macrolide (ie. Azithromycin)
-Cephalosporin AND Macrolide
Levofloxacin or Gemifloxacin

Inpatient:
-fluoroquinolone OR
- beta lactam + azithromycin

HAP pneumonia: Empiric pseudomonas coverage should be included (Beta-Lactam)

prevent; keep cd4 up and vaccinate

23
Q

Pneumocystis jiroveci Pneumonia symptoms

A

-DRY COUGH
-Fever, tachypnea, SOB
-Presentation ranges from fever and no respiratory symptoms to frank respiratory distress
-pt can look fine and become decompensated from simply walking across room*

24
Q

Pneumocystis jiroveci Pneumonia
physical findings

A

-can be disproportionate to the degree of illness and radiologic findings
-fever (over 80%)
-tachypnea (60%)
-crackles and rhonchi (50% normal chest examination)
-oral thrush common
-Without treatment -> rapid deterioration -> death

25
Q

pneumocystis jiroveci Pneumonia labs

A

-LDH
-CD4
-ABG
-O2 Sat
Induced sputum:
-Demonstrate cysts
-If negative and suspicion high: bronchoscopy- Bronchoalveolar lavage or transbronchial lung bx (not often)

26
Q

pneumocystis jiroveci Pneumonia imaging

A

CXR: Diffuse, bilateral, interstitial, or alveolar infiltrates
Apical infiltrates: Aerosolized pentamidine prophylaxis

computed tomography (HRCT) has high sensitivity for PCP among HIV+ pts ->
- Patchy or nodular ground-glass attenuation (Suggestive not diagnostic)
- Ground-glass is indicative of inflammation
- But if negative, then PCP is unlikely

27
Q

pneumocystis jiroveci Pneumonia: dx

A

Dx: induced sputum!!
-no culture bc this is fungus

If sputum is negative:
- Bronchoalveolar Lavage then PCR
- Tissue Biopsy
- Endotracheal Aspirate

Diagnosis is Unlikely if:
- Normal DLCO
- Normal CT
- CD4 > 250 cells/mcL

28
Q

PCP tx and prophylaxis

A

-TMP-SMX- BACTRIM

29
Q

when to prophylax PCP

A

-CD4 counts < 200 cells/mcL
-CD4 percentage below 14%
-Oral candidiasis (ignore this)
-Prior PCP

30
Q

most common pathogen that causes atypical pneumonia

A

-mycoplasma pneumonia- IS THE MORE COMMON ONE

31
Q

pneumocystosis jiroveci in HIV pt

A

-hazy
-diffuse interstitial infiltration
-ground glass

32
Q

HIV Bacterial Pneumonia presentation/ S+ S

A

-similar presentation to immunocompetent pts:
-abrupt onset of fever, productive cough, chills, pleuritic cp
-high WBC
-bacteremia common
-lower CD4 worser off

Pulmonary (23 decks)

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