Pneumonia PREmidterm Flashcards
community acquired pneumonia (CAP)
-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
CAP occurs when…
Defect in at least one host defense mechanism:
-cough reflex
-mucociliary clearance system
-immune responses
Very large infectious inoculum
Highly virulent pathogen overwhelms host
risk factors for increased morbidity and mortality from CAP
-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
CAP: pathogens
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
CAP: symptoms
-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
CAP: physical exam
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
Sputum labs gram stain and cutlure should be attempted in all patients who..
Requiring hospitalization
-Before antibiotics are initiated except in antibiotic failure
Sputum Induction would be used in what populaions?
-P jiroveci or Mycobacterium tuberculosis pneumonia
or cant provide expectorated sputum
Other Technique:
Transtracheal Aspiration
Fiberoptic bronchoscopy
Transthoracic needle aspiration
CAP: hospitalized pt labs
-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
CAP: chest radiography
CXR to confirm diagnosis !!!
Also used to assess severity, pleural effusion, and plan therapy
outpt setting, empiric tx of CAP
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
comorbid conditions: CAP
-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
inpatient adults with non-severe CAP tx
Without risk of MRSA or P. aeruginosa and non-severe CAP
- Beta-Lactam (Ceftraxione) AND Azithromycin
- Respiratory Levofloxacin
aspiration pneumonia- pathogen and tx
Tx:
- Augmentin or Clindamycin (risk of C. Diff)
Bacteria:
- anaerobes and streptococci
CAP: prevention
Vaccinate + stop smoking
hospital acquired pneumonia def
Definition: Pneumonia acquired > 48 hours after admission
- Microaspiration of pathogen that has colonized oropharyngeal tracy and GI tract
HAP: risks
-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
HAP: MC organisms
Aerobic gram neg:
-P. aeruginosa*
- Enterobacter*
- K. pneumoniae
- E. coli
Aerobic gram positive:
- S. Aureus
- MRSA
- Streptococcus
Empiric antimicrobial agents for VAP and HAP: MRSA + Psuedomonas aeruginosa
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
HIV disease and bacterial pneumonia
-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
HIV bacterial pneumonia sx
abrupt onset
same presentation as immune competent - fever, productive cough, chest pain
- high wbc
HIV disease pn: tx and prevention
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
Pneumocystis jiroveci Pneumonia symptoms
-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*
Pneumocystis jiroveci Pneumonia
physical findings
-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
pneumocystis jiroveci Pneumonia labs
-LDH
-CD4
-ABG
-O2 Sat
Induced sputum:
-Demonstrate cysts
-If negative and suspicion high: bronchoscopy- Bronchoalveolar lavage or transbronchial lung bx (not often)
pneumocystis jiroveci Pneumonia imaging
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
pneumocystis jiroveci Pneumonia: dx
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
PCP tx and prophylaxis
-TMP-SMX- BACTRIM
when to prophylax PCP
-CD4 counts < 200 cells/mcL
-CD4 percentage below 14%
-Oral candidiasis (ignore this)
-Prior PCP
most common pathogen that causes atypical pneumonia
-mycoplasma pneumonia- IS THE MORE COMMON ONE
pneumocystosis jiroveci in HIV pt
-hazy
-diffuse interstitial infiltration
-ground glass
HIV Bacterial Pneumonia presentation/ S+ S
-similar presentation to immunocompetent pts:
-abrupt onset of fever, productive cough, chills, pleuritic cp
-high WBC
-bacteremia common
-lower CD4 worser off
