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Clinical Medicine II > Pneumonia (quiz 2, exam 1) > Flashcards

Pneumonia (quiz 2, exam 1) Flashcards

1
Q

infection of the __, __ and __ of the lung

A
  • alveoli
  • distal airways
  • interstitium
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2
Q

pathogen in sufficient __ or __ to overwhelm __ has to reach the lower repiratory tract

A
  • numbers
  • virulence
  • host defenses
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3
Q

4 routs of infection

A
  1. microaspiration (most common)
  2. gross aspiration (of secretions, vomit; pts: stroke, nuromuscular disorders)
  3. hematogenous spread (blood)
  4. aerosolization
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4
Q

over __ microorganisms that can cause community acquired pneumonia (CAP) and they include these 4 main categories

A
  1. viruses
  2. bacteria
  3. fungi
  4. parasites
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5
Q

patholgogically, the lung changes from its normal __ to __

A
  • sponginess
  • consolidation
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6
Q

4 pathological types

A
  1. lobar pneumonia
  2. bronchopneumonia
  3. interstitial pneumonia
  4. miliary pneumonia
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7
Q

lobar pneumonia involves __, and is relatively __

A
  • entire lung
  • homogenesouly
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8
Q

bronchopneumonia involes __ and shows up as __

A
  • one or severa lobes (usually lower and posterior dependent portion of lungs)
  • patchy consolidaiton
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9
Q

interstitial pneumonia is inflammation of the __, __, and __ and shows up on on CT as __

A
  • interstitium
  • alveolar walls
  • connective tissue around broncho vascular tree
  • patchy or diffuse; gray, honeycombing
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10
Q

miliary pneumonia has numerous discrete __ resulting from the spread of pathogens to the lungs via the __, and it appears __ on xray

A
  • lesions
  • blood stream (TB)
  • speckled (miliary)
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11
Q

community acquired pneumonia includes these 2 types

A
  • ambulatory treatment
  • inpatient treatment
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12
Q

hospital acquired pneumonia (nosocomial)/healthcare associated pneumonie (HCAP) includes these 2 types

A

-ventilator-associated

non-ventilator associated

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13
Q

healthcare associated pneumonia (HCAP) differs in these 4 things

A
  1. etiologic organisms
  2. prognosis
  3. diagnostic algorithms
  4. treatment algorithms
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14
Q

2 other important pneumonias to note

A
  1. opportunistic pneumonia in immunocompromised pts (fungal, PCP in HIV)
  2. TB (mycobacterium)
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15
Q

pneumonia in residents of __ and __ have been treated as either CAP or nosocomial

A
  • nursing homes
  • long term care facilities
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16
Q

it affects __ adults per year and __% are admitted to hospital

A
  • 4 million
  • 20-25%
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17
Q

it is the __ most deadly infectious disease in US and the __ most common cause of death in US each year

A
  • # 1
  • 7th
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18
Q

epidemiology: highest rates during __ months and __% of pts hospitalized with pneumonia die

A
  • winter
  • 12-14%
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19
Q

according to IDSA and ATS guidlines, HCAP indluces any pt who

A
  1. was hospitalized in an acute care hosptial for 2 or more days within 90 days of the infection
  2. resided in a nursing home or long term care facility
  3. received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection
  4. attended a hosptial or hemodialysis clinic
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20
Q

risk factors for increased mortalitly from CAP: age older than 65 years

A
  1. increased incidence and severity
  2. 5th leading cause of death age>65 yo
  3. 4th for those >85
  4. present with less pronounced symptoms
  5. may not be able to mount a fever
  6. may present with only delirium/change in mental status
  7. have to have a high index of suspicion
  8. prophylaxis against CAP is critical in this age group (pneumococcal and influenza vaccines)
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21
Q

7 risk factors for increased mortalitly from CAP

A
  1. age >65 yo
  2. active malignancy
  3. HIV or immunocompromised
  4. neurologic disease
  5. congestive heart failure
  6. coronary artery disease
  7. diabetes
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22
Q

comorbidities as risk factors for CAP (5)

A
  1. asthma
  2. chronic obstructive pulmonary disease
  3. chronic renal failure
  4. liver disease
  5. substance use - alcohol and tobacco
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23
Q

most common pathogens

A
  1. Streptococcus pneumoniae (~70% of cases)
  2. Haemophilus influenzae
  3. Mycoplasma pneumoniae
  4. Chlamydophila (chlymydia pneumoniae)
  5. Staphylococcus aureus
  6. Morexalla catarrhalis
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24
Q

other pathogens: bacterial

A
  1. Klebsiella pneumoniae
  2. Legionella species
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25
Q

other pathogens: viral

A
  1. influenza
  2. adenovirus
  3. respiratory syncytial virus (RSV)
  4. parainfluenza
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26
Q

T or F: bacterial etiology more common than viral

A

true

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27
Q

CAP due to __ and __ is more common in __ months

A
  • S. pneumoniae
  • H. influenzae
  • (other causes of CAP do not appear to have increased seasonal prevalence)
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28
Q

__ and __ are most often responsible for lethal pneumonia, and are the most frequent bacterial pathogens leading to intensive care unit admission

A
  • S. pneumoniae
  • Legionella
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29
Q

CAP DDx: aspiration pneumonia

A
  • can lead to a clinical presentation indistinguishable from CAP
  • the causal pathogens are more likely to be gram negative enteric pathogens and oral anaerobes
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30
Q

CAP DDx: TB should always be considered in pts with risk factors for TB acquisition which include

A
  1. recent time spent in an endemic region
  2. homelessness
  3. potential exposure to infected individuals in institutionalized or medical settings
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31
Q

CAP DDx: typically the presentation of pulmonary tuberculosis is more __ than that of CAP, though this is not absolute

A

chronic (pulmonary tuebrcuosis can present with similar symptoms as CAP)

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32
Q

CAP DDx-TB: empiric treatment of CAP with __ can delay diagnosis of tuberculosis

A

quinolones (they have antimycobacterial activity)

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33
Q

CAP DDx-TB: any pt presenting with __ should be screened for TB

A

symptoms of CAP and risk factors for TB acquisition

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34
Q

Streptococcus pneumoniae gram stain findings

A

gram positive diplococci

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35
Q

Mycoplasma pneumoniae gram stain finding

A

not seen on gram stain (but RBCs are clumped together)

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36
Q

Haemophilus influenzae gram stain findings

A

gram negative coccobacilli

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37
Q

Chlamydophila pneumoniae gram stain findings

A

not seen on gram stain

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38
Q

Staphyloccocus aureus gram stain findings

A

gram positive cocci in clusters

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39
Q

Moraxella catarrhalis gram stain findings

A

gram negative diplococci

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40
Q

atypical pathogens include __ and CAP caused by these agents classically have these symptoms

A
  1. C. pneumoniae
  2. M. pneumoniae
  3. Legionella species
  • presents insidiously (not acute, like with the more common agents)
  • low grade fever
  • non-productive cough
  • prominent extra-pulmonary complaints (including myalgias and GI related symptoms)
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41
Q

atypical pneumonia: __ is often responsible for what is often termed walking pneumonia; it is transmitted via __ and is commonly spread among __

A
  • Mycoplasma
  • respiratory droplets
  • otherwise healthy individuals in close contact with one another (e.g. college dormitories or military barracks)
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42
Q

T or F: clinical presentation alone is adequate to differentiate between specific etiologic agents in CAP

A

false

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43
Q

CAP epidemiology: it is often difficult ot identify microbiologic agents in the lab, via culture or other means, because __ happens relatively frequently

A

polymicrobial infection

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44
Q

clinical condition: alcoholism

commonly encountered pathogens:

A
  1. Streptococcus pneumoniae
  2. anaerobes
  3. less commonly Klebsiella pneumoniae (jelly sputum)
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45
Q

clinical condition: COPD/smoking

commonly encountered pathogens:

A
  1. S. pneumoniae
  2. Haemophilus influenzae
  3. Moraxella cattarrhalis
  4. Legionella species
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46
Q

clinical condition: nursing home resident

commonly encountered pathogens:

A
  1. S. pneumoniae
  2. gram negative bacilli
  3. Haemophilus influenzae
  4. Staphylococcus aureus
  5. anaerobes
  6. Chlamydophila pneumoniae
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47
Q

clinical condition: poor dental hygiene

commonly encountered pathogens:

A

anaerobes

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48
Q

clinical conditino: HIV infection, early stage

commonly encountered pathogens:

A
  1. S. pneumoniae
  2. H. influenzae
  3. Mycobacterium tuberculosis
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49
Q

clinical condition: HIV infection, late stage

commonly encountered pathogens:

A
  1. S. pneumoniae
  2. H. influenzae
  3. Mycobacterium tuberculosis
  4. P. jiroveci (formerly Pneumocystis pneumoniae or PCP)
  5. Cryptococcus species (fungi)
  6. Histoplasma species (fungi)
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50
Q

clincial condition: influenza active in community

commonly encountered pathogens:

A
  1. influenza
  2. S. pneumoniae
  3. S. aureus (more common after someone has had the flu)
  4. Streptococcus pyogenes (aspiration can lead to anaerobic infection and chemical pneumonitis)
  5. H. influenzae
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51
Q

condition: suspected large colume aspiration

commonly encountered pathogens:

A

anaerobes (chemical pneumonitis, obstruction)

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52
Q

condition: structural lung disease (e.g. cystic fibrosis)

commonly encountered pathogens:

A
  1. Pseudomonas aeruginosa
  2. S. aureus
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53
Q

condition: injection drug use

commonly encounterd pathogens:

A
  1. S. aureus
  2. anaerobes
  3. M. tuberculosis
  4. S. pneumoniae
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54
Q

condition: exposure to birds (e.g. parrots, parakeets, and macaws)

commonly encountered pathogens:

A

Chlamydophila psittaci

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55
Q

condition: exposure to rats

commonly encountered pathogens:

A

Yersinia pestis (plague)

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56
Q

condition: exposure to rabbits

commonly encountered pathogens:

A

Francisella tularensis (tularemia)

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57
Q

condition: leukemia

commonly encountered pathogens:

A

Fungi

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58
Q

condition: children <1 year

commonly encountered pathogens:

A

respiratory syncytial virus (RSV)

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59
Q

condition: children 2-5 years

commonly encountered pathogens:

A

parainfluenza virus

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60
Q

condition: post-splenectomy

commonly encountered pathogens:

A
  1. S. pneumoniae (encapsulated organism)
  2. H. influenzae (encapsulated organism?)
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61
Q

condition: college student

commonly encountered pathogens:

A
  1. Mycoplasma pneumoniae
  2. C. pneumoniae
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62
Q

condition: military recruits

commonly encountered pathogens:

A
  1. Mycoplasma pneumoniae
  2. C. pneumoniae
  3. adenovirus
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63
Q

condition: travel to southwestern US

commonly encountered pathogens:

A

Coccidioides species

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64
Q

condition: exposure to aerosolized water, air conditioning

commonly encountered pathogens:

A

Legionella

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65
Q

CAP is a clinical diagnosis base on th

A
  1. patients history
  2. physical exam
  3. CXR
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66
Q

diagnosis: 3 important decisions to made with case of suspected CAP

A
  1. does the pt truly have pneumonia?
  2. what is the severity of the pneumonia?
  3. is hospitalization required?
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67
Q

there is no gold standard for the diagnosis of CAP but these 2 things are considered sufficient and highly suggestive of CAP

A
  1. new infiltrate on chest radiograph
  2. acute respiratory complaints (e.g. cough and dyspnea)
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68
Q

Diagnostic criteria for CAP

A
  1. pt presents with complaints suspicious for acute lung infection
  2. pt has 2 or more of fever, cough, dyspnea, chest pain AND CXR shows new inflitrate
69
Q

Diagnostic criteria for HCAP includes that

  1. pt presents with complaints suspicious for acute lung infection
  2. pt has CXR that shows new infiltrate and 2 or more of fever, cough, dyspnea, chest pain

3.

A
  • hospitalized in last 90 days OR
  • long term care facility resident OR
  • IV abx/chemo/wound care in last 30 days OR
  • attending dialysis
70
Q

the clinical presentatin of CAP can be highly variable depending on __ and __

A
  • age
  • medical comorbidities
71
Q

the most common complaints of pts wit pneumonia are

A
  1. cough (86%) (should be new in onset)
  2. dyspnea (72%)
  3. sputum production (64%) (for pts with chronic cough, should be change in sputum production)
72
Q

CAP symptoms

A
  1. fever
  2. cough
  3. dyspnea
  4. pleuritic chest pain
  5. hemoptysis
  6. sputum production
  7. chills or rigors
  8. diaphoresis
  9. headache
  10. nausea
  11. vomiting
  12. diarrhea
  13. myalgias
  14. arthalgias
  15. fatigue/malasie
  16. chest discomfort
  17. anorexia
  18. abdominal pain
  19. falls in elderly
  20. new onset or worsening confusion in elderly (both clinical and physical findings may be lacking in elderly)
73
Q

among infectious processes, __ is the most important diagnosis to distinguish from CAP, and a __ will frequently help distinguish them

A
  • acute bronchitis
  • CXR
74
Q

CAP DDx: acute bronchitis involves __ so there should be no change in the __ on CXR

A
  • inflammation or infectino of the upper airway and bronchi
  • lung parenchyma
75
Q

CAP DDx: penumonia is an infectino of the __ and a diagnosis of CAP requires that __ be present

A
  • lower respiratory tract
  • an infiltrate (will lag on presence of infiltrate and on clearing)
76
Q

CAP DDX: acute bronchitis is most commonly caused by __ and does not require __ therapy; CAP has an increased mortality if not managed with __

A
  • viruses
  • antibiotic
  • antibiotics
77
Q

DDx of CAP: acute bronchitis

A

no infiltrate on CXR

78
Q

DDx of CAP: URI

A

no lower respiratory tract signs/symptoms (crackles)

79
Q

DDx of CAP: sinusitis

A

post nasal dirp may cause cough

80
Q

DDx of CAP: influenza

A

PCR/diagnostic test

81
Q

DDx of CAP: pertussis

A

several weeks of cough; postive nasopharyngeal/PCR

82
Q

DDx of CAP: pulmonary embolus

A

high index of suspicion in pt with normal CXR and pulmonary complaints

83
Q

DDx of CAP: acute exacerbation of COPD

A

CXR should be without infiltrate (note: infectious illness can cause exacerbation)

84
Q

DDx of CAP: malignancy

A

CT scan and biopsy to help dx

85
Q

DDx of CAP: congestive heart failure exacerbation

A

pulmonary edema usually bilateral, lower lung fields on CXR; physical exam (jugular venous extension)

86
Q

DDx of CAP: gastroesophageal reflux (GERD)

A

CXR normal; positional and night time symptoms

87
Q

CAP: physical exam

A
  1. tachypnea (over 20)
  2. tachycardia
  3. fever or hypothermia
  4. crackles (inspiratory) or ronchi
  5. dullness to percussion (lobar consolidation or pleural effusion)
  6. arterial desaturation (check ABGs; quick screen with pulse ox)
  7. increased tactile and vocal fremitus
  8. egophony (“E” to “A” changes)
  9. whispered pectoriloquy
  10. pleural friciton rub
88
Q

CAP PE: physical exam does not always give the diagnosis; __ have been shown to be important in predicting outcome

A

vital sing abnormalities (elderly pts may not have vital sign abnormalities and minimal signs/symptoms)

89
Q

CAP PE: classic pulmonary exam with __ and __ are suggestive of consolidation or an effusion; these 3 symptoms may also be present

A
  • localized crackles (rales) on lung asucultation
  • dullness to percussion
  • decreased breath sounds or bronchial breath sounds
  • ronchi
  • egophony
90
Q

CAP: 3 signs concerning for poor outcome

A
  1. increased respiratory rate (>30/min)
  2. decreased systolic BP (<90)
  3. inceased HR (>125)
91
Q

CAP diagnosis: specific __ for CAP cannot be distinguished on the basis of clinical features alone

A

etiologies

92
Q

CAP diagnosis: poor accuracy of diagnosisng CAP on __ alone; if a diagnosis of CAP is considered, a __ should be obtained

A
  • history and physical examination
  • CXR (it is stronly recommended by the ATS/IDSA guidleines in order to diagnosie CAP)
93
Q

CAP diagnosis: there are certain signs and symptoms that are suggestive of specific etiologies- S. pnuemonia

A
  1. sudden onset of fever
  2. cough
  3. pleuritic, localized chest pain (indicative of lobar consolidation)
  4. single rigor
  5. shaking chill
94
Q

CAP diagnosis: there are certain signs and symptoms that are suggestive of specific etiologies- atypical pneumonias

A
  1. slower in onset
  2. prominent myalgias
  3. other extra-pulmonary complaints
  4. prolonged, dry cough
95
Q

CAP diagnosis: there are certain signs and symptoms that are suggestive of specific etiolgoies- aspiration pneumonias

A
  1. frequent in-hospital occurences
  2. decreased consciousness
  3. decreased neurologic insult
96
Q

CXR in diagnosis of CAP: CXR is not 100% __

A

sensitive (a negative CXR with a clinical picture highly suggestive of CAP does not rule out CAP)

97
Q

CXR in diagnosis of CAP: false negative readings can occur in the pt with CAP due to

A
  1. early stage of disease
  2. dehydratin (orthostatic hypotension, increased HR)
  3. artifact on CXR
98
Q

CXR in diagnosis of CAP: if the clinical pciture suggests CAP and the CXR is negative, __

A

repeat within 24-48 hours to evaluate for pregession of disease

99
Q

CXR in diagnosis of CAP: pts with clinical signs of dehydration can develop __ CXR findings over a several day period as their voume status was corrected with a seeminlgy __

A
  • worsening
  • blossoming infiltrate
100
Q

diagnostic tests for CAP outpatient setting: dagnostic tools appear to be relatively insensitive in screening for CAP

A
  1. blood culture: IDSA/ATS guidelines state that blood cultures are positive in only 5-14% of pts admitted to hospital; blood cultures are rarely helpful in the ambulatory setting and are NOT recommended for the outpatient management of CAP
  2. sputum gram stain: has a highly variable diagnosit yield; in outpatients, sputum provides diagnostic information in roughly 20% of those tested and usually not done in outpatients
  3. sputum culture: same as above
101
Q

diagnostic tests for CAP in outpatient setting: novel testing are considered helpful in certain situation

A

urine antigen assays for Legionella and S. pneumoniae

102
Q

CAP inpatient diagnostic tests: microbiologic testing offers an __ diagnosis in about __ of pts hospitalized with CAP

A
  • etiologic
  • 1/2
103
Q

CAP inpatient diagnostic tests: IDSA/ATS guidelines recommend __ in patients being admitted to the hospital

A

blood and sputum cultures

104
Q

CAP inpatient diagnosit tests: pts admitted ot the hosptial get __ blood cultures before antibiotic therapy (but dont delay treatment)

A

2 peripheral (do it when pt is febrile because sthey are bacteremic)

105
Q

CAP inpatient diagnostic tests: sputum culture samples are frequently contimainted by __ secretions; sputum samples with __ is deemd adequate

A
  • upper respiratore tract
  • _>_25 polymorphonuclear cells (PMN) and <10 squamous epithelial cells (SEC) per low power field
106
Q

CAP inpatient diagnostic tests: T or F, the utiltity of sputum gram stain has been debated for years

107
Q

CAP inpatient diagnostic tests: urinary antigen test available for

A

Legionella and pneumococcus

108
Q

CAP inpatient diagnostic tests: urinary antigen test for S. pneumoniae has sensitivity of __ and specificity of __

A
  • 70-90%
  • ~99%
109
Q

CAP inpatient diagnostic tests: urinary antigen tests cannot give __, are used as an adjunt to __, and used predominantly in __ pts

A
  • resistance patterns
  • blood culture and sputum gram stain and culture
  • hospitalized
110
Q

CAP inpatient diagnostic tests: these 3 are difficult to detect

A
  1. anaerobes
  2. Chlamydophila pneumonia
  3. Mycoplasma pneumonia
111
Q

CAP inpatient diagnostic tests: anaerobes that cause respiratory disease are thought to be aspirated from the mouth and oropharynx

A
  1. peptostreptococcus
  2. prevotella
  3. bacteroides
  4. fusobacterium
112
Q

CAP inpatient diagnostic tests: pts with __ are prone to anaerobic lung infection

A

decreased mental status and others at risk for aspriation

113
Q

CAP: there are 2 widely used clinical prediction rules available to guid admission and triage decisions

A
  1. Pneumonia Severity Index (PSI): helps identify pts at higher risk of complications and who are likely to benefit from inpatient hospitalization
  2. CURB-65: its less discriminating at low mortality but excellent at identifying pts with high mortality who may benefit from ICU level care
114
Q

PSI

pt characteristic: AGE, men

no. of points:

A

age, years+10

115
Q

PSI

pt characteristic: age, women

no. of points:

A

age, years -10

116
Q

PSI

pt. characteristic: age, nursing home residents
no. of points:

A

age, years +10

117
Q

PSI

pt characteristic: co-existing illnesses, neoplastic disease

no. of points:

118
Q

PSI

pt characteristic: co-existing illnesses, liver disease

no. of points:

119
Q

PSI

pt characteristic: co-existing illnesses, CHF

no. of points:

120
Q

PSI

pt characteristic: co-existing illnesses, cerebrovascular disease

no. of points:

121
Q

PSI

pt characteristic: co-existing illnesses, renal disease

no. of points:

122
Q

PSI

pt characteristic: PE findings, altered mental staus (confusion, delirium…)

no. of points:

123
Q

PSI

pt characteristic: PE finding, respiratory rate >30/min

no. of points:

124
Q

PSI

pt characteristic: PE finding, systolic BP <90 mmHg

no. of points:

125
Q

PSI

pt characteristic: PE finding, temp <35C (<95F) or >40C (>104F)

no. of points:

126
Q

PSI

pt characteristic: PE finding, HR > 125/min

no. of points:

127
Q

PSI

pt characteristic: lab and radiograph findings, arterial pH <7.35

no. of points:

128
Q

PSI

pt characteristic: lab and radiograph findings, BUN >30 mg/dL

no. of points:

129
Q

PSI

pt characteristic: lab and radiograph findings, Na < 130mmol/L

no. of points:

130
Q

PSI

pt characteristic: lab and radiograph findings, glucose > 250 mg/dL

no. of points:

131
Q

PSI

pt characteristic: lab and radiograph findings, Hct < 30%

no. of points:

132
Q

PSI

pt characteristic: lab and radiograph findings, partial press. of arterial O2 < 60 mmHg

no. of points:

133
Q

PSI

pt characteristic: lab and radiograph findings, pleural effusion

no. of points:

134
Q

PSI, Class I: risk, score, mortality, site of care

A
  • risk: low
  • score: <51
  • mortality: 0.1%
  • site of care: outpatient
135
Q

PSI, class II: risk, score, mortality, site of care

A
  • risk: low
  • score: 51-70
  • mortality: 0.6%
  • site of care: outpatient
136
Q

PSI, class III: risk, score, mortality, site of care

A
  • risk: low
  • score: 71-90
  • mortality: 0.9%
  • site of care: inpatient (briefly) (should be based on clinical judgment)
137
Q

PSI, class IV: risk, score, mortality, site of care

A
  • risk: medium
  • score: 90-130
  • mortality: 9.5%
  • site of care: inpatient
138
Q

PSI, class V: risk, score, mortality, site of care

A
  • risk: high
  • score: >130
  • mortality: 26.7%
  • site of care: inpatient
139
Q

PSI scoring: there are several factors in a patient’s presentation not accounted for in the PSI that nonetheless may qualify them for inpatient treatment, in which hospitalizaiton may benefit an otherwise low risk pt, and they include

A
  1. homelessness
  2. drug abuse
  3. rare comorbidities
  4. difficulty with medicine compliance
  5. unstable home situations
140
Q

CURB-65 asses five simple, independent predictors on increased mortality (scored as 1 point each)

A
  • Confusion
  • Uremia (BEN > 20 mg/dL)
  • Respiratory rate (> 30 bpm)
  • Blood pressure (systolic <90 mmHg OR diastolic <60 mmHg)
  • >65 years old
141
Q

CRB-65 is same the same thing as CURB-65 except no

A

Uremia (BUN > 20 mg/dL)

142
Q

CURB-65 score

A
  • 0-1 = low risk; consider home treatment
  • 2 = short inpatient hospitalization or closely supervised outpatient treatment
  • 3-5 = severe pneumonia; hosptializatoin and consider ICU
143
Q

CRB-65 score

A
  • 0 = very low predicted mortality; no hospitalization
  • 1-2 = increased risk of death; consider hospitalization
  • 3-4 = high risk of death; urgent hospitalization
144
Q

CAP treatment: __% of CAP is treated as outpatient; most patients are treated __, without identifying any __

A
  • 80%
  • empirically
  • organism
145
Q

CAP treatment: need to triage/disposition (__), antibiotic therapy must be __, and pathogen must be __ to antibiotic used

A
  • outpatient vs. inpatient
  • prompt
  • susceptible
146
Q

CAP treatment: 2 classes of antibiotics most commonly recommended for outpatient management of pneumonia (in those pts who have not received antibitoics in the previous 3 months)

A
  1. Macrolides (e.g. erythromycin, azithromycin, clarithromycin)
  2. Doxycycline
147
Q

CAP treatment: recent concern over increasing resistance of __ to macrolides throughout US; to date, reports of clinical failure of these drugs are __; similar concerns have arisen with the __

A
  • S. pneumonia
  • rare
  • fluoroquinolones (they are now considered to be the most frequently misused class of antibiotics)
148
Q

CAP treatement: current rates of resistance to fluoroquinolones are estimated at __%; this has been a __ problem in countries other than the US

149
Q

CAP treatment: a progressive rise of resistant organisms has been reported across the country and experts predict the complete loss of this antibiotic class (fluoroquinolones) in the next ten years without a __

A

change in current usage patterns

150
Q

CAP treatment: pts with CAP and no comorbidities and no recent antibiotic use should not be treated with __

A

respiratory fluoroquinolones (i.e., moxifloxacin, levofloxacin, gemifloxacin)

151
Q

CAP treatment outpatients

pt: healthy, no recent antibiotics (last 3 months)

treatment:

A
  • macrolide (erythromycin, azithromycin, clarithromycin) OR
  • doxycycline
152
Q

CAP treatment outpatients

pt: healthy and recent (<3 months) antibiotic use

treatment:

A
  • respiratory fluoroquinolone (moxifloxacin, levofloxacin, gemifloxacin) OR
  • beta-lactam (amoxicillin or amoxicillin/clavulanate preferred) PLUS macrolide
153
Q

CAP treatment outpatients

pt: comorbidities (e.g. chronic heart, lung, liver, or renal disease; DM; alcoholism; asplenia; immunosupression; malignancy)

treatment:

A
  • respiratory fluoroquinolone (moxifloxacin, levofloxacin, gemifloxacin) OR
  • beta-lactam (high dose amoxicillin or amoxicillin/clavulanate preferred) PLUS macrolide
154
Q

CAP treatment outpatients

pt: suspected aspiration with infection

treatment:

A
  • amoxicillin-clavulanate OR
  • clindamycin
155
Q

CAP treatment outpatients

pt: influenza with bacaterial superinfection

treatment:

A
  • beta lactam OR
  • respiratory fluoroquinolone
156
Q

CAP treatment outpatients: typical antibiotic treatment duration for CAP ranges from __ to __ days; IDSA/ATS guidlines recommend a minimun of __ days of antibiotic treatment for uncomplicated CAP

A
  • 5-14 days
  • 5 days
157
Q

CAP treatment outpatient: pts should be afebrile for __ hours with resolution or marked iimprovement in symptoms prior to antibiotic discontinuation

A

48-72 hours

158
Q

CAP treatment outpatients: typcially macrolides such as azithroomycin are used for __ days, while doxycycline and the quinolones are prescribed for __ days

A
  • 5 days
  • 7-10 days
159
Q

CAP treatment outpatient: it remains to the clinician to decide the appropriate regimen for his pt, while taking into account the __, __, and __

A
  1. severity of presentation
  2. pt comorbidities
  3. the potential of drug resistant infection
160
Q

CAP treament: azithromycin (macrolide): dosage, typical duration, comments

A
  • dosage: 500 mg x 1 followed by 250 mg daily x 4 days
  • typical duration: 5 days
  • comments: preferred agent for ptss without comorbidities or recent antibiotics
161
Q

CAP treatment, clarithromycin (macrolide): dosage, typical duration, comments

A
  • two 500 mg tabs daily
  • 5 days
  • erythomycin has poor coverage of H. influenzae, so azithromycin and clarithromycin preferred
162
Q

CAP treatment, doxycycline (tetracycline): dosage, typical duration, comments

A
  • 100mg twice daily
  • 7-10 days
  • alternative to macrolides
163
Q

CAP treatment, moxifloxacin (quinolone): dosage, typical duration, comments

A
  • 400mg daily
  • 5 days
  • use quinolone when comorbidities are present or recent antibitoics
164
Q

CAP treatment, gemfloxacin (quinolone): dosage, typical duration

A
  • 320mg daily
  • 5 days
165
Q

CAP treatment, levofloxacin (quinolone): dosage, typical duration

A

dosage: 750mg daily

5 days

166
Q

CAP treatment: amoxicillin-clavulanate (beta-lactam + beta-lactamase inhibitor): dosage, typical duration, comments

A
  • 2g twice dailly
  • 5 days minimum
  • given in combination with macrolide or doxycycline
167
Q

CAP course

expect improvement in __ hours with right antibiotic

CXR may __ but patient improves __

fever can last __ days with pneumococcus; longer with others

rales can persist __ days in up to __% pts

CXR may not clear for __

A
  • 48-72 hours
  • worsen, clinically
  • 2-5 days
  • >7 days, 40%
  • several weeks
168
Q

CAP course: if pt not responding to initial therapy, consider:

A
  1. virus
  2. TB
  3. resistant organism
  4. Pneumocystis (opportunistic fungal infeciton in immunocompromised pt)
  5. non-infectious illness
169
Q

CAP preventions:

A
  1. influenza vaccine
  2. pneumococcal vaccine:
  • pneumovax (>65 yo or chronic illnesses/co-morbid conditions, immunocompromised)
  • Prevnar (<9 yo)

Clinical Medicine II (11 decks)

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