Pneumonia, Tb, RSV, Flu, Croup Flashcards
The most common lethal infection in the US
S/s fever, chills, cough, sputum, Tachypnea, and inspiratory crackles
Dullness to percussion, egophany,
+/- leukocytosis, chills, night sweats, rigors, CP, fatigue, anorexia, Headache, hemoptysis with tachypnea and tachycardia
Mc to the R middle lobe
MC 2/2 S. Pneumoniea
Onset is less than 48 hours of admission to a hospital
Increased RSK with recent Viral Infectio, Age, ETOH abuse, Tobacco, COPD and Asthma, Immuno compromised
Think? CXR? W/u? Tx?
CAP
CXR infiltrates/ Lobular opacities, lobular consolidations with bronchograms, patchy airspace disease, with pleural effusions and possible cavitations
W/u: Thorcocentesis or Bronchoscopy
Check prolactin level, influenza test, legionella screening, strep screening
Dx: Cultures are only recommended for hospitalized pts
Tx: ABX and or antivirals, supportive Tx IVF, O2, and corticosteroids for severe CAP
If not responding to Tx, review cultures, order CT and send for PULM consult
Pneumonia from aspiration/ poor dentition think from?
MICROAEROPHILIC and anaerobic mouth flora
Pneumonia from gross aspiration or in a bed ridden person think from?
S. Aureus, gram neg rods, micro/anaerobic mouth flora
Pneumonia with recent travel to the southwestern US Think agent?
Coccidiosis imitus
Pneumonia anger residence in Mississippi River basins or exposure to bats think ?
H. Capsulatum
Pneumonia after exposure to birds think?
C. neofromans or H. Capsulatum
Pneumonia after exposure to sick pssiacine birds think
C. Psittaci
Pneumnia after exposure to rabbits think
F. Tularenis
Pneumonia after exposure to farm animals think?
C. Burnetti
Pneumonia from bronchietstasis or C. Fibrosis think
Pseudomonas, burkholderia, or aspergillosis
Pneumonia after travel to the Middle East
MERS coronavirus
Pneumonia classically caused by Mycoplama Pneumoniae
S/s gradual onset , dry cough, headache, malaise, and N/V
May or may not appear sick
Think? CXR? Tx?
Atypical Pneumnia (Walking Pneumo)
CXR: findings variable but often worse than pt appearance
What is the gold standard for flu Dx
PCR
What is the assay to test for legionella
Urine antigen
What is the assay to test for strep Pneumo
Urine antigen
What is the pathogenesis of CAP
CAP occurs when normal defense to prevent lower resp tract infections (LRTIs) fails
Overwhelming bacterial infection or a virulent pathogen overwhelms the immune response
Where is the right middle lobe best ausculted
Best auscultated on anterior chest at the nipple line
How long can it take pneumonia to clear of CXR
Clearing of pneumonia on CXR can take 6 or more weeks!
Image will “lag” behind clinical improvement
Follow up imaging not necessary if clinical response is present
When should you consider addition X-rays in the treatment of CAP
Consider re-imaging high risk patients at 7-10 weeks
Sometimes underlying/predisposing malignancy revealed post-treatment
(post-obstructive pneumonia)
—Smokers > 40
—Geriatric >65
If a pt with CAP has had resolution of S.s within 5-7 days of treatment should repeat X-rays be ordered
NO!
If you suspect that a pts CAP is caused by P. jirovecii or M. Tuberculosis
What special s am should be done?
Bronchoscopy
How can procalcitonin guide Dx of pnuemonia
High procalcitonin =ikely bacterial infection
Low procalcitonin = less likely bacterial, but cannot exclude
—Potential for decreased use of antibiotics when used
What are the most common agents of CAP that would not need hospitilization
S. pneumo
Mycoplama (walking Pneumo)
Chlamydia pneumo
Influenza
What is the duration of treatment for pts with CAP that meet the criteria for out pt tx
At least 5 to 7 days
(staph aureus, legionella: 10 – 14 days)
Goal: afebrile x 48-72 hrs or more
If no ABX have be given in the past 90 days what ABX can be used for outpt CAP
Macrolides
(clarithromycin or Azithromycin)
Or
Doxycycline
If a pt is receiving out pt Tx for CAP, and has recieved ABX in the past 90d
(Is age over 65, co-morbid, immunocomp, or works in a daycare)
What are the ABX that can be used
Respiraty Florinquinilones
(Moxi, genta, and levofloxacin)
Or
A Macrolide ( clrithro/Azithromycin) plus a beta-lactam (Augmentin)
While treating outpt CAP with ABX you find that there is resistance to macrolides
What are the ABX options then?
Respiratory FQ (moxi/gemi/levofloxacin) OR Macrolide PLUS beta-lactam (amox-clavulanate)
Pneumnia that presents as typical with acute onset of cough, sputum, high fever, high white cell count, dense segmental or lobar consolidations and an elevated procalcitonin level
And legionella is suspected
What is the ABX recommendation
Augmentin with Azithromycin 5-7 days
Pneumnia that presents as typical with acute onset of cough, sputum, high fever, high white cell count, dense segmental or lobar consolidations and an elevated procalcitonin level
And legionella is not suspect suspected
What is the ABX recommendation
Levo/moxi/gentamycin 5-7days
If a pt has pneumonia and a suspected influenza infection
What is the treatment choice
Oseltamivir
Pneumonia suspected to be caused by Mycoplama or chlamydia
What is the ABX option
Azithromycin or Doxycyline
What are the pathogens most likely to lead to pneumonia requiring hopitilization
S. pneumo Mycoplasma pneumo Chlamydia pneumo H. influenzae Legionella sp. Viral Also: aspiration (gastric contents, etc)
What is the goal for Inpt pnuemonia tx
Duration of antibiotic treatment—same as out patient
At least 5 days
Goal: afebrile x 48-72 hrs or more
What is the initial empiric therapy for inpatient CAP tx
Ceftriaxone and a macrolide( Azithromycin)
Or
A fluoroquinolones
(Levo/moxi/gentafloxacin)
initial tx is with IV Rx until pt is stable and then can be switched to oral medication x5-7 days
If influenza is suspected in inpatient CAP tx
What is the Tx option? What is its influenza and a bacteria infection/?
Oseltamivir
Or
Oseltamivir
plus Ceftriaxone/Ceftaroline
Plus vancomycin/linezolid
If inpatient CAP is thought to be due to pseudomonas
What is the ABX of choice
Piperacillin-Tazobactam
Or
Cefepime
If a pt is moved to the ICU with CAP
What are the ABX that can be used in the CAP ICU pt
Levo/genta/Moxifloxacin
Or
Azithromycin plus cefotaxime/ Ceftriaxone /ampicillin
(Anti-pseudomonas beta lactams)
What is the appraoch to CAP prevention
Work on risk factors
(DM, tobacco, general health)
Vaccination
- Polyvalent pneumococcal vaccine (PPV 23)
- Pneumococcal Conjugate (PCV 13)
- Influenza vaccine
- COVID
What is the admission matrix for pneumonia pts
CURB 65
Confusion Uremia>20 RR>30 BP: SBP<90 or DBP<60 65 y/o or more
Each is worth 1 point
0-1 points: low death risk (<3%)
Likely manage as outpatient
2 points: moderate risk (9%)
Consider hospitalization
3-5 points: high risk (15-40%)
Hospitalization indicated
4-5 points suggests ICU admission
What are the most common likely pathogens in nosocomial Pneumonia
S. aureus
-MRSA AND MSSA
Pseudomonas aeruginosa
Gram neg rods
- Enterobacter
- Klebsiella
- E coli
A pt is on a hospital ward and you suspect they are developing a pneumonia
What S/s would prompt Dx
Signs and symptoms: Nonspecific, 2 or more of: -Fever -Leukocytosis -Purulent sputum
Or new/progressive pulmonary opacity on imaging
What is the workup for noscomial pneumonia
Blood cultures x 2; 2 different sites
CBC w/ differential & CMP
-For severity not identification of pathogen
ABG vs. SpO2
-Guides ventilation needs
Thoracentesis/pleural fluid
What are ABX that can cover pseudomonas
Piperacillin- Tazobactam
Azithromycin PLUS cefotaxime or ceftriaxone or ampicillin (antipseudomonal beta-lactams)
What patients are at an increased risk of aspiration
ETOH seizures anesthesia tracheal/NG tubes central nervous system disease
Increased infection risk:
Periodontal disease & poor oral hygiene
S/s fever, wt loss, malaise, cough with foul smelling purulent sputum with por dentition
Think? CXR? Dx? Tx?
Anaerobic pneumonia
CXR: parenchymal bronchopneumonia process in the superior segment of the right lower lobe and the posterior segment of the upper lobes
Never in the apices
With abcess, necrotizing pneumonia, or Empyema
DX; Expectorated sputum is contaminated w/ oral flora
-Aspirate, thoracentesis, bronchoscopy required to culture
Tx: Augmentin
Or Penicillin plus metronidazole
If risk of MRSA add vancomycin
In anaerobic pneumnia with lung abcess
Is there is rick of MRSA
What ABX should be added
Vancomycin
Elderly or bedridden pt’s may require IV ABX
What ABX should be used?
- piperacillin-tazobactam
- meropenem,
- imipenem
– risk for multi-drug resistance
What is the MC pathogen in COPD pneumonia
H Influenza
What is the common pathogen in ETOH pneumnia
Klebsiella
What is the common pathogen in nosocomial infections
Pseudomonas
What is the common pathogen in pneumonia in a pt with recent water contact
Legionella
What are the 4 possible presentations of TB
- Immediate clearance
- Primary Disease
- latent infection
- Reactivation disease
A pt presents with insidious malaise, anorexia, wt loss, fever, and night sweats and chronic cough
That was initially dry and how become purulent over time with blood streaked sputum
Appears chronically ill and malnourished
With apical crackles on exam
Think? Dx?
TB
Dx:
3 consecutive sputum specimens every 8hrs.
“acid fast bacilli”
Hypertonic saline to induce sputum
Bronchoscopy w/ washings
PCR
Blood cultures
-Uncommon to be + unless CD4 count is low
What are the differences between primary and reactive TB CXR
Typical primary findings:
-Initial focus of infection can be located anywhere within the lung.
Small unilateral infiltrates, hilar adenopathy, segmental atelectasis, pleural effusion in 30-40%
In most cases infection becomes localized and a caseating granuloma forms (tuberculoma), which can calcify and is then known as Ghon lesion.
Typical reactivated findings:
Majority of cases: Cavitary or patchy consolidations in the Posterior segments of upper lobes and Superior segments of lower lobes.
Lower lobe disease may masquerade as a malignancy or pneumonia
5 millimeter of induration is postive PPD for what pts
HIV positive
Recent contact with active TB
CXR evidence of prior active TB
Organ transplants or immunosuppressive agent use
10mm on PPD is postive for what pts
Recent immigrant (5 yrs) from endemic area (Asia, Africa, L. America)
HIV-negative IV drug users
Mycobacteria lab personnel
Residents/staff of: prisons/jails, healthcare facilities, homeless shelters,
Gastrectomy, DM, advanced renal disease, malignancy
Young children (< 5 yrs)
Low body weight <90% of ideal body weight
Infants, children, and adolescents exposed to high-risk adults
What is the PPD measurement for healthy individuals with no known risk for TB
15mm
When should IGRA/ Q Gold be used to test for TB
Interferon-Gamma Release Assays (IGRAs) may be used in place of (but not in addition to) a TST in all situations in which the CDC recommends TST as an aid in diagnosing M. tuberculosis infection.
IGRA is preferred for testing persons who have received BCG (as a vaccine or for cancer therapy).
What is the Tx approach to active TB
Isoniazid (INH)
Rifampin
Pyrazinamide
Ethambutol
Regimens are based on HIV status, and need for direct observed treatment
Generally 6-9 months regimen
Resistant active TB
18-24 mos of 3+ drug regimen
Direct observed treatment
What are the ADE of Isonazid
Peripheral neuropathy, hepatitis and rash
Pyridoxine can be supplemented to reduce neuropathy
What are the Side effects of rifampin
Hepatitis, fever, rash, GI upset, bleeding, renal failure
And fluids turning orange
What are the ADE of pyrazinamide
Hyperuricemia, heptotoxicity, rash, GI, arthralgias
Monitor Uric acid and AST/ALT
What are the ADE of ethambutol
Optic neuritis, rash
Monitor red green color and visual acuity
What are the ADE of streptomycin
CN VIII damage and nephrotoxic
Monitor Audiogram and BUN/Cr
What is the tx approach to laten TB
Isoniazid (INH) x 6-9 mos*
– World Health Organization
—With pyridoxine (B-6) 25-50mg/day to prevent neuropathy
Or
-Isoniazid + Rifampin x 3 mos
-Isoniazid + Rifapentine x 3 mos (Superior to INH x 9 mos)
-Rifampin alone x 4 mos (INH resistant exposure)
How should pregnant pts with TB be managed
Untreated tuberculosis (TB) disease represents a greater hazard to a pregnant woman and her fetus than does its treatment.
Although the drugs used in the initial treatment regimen for TB cross the placenta, they do not appear to have harmful effects on the fetus.
For most pregnant women, treatment for latent TB infection can be delayed until 2–3 months post-partum to avoid administering unnecessary medication during pregnancy.
Do not delay treatment if high risk for progression
Causes acute respiratory tract illness in persons of all ages
Most common lower rti in children younger than 1 year
Signifigant risk in infants less than 6 months and in daycares
S/s bronchiolitis or pneumonia in infants
Upper respiratory Infection in children and adults
Think?
Dx?
Tx?
RSV
Dx on nasopharyngeal swab
Tx; supportive
+/- admission, IVF, and resp support
A young pt with bronchilitis. Think ?
RSV
High index <12 months old , lower respiratory tract disease, winter season, known circulation of RSV
What are the three phases of whooping cough
- Catarrhal phase: earliest phase of illness, lasting one to two weeks.
Characterized by nonspecific symptoms.
Ex. generalized malaise, rhinorrhea, and mild cough.
Two early clinical findings suggestive of pertussis are excessive lacrimation and conjunctival injection.
- Paroxysmal phase: begins during the second week of illness.
Characterized by paroxysmal cough (series of severe, vigorous coughs that occur during a single expiration).
Following a prolonged cough paroxysm, a vigorous inspiration causes the distinctive “whooping” sound.
- Convalescent phase: begins during third week of illness.
characterized by a gradual reduction in the frequency and severity of cough. It usually lasts one to two weeks but may be prolonged.
When would you not need to order labs and could empirically treat pertussis
A cough illness lasting at least two weeks without clear cause and one of the following symptoms: paroxysms of coughing, inspiratory whoop, or post-tussive emesis.
In the setting of an outbreak or known close contact to a confirmed case of pertussis, the presence of a cough lasting ≥2 weeks is sufficient for clinical diagnosis (even in the absence of other symptoms).
When should you admit a child with whooping cough
Indications for hospitalization include: increased work of breathing, pneumonia, inability to feed, cyanosis, apnea, seizures, and age <4 months
What is the DOC for whooping cough in infants younger than 1 month old
Azithromycin
What are the ABX of choice for pts wth whooping cough older than one month
Macrolides
-Azithromycin
(TMP-SMX) (Bactrim) is an alternative for children older than two months who have a contraindication to or cannot tolerate macrolide agents
What is the potential ADE of pertussis infection
Pyloric stenosis
Viral infection from parainfluenza
type 1
In children aged 6mon-3 years
Common in the fall and winter
S/s stridor, barking cough, hoarseness
Symptoms usually begin with nasal discharge, congestion, and coryza and progress over 12 to 48 hours to include fever, hoarseness, barking cough, and stridor.
Think? DX? Tx?
Croup
Dx Neither radiographs nor laboratory tests are necessary to make the diagnosis. However, radiographs may be helpful in excluding other causes if the diagnosis is in question.
CXR; Steeple sign
Tx:
mild-single dose of dexamethasone or oral prednisone
Moderate to severe:
(stridor at rest with mild to moderate retractions)
—nebulized epinephrine and a single dose of dexamethasone.
Common viral infection in the winter
From repiratory droplet spread
S/s Abrupt onset of fever, headache, myalgia, and malaise after an incubation period of one to four days (average two days).
+Nonproductive cough, sore throat, and nasal discharge.
Major compilation leads to pneumonia
Think? Dx? Tx?
Influenza A or B
Dx: Rapid Antigen Test
Tx:
<48hr Oseltamivir x 5 days
>48 hrs supportive care
Treatment should not be delayed while awaiting the results of diagnostic testing, nor should it be withheld in patients with indications for therapy who present >48 hours after the onset of symptoms,
Particularly among patients requiring hospitalization.
Ie Pregnant
Asthma
Diabetes
Heart Disease
Immunocompromised
Most common cause of pneumonia in HIV pts with a CD4 less than 200
S/s dry cough, dyspnea, and fever
Think? CXR? Dx? Tx?
HIV PNA 2/2
Pneumocystis jirovecci Pneumonia
CXR: Diffuse bilateral interstitial or alveolar infiltrates
Dx: Stains of sputum or bronchoalveolar lavage fluid.
Tx: Bactrim
Steroids indicated if arterial PO2 <70mm Hg (while on room air), or an alveolar-arterial oxygen gradient >35 mm Hg
What is the pathogenesis of pneumonia
Pathogen gains entry (inhalation, aspiration, colonization, hematogenous spread)
Microorganisms replicate
Inflammation, cytokine release
Accumulation of WBCs in alveoli
Damaged cilia
Desquamation
Predisposition for further infections
What is the most commonly recognized virus in pneumonia
Rhinovirus
Common to have rhinorrhea and sore throat
