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IPAP JUNIOR SEM. > Pneumonia, Tb, RSV, Flu, Croup > Flashcards

Pneumonia, Tb, RSV, Flu, Croup Flashcards

1
Q

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?

A

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

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2
Q

Pneumonia from aspiration/ poor dentition think from?

A

MICROAEROPHILIC and anaerobic mouth flora

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3
Q

Pneumonia from gross aspiration or in a bed ridden person think from?

A

S. Aureus, gram neg rods, micro/anaerobic mouth flora

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4
Q

Pneumonia with recent travel to the southwestern US Think agent?

A

Coccidiosis imitus

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5
Q

Pneumonia anger residence in Mississippi River basins or exposure to bats think ?

A

H. Capsulatum

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6
Q

Pneumonia after exposure to birds think?

A

C. neofromans or H. Capsulatum

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7
Q

Pneumonia after exposure to sick pssiacine birds think

A

C. Psittaci

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8
Q

Pneumnia after exposure to rabbits think

A

F. Tularenis

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9
Q

Pneumonia after exposure to farm animals think?

A

C. Burnetti

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10
Q

Pneumonia from bronchietstasis or C. Fibrosis think

A

Pseudomonas, burkholderia, or aspergillosis

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11
Q

Pneumonia after travel to the Middle East

A

MERS coronavirus

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12
Q

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?

A

Atypical Pneumnia (Walking Pneumo)

CXR: findings variable but often worse than pt appearance

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13
Q

What is the gold standard for flu Dx

A

PCR

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14
Q

What is the assay to test for legionella

A

Urine antigen

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15
Q

What is the assay to test for strep Pneumo

A

Urine antigen

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16
Q

What is the pathogenesis of CAP

A

CAP occurs when normal defense to prevent lower resp tract infections (LRTIs) fails

Overwhelming bacterial infection or a virulent pathogen overwhelms the immune response

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17
Q

Where is the right middle lobe best ausculted

A

Best auscultated on anterior chest at the nipple line

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18
Q

How long can it take pneumonia to clear of CXR

A

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

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19
Q

When should you consider addition X-rays in the treatment of CAP

A

Consider re-imaging high risk patients at 7-10 weeks

Sometimes underlying/predisposing malignancy revealed post-treatment
(post-obstructive pneumonia)

—Smokers > 40
—Geriatric >65

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20
Q

If a pt with CAP has had resolution of S.s within 5-7 days of treatment should repeat X-rays be ordered

A

NO!

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21
Q

If you suspect that a pts CAP is caused by P. jirovecii or M. Tuberculosis

What special s am should be done?

A

Bronchoscopy

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22
Q

How can procalcitonin guide Dx of pnuemonia

A

High procalcitonin =ikely bacterial infection

Low procalcitonin = less likely bacterial, but cannot exclude

—Potential for decreased use of antibiotics when used

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23
Q

What are the most common agents of CAP that would not need hospitilization

A

S. pneumo
Mycoplama (walking Pneumo)
Chlamydia pneumo
Influenza

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24
Q

What is the duration of treatment for pts with CAP that meet the criteria for out pt tx

A

At least 5 to 7 days
(staph aureus, legionella: 10 – 14 days)

Goal: afebrile x 48-72 hrs or more

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25
Q

If no ABX have be given in the past 90 days what ABX can be used for outpt CAP

A

Macrolides
(clarithromycin or Azithromycin)
Or
Doxycycline

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26
Q

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

A

Respiraty Florinquinilones
(Moxi, genta, and levofloxacin)

Or

A Macrolide ( clrithro/Azithromycin) plus a beta-lactam (Augmentin)

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27
Q

While treating outpt CAP with ABX you find that there is resistance to macrolides

What are the ABX options then?

A 
Respiratory FQ
 (moxi/gemi/levofloxacin) 
 OR
Macrolide PLUS beta-lactam 
 (amox-clavulanate)
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28
Q

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

A

Augmentin with Azithromycin 5-7 days

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29
Q

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

A

Levo/moxi/gentamycin 5-7days

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30
Q

If a pt has pneumonia and a suspected influenza infection

What is the treatment choice

A

Oseltamivir

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31
Q

Pneumonia suspected to be caused by Mycoplama or chlamydia

What is the ABX option

A

Azithromycin or Doxycyline

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32
Q

What are the pathogens most likely to lead to pneumonia requiring hopitilization

A 
S. pneumo 
Mycoplasma pneumo
Chlamydia pneumo
H. influenzae
Legionella sp.
Viral
Also:  aspiration (gastric contents, etc)
33
Q

What is the goal for Inpt pnuemonia tx

A

Duration of antibiotic treatment—same as out patient

At least 5 days

Goal: afebrile x 48-72 hrs or more

34
Q

What is the initial empiric therapy for inpatient CAP tx

A

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

35
Q

If influenza is suspected in inpatient CAP tx

What is the Tx option? What is its influenza and a bacteria infection/?

A

Oseltamivir

Or
Oseltamivir
plus Ceftriaxone/Ceftaroline
Plus vancomycin/linezolid

36
Q

If inpatient CAP is thought to be due to pseudomonas

What is the ABX of choice

A

Piperacillin-Tazobactam

Or

Cefepime

37
Q

If a pt is moved to the ICU with CAP

What are the ABX that can be used in the CAP ICU pt

A

Levo/genta/Moxifloxacin

Or

Azithromycin plus cefotaxime/ Ceftriaxone /ampicillin
(Anti-pseudomonas beta lactams)

38
Q

What is the appraoch to CAP prevention

A

Work on risk factors
(DM, tobacco, general health)

Vaccination

  • Polyvalent pneumococcal vaccine (PPV 23)
  • Pneumococcal Conjugate (PCV 13)
  • Influenza vaccine
  • COVID
39
Q

What is the admission matrix for pneumonia pts

A

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

40
Q

What are the most common likely pathogens in nosocomial Pneumonia

A

S. aureus
-MRSA AND MSSA

Pseudomonas aeruginosa

Gram neg rods

  • Enterobacter
  • Klebsiella
  • E coli
41
Q

A pt is on a hospital ward and you suspect they are developing a pneumonia

What S/s would prompt Dx

A 
Signs and symptoms:
Nonspecific, 2 or more of:
-Fever
-Leukocytosis
-Purulent sputum

Or new/progressive pulmonary opacity on imaging

42
Q

What is the workup for noscomial pneumonia

A

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

43
Q

What are ABX that can cover pseudomonas

A

Piperacillin- Tazobactam

Azithromycin PLUS cefotaxime or ceftriaxone or ampicillin (antipseudomonal beta-lactams)

44
Q

What patients are at an increased risk of aspiration

A 
ETOH
seizures
 anesthesia
 tracheal/NG tubes
central nervous system disease

Increased infection risk:
Periodontal disease & poor oral hygiene

45
Q

S/s fever, wt loss, malaise, cough with foul smelling purulent sputum with por dentition

Think? CXR? Dx? Tx?

A

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

46
Q

In anaerobic pneumnia with lung abcess

Is there is rick of MRSA

What ABX should be added

A

Vancomycin

47
Q

Elderly or bedridden pt’s may require IV ABX

What ABX should be used?

A
  • piperacillin-tazobactam
  • meropenem,
  • imipenem

– risk for multi-drug resistance

48
Q

What is the MC pathogen in COPD pneumonia

A

H Influenza

49
Q

What is the common pathogen in ETOH pneumnia

A

Klebsiella

50
Q

What is the common pathogen in nosocomial infections

A

Pseudomonas

51
Q

What is the common pathogen in pneumonia in a pt with recent water contact

A

Legionella

52
Q

What are the 4 possible presentations of TB

A
  1. Immediate clearance
  2. Primary Disease
  3. latent infection
  4. Reactivation disease
53
Q

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?

A

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

54
Q

What are the differences between primary and reactive TB CXR

A

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

55
Q

5 millimeter of induration is postive PPD for what pts

A

HIV positive

Recent contact with active TB

CXR evidence of prior active TB

Organ transplants or immunosuppressive agent use

56
Q

10mm on PPD is postive for what pts

A

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

57
Q

What is the PPD measurement for healthy individuals with no known risk for TB

A

15mm

58
Q

When should IGRA/ Q Gold be used to test for TB

A

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).

59
Q

What is the Tx approach to active TB

A

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

60
Q

What are the ADE of Isonazid

A

Peripheral neuropathy, hepatitis and rash

Pyridoxine can be supplemented to reduce neuropathy

61
Q

What are the Side effects of rifampin

A

Hepatitis, fever, rash, GI upset, bleeding, renal failure

And fluids turning orange

62
Q

What are the ADE of pyrazinamide

A

Hyperuricemia, heptotoxicity, rash, GI, arthralgias

Monitor Uric acid and AST/ALT

63
Q

What are the ADE of ethambutol

A

Optic neuritis, rash

Monitor red green color and visual acuity

64
Q

What are the ADE of streptomycin

A

CN VIII damage and nephrotoxic

Monitor Audiogram and BUN/Cr

65
Q

What is the tx approach to laten TB

A

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)

66
Q

How should pregnant pts with TB be managed

A

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

67
Q

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?

A

RSV

Dx on nasopharyngeal swab

Tx; supportive
+/- admission, IVF, and resp support

68
Q

A young pt with bronchilitis. Think ?

A

RSV

High index <12 months old , lower respiratory tract disease, winter season, known circulation of RSV

69
Q

What are the three phases of whooping cough

A
  1. 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.

  1. 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.

  1. 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.
70
Q

When would you not need to order labs and could empirically treat pertussis

A

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).

71
Q

When should you admit a child with whooping cough

A

Indications for hospitalization include: increased work of breathing, pneumonia, inability to feed, cyanosis, apnea, seizures, and age <4 months

72
Q

What is the DOC for whooping cough in infants younger than 1 month old

A

Azithromycin

73
Q

What are the ABX of choice for pts wth whooping cough older than one month

A

Macrolides
-Azithromycin

(TMP-SMX) (Bactrim) is an alternative for children older than two months who have a contraindication to or cannot tolerate macrolide agents

74
Q

What is the potential ADE of pertussis infection

A

Pyloric stenosis

75
Q

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?

A

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.

76
Q

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?

A

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

77
Q

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?

A

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

78
Q

What is the pathogenesis of pneumonia

A

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

79
Q

What is the most commonly recognized virus in pneumonia

A

Rhinovirus

Common to have rhinorrhea and sore throat

IPAP JUNIOR SEM. (43 decks)

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