pulm infectious disease Flashcards
What are the two major criteria for admitting to ICU with CAP?
septic shock w/ need for vasopressor support and respiratory failure w/ need for mechanical ventilation
What are the minor criteria for admission to ICU with CAP?
- RR 30+
- hypoxemia
- hypothermia
- hypotension requiring aggressive fluid resuscitation
- confusion/disorientation
- multi-lobar pulmonary opacities
- leukopenia
- thrombocytopenia
- uremia
- metabolic acidosis
- elevated lactate level
What is general criteria is required for admission to ICU with CAP?
one major criteria or 3+ minor criteria should be in ICU and consider other patient factors
What score should you look at considering admission with pneumonia?
CRB-65 score
What CRB-65 score means urgent admission?
3-4
What are the CRB-65 criteria?
Confusion
RR >30
BP <90 SBP <60 DBP
Age>65 years
What are these symptoms indicative of:
>5 day duration cough w/ URI symptoms, purulent or nonpurulent, mild dyspnea, chest wall/substernal pain and can be caused by various viruses?
acute bronchitis
With acute bronchitis, what may you note on a PE?
rhonchi or wheezing but does not require specific testing
What is concerning with acute bronchitis?
high fever or systemic symptoms (flu or PNA maybe)
consolidation in the lungs: rales, egophony, pleural inflammation signs, dullness to percussion, dec bronchial breath sounds (disease beyond just bronchi, do imaging)
Paroxysms of coughing, inspiratory whoops, posttussive emesis (pertussis maybe)
How do you treat acute bronchitis?
supportive treatment and recommend throat lozenges, hot tea, smoking cessation, humidifier, gen OTC meds
Review: pertussis
Kids under age 5
Bordetella pertussis
respiratory droplets
URI symptoms last 1-2 wks w hacking cough at night becoming diurnal and increasing.
Severe paroxysmal coughing fits with inspiratory high pitched whooping sound after coughing fits and posttussive vomiting. 2-4 wks phase (after 1-2 wks URI prodrome)
Resolution of cough after 4-6 total wks
Nasopharyngeal culture and PCR
Azithromycin or clarithromycin or bactrim for pt and close contacts. start w/in 3 wks of onset
Prevent w DTap vaccine and Tdap booster
What do these symptoms indicate: fever or hypothermia, cough, dyspnea, sweats/chills, discomfort, pleuritic chest pain, tachypnea, tachycardia, hypoxia, inspiratory crackles, bronchial breath sounds, dullness to percussion?
pneumonia (CAP)
What are risks for pneumonia?
advanced age, alcoholism, tobacco use, comorbidities, immunosuppression
What’s the MC CAP bacteria?
strep pneumo (rusty)
What’s the MC gradual CAP bacteria?
mycoplasma pneumo
What color is H flu CAP?
green
What pneumonia organisms should you think in CF patients?
staph aureus in infancy, pseudomonas aeruginosa or burkholderia cepacia in older children
When should you admit a CAP patient?
CRB-65 – Confusion, RR >30, BP<90 or <60, >65y.
If 1or 2, consider admission. If 3 or 4, urgent admission
When should you consider hospitalization for CAP?
Infant < 6 mo old with bacterial pneumonia,
concern for pathogen w/ increase virulence (ex. MRSA),
concerns about caregiver or pt following recommendations or recognizing symptom progression,
comorbidities
AND CRB-65 SCORE!
How do you classify pneumonia?
1) where you got the infection
2) type of pathogen
3) clinical presentation
4) extent of involvement and CXR findings
What indicates typical pneumonia on a CXR?
lobar consolidation
What causes patchy pneumonia on a CXR?
atypical
What causes interstitial pneumonia on a CXR?
Atypical, PCP
What organism causes cavitary pneumonia on a CXR?
anaerobes, klebsiella, s. aureus, TB, fungi
What organism causes large effusion pneumonia on a CXR?
s aureus, anaerobes, klebsiella
What’s preferred for diagnosis of pneumonia?
CXR
In a hospitalized patient, what’s required for diagnosis of CAP?
pulmonary opacity on chest imaging
What indicates bacterial pneumonia?
lobar infiltrates/consolidation or round pneumonia w/ pleural effusion
What indicates viral pneumonia?
diffuse, streaky infiltrates in bronchi + hyperinflation
What indicates atypical pneumonia on CXR?
increased interstitial markings or bronchopneumonia
How do you treat CAP outpatient who have not taken abx within 3 months and not in area of high resistance?
macrolide (azithromycin or clarithromycin), doxycycline, amoxicillin
How do you treat CAP outpatient in high risk for drug resistance patients outpatient?
macrolide (azithromycin or clarithromycin) + beta lactam (augmentin or amoxicillin or cephalosporin).
or a respiratory fluoroquinolone
How do you treat CAP inpatient?
macrolide (azithromycin or clarithromycin) + beta-lactam (ceftriaxone or ceftaroline)
or respiratory fluoroquinolone
How do you treat CAP inpatient in the ICU?
antipneumo beta-lactam ( cefotaxime, ceftriaxone, ceftaroline or amp-sulb )+ azithro.
or antipneumo beta-lactam ( cefotaxime, ceftriaxone, ceftaroline or amp-sulb )+ respiratory fluoroquinolone
What are some other specific situation ICU CAP treatments?
PCN allergy = fluoroquinolone + aztreonam
pseudomonas = antipneumococcal + antipseudomonal beta lactam (piperacillin-tazobactam, cefepime, imipenem, meropenem) + fluoroquinolone or azithromycin.
MRSA = add linezolid or vancomycin
What is the timeline for nosocomial pneumonia?
> 48 hrs or admission for HAP or ventilation for VAP
fever, leukocytosis, purulent sputum, worsening respiratory status (2+) and new symptoms and progressive opacity on chest xray
What bacteria is seen in VAP?
stenotrophomonas maltophilia, acetinobacter
What bacteria is seen in HAP?
staph aureus, strep, pseudomonas, klebsiella, e coli, enterobacter, anaerobic
How can you diagnose nosocomial pneumonia?
blood cultures, CBC, CMP, ABG for severity
thoracentesis w/ pleural fluid analysis
LRI culture to direct therapy
CXR often nonspecific
What is empiric treatment based upon in nosocomial pneumonia?
empiric with
- risk of MRSA, MDR, psuedomonas, other g- bacilli
- drug resistance
- local antibiograms
- mortality risk
it’s usually ~ 7 days long
What type of pneumonia is considered walking pneumonia and can worsen asthma symptoms, produce wheezing, have a gradual onset, and a variety of other sick symptoms like headache, malaise, fever, sore throat with a cough that follows w/ pleuritic CP or SOB?
mycoplasma pneumonia
When in the year does mycoplasma pneumoniae peak?
Late summer and early fall
How do you diagnose mycoplasma pneumonia?
PCR
CXR: reticulonodular opacities or patchy consolidations
Diagnosis cannot be made without testing
How do you treat mycoplasma pneumonia?
self-limiting so usually doesn’t require treatment but if you want some,
macrolide (azithro) or doxycycline or levofloxacin
If nonsevere inpatient, respiratory fluoroquinolone or beta lactam w macrolide
How do you treat serious mycoplasma pneumonia?
respiratory fluroquinolone or beta-lactam + macrolide
What does nausea, vomiting, and diarrhea indicate in a pneumonia patient?
legionella bacteria, common in people who smoke, chronic lung disease, immunocompromised, from contaminated water
How can you diagnose legionella pneumonia?
sputum PCR, culture, dieterle silver staining, urinary antigen testing
How do you treat legionella pneumonia?
azithromycin, clarithromycin, or fluoroquinolone (levofloxacin)
What does insidious onset of necrotizing pneumonia, lung abscess or empyema with fever, weight loss, malaise, cough w/ expectoration of foul-smelling purulent sputum indicate?
anaerobic pneumonia
What does aspiration pneumonia cause? (Pathogen)
anaerobic pneumonia
What do multiple areas of cavitation within areas of consolidation indicate?
necrotizing pneumonia
What does a thick-walled solitary cavity surrounded by consolidation and air fluid level present indicate?
lung abscess
What does a purulent pleural fluid and pleural loculations indicate?
empyema
How do you treat anaerobic pneumonia?
beta-lactam/lactamase inhibitor combo:
piperacillin-tazobactam or amoxicillin-clav OR carbapenem
continue until CXR improve
empyema –> tube thoracostomy or open pleural drainage
What is characterized by low grade fever and wheezing, cough, tachypnea, difficulty feeding, cyanosis (bronchiolitis), and grunting, crackles, prolonged expiration, retractions, apnea, lethargy, palpable liver/spleen?
acute bronchiolitis (respiratory syncytial virus MC)
When does acute bronchiolitis/respiratory syncytial virus peak?
winter
major risk: prematurity
What’s the leading cause of hospitilization in children?
bronchiolitis and pneumonia
When can you make an RSV/acute bronchiolitis diagnosis in infant/child?
1-3d of URI followed by cough + tachypnea +/- chest retractions + wheeze +/- crackles on auscultation
RT-PCR w/ nasal swab
How do you treat RSV/acute bronchiolitis?
time! respiratory isolation, tube feeding or IV nutrition if unable to feed
support w nasal suction, airway management, hydration, humidifier
high risk = aerosolized ribavirin
What’s RSV/ acute bronchiolitis associated with?
airway reactivity later in life and otitis media
What is respiratory syncytial virus prophylaxis?
- Vaccine for adults over 60 with increased risk, adults over 75 without increased risk, and people 32-36 wks pregnant (first pregnancy) during Sept-Jan in most of continental US (protects baby from severe illness up to 6 mo)
- Antibody (nirsevimab) immunization for age < 8 mo born during or entering their first RSV season if birth parent didn’t receive vaccine or birth w/in 14 days of parent vaccine
o Also, antibody immunization for age 8-19 mo (must not be 20+ mo old!) entering their second RSV season who fit into 1+ of the following groups:
Chronic lung disease, requiring medical therapy, during 6 mo before start of that second RSV season
Severely immunocompromised
Cystic fibrosis with severe disease
American Indian and Alaska Native
Where does aspergillus fumigatus often go?
lungs, sinuses, brain
How do you diagnose aspergillosis?
tissue or culture but should consider in patients with risk
CT chest -> nodules, wedge shaped infarcts, halo sign
What’s prophylaxis for aspergillosis?
posaconazole or voriconazole
What’s treatment for aspergillosis?
IV voriconazole
When should you hospitalize an infant for RSV?
Hospitalize if <95% O2, <3m, RR>70, toxic appearance
