Pulmonary

Question 0

What is the criteria for hospital acquired pneumonia?

Answer 0

New infection occurring 48 or more hours after hospital admission.

Question 1

What is the criteria for community acquired pneumonia?

Answer 1

Acute pulmonary infection in the patient who was not hospitalized residing in a long-term care facility 14 or more days before presentation

Question 2

What is the criteria for ventilator acquired pneumonia?

Answer 2

New infection occurring 48 or more hours after endotracheal intubation

Question 3

What is the criteria for healthcare associated pneumonia? (7)

Answer 3

• patients hospitalized for two or more days within the past 90 days.
• Nursing home or long-term-care residents.
• Patients receiving home IV antibiotic therapy.
• Dialysis patients.
• patients receiving chronic wound care.
• patients receiving chemotherapy.
• Immunocompromised patients.

Question 4

What are some of the classic bacterial etiology for pneumonia?

Answer 4

The most classic bacterial etiology is strep pneumonia. Other prevalent bacterial pneumonia include staph aureus, Klebsiella pneumonia, Pseudomonas aeruginosa and Haemophilus influenza.

Question 5

What agents can cause the bulk of atypical pneumonia?

Answer 5

Legionella pneumophila, M. pneumonia, C. pneumoniae, respiratory viruses.

Question 6

What are some of the risk factors for aspiration pneumonia?

Answer 6

Patients with seizures, stroke, other neuromuscular diseases.

Patients who use intoxicants including alcohol.

Individuals with G.I. issues including NG tube peg tubes and orogastric tube.

Question 7

How does pneumococcal pneumonia classically present as?

Answer 7

Abrupt fever, rigor, rusty brown sputum. Pleural effusions can occur in 25% of patients.

Question 8

What pathogen is worrisome for pregnant woman with pneumonia and what medication should you start in the ER?

Answer 8

Varicella pneumonia is worrisome for pregnant individuals. IV acyclovir maybe started in the ER.

Question 9

What are the 8 variables that are significant independent predictors of pneumonia in nursing home patients?

Answer 9

Increased pulse rate, respiratory rate greater than 30 breaths per minute, temperature greater than 30°C, somnolence or decreased alertness, presence of acute confusion, lung crackles on auscultation, the absence of wheezes, and increased leukocyte count.

Question 10

What agents should you worry about in HIV patients with pneumonia?

Answer 10

The most common cause is strep pneumonia. Pseudomonas is also a common cause.

opportunistic infections are more likely to occur with lower CD4 counts. Think of M. tuberculosis, C. neoformans, Histoplasma capsulatum for individuals with CD4 count of 250 to 500. PCP is more likely when the CD4 count is below 200.

Question 11

True or false: bacterial pneumonia is less common after renal transplantation.

Answer 11

True.

However it is more common in patients receiving liver, heart, or lung transplants during the first three months after surgery.

After six months post transplant, bacteria more typical of CAP are the most likely pathogens.

Question 12

What is an outpatient treatment option for uncomplicated patients?

Answer 12

Clarithromycin

Question 13

What treatment option can be offered for outpatient management of patients with significant comorbidities?

Answer 13

Floroquinolones can be used including levo and Moxi.

Question 14

What may lead you to consider an admission for a patient with pneumonia?

Answer 14

CURB – 65

Confusion, uremia greater than seven, resp rate greater than 30, diastolic blood pressure less than 60, greater than 65 years old.

Patients with a score of less than to have a low mortality rate.

Question 15

What antibiotic would you use for inpatient therapy for non-ICU patients with CAP?

Answer 15

One can use floroquinolones including levo and Moxi.

Question 16

What empiric therapy would you start for patients with suspected healthcare associated pneumonia?

Answer 16

Cipro and Vanco (for anti mrsa). And either pip-tazo, imipenem, meropenem, cefepime, or crftazidime.

Question 17

What antibiotic would you start for inpatient therapy for ICU patients with pneumonia?

Answer 17

One can consider ceftriaxone plus the fluoroquinolone including Moxi and levo. Also consider Vanco for Anti-mrsa.

Question 18

What is the difference between aspiration pneumonia and aspiration pneumonitis?

Answer 18

Aspiration pneumonia is alveolar space infection resulting from the inhalation of pathogenic material from the oropharynx; whereas aspiration pneumonitis is an inflammatory chemical injury of the tracheobronchial tree and pulmonary parenchyma produce from the inhalation of regurgitated sterile gastric contents.

Aspiration pneumonia can lead to aspiration pneumonia.

Question 19

What are risk factors for aspiration pneumonia?

Answer 19

They include conditions that promote oropharyngeal colonization with pathogenic bacteria or conditions that impair the swallowing or gag mechanisms.

Question 20

What is required to develop aspiration pneumonitis?

Answer 20

It requires aspiration of gastric contents with pH less than 2.5 and aspirated volume of 0.3 to 0.4 mL per kilogram ( 20 to 30 mL an adult ).

Question 21

What are the typical bacterial species involved in aspiration pneumonia?

Answer 21

They include strep pneumonia,ph aureus, H influenza, Enterobacteriaceae in community acquired aspiration pneumonia. In hospital acquired aspiration pneumonia Pseudomonas aeruginosa and gram-negative organisms are involved. Antibiotic coverage for typical aspiration syndrome should include coverage for anaerobic organisms

Question 22

What is the treatment options for aspiration pneumonitis?

Answer 22

For stable reliable patients who are healthy, they can be observed for a short time approximately one hour and then discharged with instructions to return for worsening symptoms. Antibiotic treatment is not necessary. However if the symptoms of aspiration when I was failed to resolve in 24 to 48 hours it should be treated with antibiotics.

If it is a patient from a nursing home or is chronically ill and stable they can be observed for 12 to 24 hours then discharged if they remain stable. If they remain symptomatic or have a new radiographic infiltrate they can be considered for admission or continued observation.

Otherwise if symptomatic I can receive antibiotics.

Question 23

What antibiotics can you consider for aspiration pneumonitis if required?

Answer 23

Levo, Moxi, Clinda.

Question 24

What antibiotics would you consider for community acquired aspiration pneumonia?

Answer 24

Can consider Moxi, Clinda

Question 25

What antibiotics can you consider for aspiration pneumonia in healthcare associated or severe periodontol disease or alcoholism?

Answer 25

PIP tazo, levo +clinda

Question 26

What are some of the causes of noninfectious pulmonary infiltrates?

Answer 26

They include CHF PE, aspiration pneumonitis, allergy bronchopulmonary aspergillosis, ARDS, sarcoidosis, Wegner granulomatosis, Goodpasture syndrome, radiation pneumonitis, fat emboli, neoplasm.

Question 27

What is the difference between empyema and lung abscess?

Answer 27

Empyema is pus in the plural space; lung abscess is a localized superlative necrotizing process occurring within the pulmonary parenchyma

Question 28

When should you suspect empyema?

Answer 28

It should be suspected if symptoms of pneumonia do not resolve.

Question 29

What is the diagnostic criteria for empyema?

Answer 29

It is aspiration of grossly. Went material on thoracentesis and at least one of the following: thoracentesis fluid with a positive Gram stain our culture, plural fluid glucose less than 40 mg/dL, pH less than 7.1, or LDH over 1000 international units per liter.

Question 30

What are the three stages of an empyema?

Answer 30

Stage one: exudative; less than 48 hours, free-flowing pleural effusion that is present is amenable to chest tube drainage

Stage 2: fibrinopurulent; causes loculation’s

Stage III: organizational, take several weeks more extensive fibrosis

Question 31

What is the treatment for an empyema?

Answer 31

Patients can use NSAIDs or opioids for pleuritic pain. There is centesis may need to be done to stabilize a patient with respiratory or cardiac distress.

Recommended antibiotics includes pip/tazo or imipenem. They go should be considered if mrsa is possible

In the Fibropurulent stage can consider intrapleural fibrinolytic agent. For the organizational stage, may require a consultation surgical intervention or pulmonologist.

Question 32

What are some of the causes of a lung abscess

Answer 32

Most common cause is aspiration pneumonia, other causes include non-pulmonary source of infection, pulmonary infarction, penetrating chest trauma, fungal and parasitic infection, primary and metastatic neoplasm, and inflammatory conditions.

Question 33

What is the antibiotic choice for the treatment of lung abscesses?

Answer 33

Combination of Clinda and Metro are effective against anaerobes.
Can also consider Moxi.

May need to consider surgical treatment for a non-draining lung abscess.

Question 34

What should the disposition of follow-up look like for an individual with newly diagnosed lung abscess?

Answer 34

Patient should be admitted to the hospital and treated with IV antibiotics and one symptoms resolved they should continue on oral antibiotics for 48 weeks.

Question 35

How infectious is TB?

Answer 35

Only 30% of patients actually become infected after significant exposure.

Question 36

What are risk factors for TB?

Answer 36

Risk factors include immigrants from high prevalence countries, patients with HIV, residents and staff of prisons are shelters for the homeless, alcoholics and illicit drug users, elderly and nursing home patients.

Question 37

Where does TB tend to survive in the body?

Answer 37

It has a tendency for survival and areas of high oxygen content or bloodflow such as apical and posterior segment of the upper lobe and superior segment of the lower lobe of the long, renal cortex, the meninges, the epiphyses of long bones, and the vertebrae.

Question 38

When does the skin test generally become positive after initial exposure to TB?

Answer 38

1 to 2 months.

Question 39

How does primary tuberculosis tend to present?

Answer 39

It is usually asymptomatic.

Question 40

Other than the lungs which other sites can TB Present?

Answer 40

Frequent sites include adrenal glands bones, joints, G.I. tract, GU tract, lymph nodes, and meninges, pericardium, peritoneum, and pleura.

Question 41

What is considered a positive TB test?

Answer 41

It is considered positive if greater than or equal to 5 mm induration in high-risk patients, greater than or equal to 10 mm induration and an increased risk patients, and greater than or equal to 15 mm induration for all others.

Question 42

What can cause a false positive PPD test?

Answer 42

Individuals who have received the BCG vaccine, exposure to non-tuberculosis mycobacteria.

Question 43

What can cause false negative PPD test?

Answer 43

Incorrect administration, individuals with abnormal immune system such as HIV. It can also be unreliable and in acute stages of the disease.

Question 44

What are some findings on chest x-ray for primary TB infection?

Answer 44

It can present as parenchymal infiltrates in any area of the long. Isolated ipsilateral hilar or mediastinal adenopathy can sometimes be the only finding. Pleural effusions are usually unilateral and occur alone or in association with parenchymal disease.

Question 45

What are some of the radiographic findings for latent tuberculosis?

Answer 45

Nonspecific findings include upper lobe or hilar nodules and fibrotic lesions which may or may not be calcified. Other findings are bronchiectasis, volume loss, plural scarring. Some will have areas of infection that appear as ghon foci.

Question 46

What is the treatment for active tuberculosis?

Answer 46

First line include INH, rifampin, pyrazinamide, ethambutol, for eight weeks followed by two drug continuation treatment for 18 to 31 weeks based on culture results.

For example daily for drug therapy for eight weeks followed by INH and rifampin treatment for 18 weeks.

Question 47

What is paradoxical reaction or immune reconstitution disease in TB?

Answer 47

It is when patients that are being treated for TB are clinically worse after the initiation of the medications.

This is typically seen in HIV patients. Systemic steroids are often added to standard TB therapy.

Question 48

What is the treatment for latent infection or for patients who have been in close contact with an individual with active TB, or for anergic individuals with known TB contact.

Answer 48

INH for a minimum of nine months if at risk for TB.

Question 49

True or false: miliary disease during primary TB is generally more rapid and severe than miliary disease during reactivation.

Answer 49

True: during primary TB it can present with multi organ failure, shock, acute respiratory distress syndrome. However during reactivation, it can present as chronic, nonspecific clinical course affecting any number of organ systems.