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CSI > pulmonary inf./TB/sarcoidosis > Flashcards

pulmonary inf./TB/sarcoidosis Flashcards

1
Q

questions to ask

A

sick contacts

travel hx

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2
Q

testing to do

A

CXR
sputum sample (40% can’t)
-may need bronchoscopy

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3
Q

sodium levels may be

A

low

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4
Q

CAP org

A

Strep pneumo

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5
Q

cough mechanism prevents

A

URI from becoming LRTI

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6
Q

S. pneumo presentation

A 
fever, hypothermia, tachypnea, cough +/- sputum (typically), dyspnea, chills/rigors/sweats
-ha, lack of appetite
-clammy, bluish skin
-N/V, joint pain
-fatigue
-inspiratory crackles, bronchial breath sounds
-may have hemoptysis
(non-hosp. pts, not chemo pt)
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7
Q

S. pneumo CXR

A

-+ CXR w/ infiltrate or consolidation

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8
Q

S. pneumo compensatory mechs

A
  • low BP

- inc. HR

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9
Q

dx testing necessary?

A

not always; empirically tx for S.pneumo

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10
Q

S.pneumo tx

A

augmentin, levoquin, PCN, clindamycin

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11
Q

other dx

A

Cx, Gs, urine antigen testing

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12
Q

other orgs

A

Legionella pneumophilia
Group A, C, G strep
Staph aureus (inc. CA-MRSA)

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13
Q

complication with S. aureus (CA-MRSA)

A

fall months, get influenza–>secondary bac. pneumo

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14
Q

consider HIV testing

A

hypoxemic, bacteremic, young, otherwise sev. pts

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15
Q

HIV+ pts w/ CD4 count >200 more likely

A

to have CAP vs. OI

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16
Q

flu season

A

(sept-march)

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17
Q

if flu pt. 5 days oral Tamiflu again has high fevers, purulent sputum

A

S. aureus

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18
Q

S. aureus tx

A

vancomycin, zyvox (linezolid)$, PCN, augmentin

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19
Q

MRSA

A

bactrin, clindamycin, doxycyclin

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20
Q
  • fever 101.5
  • ha, chills, body ache, malaise
  • “foggy”
  • hyponatremic (121)
  • WBC count low (4.2K)
  • heating/cooling repair, produce section, etc
A

Legionella pneumonia

“Legionnaire’s disease”

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21
Q

fogginess, altered may be due to

A

hyponatremia

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22
Q

Legionella on sputum Cx

A

very rarely

do urine antigen

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23
Q

Legionella symps begin

A

2-14 days post-exposure

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24
Q

Leg.: transmitted?

A

cannot be transmitted person-person

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25
Q

Leg tx 1st line

A

macrolide(clarithromycin, azithromycin)

doxycycline

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26
Q

Leg tx rec. abx, comorb.

A

resp. FQs

macrolide + B lactam (cefuroxime, amoxicillin, augmentin)

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27
Q

inpt. management

A

resp. FQ: moxifloxacin, levofloxacin, IV moxifloxacin, levaquin*

macrolide + beta lactam: azithromycin + ceftriaxone*

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28
Q

inpt ICU management

A

azithromycin or resp. FQ + antipneumococcal B lactam (cef, amp)

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29
Q

inpt. ICU tx for pts allergic to B lactams

A

FQ + aztreonam, tigecycline

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30
Q

inpt. ICU tx for high risk pseudomonas

A

piperacillin-tazobactam, cefepime, carbapenem, ciprofloxacine or levofloxacin
-poss. B lactam + aminoglycoside (gentamicin, tobramycin, amikacin)* rarely used

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31
Q

inpt. ICU tx for high MRSA risk

A

influenza, DM, HAP
(make sure covers pseudomonas and MRSA)
add vancomycin or linezolid

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32
Q

old, bed bound, nursing home: cause of pneumonia?

A

aspiration on own secretions

-don’t cough

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33
Q

HCAP orgs

A

pseudomonas, MRSA

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34
Q

HCAP risks

A
  • Antibiotic therapy in the past 90 days
  • Acute hospital stay for at least 2 days in the past 90 days
  • Residence in an extended care facility or recent prolonged rehab stay
  • Need for infusion therapy (chemotherapy) or hemodialysis
  • Home wound care
  • Family member with infections involving multidrug resistant organisms
  • Immunosuppressed patient
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35
Q

HAP develops

A

> 48 hrs AFTER admission to hospital

36
Q

VAP occurs in

A

a mech. vent. pt >48 hrs after intubation

37
Q

what to do with intubation pts

A

-keep head of bed 30 degrees
-do mouth care (suction)
CULTURE!

38
Q

HAP orgs

A
  • S. aureus (MRSA)
  • S. pneumo (DR)
  • G- orgs
  • ESBL prod. orgs (E. coli, Kleb, enterobacter)
    • resistant to PCN, cephalosporins, use carbapenems
  • CRE prod. orgs in enterobacter family: move to aminoglycosides (tigasil, tobramycin, etc)
  • acinetobacter spp. (chron. ventilated, trachs): unasyn, tigacil (otherwise resist.)
39
Q

HAP empiric tx

A

S. aureus/MRSA/pseudomonas coverage

  • antipseudomonals (cefepime, ceftazidime, imipenem, meropenem, piperacillin-tazobactam, aztreonam)
  • 2nd antipseudomonal (Levofloxacin, Cipro, aminoglycoside)
  • MRSA coverage (Vancomycin, Linezolid, also tigacil, cefteraline?)
  • known ESBL carrier? (carbapenem)* right away!*
40
Q

aminoglycoside

A

gentamicin
tobramycin
amikacin

(can give inhaled gentamicin!)

41
Q 
15 lb weight loss, 
101 F 3 weeks
gen. malaise
coughing up thick green phlegm, foul smell
etOH, bad teeth
A

aspirated inf. sputum–>purulence in lungs–>cough up from bronchus
CXR: obvious lung abscess
-weight loss from anaerobic process

42
Q

w/ lung abscess pt.

A

more…
may need to decorticate
(keep malignancy in ddx)

43
Q

lung abscess pt. dx

A

probable anaerobic pneumonia w. lung abscess

44
Q

probable anaerobic pneumonia w. lung abscess risks

A

aspiration risk : etOH, nursing home
-indolent symps w/ fever, weight loss
MORE

45
Q

probable anaerobic pneumonia w. lung abscess tx

A

clindamycin
amoxicillin-clavulanate (augmentin (for anaerobes))
amoxicillin (not usually)
moxifloxacin (anaer. cov)

IV zosyn, IV carbapenems, IV clindamycin (for hosp. pts)

46
Q

pulm. infiltrates in immuncomp pts

A

consider opportunistic orgs, viruses, protozoa, fungi

-

47
Q

pulm infilt. in HIV pt w/. high CD4 >200 more likely to be

A

Strep pneumo vs. pneumocystis jiroveci or other OI

48
Q

fungal etiology of pulm. infiltrates

A

aspergillus, histplasmosis, blastomycosis, coccidiodomycosis

49
Q

reality with aspergillus

A

infects people who are SEVERELY immune compromised (not everyday ppl to avoid rent due to mold)

  • pts will dev. fungal ball (not nec. causes sickness)
  • causes UR allergy sympts (chronic dry cough, irritation)
50
Q

coccidiodomycosis

A

valley fever

51
Q

histplasmosis, blastomycosis

A

may be in immunocompetent ppl

52
Q

viral etiologies of pulm. infiltrates

A

HSV, CMV pneumonia

53
Q

other causes of pulm. infilt.

A

atypical mycobacterial infections
(pts with sticky airways, high Ig levels, floppy airways)
(40-80 yo tiny women)
no good tx (Tb drugs)

54
Q

TB stats

A

In 2013 a total of 9,588 new TB cases were reported in the US
Incidence of 3.0 cases per 100,000 people
Decrease from incidence of 4.2% in 2012

Incidence among foreign-born is 13x greater
64.6% of all TB cases

Half of all cases of TB in 2013 occurred in California, Texas, New York, and Florida
4,917 total cases

86 total cases of MDR TB were identified in 2012

55
Q

TB greatest country

A

MEXICO

56
Q

+ tuberculin skin test

A

induration*
>15 mm in gen pop
>10 mm in HC workers, inc. risk
>5 mm in HIV+

57
Q

TB blood testing

A

INterferon Gamma Release Assay (IGRA)

  • QuantiFERON TB gold in-tube test (vs. T-spot TB test?)
  • reduces tester error, can be used on BCG vaccinated pts
58
Q

IGRA advantages

A

Requires a single patient visit to draw a blood sample.
Results can be available within 24 hours.
Does not boost responses measured by subsequent tests, which can happen with tuberculin skin tests (TST).
Is not subject to reader bias that can occur with TST.
Is not affected by prior BCG vaccination.

59
Q

IGRA disadvantages

A

Blood samples must be processed within ~24 hours after collection while white blood cells are still viable.
There is limited data on the use of QFT-GIT in children younger than 17 years of age, among persons recently exposed to M. tuberculosis, and in immunocompromised patients.
Errors in collecting or transporting blood specimens or in running and interpreting the assay can decrease the accuracy and potentially lead to indeterminate results.
False positive results can occur with Mycobacterium szulgai, Mycobacterium kansasii, and Mycobacterium marinum.

60
Q

if skin is - and quantiferon is +

A

it is POSITIVE

get CXR

61
Q

if skin is + and quantiferon is -

A

interminate, consider factors (case by case)

get CXR

62
Q

if pt. are on anti-inflammatory tx (anti-TNF)

A

MORE

drop chances of getting TB down to general population

63
Q

TB seen where in lungs

A

top, oxygen rich, aerated

64
Q

+ CXR

A

get 3 sputum samples, bronchoscopy if unable

65
Q

if active TB

A

public health for MDRTB therapy

66
Q

if 3 sputum samples neg

A

scarring on CXR

67
Q

once latent TB established

A

discontinue tx

68
Q

who should be tx?

A

everyone, esp. immuncomps, HIV+, those about to start immunosuppressive meds

69
Q

what are risks if no LTBI tx taken?

A

lifetim

MORE

70
Q

LTBI tx (6-9 mos)

A

isoniazid, rifampin

+follow liver function

71
Q

this med does not play well with other

A

rifampin (for young ppl, not on many other meds) (used back up for BC) (fine for etOH)

72
Q

active TB tx

A

RIPE: rifampin, isoniazid, pyrazinamide, ethambutol (streptomycin) core

73
Q

active TB always send..

A

susceptibility Cx

74
Q

1st 2 mos…

then 4 mos…

A

all 4 drugs

isoniazid, rifampin

75
Q

never tx active TB with

A

single agent

76
Q

isolate active causes?

A

no longer infectious after 2 wks tx

77
Q

MDR-TB

A

resist. to INH and RIF

78
Q

XDR-TB

A

less common INF, RIF, others, FQ

79
Q

INH resistance

A

&&

80
Q

Rifampin resistance

A
81
Q

INH + Rifampin resistance

A

III

82
Q

XDR-TB tx

A

admin 4-6 drugs in combo (SUSCEPTIBLE) : mult. 2nd line drugs, should include all avail. 1st line drugs

  • newer agents, trial agents
  • 18-24 mos (2 yrs!)
83
Q

sarcoidosis CXR

A

bilat perihilar finding, may have parenchymal involvement

84
Q

biopsy of hilar nodes (sarcoidosis)

A 
noncaseating granulomas
(excl. lymphoma)
85
Q

serum ACE in sarcoid.

A

elevated in 40-80% pts

86
Q

sarcoid. multisyst. presentation

A

skin, eye, joint involvement

87
Q

sarcoid. tx

A

oral prednisone (mos-yrs)

CSI (75 decks)

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