Pulmonary Infections Flashcards
Most common viral cause of mild URI and lower respiratory tract illness
Human Metapneumovirus
Kids and adults
Can cause bronchiolitis or PNA
Hard to distinguish from RSK or influenza
(late winter and early spring)
fever uncommon in adults, wheezing common
adenovirus serotype 14 causes?
Severe pneumonia
ARDS
in residential facilities and military bases
Treatment for severe pneumonic tularemia
Gentamycin (aminoglycoside) - can be monitored
Moderate dz- use fluoroquinolones
Pleural fluid with lymph predominance
Presents as CAP that does not respond
When to initiate flu antivirals in pregnant pt?
w/in 48 hrs of illness onset
empirically treat with oseltamavir
How does a Quant gold work?
delayed hypersensitivity
Which NTBM can cause false positive on quant gold?
M. kansasii, M. szulgai, M. marinum
Treatment for Babesia
Atovaquone and azithromycin
What is the def of a ventilator associated condition (VAC)?
> 48 hr on vent with initial improvement then FiO2 increases by 20% OR PEEP increases by 3+ for 2 days
What defines a infection related ventilator complication (IVAC)?
VAC (increased vent requirements 2d) + temp or increased WBC + new abx for 4d
What defines a possible ventilator associated pneumonia (PVAP)?
IVAC + culture sent or purulent secretions AND positive cultures or other tests
What is a ventilatory associated tracheobronchitis (VAT) vs VAP
VAT has all the symptoms of VAP but no imaging infiltrate
When to stop abx for VAP?
completed 7 day course
Procal decreased
if BAL <10^4 cells
Risk factors for MDR VAP?
Prior IV abx w/in 90 days
unit rate MRSA >20%
+ Screening or colonization
Treatment for VAP if no MDR risk factors
Pip/tazo (pseudomonas)
Cefepime (GNR)
Maybe
Levo (s. pneumonia)
(if structural lung dz need 2 anti-pseudomonal)
Consider adding coverage for MSSA (cefazolin, nafcillin or cephalexin)
Treatment for VAP iso MDR risk factors?
Vancomycin or Linezolid
Risk factors for pseudomonas VAP and when to start empiric treatment?
Abx in 90 days prior
unit rate >10% or unknown
Structural lung dz
need for continued vent support or shock
Empiric treatment for pseudomonal VAP?
Dual therapy
Pip/Tazo OR Cefepime OR Carbapenems OR Aztreonam
AND
Aminoglycoside (amikacin, gent, tobra) OR FQs OR Polymyxins (Colistin, polymyxin B)
Treatment for Acinetobacter sensitive to only polymyxins?
IV polymyxin + Inhaled colistin
pseudomonas resistance mechanisms for beta lactams
Amp-C-type cephalosporinase
Class A serine beta lactamases (PSE, CARB, TEM)
Class A serine ESBL (TEM, SHV, CTX-M, PER, VEB)
Class D ESBL- OXA types
pseudomonas resistance mechanisms for fluroquinolones
DNA gyrase and Topoisomerase IV
Which preventative measure decreases duration of MV, LOS and mortality related to VAP
Oral care without chlorhexidine
Minimize sedation
PT/OT
elevated HOB
early feeding
prevention of VAP iso low prevalence of abx resistant org?
Selective oral or digestive decontamination.
Treatment of CNS or disseminated Cryptococcus?
1) induction with ampho B and flucystosine until 2 wk after cx neg
2) 8 weeks high dose fluconazole
3) 1 year low dose fluconazole
Cause and Treatment of Psittacosis (parrot dz)?
Chlamydophila psittaci
tetracycline or Doxy
hepatosplenomegaly, hemoptysis, rash, bradycard, epistaxis, Mono like
Histologic appearance of PJP
Mucor on histology
Which bacteria and Treatment for carbapenemase producing organisms?
Ecoli (CTX-M), Klebsiella (KPC), enterobacter
tx: ceftazidime-avibactam or meropenem-vaborbactam
Treatment of beta lactamase producing ecoli (ie CTX-M)?
Carbapenem
How to tell CAP vs. coccidiomycosis?
Hilar LAD
increased Eos
skin changes- erythema nodosum
Treatment for Coccidiomycosis?
immunocompetent–> obs
sx >6wk –> treat
Immunosuppressed, DM or HIV -> Fluconazole
(second line itraconazole)
Severe dz: ampho B
How to diagnose Cocci?
antigen test (urine or serum)
** cross reacts with histo and blasto
Diagnosis of NTM?
2 positive sputum cultures (one is not enough)
Treatment for M. Avium
3 times a week macrolide/ethambutol/rifamycin (check for resistance to macrolide 23S rRNA.
stop abx after 12mo Cx neg
Tx for M. Kansasii
Isoniazid, rifampin, ethambutol
Stop Abx after 1yr cx neg
Diagnostic test for aspergillus if pt is high risk with neg serum antigen
Galactomannan antigen in BAL (GM index >1 good spec, >0.5 better sen)
Culture (Sputum>blood)
Beta d glucan non specific
PCR - cant tell active disease from colonization or dead fungi
What causes false + of galactomannan test
beta lactams, histo, rice/pasta, plasmalyte
Treatment for IPA
Voriconazole
Isavuconazole
Posaconazole
Presentation of Blasto
Chronic PNA 3w-3m after exposure
Skin findings (verrucous, ulcerative)
Osteomyelitis
Treatment of Blasto
Mild sx – obs
mild to mod –> itraconazole 6-12mo
Severe-> ampho B 1-2wk then itraconazole
CNS dz-> ampho
Preg-> ampho
Histoplama histology
Treatment of Cystic echinococcosis
Complicated by cyst rupture–> Albendazole
Pulmonary manifestations of strongyloidiasis
pulmonary infiltrates with eosinophilia
asthma without infiltrates hemoptysis due to alveolar hemorrhage
hyperinfection syndrome
Tx Ivermectin
Pulmonary Manifestations of paragonimiasis
Recurrent hemoptysis
Pleural effusion
Hydropneumo
cysts
Tx Praziquantel
Symptoms and presentation of pulmonary cystic echinococcosis
Contact with dogs
usually liver then lungs
Cough, CP, dyspnea, hemoptysis
PTX, pleural eff, empyema, eos if rupture cyst
tx abendazole
Def and Treatment for refractory MAC
Def: sputum cx + after 6mo tx (azithromycin, rifampicin and ethambutol)
Tx: Adding inhaled amikacin liposome suspension
treat for 12 mo after clear cx
Treatment after contact with MDR TB pt
Presume pt has MDR LTBI
Tx: Levofloxacin or moxifloxacin for 6-12mo
NOT pyrazinamide b/c lots to SE
Treatment for MAC
Mild to mod non-cavitary dz –> azithro/ethambutol/rifampin 3 x wk
Cavitary or severe dz–> daily
Very severe-> amikacin or other aminoglycoside IV for 1st 8-12wk
When to treat for NTM
pulm or systemic sx
consistent imaging (nodules or cavitary opacities, bronchiectasis esp middle lobe)
exclusion of other dx and + testing from 2 sputum cx, 1 BAL cx, biopsy w/ +cx, or pleural fluid +cx
LTBI treatment
Rifampin daily 4mo
INH +rifampin daily 3mo
Rifapentin + INH qweek x 12 dose
2nd line: INH daily 6-9mo (good if on birth control)
SE of Rifampin
Liver injury
Orange body fluid
Drug interactions (birth control! HIV meds)
SE INH
Liver injury
peripheral neuropathy
Drug induced lupus
SE PZA
Liver injury
Ethambutol SE
Optic neuropathy
Tx pan susceptible TB
6mo INH, RIF, ETH, PZA
then drop ethambutol when sus confirmed and continued others for 2 mo
When to treat TB for 9 mo vs 6mo
- Inability to tolerate PZA
- extensive cavitary dz
- persistent wt loss and + cx beyond 2mo tx
also to reduce risk of relapse or if BMI is low.
Treating TB in HIV+ pt
TB meds 1st then ART 2 wks after
use Rifabutin
Presentation of Lemierre Syndrome
Also called septic thrombophlebitis of IJ
infection with fusobacterium necrophorum
occurs 1-3wks after typical pharyngitis
- throat pain, fever, rigors, dysphagia
- septic emboli - cough, dyspnea, pleurisy and hemoptysis
Lung nodules that can cavitate
How to diagnose Lemierre syndrome
Head and neck imaging
tx pip/tazo or carbapenem or CTX + metro for 4 wks
Treatment for severe monkey pox
Tecovirimat for 14 days (2nd line Cidofocir)
treat if severely ill (airway involvement, dissemination, encephalitis) or underlying immunosupression
mpox presentation
Immunocompromised, MSM
Rash in anogenital area with variable stages of development and can spread to mucosal areas
dx with PCR
Treatment for mild mpox
if sx mild then usually self-limited so tx outpt with pain control and prevention of skin infections
Positive beta d glucan and neg glactomannan in pt with bilateral pulm infiltrates
PJP
Beta-d glucan positive in…
PJP
aspergillus (has +GM) and candida
maybe with histo, fusarium, cocci
Neg in mucor (-GM), crypto (may have +GM), blasto
Causes of false + in beta d glucan
-pseudomonas
-HD using cellulose membranes
-IVIG
-some albumin compounds
-use of cellulose filters for IV admin
-gauze used to pack serosal surfaces
Tick bite leads to anaphylaxis from contact with…
Red meat, milk products
Alpha-gal syndrome
Treatment of nocardia if CNS involvement and immunocompromised pt
Bactrim, meropenem and amikacin for 6 weeks IV then switch to PO bactrim, minocycline and/or amox/clauv for total 6-12mo
Treatment of nocardia with mild to mod infection
Sufonamide (bactrim)
If sulfa allergy –> minocycline
Tx actinomycosis
Penicillin
if allergic–> tetra cycline, erythromycin, clinda
Risks for actinomyces
poor dentition
Etoh use (aspiration)
Male
Presentation and dx of actinomycosis
intact immune pt
Usually non-pulm
invades chest wall (destroys facial plane)
confused for lung CA and TB
dx: tissue–> sulfur granules, granulomas, fibrosis
Stain with papauiculaou
Dx nocardia
Culture with BAL
If immunocompromized +smear = dz
PCR
Presentation of nocardia
Mostly pulmonary
spreads via blood so CNS involvement
Why do pts with CF get more NTM?
- Structural lung dz
- dysfunction of CF transmembrane conductance regulator protein
Empiric treatment for lung abscess
Amp/sulbactram IV
Cover anaerobes and microaerophilic strep
