Pulmonology #3 (Pneumonia)

Question 1

Community acquired pneumonia (CAP) is defined as…

Answer 1

-Acquired outside the hospital OR
-develops PNA within 48 hours of hospital admission

Question 2

On the other hand, hospital acquired pneumonia (HAP), is acquired…

Answer 2

> 48 hours after hospital admission

Question 3

What two organisms should you be concerned about with HAP?

Answer 3

Pseudomonas and MRSA

Question 4

What are the etiologies of typical PNA?

Atypical PNA?

Answer 4

Typical: Strep Pneumo (MC), H. Influenzae, Klebsiella, Staph Aureus

Atypical: Mycoplasma (MC), Chlamydophila, Legionella, Viruses

Question 5

What are the signs and symptoms of typical PNA?

Answer 5

Fever, productive cough, pleuritic chest pain, signs of consolidation (bronchial breath sounds, dullness to percussion, increased tactile remits, ego phony, inspiratory crackles/rales)

Question 6

What are some symptoms of atypical PNA?

Answer 6

-Fever, dry cough
-Extrapulmonary symptoms (myalgias, malaise, n/v, diarrhea
-Pulmonary exam often normal

Question 7

The MCC of CAP is ______

This bacteria is shaped like _______

what are some symptoms specific to this organism?

Answer 7

Strep Pneumo

Gram positive diplococci

Sudden onset of chills, rigors, fever, productive cough with blood-tinged/rusty sputum

Question 8

Another typical cause of PNA, H. Influenzae, occurs MC in those with ________. Who is at increased risk for this type of PNA?

Answer 8

Underlying pulmonary disorder (COPD, Asthma, CF)

Extremes of age, immunocompromised (DM, elderly, HIV)

Question 9

Staph Aureus, another typical cause of PNA, occurs MC after…

What shape is this bacteria?

What is unique about the CXR with this organism?

Answer 9

MC post-viral infection (flu, etc.)

Gram-positive cocci in clusters

Bilateral infiltrates on CXR

Question 10

The last cause of typical PNA, Klebsiella, occurs in those who are…

on CXR you see…

What is one unique symptom with this type of PNA?

Answer 10

Chronic alcoholism, sick patients, chronic illnesses

Cavitary lesions on CXR

Purple/currant jelly sputum

Question 11

The MCC of atypical PNA ________, occurs in those who are…

What are some symptoms of this type of PNA?

Answer 11

Mycoplasma PNA

Young and healthy living in close proximity (college students, military, etc.)

Pharyngitis and URI prodrome, dry/nonproductive cough, bullous myringitis (blisters on TM)

Question 12

What is one important complication to remember with Mycoplasma (walking) PNA?

Answer 12

Cold autoimmune hemolytic anemia (IgM)

Question 13

Treatment for Mycoplasma PNA?

Answer 13

-Macrolides (Azithromycin) or Doxycycline

Question 14

Legionella, another cause of atypical PNA, is from outbreaks from _______.

What are some symptoms of this type of PNA?

Answer 14

Contaminated water sources

-GI Symptoms (non-bloody diarrhea, n/v)
-Hyponatremia and increased LFT’s
-Neuro Symptoms: headache, confusion, AMS

Question 15

What test is best for legionella PNA?

Answer 15

PCR, Urine Antigen (nucleic acid detection)

Question 16

Treatment for Legionella (atypical) PNA?

Answer 16

Macrolides or Respiratory Fluoroquinolones (Levofloxacin, Moxi, Gemi)

Question 17

How does CXR differ in typical VS atypical PNA?

Answer 17

-Typical: Lobar PNA
-Atypical: Hazy, patchy infiltrates

Question 18

Explain the components of the CURB-65 score and how many points you need to admit the patient.

Answer 18

Confusion
Uremia (>30)
Resp Rate (>30)
BP low (SBP <90, DBP <60)
Age > 65

Need 2 points to admit the patient

Question 19

Describe the treatment for CAP, both outpatient and inpatient. Think, you’re MAD and then you’re BAD!

Answer 19

CAP Outpatient: Macrolides, Amoxicillin, Doxycycline

CAP Inpatient: Ceftriaxone (Beta-Lactam) + Macrolide (Azithromycin) + Doxycycline OR Fluoroquinolone

Question 20

Treatment for HAP (Pseudomonas and MRSA)

Answer 20

-Pseudomonas: Pip/Tazo, Ceftazidime or Cefepinem, + Amikacin, Gentamicin

-MRSA: Vanco or Linezolid

Question 21

What is the treatment for Legionella PNA?

Answer 21

Levofloxacin or Azithromycin

Question 22

Aspiration Pneumonia, caused by anaerobes and has increased incidence in _______, MC is in what part of the lung?

What is one common symptom of this?

Answer 22

Increased incidence in periodontal disease

Right lower lobe

Foul-smelling sputum (rotten egg smell)

Question 23

Treatment for aspiration PNA

-Think double whammy

Answer 23

-Ampicillin-Sulbactam or Amoxicillin-Clavulanate

Question 24

Histoplasmosis is caused by inhalation of….

What else should you remember about this disease?

Answer 24

Inhalation of soil containing bird and bat droppings in Ohio and Mississippi River Valleys

-AIDS defining illness if CD4 <150

Question 25

What is the most specific diagnostic for Histoplasmosis?

Answer 25

Culture

Question 26

Treatment for histoplasmosis?

Answer 26

Itraconazole (1st line)
Amphotericin B if severe

Question 27

What acronym should you remember for histoplasmosis?

Answer 27

-BIRD
–Bird/Bat droppings
–Itraconazole
–River Valleys (Ohio and Mississippi)
–Defining illness for AIDS if CD4 <150

Question 28

Pneumocystis Pneumonia (PCP) is caused by pneumocystis jirovecii, which is a yeast-like fungus. What should you remember about this pathogen?

Answer 28

MC opportunistic infection in HIV, especially if CD4 <200

Question 29

Symptoms of PCP

Answer 29

-Dyspnea on exertion
-Nonproductive cough
-Oxygen desaturation with ambulation*****

Question 30

What diagnostics are done for PCP?

Answer 30

CXR: diffuse bilateral interstitial infiltrates (bat wing pattern)

Labs: Increased LDH

Lung Biopsy: Definitive

Question 31

What lab finding should you look for if you suspect PCP?

Answer 31

Increased LDH!

Question 32

Treatment for PCP

if HIV+, what should you add?

Answer 32

Bactrim x 21 days

If HIV+, add Prednisone if hypoxia

Question 33

What is used for prophylaxis against PCP?

Answer 33

If CD4 < 200, give the patient Bactrim!

Question 34

What anecdote/sentence should you remember to remember the facts about PCP?

Answer 34

Posterior is course and prickly (PCP), you need your back trimmed (Bactrim)

Question 35

Pneumonia vaccines are given at two different series. Explain.

Answer 35

PCV 13 in 4 dose series: 2, 4, 6, and 12-15 months of age

PPSV23 given to all adults 65 or older AND younger patients with PNA risks

Question 36

Can you get the PNA vaccine when you are pregnant?

Answer 36

Yes, it is safe while pregnant