Pulmonology #6 (PNA #2, Tuberculosis) Flashcards
What are the 2 criteria to classify PNA as community-acquired PNA?
-Acquired outside the hospital setting OR within 48 hours of hospital admission
Hospital acquired PNA occurs ________ and is usually caused by _____, or _______
> 48 hours after hospital admission
-MRSA
-Pseudomonas
Management of CAP Outpatient
Macrolides (-mycin) or Doxy
-Fluoroquinolones if recent ABX use
Management of CAP Inpatient
B-lactam (Ceftriaxone, Unsayn) + Macrolide or Doxy OR broad spectrum fluoroquinolone (-oxacin)
Aspiration PNA, MCC by ________, has increased incidence with periodontal disease. What are some symptoms associated with this condition?
-Anaerobes
-MC in right lower lobe
-Foul-smelling sputum (rotten egg smell)
Treatment for aspiration PNA
-Ampicillin-Sulbactam (first line) or Amoxicillin-Clavulanate
Alternative: Metronidazole + Amoxicillin or Pen G
Treatment for HAP
-Anti Pseudomonal B-lactam + either anti-pseudomonas AG or FQ (Piper/Tazo, Ceftazidime, Cefepime + -acin or -oxacin)
If MRSA is suspected with HAP, what should you add to the treatment?
Vanco or Linezolid
If Legionella is suspected with HAP, what should you add to the treatment?
Levofloxacin or Azithromycin
What is the CURB-65 score and what are the points?
Criteria for admission with PNA
-Confusion
-Uremia (>30 mg/dL)
-RR < 30
-BP (SBP < 90 or DBP < 60)
-Age > 65
How do you transmit Histoplasmosis?
Inhalation of soil containing bird and bat droppings in the Mississippi and Ohio River Valleys
-Also seen with demolition, spelunkers, excavators
Risk factors for Histoplasmosis?
Immunocompromised states
-AIDS defining illness if CD4 <150
Although most patients with Histoplasmosis are asymptomatic, it does present as atypical PNA occasionally (fever, nonproductive cough, myalgias). Also, if disseminated, what are some symptoms?
Can mimic TB with hepatosplenomegaly, oropharyngeal ulcers, bloody diarrhea, adrenal insufficiency
Diagnostics for histoplasmosis
-Antigen testing via sputum (PCR) or urine
-Cultures are most specific
Treatment for Histoplasmosis
-Asymptomatic: no treatment
-Mild-Moderate: Itraconazole
-Severe: Amphotericin B
What is the schedule for the PCV-13 vaccine?
2, 4, 6, and 12-15 months of age
Who gets the PCV 23 vaccine?
All adults 65 and older or younger patients with conditions that increase the risk for developing complications from a PNA infection
True or False: Pregnancy is NOT a contraindication to the PNA vaccine?
True. Pregnant women can still get it
What are risk factors for Pneumocystis PNA (PCP)?
Immunocompromised states
Most common opportunistic infection in HIV (CD4 < 200)
What is the classic triad of symptoms for PCP PNA?
-DOE (MC)
-Fever
-Nonproductive cough
What is true about the oxygen desaturation with PCP PNA?
Desaturation with ambulation
DOC for PCP PNA
Trimethoprim-Sulfamethoxazole x 21 days
If the patient is HIV + and hypoxic, what drug should be added?
Prednisone
On CXR, what is seen with PCP PNA?
Diffuse bilateral interstitial infiltrates (but may be normal)
What is seen on labs with PCP PNA?
Increased LDH (> 200), increased beta-D-glucan
What is the prophylaxis for PCP PNA in a patient with HIV?
Bactrim if CD4 < 200
Risk factors for TB
-Close contact with an infected person
-Crowded conditons
-Healthcare workers
-Immunosuppression (DM, HIV)
What is needed in chronic (latent TB) to show infected but not infectious?
- PPD
-No symptoms
-No imaging findings of active infection
- PPD
With secondary/reactivation TB, where are the imaging findings usually positive?
Apex/upper lobes with cavitary lesions (due to increased O2 content in apices)
What are symptoms of TB?
-Cough (productive or nonproductive)
-Hemoptysis
-Fever, chills, night sweats, chest pain
-Cervical lymph nodes (scrofula)
-Pott’s disease (vertebrae)
-Miliary TB
-Pericarditis
True or False: TB can affect any organ?
True
What is Pott’s Disease?
TB of the vertebrae
What is TB of the cervical lymph nodes?
Scrofula
A CXR is often the initial test ordered for TB. Explain the differences in location for findings based on reactivation, primary TB, and miliary TB.
-Reactivation: Apical (upper lobe)
-Primary: middle/lower lobe consolidation
-Miliary: millet-seed nodular lesions 2-4 mm
Regarding sputum acid-fast staining, what must be done to rule out TB?
3 samples taken on 3 consecutive days must be negative to rule out TB
Only one + sample is needed to rule in TB
However, what is more sensitive that sputum staining?
NAAT
Management of active TB
4 drug therapy (RIPE) for 2 months followed by 4 months of RI = 6 month total treatment
What drug can used instead of Ethambutol
Streptomycin
RIPE or RIPS
Adverse effects of Rifampin
-Thrombocytopenia
-Orange colored secretions (tears, urine)
Adverse effects of Isoniazid
-Hepatitis
-Peripheral Neuropathy
Peripheral neuropathy, associated with Isoniazid, is prevented by giving the patient ______ as well.
Pyridoxine (B6)
Adverse effects of Pyrazinamide
Hepatitis and Hyperuricemia
Photosensitive rash
Adverse effects of ethambutol
-Optic neuritis
-Red/green color blindness
-Peripheral neuropathy
Adverse effects of Streptomycin
-Ototoxicity
-Nephrotoxicity
For latent TB infection, what is the treatment?
INH + Pyridoxine (with B6) x 9 months
OR
Rifampin x 4 months
Explain the rules for a positive PPD test in TB
> 5: HIV or immunosuppressed, close contact with TB infected, CXR shows old/healed TB
> 10: all other high-risk populations (healthcare)
> 15: everyone else, no known risk factors for TB
What are some reasons for false positive on a TB test?
Within 2-10 years of the BCG vaccine
Improper reading
Cross reaction with an atypical (MAC)
What are some positives with the Interferon Gamma Release Assay TB Test
-Blood test with improved specificity
-Not affected by BCG vaccine
