S8C68 - CAP, aspiration PNA, non-infectious pulmonary infiltrates Flashcards
PNA: defn by environment
- CAP: pt not hospitalized or in LTC facility 14d before sx
- HAP: 48h after hosptial admission
- VAP: 48h after ETT intubation
- HCAP: pt hospitalized for >2d w/in past 90d, nursing home resident, pt receiving home IV Abx tx, dialysis pt, pt receiving wound care or chemo, immunocompromised pt
PNA: pathogens
- pneumococcus (strep pneumo) most common
- viral
- atypical: mycoplasma, chlamydophila, legionella (MCL)
PNA: sx
-atypical: mild, non-productive cough
PNA: tx (General principles)
- CAP: should cover at least strep pneumo and legionella
- strep pneumo: increasing PCN resistance in some areas, if concerned about resistance treat with vanco, imipenem, or newer resp fluoroquinolone
- atypicals: lack a cell wall therefore beta-lactams do not work, tx with macrolide or respiratory fluoroquinolone
- new fluoroquinolones (moxi/levo/gemi) have cvg against typical bacteria and atypical sources
- in-pt PNA should be covered for atypicals and cell-walled bacteria (eg. fluoroquinolones )
Strep Pneumo
- sudden onset, fever, rigors, c/p, productive cough, dyspnea
- gram +, encapsulated diplococci
- lobar infiltrate, occassionally patchy or pleural effusion
- elderly and
Staph Aureus PNA
- gradual onset productive cough, fever, dyspnea, may follow viral illness
- gm + cocci in clusters
- patchy, multilobar infiltrate, empyeme, abscess
- pts with chronic lung dz, cancer, risk for aspn PNA
Klebsiella pneumonia
- sudden onset, rigors, dyspnea, c/p, bloody sputum, more common in EtOH or nursing home pts
- gm - encapsulated paired coccobacilli
- upper lobe infiltrate, abscess
- may be assoc with HSV labialis
Pseudomonas aeruginaosa PNA
- recently hospitalized, debilitated, immunocompromised with fever, dyspnea, cough, severe PNA
- gm - coccobacilli
- patchy infiltrate with frequent abscess, bilateral lower lobe
H. flu
- gradual onset, fever, dyspnea, c/p
- COPD/elderly
- gm - encapsulated coccobacilli
- patchy, basilar infiltrate
Legionella pneumophila
- f/c, h/a, malaise, dry cough, dyspnea, anorexia, diarrhea, n/v
- no organism visible
- multiple patchy nonsegmented infiltrates, occasional cavitation and pleural effusion
- atypical
- legionella urine antigen testing should be done in ICU pts, alcoholics, or recent travel hx (2w)
Moraxella catarrhalis
- cough, fever, sputum, c/p
- more common in COPD
- gm - diplococci
- diffuse infiltrates
Chlamydophila pneumo
- gradual onset, fever, dry cough, wheeze, sinus sx, sore throat
- no organism visible
- patchy subsegmental infiltrates
- atypical
- may lead to adult asthma
Mycoplasma pneumoniae
- URTI and LRTI, nonproductive cough, bullous myringitis, h/a, malaise, fever
- no visible organism
- reticulonodular pattern, patchy densities
- atypical
Anaerobic organisms
- gradual onset, putrid sputum, EtOH
- purulent sputum
- consolidation of dependent portion of lung, abscess
Alcoholics and PNA
-strep pneumo still most common but consider klebsiella and h flu
Diabetics and PNA
- 2-3x more likely to die from PNA
- consider: S. aureus, mucor, gm - , and mycobacterium
- strep pneumo and legionella have increased mortality
Pregnancy and PNA
- varicella PNA can be severe
- treate with acyclovir
PNA in elderly
- mortality rate 40%
- legionella more common in elderly
- do not present with typical signs/symptoms
PNA and nursing home Pts
- nursing home pt with one of the following 8 has a 33% chance of having PNA:
1. incr HR
2. RR >30
3. temp >38
4. somnolence, decr LOC
5. confusion
6. crackles on ausc
7. absence of wheeze
8. incr WBC - s. pneumo most likely cause, as well as gm- bacilli and h. flu
HIV and PNA
- strep pneumo most common cause
- pseudomonas (also assoc with neutropenia, CVC, burns, CF, bronchiectasis pts)
- opportunistic infxns: TB, c. neoformans, histoplasma capsulatum, PCP if
Transplant pts and PNA
- susceptible to gm - bacilli (pseudomonas), s aureus, legionella, klebsiellya, e. coli, fungi
- after 6mo post op: h. flu and strep pneumo
Tx for CAP: out-pt
Uncomplicated Pt:
-macrolide: clarithromycin XL 1000mg PO OD x 7d
or Azithro 500mg PO d1 then 250mg OD d2-5
-tetracycline: doxycycline 100mg BID x10-14d (2nd line)
Pt with comorbidities:
-fluoroquinolone: levofloxacin 750mg OD x5d
or moxifloxacin 400mg OD 7-14d
-beta-lactam PLUS macrolide:
amox-clav 2g BID PLUS azithro 500mg d1 then 250mg d2-
**can use a third gen cephalosporin instead of amox-clav
Tx of CAP: in-patient
-fluoroquinolone: levofloxacin 750mg IV
or Moxifloxacin 400mg IV
-cephalosporin PLUS macrolide:
CTX 1g IV PLUS azithromycin 500mg IV
-may use another 3rd gen ceph in combination with a macrolide OR doxycycline
Tx of HCAP (Health care associated PNA) 3 drug regimen
Antipseudomonal cephalosporin PLUS fluoroquinolone PLUS anti-MRSA:
-cefepime or ceftazidime PLUS ciprofloxacin PLUS vanco
Antipseudomonal ceph PLUS fluoro PLUS anti-MRSA:
-imipenem OR meropenem PLUS cipro PLUS vanco
Beta-lactam and inhibitor PLUS antipseudomonal fluoroquinolone PLUS anti-MRSA (p485):
-pip-taz PLUS cipro PLUS vanco
**an aminoglycoside may be substitued in place of fluoroquinolone, levofloxacin can be substituted for ciprofloxacin, linezolid can be substituted for vanco
Tx for PNA - ICU
- cephalosporin PLUS macrolide: CTX 1g IV plus azithro 500mg IV
- cephalosporin PLUS fluoroquinolone: CTX PLUS moxifloxacin 400mg IV OR levofloxacin 750mg IV
-fluoroquinolone PLUS monobactam or lincosamide:
moxi or levo PLUS aztreonam or clinda
-add an anti-MRSA drug if HCAP or MRSA:
vanco or linezolid
PNA - in-patient tx - risk of pseudomonas
-beta-lactam and inhibitor PLUS fluoroquinolone:
pip-taz 3.375 mg IV PLUS cipro 400mg IV
-monobactam plus fluoroquinolone:
aztreonam 1g IV PLUS moxi or levo
-anti-MRSA drug (add if HCAP or MRSA risk):
vanco 10-15mg/kg IV or linezolid 600mg IV
Do not use fluoroquinolones in pts with:
Myasthenia gravis
CURB 65 rule:
- presence of confusion
- Uremia >7mmol/L
- RR >30
- Blood pressure of diastolic 65 years old
Aspiration PNA
- typical species: s pneumo, s aureus, h flu, enterobacteriaceae and pseudomonas if hospital acquired
- Abx covereage should include anaerobic coverage
-begins with an aspiration pneumonitis, if symptoms continue for for >24-48h then consider Abx tx
Aspiration pneumonitis:
- mild/mod sx >48h: levo or clinda or moxi or amox-clav
- SBO or use of anacids/PPI: levo or CTX or moxi or pip-taz or cetrazidime
Aspiration PNA:
- CAP: moxi or clinda or amox-clav
- HCAP/periodontal dz/EtOH/putrid sputum: CTX PLUS clinda, or pip-taz or ampicillin-sulbactam or cefepime PLUS clinda or levo PLUS clilnda
CXR findings: general
- interstitial infiltrate: fine, diffuse, linear
- alveolar infiltrate: ill-defined or reticular density representing fluid or abnormal cells in alveoli
- ground glass appearance: multiple finely granular densities
CXR findings: CHF
- cephalization
- kerley B lines (thickening of interlobular septa)
- interstitial edema
- thickening of fissures
- alveolar edema
- pleural effusitons
CXR findings: PE
- cardiac enlargement
- normal
- pleural effusion
- elevated hemidiaphragm
- pulmonary artery enlargement
- atelectasis
- parenchymal pulmonary infiltrates
CXR findings: Aspn PNA
-alveolar infiltrates in a dependent lobe
CXR findings: Allergic bronchopulmonary aspergillosis
- branching band-like opacities
- alveolar infiltrates
CXR findings: eosinophilic lung dz
-alveolar and interstitial infiltrates
CXR findings: pneumonitis
- diffuse micronodular interstitial infiltrates
- maybe ground glass densities in lower/mid lungs
CXR findings: acute interstitial pneumonitis
- b/l interstitial infiltrates
- sometimes patchy alveolar densities and ground glass
CXR findings: ARDS
-patchy peripheral infiltrates
CXR findings: sarcoidosis
- hilar lymph node enlargement
- diffuse parenchymal interstitial pulmonary infiltrates
CXR findings: bronchiolitis obliterans with organizing PNA
- inflm of bronchioles leading to organizing PNA w/o infxn
- occurs with immunocompromised conditions, CTD, SLE
- patchy alveolar infiltrates
- occassionally cavitation
CXR findings: Wegener Granulomatosis
-alveolar infiltrates, nodules, cavities
CXR findings: goodpastures syndrome
- antiglomerular basement antibody dz
- diffuse b/l predominately alveolar densities
CXR findings: churg-strauss vasculitis, allergic granulomatosis
-systemic vasculitis of unknown cause primarily affecting lungs and eventually skin, neuro, renal, GI, heart
- b/l peripheral, patchy, alveolar infiltrates
- nodules
CXR findings: radiation pneumonitis
- hazy ground glass densities to marked patchy infiltrates or homogenous consolidation
- air bronchograms
CXR findings: chemical pneumonitis
-diffuse alveolar, and interstitial infiltrates
CXR findings: bronchiolar carcinoma
- butterfly distribution of alveolar infiltrates
- may be unilateral
CXR findings: bronchoalveolar cell carcinoma
- peripheral alveolar infiltrates that do not respond to Abx
- peripheral mass or nodule
CXR findings: fat emboli
-interstitial prominence, interstitial edema
CXR findings: alveolar hemorrhage
-focal/diffuse alveolar infiltrates
