Chapter 153 Pneumonia

Question 1

Risk factors for CAP include

Answer 1

alcoholism, asthma, immunosuppression, institutionalization, and an age of ≥70 years.

Question 2

Risk factors for pneumococcal pneumonia include

Answer 2

Risk factors for pneumococcal pneumonia include dementia, seizure disorders, heart failure, cerebrovascular disease, alcoholism, tobacco smoking, chronic obstructive pulmonary disease, and HIV infection.

Question 3

is more likely in patients with skin colonization or infection with CA-MRSA.

Answer 3

CA-MRSA pneumonia

Question 4

tend to infect patients who have recently been hospitalized and/or received antibiotic therapy or who have comorbidities such as alcoholism, heart failure, or renal failure.

Answer 4

Enterobacteriaceae

Question 5

is a particular problem in patients with severe structural lung disease, such as bronchiectasis, cystic fibrosis, or severe chronic obstructive pulmonary disease.

Answer 5

P. aeruginosa

Question 6

Risk factors for ____ include diabetes, hematologic malignancy, cancer, severe renal disease, HIV infection, smoking, male gender, and a recent hotel stay or ship cruise.

Answer 6

Legionella infection

Question 7

Gross hemoptysis is suggestive of

Answer 7

CA-MRSA pneumonia.

Question 8

the sensitivity and specificity of the findings on physical examination are less than ideal,

Answer 8

averaging 58% and 67%, respectively.

Question 9

In chest X-ray:

pneumatoceles suggest infection with 1._____
and
an upper-lobe cavitating lesion suggests 2._____

Answer 9

1. S. aureus

2. tubercu- losis.

Question 10

To be adequate for culture, a sputum sample must have

Answer 10

> 25 neutrophils and

<10 squamous epithelial cells per low-power field.

Question 11

Certain high-risk patients including those with —should have blood cultured.

Answer 11

neutropenia secondary to pneumonia,
asplenia,
complement deficiencies,
chronic liver disease,
or severe CAP

Question 12

Urinary antigen tests

Answer 12

Pneumococcal urine antigen

Legionella urine antigen test

Question 13

PCR can detect the nucleic acid of

Answer 13

Legionella species,
M. pneumoniae,
C. pneumoniae and mycobacteria.

Question 14

Biomarkers of severe inflammation. The two currently in use are

Answer 14

C-reactive protein (CRP) and procalcitonin (PCT).

Question 15

may be of use in the identification of worsening dis- ease or treatment failure

Answer 15

CRP C-reactive protein

Question 16

____ may play a role in determining the need for antibacterial therapy.

Answer 16

Procalcitonin PCT

Question 17

For CAP, the main resistance issues currently involve

Answer 17

S. pneumoniae and CA-MRSA.

Question 18

Risk factors for penicillin-resistant pneumococcal infection include

Answer 18

recent antimicrobial therapy, an age of <2 years or >65 years, attendance at day-care centers, recent hospitalization, and HIV infection.

Question 19

resistance to macrolides is increasing through several mechanisms:

Answer 19

Target-site modification

Efflux mechanism

Question 20

___ caused by ribosomal methylation in 23S rRNA encoded by
the ermB gene results in high-level resistance (MICs, ≥64 μg/mL) to macrolides, lincosamides, and streptogramin B–type antibiotics.

Answer 20

Target-site modification

Question 21

______ encoded by the mef gene (M phenotype) is usually associated with low-level resistance (MICs, 1–32 μg/mL)

Answer 21

efflux mechanism

Question 22

Changes can occur in one or both target sites (topoisomerases II and IV) from mutations in the gyrA and parC genes, respectively.

Answer 22

Pneumococcal resistance to fluoroquinolones

Question 23

Methicillin resistance in S. aureus is determined by the ______ gene which encodes for resistance to all β-lactam drugs

Answer 23

mecA gene

Question 24

If CA-MRSA is suspected, either ______ can be added to the initial empirical regimen;

Answer 24

linezolid or vancomycin

Question 25

Indication for CTT

Answer 25

If the fluid has

1. pH of <7
2. glucose level of <2. 2 mmol/L
3. lactate dehydrogenase concentration of >1000 U/L or
4. if bacteria are seen or cultured

then it should be completely drained

Question 26

Chest radiographic abnormalities are slowest to resolve

Answer 26

4–12 weeks

Question 27

Two forms of influenza vaccine are available:

Answer 27

intramuscular inactivated vaccine and intranasal live-attenuated cold-adapted vaccine. The latter is contraindicated in immunocompromised patients.

Question 28

Three factors are critical in the pathogenesis of VAP:

Answer 28

1. colonization of the oropharynx with pathogenic microorganisms, 2. aspiration of these organisms from the oropharynx into the lower respiratory tract
2. compromise of the normal host defense mechanism

Question 29

three common findings in at-risk patients with VAP

Answer 29

(1) tracheal colonization with pathogenic bacteria in patients with endotracheal tubes
(2) multiple alternative causes of radiographic infiltrates in mechanically ventilated patients, and
(3) the high frequency of other sources of fever in critically ill patients.

Question 30

was developed by weighting of the various clinical criteria usually used for the diagnosis of VAP

Answer 30

Clinical Pulmonary Infection Score (CPIS)

Question 31

Maximal score of Clinical Pulmonary Infection Score (CPIS)

Answer 31

12
But if
Initially 8-10

Question 32

The standard recommendation for patients with risk factors for MDR infection is for three antibiotics:

Answer 32

two directed at P. aeruginosa and one at MRSA.

Question 33

For HCAP:
Patients without Risk Factors for MDR Pathogens

Answer 33

Ceftriaxone (2 g IV q24h) or cefotaxime (2 g IV q6–8 h) or
Moxifloxacin (400 mg IV q24h), ciprofloxacin (400 mg IV q8h), or levofloxacin (750 mg IV q24h) or
Ampicillin/sulbactam (3 g IV q6h) or
Ertapenem (1 g IV q24h)

Question 34

For HCAP
Patients with Risk Factors for MDR Pathogens

Answer 34

1. A β-lactam:
   Ceftazidime (2 g IV q8h) or cefepime (2 g IV q8–12h) or
   Piperacillin/tazobactam (4. 5 g IV q6h) or
   Imipenem (500 mg IV q6h or 1 g IV q8h), or meropenem (1 g IV q8h)
   plus
2. A second agent active against gram-negative bacterial pathogens:
   Gentamicin or tobramycin (7 mg/kg IV q24h) or amikacin (20 mg/kg IV q24h) or
   Ciprofloxacin (400 mg IV q8h) or levofloxacin (750 mg IV q24h)
   plus
3. An agent active against gram-positive bacterial pathogens:
   Linezolid (600 mg IV q12h) or
   Vancomycin (15 mg/kg q12h initially with adjusted doses)

Question 35

If the CPIS decreases over the first 3 days, antibiotics should be stopped after ____.

Answer 35

An 8-day course of therapy is just as effective as a 2-week course and is associated with less frequent emergence of antibiotic-resistant strains.

Question 36

In addition to the ____% failure rate for MRSA infection treated with vancomycin,

VAP due to Pseudomonas has a ____% failure rate, no matter what the regimen.

Answer 36

40%

50%

Question 37

The most sensitive component of the CPIS is improvement in

Answer 37

oxygenation

Question 38

Clinical improvement, if it occurs, is usually evident within _____ of the initiation of antimicrobial treatment.

Answer 38

48–72 h