#8: Pulmonary Infx

Question 1

A CAP dx occurs within 48 hours of admission to the hospital, in a patient who has not: (3)

Answer 1

1. Been hospitalized >2 days in the last 90 days
2. Had significant health care contact, including HD, wound care, chemo or IV ABX
3. Has not resided >14 days in an extended care facility (ECF, SNF)

Question 2

PNA and MC’s on death: (3)

Answer 2

• 6 leading cause of death in the US
• 2 MC cause of hospital acquired infx
• 1 cause of nosocomial infx death

Question 3

PNA classification system: (4)

Answer 3

1- causative pathogenic organism
2- anatomic/radiologic location
3- process of acquisition
4- by setting in which they occur

Question 4

The major reason to classify pneumonias is:

Answer 4

to direct antibiotic therapy- and specifically to determine the risk of exposure to MDR organisms

Question 5

Risk of MDR Pathogens: (6) RIFF95

Answer 5

RIFF95
1- RF’s for HCAP
2- IS (dz/tx)
3- Family member w/ MDR pathogen
4- Frequency of abx resistance increasing in community
5- in last 90 days, pt recieved abx for infx
6- >/=5 days: current hospitalization

Question 6

Atypical organisms of CAP include: (5)

Answer 6

1- Mycoplasma pneumoniae
2- Legionella species
3- Chlamydophila psittaci aka parrot fever
4- Chlamydophila pneumoniae aka walking PNA
4- Chlamydophilia trachomatis: STI and PNA in infants

Question 7

Typical Gram Positive Pathogens: (2)

Answer 7

1- Streptococcal pneumoniae

2- S. aureus

Question 8

Typical Gram Negative Pathogens: (4 major and 4 minor)

Answer 8

1- H. influenzae
2- Moraxella catarrhalis
3- Klebsiella pneumoniae
4- Pseudomonas aeruginosa
5- Gram-negative bacilli: uncommon *EEPS
-- e.coli
-- enterobacter spp.
-- proteus spp.
-- serratia spp.

Question 9

Uncommon CAP etiologies: (4)

Answer 9

1- Francisella tularemia: Rabbit fever
2- Coxiella burnetti: Q fever
3- Bacillus anthracis (anthrax)
4- Yersinia pestis (plague)

Question 10

List and compare the two forms of Legionella Dz:

Answer 10

1- Pontiac fever: virus-like presentation with malaise, fevers and HA; relatively benign
2- Frank Legionella PNA: very aggressive w/ high mortality rate

Question 11

Describe the classic CAP presentation associated w/ PCP:

Answer 11

• sudden onset of rigors w/ pleuritic CP in young pts

Question 12

Describe the classic CAP sxs presentation associated w/ Legionella PNA: (4)

Answer 12

1- AMS
2- hyponatremia
3- diarrhea
4- other GI symptoms

Question 13

Turkeys, chickens, ducks, and birds are vectors for this pathogen:

Answer 13

Chlamydophilia psittaci (Parrot fever)

Question 14

Rabbits and rodents are vectors for this pathogen:

Answer 14

Francisella tularemia (Rabbit fever) and Yersinia pestis (Bubonic plague)

Question 15

Cats, cattle, sheep, and goats are vectors for this pathogen:

Answer 15

Bacillus anthracis (anthrax) and Coxiella burnetti (Q fever)

Question 16

Associated w/ exposures to overcrowded conditions such as jails, homeless shelters, dormitories: (4)

Answer 16

1- S. pneumoniae
2- Chlamydiophilia species
2- Mycoplasma species
4- Mycobacterium (TB)

Question 17

Associated w/ exposures to contaminated air conditioning or water systems: (1)

Answer 17

Legionella species

Question 18

Red “current jelly” sputum associated w/: (1)

Answer 18

Klebsiella pneumoniae PNA

Question 19

Rust colored sputum associated w/: (1)

Answer 19

S. pneumoniae PNA

Question 20

Green sputum associated w/: (3)

Answer 20

1- H. influenzae
2- Pseudomonas aeruginosa
3- S. pneumoniae PNA

Question 21

Foul smelling or bad-tasting sputum associated w/: (1)

Answer 21

anaerobic infx

Question 22

List the different factors that will influence the decision to hospitalize w/ CAP tx:

• Comorbidities: (4)
• PE findings: (6)
• Labs: (4)
• Imaging: (2)

Answer 22

Comorbidities: (4)
1- immunocompromised state
2- hx of CHF
3- hx of CAD 
4- hx of CVA
PE findings: (6)
1- HoTN
2- tachycardia
3- tachypnea
4- AMS
5- fever
6- hypothermia
Labs: (4)
1- uncontrolled diabetes
2- hypoxia  
3- dehydration
4- hyponatremia
Imaging: (2)
1- pleural effusion
2- extent of lung involvement

Question 23

Describe CURB-65 and it’s scoring system in making the Decision to Hospitalize:

Answer 23

• Confusion (based upon a specific mental test or disorientation to person, place, time)
• Urea (blood urea nitrogen >20 mg/dL)
• Respiratory rate >30 breaths/minute
• Blood pressure [BP] (systolic <90 mmHg or diastolic <60 mmHg) aka severe HoTN
• Age >65years
• *1= outpatient, 2-3=inpt ward, 3+= inpt, ICU

Question 24

What is a PORT/ PSI score?

Answer 24

• pneumonia severity index

- a more comprehensive scoring system than CURB-65 that allows clinicians to risk stratify pts needing hospitalization

Question 25

IDSA/ATS Minor Criteria for Severe CAP: (11)

Answer 25

1- Respirations > 30/ min 2- Hypoxia 3- Need for non-invasive ventilatory support (BiPAP or CPAP) 4- Multilobar infiltrates 5- Uremia (BUN>20mg/dL) 6- Leukopenia (<4K) 7- Thrombocytopenia (<100K) 8- Hypothermia 9- HoTN rq. aggressive fluid resuscitation 10- Confusion/disorientation 11- Major criteria are septic shock and mechanical ventilation

Question 26

Empiric outpt. tx of CAP in healthy pts without a prior ABX exposure in the last 90 days: (1+2 or 1)

Answer 26

``` 1- Macrolide- preferred - Azithromycin (Zithromax) - Clarithromycin (Biaxin) OR 2- Doxycycline ```

Question 27

Significant comorbidities prompting quinolone OR beta lactam/macrolide use in empiric tx for CAP: (9)

Answer 27

``` 1- alcoholism 2- CKD 3- Chronic lung dz 4- CHD 5- Chronic liver dz 6- uncontrolled DM 7- malignancy 8- recent macrolide use in previous 90 days 9- immunocompromised pts. ```

Question 28

CAP tx for pts w/ a chronic dz (lung, heart, liver, or kidneys), poorly controlled DM, immunosuppression, malignancy, alcoholism, or pts who have used a macrolide in the last 90 days: (1+2 or 2+5+3)

Answer 28

1- fluoroquinolone: - Levofloxacin (Levaquin) - Moxifloxacin (Avelox) ``` 2- beta lactam AND a macrolide: ---1) high dose amoxicillin ---2) amox-clav (augmentin)**preferred ---3)ceftriaxone ---4) cefuroxime ---5) cefpodoxime AND - Azithromycin (Zithromax) - Clarithromycin (Biaxin) OR - Doxycycline ```

Question 29

Inpt. CAP tx for general medical ward/telemetry and ICU pts. w/o Pseudomonas or Legionella RF's: (1+2 or 1+2)

Answer 29

1- Beta lactam with a macrolide (preferred) ---1) Ceftriaxone (Rocephin) 1-2 gram daily IVPB ---2) Cefotaxime (Claforan) 1-2 gm IVPB q 8 with Azithromycin (Zithromax) 500mg IVPB daily OR 2- fluoroquinolone: ---1) Moxifloxicin (Avelox) 500mg IV daily ---2) Levofloxacin (Levaquin) 750mg dose IV daily

Question 30

Inpt. CAP tx for ICU pts. w/ Pseudomonas or Legionella RF's: (7)

Answer 30

``` 1- Piperacillin-tazobactam (Zosyn) 4.5gm IV q6 2- Imipenem (Primaxin) 500mg IV q 6hrs 3- Meropenem (Merrem) 1gm IV q 8hrs 4- Cefepime (Maxipeme) 2gms IV q 8hrs 5- Ceftazidime (Fortaz) 2 gm IV q 8hrs *PLUS, if double coverage needed: 6- Ciprofloxacin 400mg IV or 500mg po q 8 hrs 7- Levofloxacin 750mg IV or po QD ```

Question 31

Empiric tx for CAP-MRSA with Vancomycin should be given to hospital pts with severe CAP, defined as: (5 major and 6 minor)

Answer 31

``` 1- Admission to the ICU for septic shock or mechanical ventilation 2- Necrotizing or cavitary infiltrates 3- Empyema 4- GPC in clusters on sputum gram stain 5- Risk factors for cap-MRSA: --- 1- ESRD --- 2- IVDA --- 3- MSM --- 4- prisoners --- 5- recent influenza-like illness --- 6- recent ABX therapy (particularly with quinalone) in last 3 months ```

Question 32

Vaccines recommended in prevention of CAP: (4)

Answer 32

``` 1- Seasonal influenza vaccine - IM: killed virus - Nasal spray: attenuated virus 2- PCP 3- Pneumococcal conjugate vaccine 4- Pneumococcal polysaccharide vaccine ```

Question 33

Tx of HAP/VAP w/ early and less severe infx can be tx empirically with the following: (3)

Answer 33

1- 3rd gen cephalosporins 2- Beta lactam/BLI 3- Respiratory fluoroquinalone

Question 34

Tx of HAP/VAP w/ early and less severe infx likely does not cover these organisms:

Answer 34

- pseudomonas | - mrsa

Question 35

Tx of HAP/VAP w/ more severe HAP or VAP rqs. broader abx coverage for 7 days, which includes: (2+3)

Answer 35

*An aminoglycoside or fluoroquinolone, plus one of the following: 1- An anti-pseudomonal penicillin (Zosyn) 2- An anti-pseudomonal cephalosporin (Cefepime) 3- A carbapenem

Question 36

Parenteral tx for aspiration PNA: (1)

Answer 36

ampicillin-sulbactam (unasyn)

Question 37

Tx for aspiration PNA in a pt who is not severely ill: (3)

Answer 37

1- amox-clav (augmentin) 2- metronidazole AND PCN G 3- metronidazole AND amoxicillin

Question 38

Tx for aspiration PNA in a pt who is allergic to PCN:

Answer 38

1- metronidazole AND cefotaxime (preferred) 2- metronidazole AND ceftriaxone (preferred) 3- clindamycin: may cause C. diff

Question 39

Lung abscess tx: (4)

Answer 39

``` * likely rq. IV abx initially and abx continued for 3+ wks- and ID consult 1- ampicillin-sulbactam (unasyn) 2- meropenem (merrem) 3- carbapenem-imipenem (primaxin) 4- PO augmentin ```