B4.075 Lower Airway Infection

Question 1

features of acute bronchitis

Answer 1

cough (may be purulent)
not usually associated with changes in vitals
self limiting
usually viral
no or symptomatic treatment
antibiotics not indicated

Question 2

what distinguishes pneumonia from acute bronchitis

Answer 2

similar symptoms BUT
associated with changes in vitals and/or end organ function
changes on CXR
alveoli involvement

Question 3

definition of pneumonia

Answer 3

inflammation of lung parenchyma caused by bacteria, virus, or fungi which is characterized by intra-alveolar exudation

Question 4

route of entry of pneumonia causing pathogens

Answer 4

aspiration
inhalation
bloodborne

Question 5

what causes a tip in host/organism dynamic resulting in symptoms of pneumonia

Answer 5

defect in host defenses
virulent organisms
overwhelming inoculum

Question 6

mechanical and structural defenses

Answer 6

nose
cough/gag
airway branching
mucociliary clearance
normal oropharengeal flora (acidic)

Question 7

cellular defenses

Answer 7

macrophages
epithelial cells
neutrophils

Question 8

humoral/molecular defenses

Answer 8

IgG, IgA
cytokines
colony stimulating factors

Question 9

discuss the progression of pneumonia

Answer 9

edema: presence of proteinaceous exudates and often bacteria in small airways and alveoli
inflammatory debris: erythrocytes, neutrophils, fibrin
resolution: macrophages predominate, inflamm debris cleared

Question 10

pattern of bronchopneumonia

Answer 10

alveoli filled with exudate or purulent organisms

Question 11

pattern of interstitial pneumonia

Answer 11

involved interstitium, alveolar walls, and connective tissue

alveoli not fully filled

Question 12

pattern of military pneumonia

Answer 12

numerous discrete lesion of hematogenous spread

Question 13

pneumonia symptoms seen during clinical evaluation

Answer 13

cough
fever
pleuritic chest pain
dyspnea
sputum production
rapid onset of symptoms
GI symptoms
altered mental status

Question 14

what is one of the first systemic organs affected in pneumonia?

Answer 14

kidneys

sometimes see renal failure

Question 15

vitals associated with pneumonia

Answer 15

fever
tachypnea
tachycardia
hypotension

Question 16

lab findings w pneumonia

Answer 16

leukocytosis

left shift

Question 17

lung findings w pneumonia

Answer 17

crackles

egophany

Question 18

specific testing done when called for

Answer 18

sputum culture
blood culture
urinary antigens
resp viruses
PCR
procalcitonin

Question 19

what organisms are identified by PCR

Answer 19

chlamydia pneumonia

mycoplasma pneumonia

Question 20

what organisms are identified by urinary antigens

Answer 20

strep pneumo

legionella

Question 21

why is alcohol abuse a indication for extensive testing

Answer 21

weakened defense systems

high risk for systemic involvement

Question 22

indications for most extensive diagnostic testing

Answer 22

ICU admission
alcohol abuse
pleural effusion

Question 23

which test is particularly important in diagnosing pneumonia in a patient w severe chronic lung disease

Answer 23

sputum culture

works better in these patients than other

Question 24

common outpatient pneumonia

Answer 24

step pneumo
mycoplasma pneumo
h. flu
chlamydia pneumo
resp viruses

Question 25

common non ICU inpatient pneumonias

Answer 25

``` strep pneumo mycoplasma pneumo chlamydia pneumo h. flu legionella aspiration resp viruses ```

Question 26

common ICU pneumonias

Answer 26

``` strep pneumo staph aureus legionella gram neg bacilli h. flu ```

Question 27

distinct pathogens in alcoholism

Answer 27

oral anaerobes | klebsiella

Question 28

distinct pathogens in COPD and/or smoking

Answer 28

pseudomonas | moraxella

Question 29

distinct pathogens with lung abscesses

Answer 29

CA-MRSA

Question 30

pathogens associated with early HIV infection

Answer 30

similar to non-HIV population strep pneumo h flu

Question 31

pathogens associated with hotel or cruise stay

Answer 31

legionella

Question 32

pathogens associated with late HIV infection

Answer 32

opportunistic multiple fungi pseudomonas h flu

Question 33

pathogen associated with whooping cough

Answer 33

bordetella pertussis

Question 34

distinct pathogens with structural lung disease (bronchiectasis)

Answer 34

pseudomonas burkholderia cepacia staph aureus (drug resistant)

Question 35

2 main risk stratification tools

Answer 35

PORT Score/PSI | CURB65

Question 36

how does the PORT score work

Answer 36

if you have any severe indications listed in step 1, move to step 2 step 2 lists demographics, comorbidities, exam findings, lab/radiograph findings and calculates a score

Question 37

CURB65

Answer 37

``` confusion BUN >7 resp > 30 SBP <90, DBP <60 age > 65 ```

Question 38

curb score 2

Answer 38

admit

Question 39

curb score 3-5

Answer 39

consider ICU

Question 40

HCAP

Answer 40

health care associated pneumonia "at risk" for MDR pathogens nursing home, dialysis, infusion center hospitalization in previous 90 days

Question 41

HAP/VAP

Answer 41

high risk for MDR pathogens occurs 48 hours after admission VAP- 48 hours after intubation

Question 42

risk factors for MDR VAP

Answer 42

``` prior IV antibiotic use within 90 d septic shock ARDS precedingVAP 5 or more days of hospitalization acute renal replacement therapy ```

Question 43

risk factors for MDR HAP

Answer 43

prior IV antibiotic use within 90 d

Question 44

recommended antibiotics for outpatient CAP

Answer 44

1. previously healthy and no use of antimicrobials within 3 months: macrolide 2. presence of comorbidities: fluoroquinolone OR B lactam + macrolide

Question 45

recommended antibiotics for non ICU inpatient CAP

Answer 45

fluoroquinolone OR B lactam + macrolide

Question 46

recommended antibiotics for ICU CAP

Answer 46

B lactam (ceftriaxone) + azithromycin OR fluoroquinolone

Question 47

what organisms are covered in VAP recommended treatment

Answer 47

MRSA and double antipseudomonal/gram neg coverage

Question 48

recommended antibiotics for VAP

Answer 48

A. gram + antibiotics with MRSA activity: vancomycin OR linezolid B. gram neg antibiotics with antipseudomonal activity (B lactam based): piperacillin/tazobactam OR cephalosporin OR carbapenem OR monobactams C. gram nep antibiotic with antipseudomonal activity (non B lactam based): fluoroquinolone OR aminoglycoside OR polymixin

Question 49

most common treatment for VAP

Answer 49

vanc + piperacillin/tazobactam + ciprofloxacin duration 7-14 days de-escalate with culture results

Question 50

adjunctive management with pneumonia

Answer 50

assess for pleural effusion biomarkers steroids vaccination/prevention

Question 51

uncomplicated parapneumonic effusion

Answer 51

can result from inflammation without infected fluid

Question 52

complicated parapneumonic effusion

Answer 52

fluid resulting from infected pleural space has to be drained completely antibiotics poorly penetrate the space

Question 53

which imaging modalities are most sensitive for pleural effusion

Answer 53

ultrasound | CT

Question 54

what procalcitonin

Answer 54

a peptide precursor of calcitonin that is released by parenchymal cells in response to bacterial toxins

Question 55

why is procalcitonin evaluated

Answer 55

differentiates infectious from noninfectious pneumonia | determines when to stop antibiotics

Question 56

why are steroids potentially beneficial in pneumonia

Answer 56

counteract inflammatory response in CAP that is the source of much of the end organ damahe numerous adverse effects as well, however

Question 57

who would benefit more from steroids?

Answer 57

sicker patients

Question 58

pneumococcal vaccine recommendations

Answer 58

all persons >65 high risk persons 2-64 years of age current smokers

Question 59

flu vaccine recommendations

Answer 59

all persons > 50 | all persons over 6 mo without a contra-indication

Question 60

what are pneumococcal vaccines aimed at

Answer 60

aimed at capsule of bacteria