Flashcards in Community Acquired Pneumonia Deck (36)
pathogenesis of pneumonia?
-inflammation of parenchymal structures of the lung in the lower respiratory tract (alveoli and bronchioles)
-defect in the usual respiratory defense mechanisms (cough, cilia, immune response)
-large infectious inoculum or a virulent pathogen overwhelms the immune system
Pneumonia may be community or nosocomial acquired, what timeline do we use to determine this?
-pneumonia occurred outside of the hospital or within 48hrs of hospital admission.
-in a person who has not resided in a nursing home or hospital in the prior 2 weeks.
-health care associated
What is the most common bug to cause CAP, how about NAP?
both are most commonly caused by strep pneumo.
Pneumonia may be typical or atypical, what are the differences?
typical pathogens: caused by bacterial that multiply in the alveoli
atypical pathogens: -caused by infectious agents that multiply in the spaces between the alveoli (septum and interstitum) *destruction of alveolar walls, because the air spaces arent all filled up with pus and bacteria they will not have as hard of a time exchanging gases.
Definition of CAP?
-pneumonia infection occurred outside of the hospital or within 48hrs of hospital admission.
What is the most common infectious cause of death world wide?
When is PNA most commonly occuring? in what population?
-peaks in winter months
-more common in older adults >65yo
Risk factors of PNA?
-Regular contact with children
-frequent visits to the healthcare provider
-gastric acid therapy (suppression can allow pathogens to survive in the gastric contents that normally would be killed by the acid)
Most common etiologies of bacterial PNA?
Most common viral causes of pneumonia ?
-influenza A & B
-Respiratory syncytial virus (RSV)
Can fungus cause PNA?
yes, if insidous onset with a possibility of immunocompromise consider fungal etiologies
What factors may lead you to believe your pt has legionella caused pneumonia?
-recent travel within 2weeks, hotel stays or cruise ships
-high fever (104 F)
-GI sx (water diarrhea)
-diffuse parenchymal involvement on xray
Tip to determine mycoplasma pna?
General Sx of PNA
-+/- sputum production
-rigors (abdominal rigidity and shaking of the limbs)
-pleuritic chest pain
Signs of PNA?
-appear acutely ill
-may have hypothermia (elderly)
-bronchial breath sounds
-dullness to percussion
Elderly presentation of PNA?
-more likely to have subtle sx
-decline in functional status
-confusion or change in mental status
Out patient diagnostic test for PNA?
Urinary ag testing +/-
*you generally dont have to do a big work up on outpatient, BUT if this is an older person we would want to get all of this stuff. Younger person with no comorbidities you wouldnt necessarily need these.
Inpatient Diagnostic Tests for PNA?
-Sputum gram stain
-Urinary antigen testing
-rapid Ag test for influenza
-prior to abx tx: sputum culture, blood culture (x2)
-CBC w/ diff
- HIV testing in all adult pts
What type of CXR do you order for PNA? If positive pneumonia what would you see on xray?
-always order a PA and Lateral xray
-patchy opacities, lobar consolidation w/ air bronchospasms, diffuse alveolar or interstitial opacities, pleural effusion, cavitation
PNA pt may present with pleural effusion, how do you remove this fluid and what are you looking for in this fluid?
-looking at glucose, LDH, total protein, leukocyte count, pH, gram stain, and culture.
On CXR, if you see cavitary opacities what is the most likely cause of PNA?
-most likely fungal
Whats all the fuss between community acquired and hospital acquired MRSA?
-they are genetically different.
What is the admission criteria for PNA?
B: BP1, the higher the number of points the higher the mortality.
*BUN: measure of kidney function- dehydration status. if BUN high you could be dehydrated because it should be more dilute.
What is CURB 65 good for determining?
-who will die from PNA, but not at whos going to need ventiallary support in the ICU.
Empiric Abx Tx PNA
-Not hospitalized, no co-morbidities
-Not hospitalized + comorbidities
-Hospitalized, not in ICU
-Hospitalzed, in the ICU
No hosp. no comorbid-Azithromycin**, or clarithromycin, or doxycycline (best for pt w/ hx of smoking)
Not hosp. + comorbid:
-Respiratory FQ**, or azithromycin, or clarithromycin + high dose amoxicillin, or high dose amoxicillin-CL (augmentin), or cefdinir, cefpodoxime, cefprozil
Hosp. no ICU
-Respiratory FQ*, or Macrolide + Cefriaxone, ampicillin, cefotaxime
Hosp. In ICU
-Res. FQ or Azithro + cefotaxime, ceftriaxone, ampicillin/sulbactam
*ask if at risk for pseudomonas; add antipseudomonal beta-lactams (piperacillin/tazobactam, cefepime, imipenem, miropeneim) + cipro/levo
antipseudomonal beta lactam + aminoglycoside + azithro or resp FQ
Best outcomes if abx are started within how many hours of admission for pna?
Duration of PNA treatment
-min 5 days
-afebrile for 48-72hrs
-avg for other meds other than azithromycin 5-7days unless severe infection or other sites infected
*azithromycin has a very long half life so duration of therapy studies dont equate to other drugs
how to prevent pna?
-seasonal flu vaccine
risk factors for anerobic pulmonary infection?
- decreased level of conciousness d/t drug or ETOH
-poor dental hygiene