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Respiratory 2 > community acquired Pneumonia > Flashcards

community acquired Pneumonia Flashcards

1
Q

Epidemiology on Community acquired Pneumonia?

A

• 4 million cases/year1 • 800,000 patients require hospitalization/year1 • Increasingly common among older patients and those with coexisting illness • Expanding spectrum of causative organisms – Streptococcus pneumoniae is the most common – No causative agent identified in • 50% of patients • Increasing resistance of pathogens to older antimicrobial agents2

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2
Q

Who is at risk for CAP?

A

• Elderly and the very young • Immunocompromised • Persons with specific comorbidities – Diabetes Mellitus – Chronic obstructive pulmonary disease (COPD) – Chronic renal failure – Splenectomy or functional asplenia

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3
Q

Effect of age on CAP?

A

• Incidence: Proportion requiring hospitalization from CAP – 35/100,000 adults age 20-24 years – 1200/100,000 adults > age 75 years • ICU Admissions – 10% 0f patients with CAP

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4
Q

Explain the chart of which etiologies of pneumonia different ages get? Newborns, children, young adults, middle age, and elderly

A
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5
Q

Common pathogens for alcoholism?

A

Oral anaerobes, gram-negative bacilli, Streptococcus pneumonia

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6
Q

Nursing home residents common pathogens?

A

Streptococcus pnuemoniae, gram-negative bacilli, Haemophilus influenzae, Staphylococcus aureus, including methicillin –resistant Staphylococcus aureus (MRSA)

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7
Q

COPD common pathogens?

A

Haemophilus influenzae, Streptococcus pneumoniae, Moraxella (Branhamella) catarrhalis

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8
Q

Common pathogens during an influenza outbreak?

A

Influenza virus, Streptococcus pnuemoniae, Staphylococcus aureus, Haemophilus influenzae

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9
Q

Common pathogens seen with poor dental hygeine?

A

Oral anaerobes

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10
Q

Explain the changing etiology of CAP?

A
  • Causative pathogen unknown in 1/3 to 1/2 of all cases of CAP
  • Increase in antimicrobial resistant strains
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11
Q

When the pathogen is documented in CAP which are common ones? and atypical?

A
  • Traditional pathogens Streptococcus pneumoniae

Haemophilus influenzae

Moraxella catarrhalis

Staphylococcus aureus

Gram negative bacteria

Acinetobacter

Anaerobic bacteria (Peptostreptococci, Bacteroides sp., Prevotella)

  • Viruses

Atypical pathogens: Mycoplasma pneumonia, chlamydia pneumonia, legionella sp.

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12
Q

What are the routes of pneumonia infection?

A

• Inhalation • Aspiration • Hematogenous (rare)

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13
Q

List the Major defenses against pulmonary infection and the things that impair them?

A

Gag reflex: Alcohol, Stroke, Coma

Mucociliary Elevator: Alcohol, Viral infection, Smoking, Kartegener Syndrome

Alveolar Macrophages: Alcohol, Viral infection, Smoking, Pulmonary edema, Steroids

Specific Ig: deficiency

CMI :Steroids, Viral infection

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14
Q

Explain what things we do for the diagnosis of CAP?

A
  • Patient history and physical examination findings
  • Confirmation by chest radiograph
  • Gram stain and culture of sputum*
  • Blood culture
  • Serologic tests
  • Special tests
  • Invasive techniques
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15
Q

CAP symptomology?

A
  • Cough associated with fever +/- sputum, dyspnea, pleurisy, malaise, GI symptoms
  • Acute confusion or deterioration of baseline function (elderly or debilitated patients) – Advanced illness
  • Difficult to differentiate between typical/atypical pathogens on clinical presentation
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16
Q

Symptoms indicative of Pneumococcal Pneumonia?

A

– Abrupt onset of single shaking chill

– Fever, cough productive of rust-colored sputum

– Pleuritic chest pain

17
Q

Symptoms indicative of H.Influenza pneumonia?

A

– Insidious worsening of baseline cough and sputum production

18
Q

Symptoms indicative of Chlamydia Pneumonia?

A

– URI, bronchitis or laryngitis, subacute in onset, progression to pneumonia in a minority of patients

19
Q

Symptoms indicitive of Mycoplasma Pneumonia?

A

– Flu-like illness with headache, malaise, and fever – Cough may produce mucoid sputum – Pharyngeal erythema, cervical adenopathy, scattered rales and rhonchi

20
Q

What are the traditional tests for CAP? Evolving tests?

A

Chest radiogaphy

Expectorated sputum, with gram stain and culture

Blood culture

Evolving: Biochemical, immunologic, molecular

21
Q

Explain the localized alveolar infiltrates of common pneumonia types?

A
  • Pneumococcal pneumonia – most common
  • Klebsiella pneumonia – lobar enlargement evidenced by bowing or bulging of a fissure favors Klebsiella or pneumococcal Type III pneumonia
  • Staphylococcal pneumonia – empyema common
  • Anaerobic pneumonia – favored if posterior segment right upper lobe or superior right lower lobe with cavitation
  • Tuberculosis pneumonia
  • Histoplasmosis – acute pneumonia form
  • Legionnaire’s disease
22
Q

ddx of multiple nodular lesions?

A
  • Metastases
  • Granulomas (e.g., histoplasmosis, tuberculosis, blastomycosis, coccidioidomycosis)
  • Hamartomas
  • Arteriorvenous malformations
  • Septic emboli with abscess
  • Rheumatoid nodules
  • Wegener’s granulomatosis
  • Sarcoidosis
  • Pulmonary infarcts
23
Q

Explain the advantages and disadvantages of expectoration of sputum, endotrachial aspiration, trantracheal aspiration, fiberoptic brochoscopy, Transthoracic lung aspiration?

A
24
Q

Laboratory Analysis for CAP includes? how are the specimins collected?

A

Laboratory Analysis

Culture (2 days)- Nasopharynx wash/swab or throat culture

Rapid antigen detection methods (2-3 hours) - same as above

ELISA: Immunofluorescent, antigen detection- bronchoalveolar lavage.

PCR (investigational) - sputum

Histopathology (2-3 days)- lung tissue

25
Q

Differential Diagnosis of CAP?

A
  • Direct staining of sputum can differentiate pulmonary infections due to the following organisms: – Mycobacterium spp – Endemic fungi (Histoplasma, Blastomyces, Coccidioides, Cryptococcus) – Legionella spp (requires direct fluorescent antibody staining) – Pneumocystis carinii
  • Chest radiographic findings may suggest tuberculosis or Pneumocystis carinii pneumonia; multilobular involvement indicates severe illness
  • Atypical pneumonias (Chlamydia pneumoniae, mycoplasma pneumoniae, Legionella spp) are unresponsive to conventional antibiotic therapy (penicillins, cephalosporins, trimethoprim/sulfamethoxazole) or present with extrapulmonary features
26
Q

Indications for Hospitalization in community acquired pneumonia?

A
  • Age >65 years
  • Coexisting illness or other findings – COPD - Congestive heart failure – Diabetes mellitus - Chronic liver disease – Chronic renal failure - Hospitalization during previous year
  • Physical findings – RR >30 per minute – Systolic/diastolic BP ”90/”60 mm Hg – T >38.3C/101F
  • Laboratory findings – WBC <4,000/L or > 30,000/L or - PaCO2 >50 mm Hg absolute neutrophil count <1,000/ - HCT <30% – PaO2 <60 mm Hg - Hb <9 g/dL
  • Absence of competent caregiver in stable home situation
27
Q

Streptococus pneumonia Frequency? Hospitalizations? Lethality? Most frequent in? Clinical features? treatment?

A
  • Frequency of pathogen identification – 1930-1937: 81% – 1950-1985: 35%-76% – 1985-present: 10%-20%
  • Hospitalized CAP patients with etiologic diagnosis: 66%*
  • Identified pathogen in lethal cases of CAP with an etiologic diagnoses: 67%
  • Bacteremic pneumonia: 66%
  • Most frequent pathogen in elderly
  • Most common bacterial pathogen in AIDS patients
  • Clinical features: Single shaking chill, fever, cough with rust-colored sputum, pleuritic chest pain
  • Treatment: Amoxicillin, cefotaxime, ceftriaxone, fluoroquinolones (levofloxacin, trovafloxacin, grepafloxacin, sparfloxacin), vancomycin, macrolides, clindacycim
28
Q

Incidence of Mycoplasma Pneumonia? Incubation? Clinical features? Extrapulmonary consequences or symptoms? Diagnosis? Treatment?

A
  • Incidence: ~12% patients hospitalized for CAP
  • Incubation period: 2-4 weeks
  • Clinical features: Prodrome ĺ tracheobronchitis with cough for 3-4 weeks 㼼 pneumonitis (3%)
  • Extrapulmonary consequences or symptoms: GI rash, subclinical anemia, neurologic symptoms, myocarditis
  • Diagnosis: Culture, serology for IgG or IgM, enzymelinked immunosorbent assay (ELISA) or complement fixation (CF) or PCR Cold agglutinins >1:64
  • Treatment: Tetracycline or doxycycline, macrolide, fluoroquinolones
29
Q

Chlamydia pneumonia incidence? Epidemiology? Clinical Features? Diagnosis? MIF criteria? Treatment?

A
  • Incidence: 5%-15% of CAP
  • Epidemiology: Sporadic and epidemic
  • Clinical features: Pharyngitis, laryngitis, tracheobronchitis, and may precipitate asthma
  • Diagnosis: Serology microimmunofluorescence (MIF) preferably with confirmation by polymerase chain reaction (PCR) or culture
  • MIF Criteria: 4-fold increase IgG or IgG> 1:512 or IgM> 1:16
  • Treatment: Doxycycline, macrolide, fluoroquinolones
30
Q

Legionella Pneumophila incidence, epi, clinical features? Diagnosis? Treatment?

A
  • Incidence: 2%-6% of patients hospitalized for CAP
  • Epidemiology: Epidemics (summer) or sporadic (not seasonal)
  • Clinical features: Non-distinctive • Host susceptibility factors: Age >40, compromised cell-mediated immunity (non-AIDS), and smoking • Mortality: 15%-25% of patients hospitalized with Legionella pneumonia
  • Diagnosis: Urinary Ag (for L. pneumophila serogroup 1) and culture on selective media
  • Treatment: Macrolide (azithromycin, erthromycin, clarithromycin), fluoroquniolones, doxycycline
31
Q

What are the respiratory viruses that can cause Pneumonia?

A

influenza A and B

Respiratory Synticial Virus (RSV)

Parainfluenza virus 1, 2, and 3

Adenovirus

Coronovirus

Rhinovirus

32
Q

What are the non-respiratory viruses that can cause pneumonia?

A

Herpes simplex virus type 1

Varicella zoster

CMV

EBV

Human herpes virus 6

measels Virus

hantavirus

33
Q

What are the two treatment styles in CAP?

A

Empirical: 1993 guidelines

Therapy to be based on likely spectrum of pathogens. Prescence of advanced age or underlying illness, Severity of illness on presentation, inpatient versus outpatient management.

Etiologic or pathogen-derived guidelines 1998

Therapy to emphasize the identification of causitive pathogen with pathogen specific therapy. Minimize polypharmacy, reduce resistance, reduce adverse drug reactions, reduce cost.

34
Q

Who should receive the pneumococcal polysaccharide vacine?

A

Respiratory 2 (10 decks)

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