Infectious Disease Pt 2

Question 1

Your imaging is showing an entire lobe has been “wiped out”. What is your first thought?

Answer 1

PNA. And inversely, if you thought your patient had PNA, but you see capsules or some diffuse process, EXPAND your DDx

Question 2

if you smoke or have COPD, you are at risk for infection by what pathogens?

Answer 2

h.flu and strep

Question 3

if you live in a SNF, you are at risk for infection by what pathogens?

Answer 3

strep, TB, hflu, gram negatives

Question 4

If you have h/o ETOH abuse, you are at risk for infection by what pathogens?

Answer 4

strep, gram negs, anaerobes

Question 5

If you have exposure to bats, you are at risk for infection by what pathogens?

Answer 5

histoplasma capsulatum

Question 6

if you have exposure to birds, you are at risk for infection by what pathogens?

Answer 6

Cryptococcus neoformans and chlamydia

Question 7

If you have recently had the flu, you are at risk for infection by what pathogens?

Answer 7

staph, strep, hflu

Question 8

If you have CF, you are at risk for infection by what pathogens?

Answer 8

pseudomonas infections

Question 9

If you are an IV drug user, you are at risk for infection by what pathogens?

Answer 9

staph, TB, anaerobes

Question 10

If you aspirated, you are at risk for infection by what pathogens?

Answer 10

anaerobes

Question 11

If you have HIV, you are at risk for infection by what pathogens?

Answer 11

pneumocystis carinii

Question 12

What is the #1 cause of CAP (community acquired pna)?

Answer 12

strep. pna

Question 13

What pna causing germ causes dyspnea and diarrhea and is associated with a water source?

Answer 13

Legionella

Question 14

What pna causing bug also causes abscesses to form in the lungs. It is characterized by a dry cough and headache. Often, it is associated with IV drug abusers

Answer 14

staph aureus

Question 15

Which PNA causing germ presents with a fever and a rusty colored sputum?

Answer 15

strep. PNA

Question 16

Which PNA causing germ is most common amoung alcoholics and diabetic patients? It presents with hemoptysis and currant jelly colored sputum. CXR’s often reveal lobar consolidation

Answer 16

K. PNA

Question 17

You have PNA and you have COPD second to smoking. Your PNA is most likely caused by what germ?

Answer 17

H. PNA

Question 18

You have a patient with CAP. She is a healthy 29 yof with no risk factors. What is the BEST way to treat her?

Answer 18

as an outpatient using either 1) MACROLIDE 2) FLOROQUINOLONE, or 3) DOXYCYCLINE

Question 19

Your healthy 29 yo patient with CAP is allergic to one of the preferred medications. What the heck are you going to do now?

Answer 19

AUGMENTIN or BETA LACTAM

Question 20

Uh oh, you have a 53 year old female patient with HTN, DM, and COPD. She is in your office coughing up sputum. You detect crackles in her lungs. Vitals: temp 102.1 HR 103 BP 150/95 resp 18 O2sat–94. She is A&Ox4. Her CBC and CMP show elevated WBC, otherwise wnl. You don’t need a CXR to know this is PNA. How will you treat?

Answer 20

MACROLIDE, FLOROQUINOLONE, or DOXY

Patient has comorbidities, so you have to determine her “prognostic index”. Meaning…how severe is this? Using the CURB65, you determine she is actually low risk (1/5 risk factors). So she can be treated as an outpatient.

Question 21

What types of symptoms typically occur with a CAP infection?

Answer 21

fever (90%), cough, tachycardia, crackles/rales, tachypnea (>24), tachycardia

Question 22

You suspect your patient has PNA because they have a cough and crackles. Your patient’s vital signs are stable. Do you need to do a CXR?

Answer 22

No. The absence of v/s abnormalities (fever, tachypnea, tachycardia) has a 99% negative predictive value of PNA. But of course, you want to follow up with your patient to make sure none of these things have developed.

Question 23

What kinds of tests can you use to make a definitive diagnosis?

Answer 23

CXR is standard. sputum culture or staining. labs (CBC, chem panel), blood cultures

Question 24

What is a simple way to measure severity of a PNA infection?

Answer 24

CURB-65. Evaluate for confusion, Urea (BUN), Respirations, Blood Pressure, Age>65. Assign 1 point to each abnormal finding. If score is 0-1 treat as outpatient. Score of 2 use clinical judgment, score 3+ requires admission

Question 25

Your 50 year old male patient with high cholesterol, 20 pack/year history, and COPD is in your office coughing up sputum. You detect crackles in his lungs. Vitals: temp 103.0 HR 116 BP 165/100 resp 26, O2sat–95. He seems alert to self and place, but is not sure what time it is. The history he gives you doesn’t make complete sense. His CBC and CMP show elevated WBC, and an elevated BUN. You don’t need a CXR to know this is PNA. What is his CURB65 score? How will you treat?

Answer 25

Admit! IV BETA LACTAM and a MACROLIDE…… OR IV FLOROQUINOLONE alone
(This patient’s CURB65 is a 4/5)

Question 26

What criteria would constitute a diagnosis of HCAP (health care associate pna) vs regular old CAP?

Answer 26

1) SNF patient (or other care fascility
2) Dialysis patient (dialyzed w/in 30 days)
3) Hospitalized at least 2 days out the past 90 days (but not withing 48 hours)
4) Receives home IV/wound care in the last 30 days

Question 27

What criteria would constitute a diagnosis of HAP (hospital acquired pna) vs CAP or HCAP?

Answer 27

PNA develops over 48 hours after a hospital admission and was not incubating at time of admission

Question 28

What antibiotic would you add, if you had a suspicion that the pna germ was MRSA?

Answer 28

Vancomycin

Question 29

If your patient is unable to clear their secretions during an PNA infection, what bug are you worried about? How would you treat?

Answer 29

Pseudomonas (anaerobe), treat with IV antipseudomonal beta lactam AND either IV QUINOLONE or IV AMINOGLYCOSIDE for a MINIMUM of 14 days EVERY TIME (high resistance rate)

Question 30

Who should you be recommending the pneumovax for?

Answer 30

everyone >65. Immunocompromised. SNF residents. People over the age of 2 years with diseases of the heart, lungs, liver. With DM, ETOH abuse, tobacco use, CSF problems

Question 31

Who gets viral pna?

Answer 31

kids under 3, typically

Question 32

Who’s the big trouble maker in viral pna?

Answer 32

RSV, parainfluenza

Question 33

How can we treat viral pna?

Answer 33

Gandolf, acyclovir, oseltamivir, a bunch more I don’t think we need to know

Question 34

What, specifically, should you know about fungal PNA?

Answer 34

it exists. it is BAD!

Question 35

Necrosis of the pulmonary parenchyma caused by microbial infection

Answer 35

pulmonary abscess

Question 36

Who usually gets pulmonary abscesses?

Answer 36

people at risk of aspiration, IV drug users

Question 37

How would you treat pulmonary abscess?

Answer 37

CLINDAMYCIN (because abscesses are usually anaerobic)……or Beta lactam if suspect staph. Vancomyciin if MRSA….and if abx fail, may need surgical excision.

Question 38

Your patient has PNA and you notice a pleural effusion has developed, you decided to do a thoracentesis to make a definitive dx. It appears that the effusion was full of bacteria and appeared milky. What have you discovered?

Answer 38

Empyema

Question 39

What if you suspect an empyema, but do not want to risk a thoracentesis. What other diagnostic tools could help you make this diagnosis?

Answer 39

Low glucose, high LDH (lactate dehydronase–which indicates tissue damage), high protein, low pH.

Question 40

How do you treat an empyema?

Answer 40

chest tube + abx (not specified which ones)

Question 41

What are the potential complications of empyema?

Answer 41

pleural thickening, reduced lung fxn, death