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Pulm > Lecture 4: Pneumonia > Flashcards

Lecture 4: Pneumonia Flashcards

1
Q

What # cause of death is pneumonia for infectious causes of death?

A

1!

Also 2nd most common cause for hospitalization

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2
Q

Define pneumonia.

A

Inflammation of the lung parenchyma, resulting in consolidation of the affected part.

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3
Q

Describe the 5 pathophysiological steps of pneumonia, beginning with infection.

A
  1. Infection of the lung
  2. Inflammatory response
  3. Alveolar edema and exudate formation
  4. Alveoli and respiratory bronchioles fill up
  5. Consolidation of lung tissue.
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4
Q

What is the most common causative organism
of community acquired pneumonia?

A

Strep pneumo.

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5
Q

What is the most common cause of hospital acquired pneumonia?

A

Pseudomonas aeruginosa

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6
Q

What are the 3 classifications for pneumonia?

A
  • Anatomic location (on radiograph)
  • Mechanism of acquisition (aspiration vs vent vs etc)
  • Setting of acquisition (CAP vs HAP vs VAP)
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7
Q

What is the primary causative organism of lobar pneumonia?

A

Strep pneumo accounts for 95% of causative organisms.

Lobar is the usual CAP.

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8
Q

Which lung is typically more affected in lobar pneumonia?

A

R lobe.

RLL specifically, due to proximity to the R main bronchus.

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9
Q

What lobe does klebsiella typically affect and why?

A

RUL due to an alcoholic passing out and aspirating.

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10
Q

What lung fields does legionella tend to appear in?

A

Lower lung fields.

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11
Q

How does a lobular/bronchopneumonia typically appear on CXR?

A
  • Patchy appearance
  • Peribronchial thickening
  • Poorly defined air-space opacities

Destructive pneumonia that is not isolated.

Typically will lead to abscesses, cavitation, necrosis, and pleural effusions.

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12
Q

What are the more causative organisms for lobular pneumonia?

A
  • Staph Aureus (MRSA)
  • Strep
  • H flu
  • Klebsiella
  • P aeruginosa

Staph is very common in COPD patients as well.

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13
Q

Define interstitial pneumonia.

A
  • Focal or diffuse
  • Edema and inflammatory cellular infiltrate into the interstitium
  • Appears as fluffy clouds around the lung.
  • Ground-glass appearance
  • Bilateral and symmetric.

Will usually begin with viral prodrome => ARDS

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14
Q

What is aspiration pneumonia?

A

Inhalation of oropharyngeal secretions, gastric contents, or colonized organisms.

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15
Q

What are the two most common sites of infiltration for aspiration PNA?

A
  • RLL: most common due to vertical orientation of RMB.
  • RUL: most common in alcoholics who aspirate in a prone position.
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16
Q

Why is aspiration PNA pathophysiology more concerning than normal lobar CAP?

A

Formation of cavities and necrosis.

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17
Q

What is VAP?

A

Ventilator acquired PNA, which occurs 48hrs+ mechanical ventilation via ET tube or tracheostomy.

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18
Q

What is the main concern with organisms in VAP?

A

Multi drug resistance.
Need to cover MRSA, pseudomonas, and other G-.

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19
Q

Why does VAP occur?

A

Inability to cough and naturally clear airway, so bacteria can contaminate and colonize.

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20
Q

What counts as CAP vs nosocomial?

A
  • CAP: OP or within 48 hrs of admittance.
  • Nosocomial: everything else :)

HCAP refers to within 48 hrs of admittance even thought it is also CAP.

HAP is 48hrs post admission.
VAP is 48 hrs post intubation OR within 48hrs of extubation.

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21
Q

Where is most CAP treated?

A

Outpatient

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22
Q

What are the most common causes of viral pneumonia?

A
  • Influenza
  • RSV
  • Parainfluenza
  • Adenovirus
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23
Q

For pneumonia, what do sputum colors generally correlate with in terms of bacterial etiology?

A
  • Rust colored: strep pneumo
  • Green: pseudomonas, H flu, and other pneumococci
  • Red currant jelly: Klebsiella
  • Foul-smelling: Anaerobes
24
Q

What are the additional symptoms of PNA?

A
  • Fever (80%)
  • Dyspnea (45-70%)
  • Pleuritic chest pain (30%)
  • Sweats
  • Chills (40-50%)
  • Rigors (15%)
  • N/V/D
  • AMS
25
Q

What is the gold standard for diagnosing PNA?

A

Infiltrate on CXR.

Definitively can say someone has PNA. Unknown etiology.

26
Q

What organisms can an urine antigen test detect for pneumonia etiologies?

A
  • Strep pneumo
  • Legionella

Only checks for 1 serotype group of legionella

Test is very sensitive and specific for legionella.
Generally reliable and can detect post ABX therapy.

27
Q

What PSI and CURB-65 scores indicate outpatient treatment?

A
  • PSI of 2 or lower.
  • CURB-65 of 1 or lower.

PSI is more extensive, but CURB-65 is shorter.

28
Q

What is CURB 65 criteria?

A
  • Confusion of new onset
  • Blood Urea Nitrogen > 19mg/dL or 7mmol/L
  • RR >= 30 bpm
  • BP < 90 SBP or DBP <=60
  • Age of 65 or more.

Predicts 30day mortality.

2 or more = inpatient.

29
Q

How long should ABX be used for outpatient CAP?

A
  • 5-7 days at minimum.
  • 48-72 hrs post afebrile is recommended.
30
Q

What are the additional treatments for CAP?

A
  • Rest/hydration
  • Analgesics (acetaminophen or ibuprofen)
  • Expectorants (guaifenesin)
  • Steroids (debateable)
31
Q

What is the empiric treatment for regular outpatient CAP?

A
  • Amoxicillin 1g PO TID
  • Azithromycin 500mg PO 1 dose + 250mg PO daily for 4 days
  • Clarithomycin 500mg PO BID or ER 1000mg PO q24hr (bad in h flu and mcat)
  • Doxycycline 100mg PO BID

No comorbidities
No factors for MDR strep pneumo
No ABX in 3 months

32
Q

What is the modified empiric treatment for outpatient CAP with prior ABX use or comorbidities?

A
  • Azithro/Claritho + beta lactam
  • Respiratory fluoroquinolone (levofloxacin or moxi)
33
Q

What is the treatment for standard IP CAP?

A

Same as OP w/ comorbidities.

  • Macrolide + beta lactam (azithro + rocephin)
  • Respiratory fluoroquinolone
34
Q

What is the treatment for ICU CAP?

A
  • Rocephin + azithromycin
  • Levo/moxi + Rocephin
  • Levo + aztreonam (for PCN allergy)
35
Q

Who is pneumococcal vaccination indicated for?

A

Age >=65 or any chronic illness that increases CAP risk.

36
Q

In HIV patients, what other organism is highly likely to cause PNA?

A

Pneumocystis jirovecii

37
Q

In transplant patients, what are some more common causative organisms that can result in PNA?

A
  • Fungi
  • Nocardia
  • CMV
38
Q

What risk factors are associated with nosocomial pneumonia?

A
  • ABX in last 3 months
  • Acute hospitalization > 2 days in past 3 months
  • Nursing home
  • Home infusion therapy
  • Dialysis in past 30 days
  • Wound care
  • Family member w infection
  • Immunosuppressed
39
Q

What 3 factors distinguish nosocomial PNA from CAP?

A
  1. Different infectious causes
  2. Different ABX susceptibility
  3. Different underlying health conditions
40
Q

What is the concern with causative organisms in nosocomial pneumonia?

A

Drug resistance.

41
Q

What is the initial treatment for nosocomial pneumonia?

A

Empiric ABX followed by targeted therapy once cultures result.

42
Q

For a patient with a low risk for drug-resistant bacteria, what is the treatment for nosocomial PNA?

A
  • Levofloxacin
  • Piptazo
  • Cefepime
43
Q

For a patient with high risk for MDR pathogens resulting in nosocomial PNA, what is the treatment protocol?

A
  1. Antipseudomonal + carbapenem + beta-lactam
  2. Antipseudomonal fluoroquinolone + aminoglycoside
  3. MRSA coverage

1 from each category.

44
Q

What demographic is most susceptible to klebsiella and what is the hallmark finding of a klebsiella PNA?

A
  • Alcoholics who aspirate after passing out.
  • Red-currant like jelly sputum.
  • Ground-glass opacity on CT (100%)
45
Q

A patient with a history of COPD presents with PNA and it is cultured. Culture reveals a gram positive bacteria that tends to clump and is shaped like a sphere. What is the most likely causative organism?

A

Staphylococcal pneumonia.

46
Q

What is the primary treatment for staphylococcal pneumonia?

A
  • Clindamycin
  • IP Vancomycin
47
Q

What are the characteristics of mycoplasma?

A
  • Smallest living organism
  • No cell wall
  • Causes atypical pneumonia usually.
48
Q

What is unique about mycoplasma pneumonia?

A
  • Intractable, non-productive cough.
  • CXR is generally normal.
  • Potentially a bullous myriginitis in TM.
49
Q

What drug classes treat mycoplasma pneumonia?

A
  • Macrolides
  • Fluoroquinolones
50
Q

What is different between bacterial and viral pneumonia?

A

Viral pneumonia generally is nonproductive with their cough.

51
Q

What is the treatment for viral pneumonia?

A

Supportive care.

52
Q

What is unique about PJP?

A

Unicelluar fungal infection that does not respond to antifungals.

53
Q

What labs are elevated and abnormal diagnostics in PJP?

A
  • Serum LDH
  • Serum Beta-D-glucan
  • CXR: diffuse, bilateral interstitial infiltrates
  • CT: Hallmark ground glass opacities
54
Q

What is the treatment for PJP?

A
  • ART (anti-retroviral therapy)
  • Bactrim
55
Q

What is the prophylaxis for PJP and the cell count?

A

< 200 cell count with bactrim.

Pulm (12 decks)

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