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PSBIM Harrison 21st Edition > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

Risk factors for infection with MRSA and P. aeruginosa

A
  1. Prior isolation of the organism
  2. Hospitalization and treatment with an antibiotic in the previous 90 days
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2
Q

Aspiration pneumonia accounts for _____ of CAP cases

A

5-15%

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3
Q

The result of the proliferation of microbial pathogens at the alveolar level and the host’s response to them.

A

Pneumonia

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4
Q

3 factors that determines the constitution of the lung microbiota

A
  1. Microbial entry into the lungs
  2. Microbial elimination
  3. Regional growth conditions for bacteria (pH, oxygen tension, temperature)
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5
Q

Pneumonia: IL6 & TNF

A

fever

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6
Q

Pneumonia: IL8 & GSF

A

increase in local neutrophils

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7
Q

Cardiovascular events associated with pneumonia

A
  1. Congestive heart failure
  2. Arrhythmia
  3. Myocardial infarction
  4. Stroke

may be acute, or who occurrence may extend to at least 1 year

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8
Q

Mechanisms of cardiovascular events in pneumonia

A
  1. Increased myocardial load
  2. Destabilization of atherosclerotic plaques by inflammation
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9
Q

Stage of Pneumonia: proteinaceaous exudate, and often bacteria in the alveoli

A

Edema

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10
Q

Stage of Pneumonia: Erythrocytes in the intraalveolar exudate

A

Red Hepatization

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11
Q

Stage of Pneumonia: Lysis of erythrocytes, Neutrophil is the predominant cell, fibrin deposition as abundant, bacteria has disappeared

A

Gray hepatization

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12
Q

Stage of Pneumonia: corresponds to successful containment of infection and improvement of gas exchange

A

Gray hepatization

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13
Q

Stage of Pneumonia: macrophage reappears as dominant stage

A

Resolution

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14
Q

Common pattern in nosocomial pneumonia

A

Bronchopneumonia

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15
Q

Common patten in Bacterial CAP

A

Lobar pattern

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16
Q

Typical bacterial pathogens

A

S. pneumoniae
Haemophilus influenzae
S. aureus (in selected patients)
Gram negative bacilli (K. pneumoniae,P. aeruginosa)

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17
Q

Atypical bacterial pathogens

A

M. pneumoniae
C. pneumoniae
Legionella species
Respiratory Viruses

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18
Q

___ cannot be cultures on standard media or seen on GS

A

Atypical organisms

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19
Q

Atypical organisms typically resistant to all beta lactams, and require treatment with

A

Macrolide
Fluoroquinolone
Tetracycline

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20
Q

____ of CAP cases are polymicrobial

A

10-15%

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21
Q

Known to complicate influenza virus infection

A

Staphylococcus aureus

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22
Q

Mortality patient of CAP patients treated as outpatient

A

<5%

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23
Q

Mortality rate of hospitalized CAP patients

A

12-40%

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24
Q

18% of hospitalized CAP patients are readmitted within _______

A

1 month of discharge

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25
Q

Risk factors for Community Acquired Pneumonia

A
  1. Alcoholism
  2. Asthma
  3. Immunosuppression
  4. Institutionalization
  5. Age >70 years old
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26
Q

Factors increasing likelihood of pneumonia in the elderly

A
  1. Decreased cough reflex
  2. Decreased gag reflex
  3. Reduce antibody and toll-like receptors
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27
Q

Risk factors for Pneumococcal pneumonia

A
  1. Dementia
  2. Seizure disorders
  3. Heart failure
  4. Cerebrovascular disease
  5. Alcoholism
  6. Tobacco smoking
  7. Chronic obstructive pulmonary disease
  8. HIV infection
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28
Q

Common type of pneumonia in patients with skin colonization/infection

A

CA-MRSA

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29
Q

Infection with _______ usually tend to infect patients who have recently been hospitalized, given antibiotics, who have co-morbidites

A

Enterobacteriaceae

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30
Q

Common etiology in patients with severe structural lung disease

A

P. aeruginosa

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31
Q

Risk factors for Legionella infection

A
  1. Diabetes
  2. Hematologic malignancy
  3. Cancer
  4. Severe renal disease
  5. HIV infection
  6. Smoking
  7. Male gender
  8. Recent hotel stay/trip on a cruise ship
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32
Q

Possible pathogen for Alcoholism

A

Streptococcus pneumoniae
Oral anaerobes
Klebsiella pneumoniae
Acinetobacter spp.
Mycobacterium tuberculosis

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33
Q

Possible pathogen for COPD and/or Smoking

A

Haemophilus influenzae
Pseudomonas aeruginosa
Legionella spp.
S. pneumoniae
Moraxella catarrhalis
Chlamydia pneumoniae

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34
Q

Possible pathogen for Structural lung disease

A

P. aeruginosa
Burkholderia cepacia
Staphylococcus aureus

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35
Q

Possible pathogen for Dementia, stroke, decreased level of consciousness

A

Oral anaerobes
Gram-negative enteric bacteria

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36
Q

Possible pathogen for Lung Abscess

A

CA-MRSA
Oral anaerobes
Endemic fungi
M. tuberculosis
Atypical mycobacteria

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37
Q

Possible pathogen for travel to Ohio or St. Lawrence river valley

A

Histoplasma capsulatum

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38
Q

Possible pathogen fortravel to southwestern USA

A

Hantavirus
Coccidioides spp

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39
Q

Possible pathogen for travel to Southeast Asia

A

Burkholderia pseudomallei
Avian influenza virus

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40
Q

Possible pathogen for stay in hotel or cruise ship in previous 2 weeks

A

Legionella sp

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41
Q

Possible pathogen for local influenza activity

A

Influenza virus
S. pneumoniae
S. aureus

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42
Q

Possible pathogen for exposure to infected humans

A

SARS CoV-2

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43
Q

Possible pathogen for Exposure to birds

A

H, capsulatum
Chlamydia psittaci

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44
Q

Possible pathogen for Exposure to rabbits

A

Francisella tularensis

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45
Q

Possible pathogen for Exposure to sheeps, goats, parturient cats

A

Coxiella burnetti

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46
Q

Clinical finding suggestive of Necrotizing pneumonia

A

Gross hemoptysis

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47
Q

_______ of patients has GI symptoms

A

20%

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48
Q

Possible initial symptom of CAP in the elderly

A

New-onset or worsening CONFUSION

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49
Q

Sensitivity and Specificity of Physical Exam on CAP

A

Sensitivity: 58%
Specificity: 67%

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50
Q

Chest Xray: Pneumatoceles

A

Staphylococcus aureus

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51
Q

Chest Xray: Upper-lobe cavitation

A

Tuberculosis

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52
Q

Test used to ensure suitability of specimen for culture

A

Sputum gram stain

Neutrophils >25
Squamous epithelial cells <10

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53
Q

Sputum CS, positive yield

A

≤50%

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54
Q

Sputum GSCS recommended in

A

Hospitalized patients

55
Q

Only ______ of hospitalized CAP is positive in Blood CS

A

5-14%

56
Q

Most common pathogen isolated in Blood CS of CAP patients

A

S. pneumoniae

57
Q

Indications for Blood CS in CAP

A
  1. High Risk/Severe CAP
  2. Neutropenia secondary to CAP
  3. Asplenia
  4. Complement deficiencies
  5. Chronic liver disease
  6. Risk for MRSA or P. aeruginosa
58
Q

Test that can detect antigen even after the initiation of appropriate antibiotic therapy

A

Urinary Antigen test

Reserved for Severe cases

59
Q

Etiologic agent where Serology can be helpful

A

Coxiella burnetii

60
Q

Standard for diagnosis of Respiratory Viral Infections

A

Polymerase chain reaction

61
Q

PSI score needing admission

A

Class III and above

62
Q

CURB-65 score needing ICU admission

A

≥3
22% Mortality rate

63
Q

Criteria of CURB 65

A

Confusion
Urea >7 mmol/L
RR ≥30 cpm
BP: Systolic ≤90, Diastolic ≤60
65 Age ≥65

64
Q

Minor Criteria for SEVERE CAP

A

3 out of 9

Respiratory rate ≥30 breaths/min
PaO2/Fio2 ratio ≤250
Multilobar infiltrates
Confusion/disorientation
Uremia (BUN level ≥20 mg/dL)
Leukopenia (WBC count <4000 cells/μL)
Thrombocytopenia (platelet count <100,000 cells/μL)
Hypothermia (core temperature <36°C)
Hypotension requiring aggressive fluid resuscitation

65
Q

Risk factors for penicillin-resistant pneumococcal infection

A
  1. Recent antimicrobial therapy
  2. Age of <2 or >65 years
  3. Attendance at a day-care center
  4. Recent hospitalization
  5. HIV infection.
66
Q

Macrolide resistance: target site modification

A

Ribosomal methylation in 23S rRNA encoded by the ermB gene results in high-level resistance

40%
Higher level resistance

67
Q

Major Criteria for SEVERE CAP

A

Respiratory failure requiring invasive mechanical ventilation
Septic shock requiring vasopressors

68
Q

Pneumococcal resistance to Beta-Lactams

A

(1) direct DNA incorporation and remodeling of penicillin-binding proteins through contact with closely related oral commensal bacteria (e.g., viridans group streptococci)
(2) the process of natural transformation
(3) mutation of certain genes

69
Q

Fluoroquinolones: mutations in gyrA

A

Topoisomerase II

70
Q

Macrolide resistance: efflux mechanism

A

Encoded by the mef gene (M phenotype) is usually associated with low-level resistance

60%
Lower level resistance

71
Q

TRUE OR FALSE

Macrolide should can be used as empirical monotherapy in CAP.

A

FALSE

72
Q

Fluoroquinolones: mutations in parC genes

A

Topoisomerase IV

73
Q

Isolates resistant to ______ are considered MDR

A

≥3

74
Q

Most important risk factor for antibiotic-resistant pneumococcal infection is ___

A

Use of a specific antibiotic within the previous 3 months.

75
Q

Resistance in MRSA is determined by

A

mecA gene which encodes for resistance to all β-lactam drugs

76
Q

Superantigens released by CA-MRSA

A

Enterotoxins B and C
Panton-Valentine Leukocidin

77
Q

Mycoplasma resistance to macrolides is increasing as a result of ____

A

Binding-site mutation in domain V of 23S rRNA

78
Q

Enterobacter species are typically resistant to cephalosporins, and the drugs of choice for use against these organisms are usually ____ (2)

A

Fluoroquinolones
Carbapenems

79
Q

Indications for Routine coverage for Anaerobes

A
  1. Poor dentition
  2. Lung abscess
  3. Necrotizing pneumonia
80
Q

First line therapy CAP: Outpatient, No comorbidities/RF

A

Combination therapy
Amoxicillin 1g TID

+

Macrolide or Doxycycline

OR

Monotherapy with Doxycycline (100 mg BID)

81
Q

First line therapy CAP: Outpatient, with Comorbidities +/- RF

A

Combination therapy
Amoxicillin/Clavulanate or Cephalosporin

+

Macrolide or Doxycycline

OR

Monotherapy with Respiratory Fluoroquinolone

82
Q

First line therapy CAP: Inpatient, NON-SEVERE, No RF

A

IV Beta-lactam + Macrolide

OR

Respiratory Fluoroquinolone
(Levofloxacin, Moxifloxacin, Gemifloxacin)

83
Q

First line therapy CAP: Inpatient, NON-SEVERE, Prior respiratory isolation

A

IV Beta-lactam + Macrolide

OR

Respiratory Fluoroquinolone
(Levofloxacin, Moxifloxacin, Gemifloxacin)

PLUS coverage for MRSA or P. aeruginosa

84
Q

First line therapy CAP: Inpatient, NON-SEVERE, Recent hospitalization

A

V Beta-lactam + Macrolide

OR

Respiratory Fluoroquinolone
(Levofloxacin, Moxifloxacin, Gemifloxacin)

PLUS coverage for MRSA or P. aeruginosa ONLY IF CULTURES ARE POSITIVE

85
Q

First line therapy CAP: Inpatient, SEVERE, NO RF

A

IV Beta-lactam + Macrolide

OR

IV Beta-lactam + Respiratory Fluoroquinolone

86
Q

First line therapy CAP: Inpatient, SEVERE, Prior respiratory isolation, recent hospitalization

A

IV Beta-lactam + Macrolide

OR

IV Beta-lactam + Respiratory Fluoroquinolone

PLUS coverage for MRSA or P. aeruginosa

87
Q

More robust risk factor than recent hospitalization and exposure to parenteral antibiotics.

A

Prior isolation of MRSA or P. aeruginosa

88
Q

Preferred first-line treatment for MRSA

A

Linezolid
Inhibits exotoxin and better drug penetration

89
Q

Duration of treatment for Uncomplicated CAP

A

5 days

90
Q

Drainage needed if Pleural studies results are?

A
  1. pH <7.2
  2. glucose level of <2.2 mmol/L
  3. lactate dehydrogenase concentration of >1000 U/L
  4. bacteria are seen or cultured
91
Q

Resolution: fever and leukocytosis

A

2-4 days

92
Q

Resolution: chest radiographic abnormalities

A

4-12 weeks

93
Q

Full recovery of young patient with no comorbidities in CAP

A

2 weeks

94
Q

Main preventive measure for CAP

A

Vaccination

95
Q

T-cell dependent antigen, resulting in long term immunologic memory

A

PCV13 vaccine

96
Q

Once a ventilated patient is transferred to a chronic-care facility or to home, the incidence of pneumonia drops significantly, especially in the absence of other risk factors for pneumonia. However, in chronic ventilator units, ________ becomes a significant issue

A

purulent tracheobronchitis

97
Q

Three factors are critical in the pathogenesis of VAP

A
  1. Colonization of the oropharynx with pathogenic microorganisms
  2. Aspiration of these organisms from the oropharynx into the lower respiratory tract
  3. Compromise of normal host defense mechanisms.
98
Q

Most obvious risk factor for VAP

A

endotracheal tube

99
Q

Most important risk factors for VAP

A
  1. Antibiotic selection pressure
  2. Cross-infection from other infected/colonized patients or contaminated equipment
  3. Severe systemic illness
  4. Malnutrition
100
Q

In VAP: Major risk factor for infection with MRSA and ESBL-positive patients

A

Frequent use of Beta-Lactam (eg Cephalosporins)

101
Q

In VAP: ________can develop resistance to all routinely used antibiotics, and, even if initially sensitive, isolates may develop resistance during treatment.

A

P. aeruginosa

102
Q

In VAP: Etiologic agents that are intrinsically resistant to many of the empirical antibiotic regimens employed

A
  1. Acinetobacter species
  2. Stenotrophomonas maltophilia
  3. Burkholderia cepacia
103
Q

In VAP: The major difference from CAP is the markedly lower incidence of atypical pathogens in VAP; the exception is _______

A

Legionella

104
Q

The standard recommendation for patients with risk factors for MDR infection and a high mortality risk is for three antibiotics: ____

A

Two directed at P. aeruginosa
One directed at MRSA

105
Q

In VAP: Therapy for carbapenem-resistant Enterobacteriaceae can consist of ____

A
  1. Ceftazidime–avibactam
  2. Imipenem–relebactam
  3. Meropenem– vaborbactam
106
Q

In VAP: Therapy for organisms that produce metallo-β-lactamases can be treated with : ____

A
  1. Ceftazidime–avibactam
  2. Cefiderocol
107
Q

TRUE OR FALSE

In VAP: A negative tracheal-aspirate culture or growth below the threshold for quantitative cultures of samples obtained before any antibiotic change strongly suggests that antibiotics should be discontinued or that an alternative diagnosis should be pursued.

A

TRUE

108
Q

Apart from death, the major complication of VAP is ___

A

Prolongation of Mechanical Ventilation

109
Q

VAP crude mortality rate

A

50-70%

110
Q

Marker for patient whose immune system is so compromised that death is almost inevitable

A

Stenotrophomonas maltophilia

111
Q

Most important preventive intervention for VAP is ___

A

Avoid intubation or Minimize its duration

112
Q

VAP Treatment: NO RISK FACTORS FOR RESISTANT GRAM-NEGATIVE PATHOGEN

A

Piperacillin- tazobactam (4.5 g IV q6h)
Cefepime (2 g IV q8h)
Levofloxacin (750 mg IV q24h)

113
Q

VAP Treatment: RISK FACTORS FOR RESISTANT GRAM-NEGATIVE PATHOGEN

A

Choose One

Piperacillin-tazobactam (4.5 g IV q6h)
Cefepime (2 g IV q8h)
Ceftazidime (2 g IV q8h)
Imipenem (500 mg IV q6h)
Meropenem (1 g IV q8h)

PLUS (Choose One)

Amikacin (15–20 mg/kg IV q24h)
Gentamicin (5–7 mg/kg IV q24h)
Tobramycin (5–7 mg/kg IV q24h)
Ciprofloxacin (400 mg IV q8h)
Levofloxacin (750 mg IV q24h)
Colistin (loading dose of 5 mg/kg IV followed by maintenance doses of 2.5 mg × [1.5 × CrCl + 30] IV q12h)
Polymyxin B (2.5–3.0 mg/kg per day IV in 2 divided doses)

114
Q

VAP Treatment: Risk Factors for MRSA

A

ADD:

Linezolid (600 mg IV q12h) or
Adjusted-dose vancomycin (trough level, 15–20 mg/dL)

115
Q

In VAP, preventive measure for: Elimination of normal flora, overgrowth by pathogenic bacteria

A

Avoidance of prolonged antibiotic courses; consider oral chlorhexidine

116
Q

In VAP, preventive measure for: Large-volume oropharyngeal aspiration around time of intubation

A

Short course of prophylactic antibiotics for comatose patients

117
Q

In VAP, preventive measure for: Gastroesophageal reflux

A

Postpyloric enteral feeding with orally placed feeding tube
Avoidance of high gastric residuals
Prokinetic agents

118
Q

In VAP, preventive measure for: Cross-infection from other colonized patients

A

Hand washing, especially with alcohol- based hand rub
Intensive infection control education; isolation
Proper cleaning of reusable equipment

119
Q

In VAP, preventive measure for: Bacterial overgrowth of stomach

A

Avoidance of prophylactic agents
that raise gastric pH
Selective decontamination of digestive tract with non-absorbable antibiotics

120
Q

In VAP, preventive measure for: Large-volume aspiration Ventilator circuit humidification

A

Endotracheal intubation
Rapid- sequence intubation technique
Avoidance of sedation
Decompression of small-bowel obstruction
Change ventilator circuits only when soiled and with new patient
Drain ventilator circuit condensate away from patient
Replace heat moisture exchanger every 5–7 days or if soiled or malfunctioning

121
Q

In VAP, preventive measure for: Endotracheal intubation

A

Noninvasive ventilation

122
Q

In VAP, preventive measure for: Prolonged duration of ventilation

A

Daily awakening from sedation
Weaning protocols

123
Q

In VAP, preventive measure for: Secretions pooled above endotracheal tube

A

Head of bed elevated
Continuous aspiration of subglottic secretions with specialized endotracheal tube
Avoidance of reintubation
Minimization of sedation and patient transport
Prophylactic PEEPc of 5–8 cm

124
Q

In VAP, preventive measure for: Altered lower respiratory host defenses

A

Tight glycemic control
Lowering of hemoglobin transfusion threshold

125
Q

In HAP, ____ are common, because of greater risk of macroaspiration and lower oxygen tension in the lower respiratory tract

A

Anaerobes

126
Q

TRUE OR FALSE

In HAP, the lower frequency of MDR pathogens allows monotherapy in a larger proportion of cases of HAP than of VAP.

A

TRUE

127
Q

Initial symptom of CAP in elderly

A

New or worsening CONFUSION

128
Q

In CAP: CT scan of the chest is requested for

A
  1. Suspected loculated pleural effusion
  2. Suspected cavitary cases
  3. Post-obstructive pneumonia caused by tumor or foreign body
129
Q

Predominant pathogens in VAP, if it develops within 7 days of admission

A

Non-MDR pathogens
S. pneumoniae
Other Streptococcus
H. influenzae
MSSA
Antibiotic-sensitive Enterobacteriaceae

130
Q

Adversely affects the immune response in VAP

A

Hyperglycemia
Frequent Transfusions

131
Q

Threshold for quantitave-culture approach

A

Proximal: 10^6 CFU/mL
Distal: 10^3 CFU/mL

132
Q

Failure to improve, VAP: MRSA

A

40% failure rate if treated with standard dose of vancomycin

133
Q

Failure to improve, VAP: Pseudomonas

A

40-50% failure rate, no matter what regimen is started

134
Q

Ways to decrease treatment failure in VAP

A
  1. Optimized beta-lactam dosing
  2. Prolonged or Continuous infusion therapy

PSBIM Harrison 21st Edition (15 decks)

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