pneumonia
- infection of pulmonary parenchyma
- starts in alveoli and spreads up
- due to microaspiration, defect in host organ system, or organism virulence
- main cause= bacteria
supportive care for pneumonia
- rest
- IV/ PO fluids
- oxygen
- cough meds
- antipyretics, analgesics
- incentive spirometer
prevention of pneumonia
- smoking cessation
- pneumococcal vaccines for at risk pts
- flu vaccine
community acquired pneumonia (CAP)
- pneumonia outside of health care setting
- 2nd most common cause of hospitalizations and most common cause of infectious related death
CAP risk factors
- age
- chronic comorbidities
- viral respiratory infections
- impaired airway protection
- etoh
- smoking
- crowded living conditions
- low income settings
- toxins
typical bacteria associated with CAP
- strep pneumonia*- most common cause
- haemophilus influenza
- moraxella catarrhalis
- s aureus
- group a strep
atypical bacteria associated with CAP
- mycoplasma pneumonia*
- leigonella species
- chlamydia pneumonia
- chlamydia psittraci
- coxiella burnetiid
other bacteria associated with CAP
- klebsiella pneuonia
- histoplasma capsulatum
- francisella tularenis
what is assoc with rust colored sputum
- s pneumonia
what typical bacteria is associated with COPD and smokers
- haemophilus influenza
what is the main cause of walking pneumonia
- mycoplasma pneumoniae
- common in young or college aged
- assoc with bullous myringitis- blisters on TM
what is legionella associated with
- water
- contaminated water
- air conditioners
- hot tubs
- cruise
- travel
clinical presentation of CAP
- fever/chills
- cough
- pleuritic pain
- hemoptysis
- HA, myalgias
- nausea
- in kids poor feeding or restlessness
- altered mental status
PE findings for CAP
- fever
- tachypnea
- hypoxemia
- tachycardia
- hypotension
- rales/crackles
- decreased breath sounds
- asymmetric breath sounds
- expiratory wheezing
- egophony, whispered pectoriloquy, increased tactile fremitus
CXR findings for CAP
- need PA and lateral views, get portable if unable to get 2 views
- lobar consolidations- more well defined
- interstitial infiltrates- less defined, hazy
- bronchopneumonia
- cavitations- must get CT without contrast
labs for pneumonia
- CBC with diff*
- BMP*
- flu swab
- lactic acid, CRP, ESR, pro-calcitonin
- urine antigens- s pneumoniae and legionella
- sputum gram stain and cultures
- blood culture X 2
CURB-65
- assesses severity of pneumonia
- confusion (new onset)
- urea > 7 (BUN > 19)
- RR > 30
- BP <90/60
- 65 years or older
usually admit to ICU if pt has 3+ of following:
- altered mental status
- hypotension
- temp < 96.8
- RR >30
- PaO2/ FiO2 ratio <250
- BUN > 20
- leukocyte count < 100,000
- multi-lobar infiltrates
first line OP tx for CAP
- azythromycin or doxycycline
- for atypical coverage
second line OP tx for CAP or if pt is sicker
- first line azythromycin or doxicycline tx PLUS
- amoxicillin
- augmentin
- cefpodoxime
- cefuroxime
- gives typical + atypical coverage
alternative OP tx for CAP wtih PCN allergy
- respiratory fluoroqinolones
- levofloxacin
- moxifloxacin
when should you see improvement of CAP sx?
- after 72 hours
- before stopping abx sx should start to improve and be afebrile for 48 hours
- sx may persist for 5-7 days after abx
how soon should you start IP abx treatment for CAP
- within four hours
how soon should you start ICU abx treatment for CAP
- within one hour
IP/ICU CAP tx considerations
- determine if pseudomonas risk, MRSA risk, or both
- if not at risk then start IV tx then transition to PO
- if not at risk give beta lactam + macrolide/tetracycline or respiratory quinolone
IP CAP tx for MRSA risk
- combo beta lactam or quinolone plus VANCO
IP CAP tx for pseudo risk
- cipro or levo PLUS
- zosyn, cefepime, ceftazidime, meropenom, imipenem
risk factors for MRSA
- GP cocci in clusters
- MRSA colonization
- abx (esp quinolones) in last 3 mo
- necrotizing or cavitary pneumonia
- empyema
- presence of MRSA colonizing risks
MRSA colonizing risks
- end stage renal disease
- MSM
- crowded conditions/ incarceration
- IVDU
- contact sports
pseudomonas risk factors
- structural lung abnormalities
- frequent COPD exacerbations requiring frequent steroid or abx use
- GN bacilli on sputum
hospital acquired pneumonia (HAP)
- pneumonia > 48 hours after hospital admission
- common hospital infection
- highest risk if ventilated
- increased mortality assoc with ventilation and septic shock
most common bacteria assoc with HAP
- pseudomonas
- MRSA
- high risk for pseduo or MRSA if IV abx within last 90 days
- can also be polymicrobial
MDR
- nonsusceptibility to at least 1 agent in 3 dif abx classes
XDR
- nonsusceptibility to at least 1 agent in all but 2 abx classes
pandrug resistant
- nonsusceptibility to all abx that can be used for tx
risk for MDR pseudomonas in HAP
- structural lung disease
- sputum with GN bacilli
risk for MRSA in HAP
- tx in unit with > 20% of s aureus being MRSA
- tx in a unit where MRSA prevalence isn ot known
diagnosis of HAP
- new onset fever
- purulent sputum
- leukocytosis
- decline in oxygenation
ventilator acquired pneumonia
- pneumonia > 48 hours after endotracheal intubation
risk factors for MDR in VAP
- IV abx within last 90 days
- > 5 days of hospitalizations prior to occurrence of VAP
aspiration pneumonia
- d/t abnormal fluid entry, exogenous substances, or endogenous secretions into lower airways
- compromise in host defenses
- inoculum is deleterious to lower airways
cause of aspiration pneumonia
- oral anaerobes
- strep
- can be mixed aerobes and anaerobes
predisposing conditions assoc with aspiration pneumonia
- altered consciousness
- dysphagia
- neurologic disorders
- mechanical disruption of usual defense barriers
most common predisposing conditions assoc with aspiration pneumonia
- drug abuse
- alcoholism
- anesthesia
- dysphagia - can be d/t neoplasm, diverticula, fistula, xerostomia, achalasia
diagnosis of aspiration pneumonia
- presence of predisposing condition
- no rigors
- putrid odor of sputum
- periodontal disease
- CXR- right lower lobe pneumonia
- CT- pulmonar necrosis wiht lung abscess/ empyema
treatment for aspiration pneumonia
- first line IV- unasyn
- first line PO- augmentin
- alternatives- metronidazole + amoxicillin/pen G; clindamycin
risk factors for opportunistic infections
- neutropenia*
- chronic steroid use
- biologics
- t cell suppression and lymphocyte depletion
- autoimmune and inflammatory conditions
- HIV
- transplant pts
PCP pneumonia
- aka pneumocysis jirovecci
- most common opportunistic infection in HIV/AIDs with a low CD4 count
- prolonged steroids and deficits in cell mediated immunity are other common causes
diagnosis of PCP pneumonia
- CD4 count < 200
- ABGs
- I-3- beta-d glucone levels (fungal infections)
- sputum culture
- CXR- diffuse bilateral infiltrates
- CT- ground glass appearance
treatment of PCP pneumonia
- mild- bactrim
- mod- bactrim + PO steroids
- severe- bactrim + IV steroids
prevention of PCP pneumonia
- bactrim SS daily or DS 3X week
- bactrim DS daily if CD4 < 100
acute bronchitis
- lower respiratory tract infection
- large bronchi involvement
- lasts 5 days
- usually self limited 1-3 weeks
most common cause of acute bronchitis
- viral
clinical manifestations of acute bronchitis
- persistent cough 1-3 weeks
- +/- sputum
- low grade fever
- wheezing, mild dyspnea
- ronchi that clear with cough
- first few days may be indistinguishable from URI
- chest pain usually d/t cough
dx of acute bronchitis
- clinical dx
- suspect if pt has cough for 5 days and no sx of pneumonia or COPD
- CXR and sputum usually not needed
- procalcitonin is emerging blood marker for bacterial infections
indications for CXR in possible acute bronchitis
- tachycardia, tachypnea
- high grade fever
- hypoxia
- dementia, mental status change in elderly
- rales, egophony, tactile fremitus
management of acute bronchitis
- pt edu
- antitussives
- bronchodilators for pts who are wheezing or comorbidities
- steroids dont have much use
OTC cough meds
- dextromethorphan- cough suppressant
- nyquil, mucinex, robitussin
- dissociative hallucinogen in high doses
RX cough meds
- robitussin AC- guanifenesin + codeine
- tessalon pearles- local anesthetic