Pneumonia (quiz 2, exam 1) Flashcards
(169 cards)
1
Q
infection of the __, __ and __ of the lung
A
- alveoli
- distal airways
- interstitium
2
Q
pathogen in sufficient __ or __ to overwhelm __ has to reach the lower repiratory tract
A
- numbers
- virulence
- host defenses
3
Q
4 routs of infection
A
- microaspiration (most common)
- gross aspiration (of secretions, vomit; pts: stroke, nuromuscular disorders)
- hematogenous spread (blood)
- aerosolization
4
Q
over __ microorganisms that can cause community acquired pneumonia (CAP) and they include these 4 main categories
A
- viruses
- bacteria
- fungi
- parasites
5
Q
patholgogically, the lung changes from its normal __ to __
A
- sponginess
- consolidation
6
Q
4 pathological types
A
- lobar pneumonia
- bronchopneumonia
- interstitial pneumonia
- miliary pneumonia
7
Q
lobar pneumonia involves __, and is relatively __
A
- entire lung
- homogenesouly
8
Q
bronchopneumonia involes __ and shows up as __
A
- one or severa lobes (usually lower and posterior dependent portion of lungs)
- patchy consolidaiton
9
Q
interstitial pneumonia is inflammation of the __, __, and __ and shows up on on CT as __
A
- interstitium
- alveolar walls
- connective tissue around broncho vascular tree
- patchy or diffuse; gray, honeycombing
10
Q
miliary pneumonia has numerous discrete __ resulting from the spread of pathogens to the lungs via the __, and it appears __ on xray
A
- lesions
- blood stream (TB)
- speckled (miliary)
11
Q
community acquired pneumonia includes these 2 types
A
- ambulatory treatment
- inpatient treatment
12
Q
hospital acquired pneumonia (nosocomial)/healthcare associated pneumonie (HCAP) includes these 2 types
A
-ventilator-associated
non-ventilator associated
13
Q
healthcare associated pneumonia (HCAP) differs in these 4 things
A
- etiologic organisms
- prognosis
- diagnostic algorithms
- treatment algorithms
14
Q
2 other important pneumonias to note
A
- opportunistic pneumonia in immunocompromised pts (fungal, PCP in HIV)
- TB (mycobacterium)
15
Q
pneumonia in residents of __ and __ have been treated as either CAP or nosocomial
A
- nursing homes
- long term care facilities
16
Q
it affects __ adults per year and __% are admitted to hospital
A
- 4 million
- 20-25%
17
Q
it is the __ most deadly infectious disease in US and the __ most common cause of death in US each year
A
- # 1
- 7th
18
Q
epidemiology: highest rates during __ months and __% of pts hospitalized with pneumonia die
A
- winter
- 12-14%
19
Q
according to IDSA and ATS guidlines, HCAP indluces any pt who
A
- was hospitalized in an acute care hosptial for 2 or more days within 90 days of the infection
- resided in a nursing home or long term care facility
- received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection
- attended a hosptial or hemodialysis clinic
20
Q
risk factors for increased mortalitly from CAP: age older than 65 years
A
- increased incidence and severity
- 5th leading cause of death age>65 yo
- 4th for those >85
- present with less pronounced symptoms
- may not be able to mount a fever
- may present with only delirium/change in mental status
- have to have a high index of suspicion
- prophylaxis against CAP is critical in this age group (pneumococcal and influenza vaccines)
21
Q
7 risk factors for increased mortalitly from CAP
A
- age >65 yo
- active malignancy
- HIV or immunocompromised
- neurologic disease
- congestive heart failure
- coronary artery disease
- diabetes
22
Q
comorbidities as risk factors for CAP (5)
A
- asthma
- chronic obstructive pulmonary disease
- chronic renal failure
- liver disease
- substance use - alcohol and tobacco
23
Q
most common pathogens
A
- Streptococcus pneumoniae (~70% of cases)
- Haemophilus influenzae
- Mycoplasma pneumoniae
- Chlamydophila (chlymydia pneumoniae)
- Staphylococcus aureus
- Morexalla catarrhalis
24
Q
other pathogens: bacterial
A
- Klebsiella pneumoniae
- Legionella species
25
other pathogens: viral
1. influenza
2. adenovirus
3. respiratory syncytial virus (RSV)
4. parainfluenza
26
T or F: bacterial etiology more common than viral
true
27
CAP due to __ and __ is more common in __ months
* S. pneumoniae
* H. influenzae
* (other causes of CAP do not appear to have increased seasonal prevalence)
28
\_\_ and __ are most often responsible for lethal pneumonia, and are the most frequent bacterial pathogens leading to intensive care unit admission
* S. pneumoniae
* Legionella
29
CAP DDx: aspiration pneumonia
* can lead to a clinical presentation indistinguishable from CAP
* the causal pathogens are more likely to be gram negative enteric pathogens and oral anaerobes
30
CAP DDx: TB should always be considered in pts with risk factors for TB acquisition which include
1. recent time spent in an endemic region
2. homelessness
3. potential exposure to infected individuals in institutionalized or medical settings
31
CAP DDx: typically the presentation of pulmonary tuberculosis is more __ than that of CAP, though this is not absolute
chronic (pulmonary tuebrcuosis can present with similar symptoms as CAP)
32
CAP DDx-TB: empiric treatment of CAP with __ can delay diagnosis of tuberculosis
quinolones (they have antimycobacterial activity)
33
CAP DDx-TB: any pt presenting with __ should be screened for TB
symptoms of CAP and risk factors for TB acquisition
34
Streptococcus pneumoniae gram stain findings
gram positive diplococci
35
Mycoplasma pneumoniae gram stain finding
not seen on gram stain (but RBCs are clumped together)
36
Haemophilus influenzae gram stain findings
gram negative coccobacilli
37
Chlamydophila pneumoniae gram stain findings
not seen on gram stain
38
Staphyloccocus aureus gram stain findings
gram positive cocci in clusters
39
Moraxella catarrhalis gram stain findings
gram negative diplococci
40
atypical pathogens include __ and CAP caused by these agents classically have these symptoms
1. C. pneumoniae
2. M. pneumoniae
3. Legionella species
* presents insidiously (not acute, like with the more common agents)
* low grade fever
* non-productive cough
* prominent extra-pulmonary complaints (including myalgias and GI related symptoms)
41
atypical pneumonia: __ is often responsible for what is often termed walking pneumonia; it is transmitted via __ and is commonly spread among \_\_
* Mycoplasma
* respiratory droplets
* otherwise healthy individuals in close contact with one another (e.g. college dormitories or military barracks)
42
T or F: clinical presentation alone is adequate to differentiate between specific etiologic agents in CAP
false
43
CAP epidemiology: it is often difficult ot identify microbiologic agents in the lab, via culture or other means, because __ happens relatively frequently
polymicrobial infection
44
clinical condition: alcoholism
commonly encountered pathogens:
1. Streptococcus pneumoniae
2. anaerobes
3. less commonly Klebsiella pneumoniae (jelly sputum)
45
clinical condition: COPD/smoking
commonly encountered pathogens:
1. S. pneumoniae
2. Haemophilus influenzae
3. Moraxella cattarrhalis
4. Legionella species
46
clinical condition: nursing home resident
commonly encountered pathogens:
1. S. pneumoniae
2. gram negative bacilli
3. Haemophilus influenzae
4. Staphylococcus aureus
5. anaerobes
6. Chlamydophila pneumoniae
47
clinical condition: poor dental hygiene
commonly encountered pathogens:
anaerobes
48
clinical conditino: HIV infection, early stage
commonly encountered pathogens:
1. S. pneumoniae
2. H. influenzae
3. Mycobacterium tuberculosis
49
clinical condition: HIV infection, late stage
commonly encountered pathogens:
1. S. pneumoniae
2. H. influenzae
3. Mycobacterium tuberculosis
4. P. jiroveci (formerly Pneumocystis pneumoniae or PCP)
5. Cryptococcus species (fungi)
6. Histoplasma species (fungi)
50
clincial condition: influenza active in community
commonly encountered pathogens:
1. influenza
2. S. pneumoniae
3. S. aureus (more common after someone has had the flu)
4. Streptococcus pyogenes (aspiration can lead to anaerobic infection and chemical pneumonitis)
5. H. influenzae
51
condition: suspected large colume aspiration
commonly encountered pathogens:
anaerobes (chemical pneumonitis, obstruction)
52
condition: structural lung disease (e.g. cystic fibrosis)
commonly encountered pathogens:
1. Pseudomonas aeruginosa
2. S. aureus
53
condition: injection drug use
commonly encounterd pathogens:
1. S. aureus
2. anaerobes
3. M. tuberculosis
4. S. pneumoniae
54
condition: exposure to birds (e.g. parrots, parakeets, and macaws)
commonly encountered pathogens:
Chlamydophila psittaci
55
condition: exposure to rats
commonly encountered pathogens:
Yersinia pestis (plague)
56
condition: exposure to rabbits
commonly encountered pathogens:
Francisella tularensis (tularemia)
57
condition: leukemia
commonly encountered pathogens:
Fungi
58
condition: children \<1 year
commonly encountered pathogens:
respiratory syncytial virus (RSV)
59
condition: children 2-5 years
commonly encountered pathogens:
parainfluenza virus
60
condition: post-splenectomy
commonly encountered pathogens:
1. S. pneumoniae (encapsulated organism)
2. H. influenzae (encapsulated organism?)
61
condition: college student
commonly encountered pathogens:
1. Mycoplasma pneumoniae
2. C. pneumoniae
62
condition: military recruits
commonly encountered pathogens:
1. Mycoplasma pneumoniae
2. C. pneumoniae
3. adenovirus
63
condition: travel to southwestern US
commonly encountered pathogens:
Coccidioides species
64
condition: exposure to aerosolized water, air conditioning
commonly encountered pathogens:
Legionella
65
CAP is a clinical diagnosis base on th
1. patients history
2. physical exam
3. CXR
66
diagnosis: 3 important decisions to made with case of suspected CAP
1. does the pt truly have pneumonia?
2. what is the severity of the pneumonia?
3. is hospitalization required?
67
there is no gold standard for the diagnosis of CAP but these 2 things are considered sufficient and highly suggestive of CAP
1. new infiltrate on chest radiograph
2. acute respiratory complaints (e.g. cough and dyspnea)
68
Diagnostic criteria for CAP
1. pt presents with complaints suspicious for acute lung infection
2. pt has 2 or more of fever, cough, dyspnea, chest pain AND CXR shows new inflitrate
69
Diagnostic criteria for HCAP includes that
1. pt presents with complaints suspicious for acute lung infection
2. pt has CXR that shows new infiltrate and 2 or more of fever, cough, dyspnea, chest pain
3.
* hospitalized in last 90 days OR
* long term care facility resident OR
* IV abx/chemo/wound care in last 30 days OR
* attending dialysis
70
the clinical presentatin of CAP can be highly variable depending on __ and \_\_
* age
* medical comorbidities
71
the most common complaints of pts wit pneumonia are
1. cough (86%) (should be new in onset)
2. dyspnea (72%)
3. sputum production (64%) (for pts with chronic cough, should be change in sputum production)
72
CAP symptoms
1. fever
2. cough
3. dyspnea
4. pleuritic chest pain
5. hemoptysis
6. sputum production
7. chills or rigors
8. diaphoresis
9. headache
10. nausea
11. vomiting
12. diarrhea
13. myalgias
14. arthalgias
15. fatigue/malasie
16. chest discomfort
17. anorexia
18. abdominal pain
19. falls in elderly
20. new onset or worsening confusion in elderly (both clinical and physical findings may be lacking in elderly)
73
among infectious processes, __ is the most important diagnosis to distinguish from CAP, and a __ will frequently help distinguish them
* acute bronchitis
* CXR
74
CAP DDx: acute bronchitis involves __ so there should be no change in the __ on CXR
* inflammation or infectino of the upper airway and bronchi
* lung parenchyma
75
CAP DDx: penumonia is an infectino of the __ and a diagnosis of CAP requires that __ be present
* lower respiratory tract
* an infiltrate (will lag on presence of infiltrate and on clearing)
76
CAP DDX: acute bronchitis is most commonly caused by __ and does not require __ therapy; CAP has an increased mortality if not managed with \_\_
* viruses
* antibiotic
* antibiotics
77
DDx of CAP: acute bronchitis
no infiltrate on CXR
78
DDx of CAP: URI
no lower respiratory tract signs/symptoms (crackles)
79
DDx of CAP: sinusitis
post nasal dirp may cause cough
80
DDx of CAP: influenza
PCR/diagnostic test
81
DDx of CAP: pertussis
several weeks of cough; postive nasopharyngeal/PCR
82
DDx of CAP: pulmonary embolus
high index of suspicion in pt with normal CXR and pulmonary complaints
83
DDx of CAP: acute exacerbation of COPD
CXR should be without infiltrate (note: infectious illness can cause exacerbation)
84
DDx of CAP: malignancy
CT scan and biopsy to help dx
85
DDx of CAP: congestive heart failure exacerbation
pulmonary edema usually bilateral, lower lung fields on CXR; physical exam (jugular venous extension)
86
DDx of CAP: gastroesophageal reflux (GERD)
CXR normal; positional and night time symptoms
87
CAP: physical exam
1. **tachypnea (over 20)**
2. **tachycardia**
3. **fever or hypothermia**
4. crackles (inspiratory) or ronchi
5. dullness to percussion (lobar consolidation or pleural effusion)
6. arterial desaturation (check ABGs; quick screen with pulse ox)
7. increased tactile and vocal fremitus
8. egophony ("E" to "A" changes)
9. whispered pectoriloquy
10. pleural friciton rub
88
CAP PE: physical exam does not always give the diagnosis; __ have been shown to be important in predicting outcome
vital sing abnormalities (elderly pts may not have vital sign abnormalities and minimal signs/symptoms)
89
CAP PE: classic pulmonary exam with __ and __ are suggestive of consolidation or an effusion; these 3 symptoms may also be present
* localized crackles (rales) on lung asucultation
* dullness to percussion
* decreased breath sounds or bronchial breath sounds
* ronchi
* egophony
90
CAP: 3 signs concerning for poor outcome
1. increased respiratory rate (\>30/min)
2. decreased systolic BP (\<90)
3. inceased HR (\>125)
91
CAP diagnosis: specific __ for CAP cannot be distinguished on the basis of clinical features alone
etiologies
92
CAP diagnosis: poor accuracy of diagnosisng CAP on __ alone; if a diagnosis of CAP is considered, a __ should be obtained
* history and physical examination
* CXR (it is stronly recommended by the ATS/IDSA guidleines in order to diagnosie CAP)
93
CAP diagnosis: there are certain signs and symptoms that are suggestive of specific etiologies- S. pnuemonia
1. sudden onset of fever
2. cough
3. pleuritic, localized chest pain (indicative of lobar consolidation)
4. single rigor
5. shaking chill
94
CAP diagnosis: there are certain signs and symptoms that are suggestive of specific etiologies- atypical pneumonias
1. slower in onset
2. prominent myalgias
3. other extra-pulmonary complaints
4. prolonged, dry cough
95
CAP diagnosis: there are certain signs and symptoms that are suggestive of specific etiolgoies- aspiration pneumonias
1. frequent in-hospital occurences
2. decreased consciousness
3. decreased neurologic insult
96
CXR in diagnosis of CAP: CXR is not 100% \_\_
sensitive (a negative CXR with a clinical picture highly suggestive of CAP does not rule out CAP)
97
CXR in diagnosis of CAP: false negative readings can occur in the pt with CAP due to
1. early stage of disease
2. dehydratin (orthostatic hypotension, increased HR)
3. artifact on CXR
98
CXR in diagnosis of CAP: if the clinical pciture suggests CAP and the CXR is negative, \_\_
repeat within 24-48 hours to evaluate for pregession of disease
99
CXR in diagnosis of CAP: pts with clinical signs of dehydration can develop __ CXR findings over a several day period as their voume status was corrected with a seeminlgy \_\_
* worsening
* blossoming infiltrate
100
diagnostic tests for CAP outpatient setting: dagnostic tools appear to be relatively insensitive in screening for CAP
1. blood culture: IDSA/ATS guidelines state that blood cultures are positive in only 5-14% of pts admitted to hospital; blood cultures are rarely helpful in the ambulatory setting and are NOT recommended for the outpatient management of CAP
2. sputum gram stain: has a highly variable diagnosit yield; in outpatients, sputum provides diagnostic information in roughly 20% of those tested and usually not done in outpatients
3. sputum culture: same as above
101
diagnostic tests for CAP in outpatient setting: novel testing are considered helpful in certain situation
urine antigen assays for Legionella and S. pneumoniae
102
CAP inpatient diagnostic tests: microbiologic testing offers an __ diagnosis in about __ of pts hospitalized with CAP
* etiologic
* 1/2
103
CAP inpatient diagnostic tests: IDSA/ATS guidelines recommend __ in patients being admitted to the hospital
blood and sputum cultures
104
CAP inpatient diagnosit tests: pts admitted ot the hosptial get __ blood cultures before antibiotic therapy (but dont delay treatment)
2 peripheral (do it when pt is febrile because sthey are bacteremic)
105
CAP inpatient diagnostic tests: sputum culture samples are frequently contimainted by __ secretions; sputum samples with __ is deemd adequate
* upper respiratore tract
* _\>_25 polymorphonuclear cells (PMN) and \<10 squamous epithelial cells (SEC) per low power field
106
CAP inpatient diagnostic tests: T or F, the utiltity of sputum gram stain has been debated for years
true
107
CAP inpatient diagnostic tests: urinary antigen test available for
Legionella and pneumococcus
108
CAP inpatient diagnostic tests: urinary antigen test for S. pneumoniae has sensitivity of __ and specificity of \_\_
* 70-90%
* ~99%
109
CAP inpatient diagnostic tests: urinary antigen tests cannot give \_\_, are used as an adjunt to \_\_, and used predominantly in __ pts
* resistance patterns
* blood culture and sputum gram stain and culture
* hospitalized
110
CAP inpatient diagnostic tests: these 3 are difficult to detect
1. anaerobes
2. Chlamydophila pneumonia
3. Mycoplasma pneumonia
111
CAP inpatient diagnostic tests: anaerobes that cause respiratory disease are thought to be aspirated from the mouth and oropharynx
1. peptostreptococcus
2. prevotella
3. bacteroides
4. fusobacterium
112
CAP inpatient diagnostic tests: pts with __ are prone to anaerobic lung infection
decreased mental status and others at risk for aspriation
113
CAP: there are 2 widely used clinical prediction rules available to guid admission and triage decisions
1. Pneumonia Severity Index (PSI): helps identify pts at higher risk of complications and who are likely to benefit from inpatient hospitalization
2. CURB-65: its less discriminating at low mortality but excellent at identifying pts with high mortality who may benefit from ICU level care
114
PSI
pt characteristic: AGE, men
no. of points:
age, years+10
115
PSI
pt characteristic: age, women
no. of points:
age, years -10
116
PSI
pt. characteristic: age, nursing home residents
no. of points:
age, years +10
117
PSI
pt characteristic: co-existing illnesses, neoplastic disease
no. of points:
30
118
PSI
pt characteristic: co-existing illnesses, liver disease
no. of points:
20
119
PSI
pt characteristic: co-existing illnesses, CHF
no. of points:
10
120
PSI
pt characteristic: co-existing illnesses, cerebrovascular disease
no. of points:
10
121
PSI
pt characteristic: co-existing illnesses, renal disease
no. of points:
10
122
PSI
pt characteristic: PE findings, altered mental staus (confusion, delirium...)
no. of points:
20
123
PSI
pt characteristic: PE finding, respiratory rate \>30/min
no. of points:
20
124
PSI
pt characteristic: PE finding, systolic BP \<90 mmHg
no. of points:
20
125
PSI
pt characteristic: PE finding, temp \<35C (\<95F) or \>40C (\>104F)
no. of points:
15
126
PSI
pt characteristic: PE finding, HR \> 125/min
no. of points:
10
127
PSI
pt characteristic: lab and radiograph findings, arterial pH \<7.35
no. of points:
30
128
PSI
pt characteristic: lab and radiograph findings, BUN \>30 mg/dL
no. of points:
20
129
PSI
pt characteristic: lab and radiograph findings, Na \< 130mmol/L
no. of points:
20
130
PSI
pt characteristic: lab and radiograph findings, glucose \> 250 mg/dL
no. of points:
10
131
PSI
pt characteristic: lab and radiograph findings, Hct \< 30%
no. of points:
10
132
PSI
pt characteristic: lab and radiograph findings, partial press. of arterial O2 \< 60 mmHg
no. of points:
10
133
PSI
pt characteristic: lab and radiograph findings, pleural effusion
no. of points:
10
134
PSI, Class I: risk, score, mortality, site of care
* risk: low
* score: \<51
* mortality: 0.1%
* site of care: outpatient
135
PSI, class II: risk, score, mortality, site of care
* risk: low
* score: 51-70
* mortality: 0.6%
* site of care: outpatient
136
PSI, class III: risk, score, mortality, site of care
* risk: low
* score: 71-90
* mortality: 0.9%
* site of care: inpatient (briefly) (should be based on clinical judgment)
137
PSI, class IV: risk, score, mortality, site of care
* risk: medium
* score: 90-130
* mortality: 9.5%
* site of care: inpatient
138
PSI, class V: risk, score, mortality, site of care
* risk: high
* score: \>130
* mortality: 26.7%
* site of care: inpatient
139
PSI scoring: there are several factors in a patient's presentation not accounted for in the PSI that nonetheless may qualify them for inpatient treatment, in which hospitalizaiton may benefit an otherwise low risk pt, and they include
1. homelessness
2. drug abuse
3. rare comorbidities
4. difficulty with medicine compliance
5. unstable home situations
140
CURB-65 asses five simple, independent predictors on increased mortality (scored as 1 point each)
- Confusion
- Uremia (BEN \> 20 mg/dL)
- Respiratory rate (_\>_ 30 bpm)
- Blood pressure (systolic \<90 mmHg OR diastolic \<60 mmHg)
- \>65 years old
141
CRB-65 is same the same thing as CURB-65 except no
Uremia (BUN \> 20 mg/dL)
142
CURB-65 score
* 0-1 = low risk; consider home treatment
* 2 = short inpatient hospitalization or closely supervised outpatient treatment
* 3-5 = severe pneumonia; hosptializatoin and consider ICU
143
CRB-65 score
* 0 = very low predicted mortality; no hospitalization
* 1-2 = increased risk of death; consider hospitalization
* 3-4 = high risk of death; urgent hospitalization
144
CAP treatment: \_\_% of CAP is treated as outpatient; most patients are treated \_\_, without identifying any \_\_
* 80%
* empirically
* organism
145
CAP treatment: need to triage/disposition (\_\_), antibiotic therapy must be \_\_, and pathogen must be __ to antibiotic used
* outpatient vs. inpatient
* prompt
* susceptible
146
CAP treatment: 2 classes of antibiotics most commonly recommended for outpatient management of pneumonia (in those pts who have not received antibitoics in the previous 3 months)
1. Macrolides (e.g. erythromycin, azithromycin, clarithromycin)
2. Doxycycline
147
CAP treatment: recent concern over increasing resistance of __ to macrolides throughout US; to date, reports of clinical failure of these drugs are \_\_; similar concerns have arisen with the \_\_
* S. pneumonia
* rare
* fluoroquinolones (they are now considered to be the most frequently misused class of antibiotics)
148
CAP treatement: current rates of resistance to fluoroquinolones are estimated at \_\_%; this has been a __ problem in countries other than the US
* 2%
* larger
149
CAP treatment: a progressive rise of resistant organisms has been reported across the country and experts predict the complete loss of this antibiotic class (fluoroquinolones) in the next ten years without a \_\_
change in current usage patterns
150
CAP treatment: pts with CAP and no comorbidities and no recent antibiotic use should not be treated with \_\_
respiratory fluoroquinolones (i.e., moxifloxacin, levofloxacin, gemifloxacin)
151
CAP treatment outpatients
pt: healthy, no recent antibiotics (last 3 months)
treatment:
* macrolide (erythromycin, azithromycin, clarithromycin) OR
* doxycycline
152
CAP treatment outpatients
pt: healthy and recent (\<3 months) antibiotic use
treatment:
* respiratory fluoroquinolone (moxifloxacin, levofloxacin, gemifloxacin) OR
* beta-lactam (amoxicillin or amoxicillin/clavulanate preferred) PLUS macrolide
153
CAP treatment outpatients
pt: comorbidities (e.g. chronic heart, lung, liver, or renal disease; DM; alcoholism; asplenia; immunosupression; malignancy)
treatment:
* respiratory fluoroquinolone (moxifloxacin, levofloxacin, gemifloxacin) OR
* beta-lactam (high dose amoxicillin or amoxicillin/clavulanate preferred) PLUS macrolide
154
CAP treatment outpatients
pt: suspected aspiration with infection
treatment:
* amoxicillin-clavulanate OR
* clindamycin
155
CAP treatment outpatients
pt: influenza with bacaterial superinfection
treatment:
* beta lactam OR
* respiratory fluoroquinolone
156
CAP treatment outpatients: typical antibiotic treatment duration for CAP ranges from __ to __ days; IDSA/ATS guidlines recommend a minimun of __ days of antibiotic treatment for uncomplicated CAP
* 5-14 days
* 5 days
157
CAP treatment outpatient: pts should be afebrile for __ hours with resolution or marked iimprovement in symptoms prior to antibiotic discontinuation
48-72 hours
158
CAP treatment outpatients: typcially macrolides such as azithroomycin are used for __ days, while doxycycline and the quinolones are prescribed for __ days
* 5 days
* 7-10 days
159
CAP treatment outpatient: it remains to the clinician to decide the appropriate regimen for his pt, while taking into account the \_\_, \_\_, and \_\_
1. severity of presentation
2. pt comorbidities
3. the potential of drug resistant infection
160
CAP treament: azithromycin (macrolide): dosage, typical duration, comments
* dosage: 500 mg x 1 followed by 250 mg daily x 4 days
* typical duration: 5 days
* comments: preferred agent for ptss without comorbidities or recent antibiotics
161
CAP treatment, clarithromycin (macrolide): dosage, typical duration, comments
* two 500 mg tabs daily
* 5 days
* erythomycin has poor coverage of H. influenzae, so azithromycin and clarithromycin preferred
162
CAP treatment, doxycycline (tetracycline): dosage, typical duration, comments
* 100mg twice daily
* 7-10 days
* alternative to macrolides
163
CAP treatment, moxifloxacin (quinolone): dosage, typical duration, comments
* 400mg daily
* 5 days
* use quinolone when comorbidities are present or recent antibitoics
164
CAP treatment, gemfloxacin (quinolone): dosage, typical duration
* 320mg daily
* 5 days
165
CAP treatment, levofloxacin (quinolone): dosage, typical duration
dosage: 750mg daily
5 days
166
CAP treatment: amoxicillin-clavulanate (beta-lactam + beta-lactamase inhibitor): dosage, typical duration, comments
* 2g twice dailly
* 5 days minimum
* given in combination with macrolide or doxycycline
167
CAP course
expect improvement in __ hours with right antibiotic
CXR may __ but patient improves \_\_
fever can last __ days with pneumococcus; longer with others
rales can persist __ days in up to \_\_% pts
CXR may not clear for \_\_
* 48-72 hours
* worsen, clinically
* 2-5 days
* \>7 days, 40%
* several weeks
168
CAP course: if pt not responding to initial therapy, consider:
1. virus
2. TB
3. resistant organism
4. Pneumocystis (opportunistic fungal infeciton in immunocompromised pt)
5. non-infectious illness
169
CAP preventions:
1. influenza vaccine
2. pneumococcal vaccine:
* pneumovax (\>65 yo or chronic illnesses/co-morbid conditions, immunocompromised)
* Prevnar (\<9 yo)
