Pneumonia VAP, CAP, Atypical Walking, Influenza

Question 1

mycoplasma pneumoniae is

Answer 1

smallest free living organisms and do not have a cell wall.

Question 2

presentation of mycoplasma pneumonia infection

Answer 2

generalized aches, pains, low grade fever, temperature >102 and non productive cough and non exudative pharyngitis headache, myaglias, chills without rigors and nasal congestion with coryza and pneumonia.

flu like symptoms with higher fever and dry cough. see pharyngitis, chills, nasal congestio nand coryza

Question 3

labs related to mycoplasma pneumonia infection

Answer 3

subclinical hemolysis,

positive coombs (DAT) and low complement levels

and elevated cold agluttin titer. Diagnosis is clinical but can get serology

may have underlying EBV infection.

Treatment of hemolytic anemia and cold agluttin dx related to this is avoidance of cold (even in warm weather) and heavy socks and coats to prevent agluttination.

Question 4

treatment of mycoplasma

Answer 4

azithromycin.

Question 5

moraxella catarrhalis is associated with people who have

Answer 5

COPD, pneumoconiosis, asthma, malginancies, or immuno suppressions.

Question 6

VAP is

Answer 6

ventilator associated pneumonia happening after 48-72 hrs after ET higher risk for aspiration of organisms colonizing the oropharyngeal tract

Question 7

Common VAP organisms

Answer 7

staph aureus (MRSA and MSSA) and P aeruginosa, Stenorophomonas maltphilia and acinetobacter

Question 8

which antibody is not recommended for treatment of MRSA pneumonia? Linezolid or daptomycin

Answer 8

daptomycin because the pulmonary surfactant inhibits drug Daptomycin is approved for treating skin and soft tissue infectiosn and bacteremia with and without endocarditis

Question 9

treatment of MRSA is with

Answer 9

vancomycin or linezolid. Linezolid is preferred in hospitals where majority of MRSA isolates have a vancomycin minimum inhibitory concentration (MIC)>2 mcg/ml.

Question 10

azithromycin treats

Answer 10

gram positive and atypical and some gram negative bacteria. Not effective to MRSA.

Question 11

who is at high risk for complications from influenza infection?

Answer 11

<2 yrs or >65 yrs

<19 on chronic aspirin therapy

women who are pregnant and up to 2 weeks post partum

underlying chronic medical illness (chronic pulmonary, cardiovascular, neurocognitive dx, renal or hepatic)

immunosuppressed (HIV too)

morbidly obese

Native Americans

nursing home or chronic care facility residents

DM2

Question 12

pt has fever + cough and sore throat and high clinical suspicion for influenza should get

Answer 12

treatment for influenza with oseltamivir

Question 13

risk factors that make influenza infection likely:

Answer 13

winter season, abrupt symptom onset, sick contact

Question 14

What is the benefit for starting early antiviral therapy for influenzae

Answer 14

decreases symptom duration,

illness severity,

complication rates,

Question 15

when should we start oseltamvir for suspected or confirmed influenza infections?

Answer 15

48 hrs of symptom onset (neuramindase inhibitor - like oseltamivir or zanamivir)

Question 16

who should not get zanamivir for treatment of influenza?

Answer 16

chronic pulmonary disease (COPD and asthma) as it can precipitate bronchospasm and respiratory function decline?

Question 17

can you start oseltamivir before getting results for rapid antigen for flu?

Answer 17

yes. don’t delay treatment. Also should NOT be stopped due to a negative rapid antigen test result in pts who the suspicion for influenza is high. This is because rapid antigen test is low sensitivity in diagnosing influenza. Reverse transcriptase PCR is more sensitive but less readily available.

Question 18

When do we use ribavirin?

Answer 18

treat immunosuppressed pts with suspected lower respiratory tract infection from RSV not effective against influenza.

Question 19

do we ever use amantidine or rimantadine for influenza?

Answer 19

no because of high drug resistance

Question 20

Can you still get the flu after vaccination?

Answer 20

yes it only works about 40-60% of older individuals and outbreaks happen in vaccinated pts

Question 21

how to stop spread of influenzae in a SNF or nursing home?

Answer 21

if 2 or more residents in a SNF develop a flu like illness within 72 hrs of each other , need to get tested. If positive for flu, residents at the facility (whether vaccinated or not and regardless of ward or floor) gets prophylactic antiviral therapy.

Question 22

Prophylactic influenza therapy should last until

Answer 22

14 days or for 10 days after onset of illness in the last person affected, whichever is longer.

Question 23

how to prevent spread of flu in healthcare settings?

Answer 23

immunize all healthcare workers standard isolation precautions (hand hygiene : gloves, hand washing with soap and water) and gowns

Question 24

Droplet precaution measures for suspected or confirmed influenza pts in a SNF include:

Answer 24

droplet isolation precautions for 7 days after illness onset or 24 hrs after symptom resolution put pt in private room face mask on all personnel entering room N95 respirator for aerosol generating procedures (bronchscopy, intubation, extubation, sputum induction) limit visitors to infected room.

Question 25

Cormorbid conditions that require a respiratory floroquinolone for treatment of CAP are:

Answer 25

DM2, CHF, lung dx, liver dx, renal dx, alcoholism, malignancy, asplenia and immunosuppression.

Question 26

Criteria for needing respiratory floroquinolone (levofloxacin or moxifloxacin) for CAP?

Answer 26

risk factors for drug resistant Strep pneumo, antibiotic use in the last 3 months cormobid conditions: DM2, CHF, lung dx, liver dx, renal dx, alcoholism, malignancy, asplenia and immunosuppression.

Question 27

why do we need to use a respiratory fluoroquinolone in diabetes?

Answer 27

because hyperglycemia can impair neutrophil chemotaxis, phagocytosis and cell mediated immunity and contribute to increased susceptibility to infection in DM2

Question 28

Pt who has suspected CAP and has no risk factors for tx resistant Strep and antibiotic use in the past 3 months and no comorbid conditions should be treated with

Answer 28

azithromycin or doxycycline.

Question 29

what does CURB 65 stand for?

Answer 29

Confusion Uremia Respiratory rate Blood pressure \>65 yrs old used to determine how to triage pt if 1-2 should get hospitalized 3-4 should go to the ICU 0 - outpatient treatment.

Question 30

CURB 65 chart and algorithm

Answer 30

Question 31

Name the clues that should increase your index of suspicion for Legionella pneumonia

Answer 31

Also can see renal acidosis too.

Question 32

Cough, new infiltrate on CXR Risk factors for legionella (elderly age, COPD, SNF resident) and confusion with high fever with bradycardia and hyponatremia and thrombocytopenia with LFTs and failure to respond to vancomycin and zosyn suggest

Answer 32

legionella infection. Need to treat with respiratory quinolone or newer macrolide like azithromycin for suspected Legionella pneumonias

Question 33

Legionella bacteria like living in What is seen on CXR with Legionella pneumonia?

Answer 33

lakes, streams, man made reservoirs or standing water. Intracellular gram negative bacilli. On XR they have unilateral pulmonary infiltrate that forms lobar pneumonia

Question 34

Diagnosis of Legionella

Answer 34

urinary legionella antigen test (detects only L pneumophilia serotype 1) and respiratory sample with (sputum or BAL) for legionella culture.

Question 35

Pneumococcal vaccination schedule

Answer 35

**Remember that PCV13 gives lifelong immunity.** Way to think of this is at 65 yrs, everyone gets PCV13 for lifelong coverage then PPSV23 1 year later. People at greater risk - CHF, COPD, cirrhotics, DM2, smokers, ETOH, get PPSV 23 before age 65 yrs then get PCV13 People at greatest risk - CKD, HIV, cochlear implants, CSF leaks, get PCV13 NOW then PPSV23 in 8 weeks.

Question 36

who gets post PNA CXR (7-12 weeks after)

Answer 36

pts who have higher risk of: \>50 yrs male sex history of smoking To rule out presence of underlying lung cancer

Question 37

Follow up measures for someone who has recovered from pneumonia are:

Answer 37

If high risk, get a CXR in 7-12 weeks (smoking, \>50, male) quit smoking pneumococcal vaccination who are \>65 yrs or DM2 or other risk factors.

Question 38

who is high risk for influenza complications?

Answer 38

adults \>65 women pregnant and up to 2 weeks post partum underlying chronic medical illness (COPD, CAD, CKD, chronic liver) immunosuppressed morbidly obese Native Americans SNF or chronic care residents

Question 39

what happens if someone has influenza and transiently improves and then worsesn with lower respiratory manifestations of cough, pleurisy and dyspnea

Answer 39

secondary bacteria pneumonia by Strep or Staph. H influenzae also can happen. Need to treat with CAP (ceftriaxone and azithromycin) + MRSA coverage (vancomycin) Only add antiviral treatment in pts who develop influenzae complications as secondary pneumonia are typically treated with antivirals even if they present \>48 hrs of onset.

Question 40

Tx of post influenzae secondary pneumonia

Answer 40

Need to treat with CAP (ceftriaxone and azithromycin) + MRSA coverage (vancomycin) Only add antiviral treatment in pts who develop influenzae complications as secondary pneumonia are typically treated with antivirals even if they present \>48 hrs of onset.

Question 41

what are the risk factors for pneumonia for MRSA and gram negative organisms (pseudomonas and strep) :

Answer 41

history of MRSA infection so may be colonized risk factors for pseudomonas: prior abx therapy, recent hospitalization, multiple medical cormobidities like ETOH, DM2, immunosuppression, possible aspiration and structural lung dx drug resistant Strep Pneumo risk factors: age\>65 and medical comorbidities, exposure to kids at day care and immunosuppresion and recent beta lactam, macrolid or floroquinolone

Question 42

MRSA risk factors for pneumonia:

Answer 42

history of MRSA infection so may be colonized IVDA recent antibiotics

Question 43

Risk factors for pseudomonal pneumonia

Answer 43

risk factors for pseudomonas: prior abx therapy, recent hospitalization, multiple medical cormobidities like ETOH, DM2, immunosuppression, possible aspiration and structural lung dx (COPD, bronchiectasis)

Question 44

Risk factors for development of multidrug resistant strep pneumo

Answer 44

age\>65 and medical comorbidities, exposure to kids at day care and immunosuppresion recent beta lactam, macrolid or floroquinolone

Question 45

Tx for pneumonia with new right lung infiltrate and has history of MRSA, risk factors for strep pneumo and pseudomonas

Answer 45

Vancomycin and cefepime if allergic to vancomycin:linezolide and cefepime. Don't use daptomycin (D for don't or daptomycin) as surfactant inactivates it in the lugns.

Question 46

Treatment of legionella pneumonia

Answer 46

gram negative rod with poor gran stain. grows on charcoal yeast with iron and cysteine treat with macrolide (azithromycin) or fluoroquinolone

Question 47

Drug induced optic neuropathy is caused by these drugs

Answer 47

Question 48

Toxicity associated with linezolid:

Answer 48

bone marrow suppression peripheral neuropathy - can be irreversible see below optic neuropathy - can be irreversible due to mitochondrial toxicity No more than 28 weeks of this; need weekly CBC for bone marrow and periodic eye and neuro exams for \>4 weeks. Treats: MRSA and VRE and strepococcus and used for skin, soft tissue, and pneumonia.

Question 49

Treatment of RSV in immunocompromised pts

Answer 49

**give ribavirin and IVIG for immunocompromised** or those with **hematopoetic stem cell transplant** **contraindicated in pregnant pts** and men with close contact with pregnant pt. need to _remain not pregnant for at least 6 months_ after taking it due to long half life.

Question 50

Legionella causes two types of syndromes:

Answer 50

Legionnaires dx and Pontiac fever Legionnaires dx - primary pneumonia due to Legionella.

Question 51

Treatment of Legionella Pneumonia is with

Answer 51

Legionella is treated with atypical coverage with **azithromycin 1000 mg x1 then 500 mg for 6 days (total of 1 week)** **Levofloxacin 750 mg daily for 7 days.** IV antibiotics are recommended until fever is cleared treat with a longer course instead of typical azithromycin 500 mg x1 then 250 mg daily for 4 days. can use clarithromycin and ciprofloxacin and ofloxacin moxifloxacin, doxycycline minocycline tetracycline or tigecycline or bactrim. **_Remember ceftriaxone and zosyn are ineffective against legionella pneumonia._**

Question 52

Hospital acquired pneumonia empiric abx coverage

Answer 52

HAP - pneumonia that _develops \>48 hrs after hospitalization and not present at admission. Cover for MRSA and pseudomonas_ **vancomycin and cefepime** **will need to _double coverage_** if pt needs ICU Level of care **(antipseudomonal beta lactam and aminoglycoside**)

Question 53

what kind of bacteria is a non lactose fermenting aerobic gram NEGATIVE bacteria

Answer 53

pseudomonas.

Question 54

empiric coverage for VAP pneumonia

Answer 54

Treat with cefepime/pipercillin/carbapenem + vancomycin + atypical coverage (levoquin) Need to cover for pseudomonas, MRSA and atypicals