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40 Cards in this Set
- Front
- Back
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Define
Effusion Empyema Pneumothorax Respiratory distress syndrome |
Effusion – fluid in the pleural lining of lung
Empyema – similar to effusion but like a pus-filled area = requires drainage Pneumothorax – air (not an infx, just conditioin) Respiratory distress syndrome – babies who lack surfactant, adults: like lungs are brittle-no treatment avail-they can get pneumonia so bad they go into this and die |
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Hospital-acquired pneumonia (HAP)
Have to be in hospital for ____ hrs Pneumonia caused by aspiration is of what type? |
>24
CA |
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CA-pneumonia
Signs and symptoms |
Abrupt onset of
fever chills dyspnea and productive cough Rust-colored sputum or hemoptysis Pleuritic chest pain |
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CA-pneumonia
Laboratory Examination |
WBC high/normal; If bacterial, more neutrophils
Sputum – look at gram stain, WBCs, epithelial cells, bacterial presence Blood culture (hospitalized) – required by JCAHO, 1-20% positive for CAP |
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CA-pneumonia
Ideal Sputum vs. Spit |
Gram stain
Lots of WBC No (or little) epithelial cells (<10) 1 organism growing Culture 1-2 organisms growing SPIT: Epithelial cells present Low number of WBC Multiple types of organisms Yeast present |
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CA-pneumonia
Assessment tool is called.. list the levels for each component Outpt = healthy w/comorbid Inpt = mod-sev pneumonia |
CURB-65
Confusion Uremia (BUN > 20 mg/dL) Respiratory rate ≥ 30 per minute Blood pressure (systolic < 90 mmHg or diastolic < 60 mmHg) Age > 65 years |
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CA-pneumonia
CURB-65 score >= ____ buys admission to the hospital |
>=2
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CA-Pneumonia
Atypical (intracellular) organisms Who are they? How treat? |
Mycoplasma pneumoniae
Chlamydia pneumonia Legionella species FQ/Macro/Doxy |
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CA-Pneumonia
DRSP means... |
Drug Resistant Streptococcus pneumoniae
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CAP Outpt Tx
healthy and no risk factors for DRSP infections = Patients with co-morbidities or other DRSP risk factors |
Macrolide
Doxycycline w/RFs Respiratory fluoroquinolone (moxy/levo) β-lactam PLUS macrolide Β-lactam + doxycycline |
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CAP – Inpatient Treatment
Non-ICU |
Resp FQ
Respiratory fluoroquinolone Β-lactam PLUS macrolide -cefotaxime, ceftriaxone and ampicillin; ertapenem B-lactam PLUS doxycycline |
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CAP – Inpatient Treatment ICU
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Need to cover pseudo
B-lactam (cefotaxime, ceftriaxone, amp-sulbactam) PLUS azithromycin B-lactam (cefotaxime, ceftriaxone, amp-sulbactam) PLUS respiratory fluoroquinolone Respiratory fluoroquinolone PLUS aztreonam *for PCN allergy |
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“Patients with CAP should be treated for a minimum of ____ days, should be afebrile for ____ hours and should have no more than 1 CAP-associated sign of clinical instability (see next slide) before discontinuation of therapy
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min tx = 5 days
afebrile 48-72 |
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CAP
Clinical Stability Criteria Temp HR RR Sys BP PO2 Can take things orally Mental status |
Clinical Stability Criteria
Temp <38 HR <100 bpm RR <24 Sys BP >90 PO2 >60 Can take things orally Mental status |
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HSAP - includes:
TX SAME FOR ALL Hospital-acquired pneumonia (HAP) > 48 hours after admission Ventilator-associated pneumonia (VAP) > 48 hours after endotracheal intubation Healthcare-associated pneumonia (HCAP) Hospitalized or in acute care setting w/in 90d Resided in NH or LTCF, received IV abx, chemo or wound care in previous 30d Attended hospital clinics or HD clinic |
NA
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HSAP
DX: temp wbcs pus? |
fever
leukoctosis / leukopenia purulent |
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ATS/IDSA Guidelines
tx algorithm |
HAP, VAP, or HCAP Suspected*
Obtain Lower Respiratory Tract Sample for Culture Start Empiric Antibiotic Therapy |
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HSAP
Empiric Therapy late onset is >____ and is signif b'c indicative of |
>5 days
drug resistant |
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Risk Factors for MDR Organisms
don't memorize --> |
abx in preceding 90 days
> 5 days hospital abx resist in hosp/comm Immunosuppressive disease or therapy LTCF home infusion chronic hd w/in 30d wound cre family member with MDR pneumonia |
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HSAP
Late Onset (>5d) or Risk Factors for MDR Pathogens means we tx with.... early onset = (general answer) |
ext spectrum
limited spectrum |
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which LIMITED SPECTRUM drugs choose for these
pathogens Strep pneumonia H. influenza MSSA Sensitive enteric GNB E.coli, Klebsiella, Enterobacter, Proteus, Serratia |
Ceftriaxone
Levofloxacin, Cipro, Moxi Unasyn Ertapenem |
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which LIMITED SPECTRUM drugs choose for these
pathogens ___THPY, W/DOUBLE UP ON____ now guess the drugs...and combos Pseudomonas Klebsiella (ESBL) Acinetobacter MRSA Chill, just think of pseudomonas here...you know the two cefs...so try to figure out the others. |
TRIPLE THPY WITH DOUBLE UP ON PSEUDOMONAS
Ceftazidime / Cefepime OR Imipenem / Meropenem OR Zosyn ----PLUS---- Ciprofloxacin / Levoflox OR Aminoglycoside ----PLUS---- Vancomycin or Linezolid |
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Pneumonia
BROAD SPECTRUM pathogens (in addition to narrow spectrum) |
Pseudomonas
Klebsiella (ESBL) Acinetobacter MRSA |
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Pneumonia
NARROW SPECTRUM empiric abx |
Ceftazidime / Cefepime OR
Imipenem / Meropenem OR Zosyn --PLUS-- Ciprofloxacin / Levoflox OR Aminoglycoside --PLUS-- Vancomycin or Linezolid |
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TX ALG if HAP, VAP, or HCAP Suspected
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1. LR tract culture
2. Empiric thpy 3. check cultures 4. clinical improvment? --yes w/neg cult = stop abx --yes w/pos cult = de escalate --no w/neg cult = look for other cause --no w/pos cult = adj abx |
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Pneumonia
Most patients show clinical improvement by days ____, with fever resolution by day ____ |
3-5d
7d |
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Clinical Guideline for VAP
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Empiric coverage for >90% of pneumonia pathogens for that ICU (MRSA and Pseudomonas)
Must modify tx 24-48h based on cx and clinical course Proposed 7 day course of adequate abx unless Temp > 38.3 No improvement on CXR WBC > 10 Cont’d purulent sputum |
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Clinical Guideline for VAP
Empiric coverage for >___% of pneumonia pathogens for that ICU (MRSA and Pseudomonas) Must modify tx ____h based on cx and clinical course Proposed 7 day course of adequate abx unless... |
90%
24-48 Temp > 38.3 No improvement on CXR WBC > 10 Cont’d purulent sputum |
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Bronchitis
def...acute and chronic |
Acute – cough persisting >5 DAYS - WEEKS
Chronic – coughing sputum on most days for as least 3 CONSECUTIVE MONTHS each year for 2 CONSECUTIVE YEARS in patients >40 |
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Bronchitis
Normally caused by .... but sometimes starts as a ____ what does the chest radiograph look like? |
viral-cold viruses (rhino or coronaviruses) or influenza and adenovirus
Mycoplasma pneumoniae URI NORMAL CHEST RADIOGRAPH |
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Bronchitis
TX Antipyretics ? Antihistamines, sympathomimetics, and antitussives-? Antibiotics-? |
Antipyretics – acetaminophen/ibuprofen
Antihistamines, sympathomimetics, and antitussives- ? Bad-dries up and stuff stays there Antibiotics-certain patients, fever >4-6 days, elderly or immunocmpromised…..consider possible bacterial infection also |
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Chronic Bronchitis
More common seen in patients with ____ |
More common seen in patients with COPD
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Chronic Bronchitis
Definition |
coughing sputum on most days for as least 3 consecutive months each year for 2 consecutive years in patients >40
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Clinical Presentation
Bronchitis |
Cough
Sputum Copious amounts White to yellow-green Cyanosis Obesity Rales, rhonchi, wheezing Clubbing |
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Bronchitis
Antibiotics Controversial |
amoxicillin, AUGMENTIN, fluoroquinolones, macrolides
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Bronchitis
Length of Therapy |
5 – 7 days
Patient afebrile for 3 consecutive days |
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1. FM is a 45 year old male who is seen by his family practice physician for a fever, increased work of breathing (RR 22), cough and fatigue. Normal blood pressure. All lab results are normal. Based on his symptoms and chest xray he is diagnosed with a community acquired pneumonia that does not require hospitalization. What is this patients CURB 65 score?
Which antibiotics are appropriate to start this patient on? What should be the length of therapy assuming he responds to therapy? (specify per each antibiotic) Where did you look? If the patient was on clarithromycin instead would there be a difference. Why or why not? |
What is this patients CURB 65 score? NONE
Doxy / macrolide What should be the length of therapy assuming he responds to therapy? (specify per each antibiotic) minimum of 5d (3 afebrile) Yes, it has CYP interxs |
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LK is a 66 year old male gentleman seen by his practitioner. He has a fever, increasing respiratory rate (24 breaths/minute) and heart rate, increased confusion, and normal blood pressure. He has hypertension and CAD (comorbidities). He is on metoprolol XL po daily. Nitroglycerin 0.4mg SL prn. He has no other disease states. Labs are normal. The physician does the CURB-65 score and decides to admit him onto an inpatient unit (non-icu). Cultures will be sent.
What antibiotics should he be started on and why? |
Cultures will be sent. What antibiotics should he be started on and why? Resp FQ/Blact+macro/Blact+doxy
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LK’s sputum gram stain comes back as the following: 3+ WBC 2+GPC 1+GNR mixed oral flora 25 epithelial cells
What does this gram stain tell you? |
Nothing
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LK has been in the hospital for 3 days. His fever is gone, vital signs are normal, and he no longer has confusion. He is eating a normal diet. He has been on IV moxifloxacin for the past 3 days. What changes do you recommend? Length of therapy? (cultures were inconclusive)
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5days min, 3d afebrile
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