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43 Cards in this Set

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what is the #1 cause of death from infectios disease in the US?
pneumonia
CAP has a greater prevalence in what groups?
COPD
DM
Renal Insufficiency
CHF
Chronic liver disease
What is involved in the cellular immnity in the lung?
Alveolar macrophages
Neutrophils
CD4 and CD8 lymphocytes
NK cells
B cells
What is the most common route of infection in CAP?
Aspiration of nasopharyngeal secretions
what is the most common organism involved in inhalation and getting CAP?
Influenza
What physiologic changes go along with CAP
-Increased VO2, VCO2, and alveolar ventilation
-Increased shunt fraction bc of poor diffusion
-V/Q mismatch because of vasoconstriction from inflammatory response
-increased hypoxemia and hypocarbia
-Decreased lung compliance
-Increased cardiac output bc of hypercatabolic state but may become depressed later
What clinical symptoms occur?
Fever/chills
Dyspnea
Cough
Pleuritic chest pain
HA, N/V
Abdominal pain, diarrhea
myalgia
athralgia
What might be an atypical pneumonia presentation?
Elderly with vague symptoms like somnolence without a fever or cough
What would be a typical CAP?
Strep pneumo
-sudden onset, no viral prodrome, purulent sputum, signs of consolidation, response to B-lactam
What would be an atypical CAP?
Mycoplasma, chlamydia, legionella
-no response to B-lactams, there is a viral prodrome, dry cough, absence of consolidation, no response to B-lactam
What might you find on physical exam?
-crackles, rales
-consolidation
-pleural friction rub sometimes
-Bronchophony and whispered pectorioquey could be present
What diagnostic studies do you need for pneumonia
CXR- this can differentiate pneumonias form other stuff.
It can identify more complicated forms and can tell the severity
What do atypical pneumonias look like on CXR
Bilateral haziness
More interstitial infiltrates
Less consolidation
What is the use of sputum gram stains?
Debatable. They can be diagnostic for mycobacterium, endemic fungi, legionella, and PCP

Can ID pneumococcus in CAP
Would a CT scan help diagnose CXR?
No they do not ad any info a CXR can't add
What might you find on physical exam?
-crackles, rales
-consolidation
-pleural friction rub sometimes
-Bronchophony and whispered pectorioquey could be present
What diagnostic studies do you need for pneumonia
CXR- this can differentiate pneumonias form other stuff.
It can identify more complicated forms and can tell the severity
What do atypical pneumonias look like on CXR
Bilateral haziness
More interstitial infiltrates
Less consolidation
What is the use of sputum gram stains?
Debatable. They can be diagnostic for mycobacterium, endemic fungi, legionella, and PCP

Can ID pneumococcus in CAP
Would a CT scan help diagnose CXR?
No they do not ad any info a CXR can't add
What workup do you do on a CAP patient?
2 blood cultures
Thoracentesis if pleural effusion present
CBC
Electrolytes
Liver lung function tests
Risk factors for mortality in CAP?
Older than 65
Coexisting illness:
COPD
Bronchiectasis
DM
CHF
Renal insufficiency
Chronic liver disease
Recent hospitalization
AMS
post-splenectomy
Chronic alcohol abuse
malnutrition
malignancy
What physical findings predict mortality or bad course?
RR >30
DBP <60 or SBP <90
Temperature either high or low
Extrapulmonary sites of disease (meningitis or septic arthritis)
HR > 125
AMS
Predictive labs of mortality
Need mechanical ventilation
Abnormal renal function
low hematocrit or hemoglobin
low pH
CXR with more lobes infolved, cavities, pleural effusion
Evidence of sepsis like metabolic acidosis or DIC
What is the most common bacterial cause of CAP
strep pneumo
Describe strep pneumo CAP
-Prototype of lobar pneumonia
-5% mortality overall
What is the most common cause of ARDS?
Pneumonia. Trauma is second
Who is at high risk for strep pneumo?
-Post-splenectomy or Sickle Cell patients
-Immunodeficient

This is because strep pneumo is encapsulated and they can't activate complement
You have a young patient with slow onset upper respiratory infection with dry cough and extrapulmonary complications (liver, cardiac, Joints). They had malaise leading up to it.
Might be Mycoplasma pneumoniae
-this is the second most common CAP
-Can diagnose with cold agglutins. difficult to culture.
How do you treat mycoplasma pneumonia
macrolides, quinolones, doxycycline, tetracycline
What pneumonia would cause multi-organ failure?
Legionella
Name some unique symptoms of legionella pneumonia
Hyponatremia, increased liver transaminases, rhabdomyolysis, myocarditis
How would you distinguish viral pneumonia from atypical pneumonia
-Both have prodromes
-Influenza has shorter temporal profile though (a few days not a few weeks)
-Commonly develop bacterial superinfection after 1-3 days with influenza
What would increase your risk for DRSP?
-elderly
-Those on B-lactam therapy recently
-steroid use
-Multiple medical comorbidities
-Exposure to child daycare
What puts you at risk for GN rods?
Nursing home residents
What increases risk for pseudomonas?
-structural lung disease/dilated airways
-chronic steroid use
-patients on broad spectrum antibiotics
-malnourished
What organisms do you suspect in outpatient with no comorbities?
Pneumococcus
Mycoplasma/Chlamydia
H. influenza (smoker)
Respiratory viruses
What organisms do you suspect in an outpatient with comorbidities?
Pneumococcus
Mycoplasma/Chlamydia
GNR
Maybe legionella
If sick, maybe staph
Inpatient organisms?
Pneumococcus, H influenza, legionella
ICU organisms?
Pneumococcus, Legionella, H. Influenza, GNR, S. aureus
Possibly pseudomonas

Mycoplasma/chlamydia not expected
What would you treat an outpatient with no comorbidities with?
Macrolide like Azithromycin or Clarithromycin

Use doxycycline if they are allergic to the macrolide
Treat an outpatient with comorbidities with?
Macrolide plus B-lactam for the GNR and DRSP
Treat an inpatient or an ICU patient with?
IV broad spectrum B-lactam
Macrolide