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63 Cards in this Set
- Front
- Back
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Clinical definition of CAP
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infection of LOWER respiratory tract w/in pulmonary parenchyma
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Diagnosis of CAP to those living at _____
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home, admitted to healthcare facilities for 14 days prior
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What is the number one cause of death from infectious disease?
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CAP
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Patients w/ these diseases are more susceptible to CAP:
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COPD, DM, renal insufficiency, CHF, chronic liver disease
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Involved in scavenging particles and cellular debris in alveolar spaces
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Alveolar macrophages
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Five routes of infection
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aspiration - most common
inhalation - influenza bloodstream invasion lymphatic invasion direct extension |
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How does using a proton pump inhibitor cause CAP?
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changing the normal pH of GI tract changes the normal flora which becomes important in aspiration pneumonia
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Physiologic changes seen in CAP
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increased: O2 consumption, alveolar ventilation, shunt fraction, V/Q mismatch, hypoxemia, hypocarbia (initially), CO, HR
decreased: compliance of lung tissue, later CO and HR |
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Respiratory symptoms of CAP:
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cough, dyspnea, pleuritic chest pain
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Non-respiratory symptoms of CAP:
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fevers/chills, HA, nausea, vomiting, GI probs, myalgia, arthralgia, altered mental status
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Elderly typically present w/ _____ symptoms.
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vague/nonspecific
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Most common cause of typical CAP
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S. pneumoniae
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Presentation of typical CAP
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abrupt onset, dypnea, purulent sputum
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Causes of atypical CAP
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mycoplasma, chlamydia, and legionella
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Presentation of atypical CAP
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prodrome of a couple of weeks, myalgias, arthralgias, fever, decreased appetite, GI probs, dry cough
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Physical findings of CAP
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fever or hypothermia, crackles, consolidation, dullness to percussion, increased tactile fremitus, whisper pectoriliquy, bronchial breath sounds, egophany, pleural friction rub
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What is the benefit of CXR in CAP?
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can differentiate CAP from other diagnoses, helps identify more complicated forms of CAP, abscess, pleural effusions, bronchial obstruction causing atelectasis
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Poor prognostic factor, more likely to admitted to ICU
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multilobar involvement
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How do lateral films help?
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to localize findings and better determine presence of pleural effusion
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Interstitial infiltrates confined to outer third of lung field.
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CXR finding of atypical pneumonias
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Sputum gram stain can be diagnostic for:
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mycobacterium, endemic fungi, Legionella, PCP
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T/F: CT are very useful when diagnosing CAP.
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False
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Work up of CAP patient
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2 sets of blood cultures, diagnostic thoracocentesis if pleural effusion present, CBC, electrolytes, LFTs
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Who should you hospitalize w/ CAP
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older than 65, coexisting illnesses, previous hospitalization w/in 1 year, suspicion of aspiration, AMS, post-splenectomy, chronic alcohol abuse, malnutrition, malignancy
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Predictive physical findings for mortality/morbidity
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RR>30
DBP<60, SBP<90, MAP<60 Temp<35 or >40 septic arthritis, meningitis HR>125 |
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Predictive Labs for mortality/morbidity:
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BUN>20
Cr>1.2 HCT<30% Hgb<9 WBC<4X10^9 or >30X10^9 ANC<1X10^9 PaO2<60, PaCO2>50 RA |
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Unfavorable CXR:
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more than 1 lobe involved, presence of cavity (give IV), rapid radiographic spreading, pleural effusion
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Evidence of sepsis or organ dysfxn:
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metabolic acidosis, DIC
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Most common cause of CAP
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Streptococcus pneumoniae
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Most common cause of ARDS
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pneumonia
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T/F: A healthy individual can carry S. pneumoniae.
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True (20% carrier rate)
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prototype for lobar pneumonia
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S. pneumoniae
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High risk groups for S. pneumoniae:
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need to activate complement b/c of capsule,
post-splenectomy Sickle Cell patients immune deficient |
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Clinical manifestations of S. pneumoniae:
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dense consolidation, abrupt onset, rusty sputum
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Second most common cause of CAP
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Mycoplasma pneumoniae
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Clinical manifestations of m. pneumoniae.
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slow onset/general malaise prodrome, upper respiratory, sore throat, HA, dry cough, bullous myringitis (inf. of tympanic membrane), EXTRAPULMONARY COMPLICATIONS
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Diagnosis of M. pneumoniae
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cold agglutins and serology
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Treatment of M. pneumoniae.
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macrolides, quinolones, doxycycline, tetracycline
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Which drugs will not work for atypical pneumonias?
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penicillins, Beta-lactams, cephalosporins, and sulfa drugs
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Most common CAP to cause multi organ failure:
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Legionella
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Manifestions of Legionella
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fever, cough, sputum, myalgias, dyspnea, diarrhea, altered sensorium, renal failure, rhabdomyolysis, myocarditis, resp. failure, thrombocytopenia,hyponatremia, increased liver transaminases
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Viral pneumonias seen in immune competenet host
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influenza, adenovirus, measles, varicella-zoster, RSV
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Clinical features of influenza
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prodrome similar to atypicals, but shorter temporal profile (1-3 days)
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Viral pneumonias seen in immune compromised hosts
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CMV, varicella zoster, Herpes simplex, EBV
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What indicates resistance in infectious disease?
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MIC>2mg/L, for lungs the threshold is MIC>4
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At risk groups for drug resistant s. pneumoniae
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elderly, on beta lactam therapy w/in three months, steroid use, multiple medical comorbidities, exposure to child in daycare
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At risk groups for GNR infection:
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nursing home residents, medical comorbidities, recent antibiotic therapy
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At risk groups for Pseudomonas infection
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structural lung disease, dilated airways, chronic steroid therapy, patient on broad spectrum antiobiotics w/in a month, malnourished
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What are they likely to have: outpatient w/o comorbidities?
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Pneumococcus, mycoplasma/chlamydia, H. influenzae, resp. viruses
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What are they likely to have: outpatient w/ comorbidities?
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Pneumococcus, mycoplasma/chlamydia, H. flu, GNR
sicker patients - legionella, H flu, GNR, staph |
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What are they likely to have: inpatient?
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pneumococcus, H flu, Legionella
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What are they likely to have: ICU patient?
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Pneumococcus, Legionella, H flu, GNR, staph
pseudomonas if previously infected and treated for pseudomonas |
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What do you treat an outpatient w/ no comorbidities?
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macrolide (azithromycin 500mg QD or clarithromycin BID)
doxycycline if allergic to macrolide |
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How do you treat outpatient w/ comorbidities?
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Beta lactam to cover pneumoccoccus and GNR
Macrolide or doxycycline for atypicals if allergic to penicillin give broad spectrum fluoroquinolone |
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How do you treat inpatient?
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IV beta lactam for pneumococcus and GNR
macrolide for atypicals fluoroquinolone if allergic to penicillin |
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How do you treat ICU patient?
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IV beta lactam for pneumococcus and GNR
macrolide for atypicals fluoroquinolone if allergic to penicillin If at risk for Pseudomonas -- same w/ aminoglycoside |
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Treatment duration for bacterial infection?
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7-10 days
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Treatment duration for mycobacterial/chlamydia infection?
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10-14 days
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Treatment duration for Legionella?
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14 days
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When do you swith from IV to oral meds?
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improvement in cough and dyspnea
afebrile on two occasions 8 hours apart decrease WBC |
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T/F: If CXR clears up right away, it wasn't pneumonia.
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true
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If you give an antibiotic and nothing changes in a day should you change regimen/
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No, antiobiotics take a while to work.
fever - 2-4 days WBC - several days physical exam - week CXR - over a week |
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What are some possibilities if pneumonia doesn't improve w/ treatment?
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wrong diagnosis
host issues wrong antibiotics abscess pleural effusion |
