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63 Cards in this Set

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