Nosocomial Infections, Pneumonia

Front 1

What % of patients admitted to acute care hospitals acquire infections?

Back 1

5-10%

Front 2

Most commonly acquired hospital infections

Back 2

Urinary tract 40%
Pneumonia 20%
Surgical site 17%
Bloodstream (IV) 8%

Front 3

3 ingredients for healthcare associated infections

Back 3

Susceptible host; Virulent organism; Portal of entry

Front 4

Mechanism of Transmission:
Contact : defn

Back 4

Direct person to person; Indirect thru an object like contaminated instruments

Front 5

Mechanism of Transmission:
Airborne: defn

Back 5

Organisms having a true airborne phase as pattern of dissemination (<5 microns)

Front 6

Mechanism of Transmission:
Common-vehicle: defn

Back 6

Extremely rare in US hosiptals.

Common animate vehicle as agent of transmission (ingested food or water, blood products, IV fluids)

Front 7

Mechanism of Transmission:
Droplet: defn

Back 7

Larger particles than airborne (>5 microns); Don't go as far. Brief passage thru air when source and patient in close proximity.

Front 8

T/F hospital acquired pneumonia mortality is very high

Back 8

T

Front 9

What % of ventilated people develop pneumonia?

Back 9

1-3 per DAY of intubation

Front 10

Early onset healthcare associated pneumonia organisms (First 3-4 days of ventilation) have what characteristics?

Back 10

Antibiotic sensitive; community organisms.

S. pneumoniae, H. influenzae, S. aureus

Front 11

Late onset associated pneumonia organisms (>4 days of ventilation) have what characteristics?

Back 11

NOSOCOMIAL. Antibiotic resistant.

Pseudomonas aeruginosa, Acinetobacter spp. Enterobacter.

Front 12

risk factors for ventilator pneumonia

Back 12

1) ENDOTRACHEAL INTUBATION!! massive point of entry. Pooling of oral secretions.

2) ICU
3)Abx
4) Sx
5) Chronic lung disease

Front 13

How to prevent hospital pneumonia?

Back 13

Pulmonary toilet - changing position every 2 hours.

Elevation of head to 30-45 degrees.

Frequent suctioning.

Bronchoscopy to remove mucous plugging.

Front 14

incidence of healthcare associated UTI

Back 14

5%/day

Front 15

Of patients who develop bacteriuria, ___% develop bacteremia

Back 15

3

Front 16

Comprise the largest pool of antibiotic-resistant pathogens in hospital

Back 16

Catheter-associated UTIs

Front 17

#1 catheter-associated pathogen

Back 17

E Coli

Front 18

Most impt prevention of nosocomial UTI

Back 18

Avoid catheter when possible and discontinue ASAP

Front 19

3rd most common nosocomial infection

Back 19

surgical site infections

Front 20

bacitracin and polymixin have activity against what type of organisms?

Back 20

bacitracin: gram +
polymixin: gram -

Front 21

indurated: defn

Back 21

firm, not spongy and soft

Front 22

When do most SSIs occur?

Back 22

Within 30 days of surgery.

BUT implantations can cause infections up to 1 year

Front 23

Receipt of right choice of perioperative antibiotic: how important is this? When should it be started?

Back 23

SO IMPORTANT. 30-60 minutes before procedures.

Front 24

Whenever you see pus, what is ALWAYS in DDX?

Back 24

S aureus

Front 25

When should prophylactic perioperative abx be given?

Back 25

30-60 minutes prior to incision

Front 26

T/F Hair should be removed by shaving prior to surgery

Back 26

F. Microscopic exudative rashes and skin abrasions can occur during hair removal.
These rashes and skin abrasions can provide a portal of entry for microorganisms

Front 27

Blood stream infections are almost always due to what?

Back 27

Presence of central venous catheter

Front 28

What is the most common cause of Central Line Associated Bloodstream Infection (CLABSI)?

Back 28

Coagulase-neg staph. Generally wimpy unless in the presence of foreign material.

Front 29

Prevention of CLABSI: Hopkins Model (Central Line Bundle): what is it?

Back 29

1) Designated central line insertion cart

2) Insertion checklist

3) Bedside nurse empowered to stop procedure if step is missed.

4) Ask every day during rounds whether catheters can be removed

Front 30

Most feared airborne particle?

Back 30

TB

Front 31

What mask needs to be worn to enter room?

Back 31

N95

Front 32

For airborne precautions, what do you need?

Back 32

1) Negative pressure (air in but not out)

2) Private room

3) Door kept closed

4) Wear N95 mask

Front 33

What kind of precautions does meningoccocal infection require?

Back 33

Droplet

Front 34

Agent of choice to keep bacteria down

Back 34

chlorhexidine

Front 35

2 major types of pneumonia

Back 35

Community Acquired Pneumonia (CAP)- typical vs. atypical
Healthcare Associated Pneumonia (HAP)

Front 36

2 kinds of community acquired pneumonia

Back 36

1) typical
2) atypical

Front 37

Leading cause of infection related death in hospitalized pts

Back 37

pneumonia (33-50%)

Front 38

6th most common cause of death in community

Back 38

pneumonia

Front 39

most common cause of pneumonia worldwide

Back 39

streptococcus pneumoniae

Front 40

4 ways someone can develop pneumonia

Back 40

1) Microaspirations: small amounts of lower resp secretions get into lungs

2) Macroaspirations

3) Hematogenous spread (eg., endocarditis)

4) Direct spread from contiguous focus

Front 41

Virulence factors : Chlamydophila pneumoniae

Back 41

Chlamydia inhibits activity of cilia (ciliostatic)

Front 42

Virulence factors : Mycoplasma pneumoniae

Back 42

Shears off cilia

Front 43

Virulence factors : influenza virus

Back 43

Causes thickening of tracheal mucus that can persist for months postinfection

Front 44

Virulence factors :S. pneumoniae

Back 44

produces proteases that can split secretory IgA. Capsulation is a virulence factor (inhibits phagocytosis). Neuraminidase, hyaluronidase.

Front 45

Virulence factors: mycobacterium spp., nocardia spp., legionella spp.

Back 45

Resistant to microbicidal activity of phagocytes

Front 46

Alterations in the level of consciousness: how does it affect pneumonia?

Back 46

predispose to macroaspiration of stomach contents and to microaspiration of upper airway secretions during sleep

Front 47

Most common viral causes of pneumonia

Back 47

Influenza virus is the most common viral cause of CAP in adults; less often parainfluenza, RSV, adenovirus, varicella

Front 48

Stayed in cabin in Rocky Mountains for a week: raises suspicion for what?

Back 48

hantavirus

Front 49

Characteristics of typical pneumonia

Back 49

High fever

Quick onset

Pleuritic chest pain (on inspiration)

Focal findings on exam except one spot where it hurts

Can see it on chest x ray

Front 50

Causes of typical pneumonia

Back 50

S. pneumoniae; H influenzae; S aureus, Group A Strep; Moraxella catarrhalis, aerobic gram negative

Front 51

Characteristics of atypical pneumonia

Back 51

Subacute; Dry cough, may or may not have fever, extrapulmonary manifestations (headache, nausea, vomiting);
diffuse, patchy, cavitary findings on CXR

Front 52

Causes of atypical pneumonia

Back 52

Legionella spp

Mycoplasma pneumoniae

Chlamydophila spp.

anaerobic bacteria (tend to be less virulent than aerobic and so have more indolent course), Mycobacteria spp., viral pathogens, PJP, endemic fungi

Front 53

______, also called Whitmore's disease, is an infectious disease caused by the bacterium Burkholderia pseudomallei.

Back 53

Melioidosis

Front 54

Infiltrate: defn

Back 54

abnormal shadow

Front 55

focal infiltrate: defn

Back 55

one area of lung where you see a shadow. Fluid and inflammatory cells.

Front 56

pleural effusion

Back 56

Fluid around the lung.

very virulent bacteria can cause it.

Front 57

Diffuse scattered infiltrates associated with what?

Back 57

PJP, legionella, viral

Front 58

Multiple nodule infiltrates associated with what?

Back 58

S aureus, fungi, nocardia

Front 59

Typical lesion of TB

Back 59

upper lobe cavities

Front 60

What pathogens cause cavities?

Back 60

anaerobic bacteria, Mycobacteria (TB), Rhodococcus equi, Aspergillus species

Front 61

fastest way to dx legionella?

Back 61

urinary antigen

Front 62

nasopharyngeal swab is useful for what diseases?

Back 62

flu, adenovirus

Front 63

bronchoalveolar lavage (BAL) with special stains: used to dx what?

Back 63

(MTB, Pneumocystis, fungi), biopsy (cytomegalovirus) and others

Front 64

CURB 65: score. What is it?

Back 64

Confusion of new onset

Urea (BUN) greater than 19 mg/dL

Respiratory rate of 30 breaths per minute or greater

Blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg or less


age 65 or older

Front 65

PSI (Pneumonia Severity Index) : what does it help assess?

Back 65

How sick the patient is and whether they should be admitted to hospital

Front 66

What kind of pneumonia would Mycoplasma pneumoniae cause?

Back 66

Atypical presentation, aka "walking pneumonia"

Ex. 3 weeks wtih extrapulmonary manifestations

Hemolytic anemia. Erythema multiform.

Usually young adults from a communal setting (eg., military recruits, college kids)

Very subacute course. Possibly low grade fever. Dry cough. Lots of different complains.

CXR: interstitial pattern.

Front 67

bullous myringitis is suggestive of what?

Back 67

Mycoplasma pneumoniae infection

Front 68

Quellung reaction: what is it?

Back 68

anticapsular antiserum reacts w/ capsular polysaccharide, reveals distinctly outlined capsule

Front 69

What type of pneumonia does s. pneumoniae cause?

Back 69

Typical.

Front 70

Symptoms of s. pneumoniae pneumonia?

Back 70

Acute onset, fevers and chills, cough, lobar pneumonia. Beware if no spleen. Austrian’s triad-pneumonia, bacteremia, meningitis.
Gram positive diplococci, Quellung reaction
Bacterial infections in general, and pneumococcal pneumonia in particular, are much more frequent in HIV+ patients even at high CD4. Trimethoprim/sulfamethoxazole (Bactrim) reduces risk of pneumococcal CAP. Pneumovax every 5 yrs is recommended, 23 serotypes.
Resistance a growing problem, use ceftriaxone, +/-vancomycin. Beta-lactam antibiotics are preferred.

Front 71

What is Austrian's triad?

Back 71

Pneumonia, bacteremia, meningitis

Front 72

Why is having no spleen a risk factor of s. pneumoniae?

Back 72

ppl with no spleen are susuceptible to ENCAPSULATED bacteria

Front 73

What is TMP/SMX used to treat in AIDS patients?

Back 73

S. pneumoniae, PJP

Front 74

What kind of pneumonia does PJP cause?

Back 74

Usually in HIV CD4 <200.

Subacute course, often with relatively asymptomatic severe hypoxia at presentation. Dry cough, clear lungs, diffuse infiltrates on CXR.

Front 75

What kind of pneumonia does Klebsiella cause?

Back 75

Classic “Friedlander” pneumonia occurs in an alcoholic and is severe, necrotizing upper lobar pneumonia, often with cavitation.
Associated with viscous, dark-brown “currant jelly” sputum

Front 76

One of most common causes of gram-negative pneumonias and important cause nosocomial pneumonias (HAP and VAP)

Back 76

klebsiella

Front 77

What patients are at risk for klebsiella infection?

Back 77

Patients with COPD (chronic obstructive pulmonary disease), diabetes, nursing home residents, and neutropenic (very low WBC, eg w chemotherapy) patients also at risk.

Front 78

Aspiration pneumoniae is associated with what type of bacteria?

Back 78

Anaerobic

Front 79

What kind of pneumonia do anaerobic bacteria cause?

Back 79

Subacute course, often resulting in abscess formation and pleural collection of pus (empyema).

Foul smelling sputum, poor response to “usual” antibiotics (lack anaerobic coverage).

Front 80

Treatment of aspiration/anaerobic pneumonia

Back 80

penicillin, clindamycin: gram positive anaerobes (oral flora)

Front 81

Patients at risk for aspiration pneumonia

Back 81

alcoholics, seizure disorder, stroke, swallowing difficulties

Front 82

What kind of pneumonia does Group A Strep cause?

Back 82

Very severe typical pneumonia. Can happen after flu.

Clues are viral prodrome, then very high fever, pleuritic chest pain, early pleural effusions/empyema (bilateral “syn-pneumonic” effusions are classic - happen at same time).

Front 83

What kind of pneumonia does Legionella cause?

Back 83

Clues are high fever, severe illness (altered mental status), temp-pulse dissociation (Faget’s sign), gastrointestinal symptoms, headache, low sodium, hepatitis, purulent gram stain w/o organisms, rapid deterioration

Front 84

Difference between Legionairre's disease and Pontiac Fever?

Back 84

Legionnaire’s disease is the more common syndrome of pneumonia. Pontiac fever is acute, febrile, self-limited illness, no treatment necessary. Often associated with water sources—Hot tubs.

Front 85

Treatment of Legionella

Back 85

Antibiotic with intracellular coverage: Macrolides, quinolones

Front 86

Risk factors for TB

Back 86

At risk are elderly, malnourished, homeless, HIV+, incarcerated

Front 87

What kind of pneumonia does TB cause?

Back 87

Often a nonspecific presentation as “the dwindles”, often mistaken for congestive heart failure. Clues are low sodium, anemia (anemia of chronic disease), high ESR (erythrocyte sedimentation rate- marker of inflammation).

Front 88

erythrocyte sedimentation rate: what is this?

Back 88

nonspecific marker of inflammation

Front 89

About 60% of people with cystic fibrosis have a chronic respiratory infection caused by a bacteria called ______ that settles into the thick mucus trapped in the airways.

Back 89

Pseudomonas aeruginosa