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27 Cards in this Set

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What is the most common lethal nosocomial infection?

Leading cause of death from an infectious dz?
HAP

CAP
What is the most common route of infection that leads to pneumonia?
microaspiration of pathogens colonizing the oropharynx
What often causes pneumonias in alcoholics?
Smokers, COPD?
Often has a younger host?
Most common cause of CAP?
Seen after influenza infections, nosocomial, is also a hematogen?
Sick host, associated with bronchiectasis, nosocomial?
Klebsiella pneumoniae (-)
H. influ (-)
Mycoplasma pneumonia
Strep Pneumo (+)
Staph aureus (+)
P. Aeruginosa (-)
Are the clinical sx of pneumonia onset highly predictive of specific pathogens?
No.
Classify the following Sx list as either a typical or atypical presentation of pneumonia:

Rapid onset
Ill appearing
High fever, rigors, chest pain, purulent sputum

Consolidation, rales on exam
Leukocytosis

Airspace filling/lobar infiltrate on CXR


What was this meant to describe?
Typical

Meant to describe: S. pneumo, S. aureus, GN bacilli
Does the following Sx list describe a typical or an atypical presentation of pneumonia:

Indolent onset
Less ill appearing
Low-grade fever, malaise, headache, dry cough
Rales without consolidation
Mild/no leukocytosis; negative cultures
Patchy/interstitial infiltrates

What types of organism(s) is this *meant* to describe?
Atypical

Mycoplasma or Chlamydia
What usefulness does CXR have in Dx'ing pneumonia?
may dist. b/t pneumonia and other issues (TB, CHF, etc)

Assesses severity
Identifies complications
What kind of pneumonia causes an interstitial infiltrate, and is often seen in HIV+ pts?
PCP
Are blood cultures specific for pneumonia dx? Sensitive?
Are gram stains/cultures useful, generally speaking?

How do you test for TB microbiologically? Fungus? Legionella?
Specific, but not sensitive.

Meh: high false neg and pos rates.

AFB smear/culture
KOH/culture
urinary antigen immunoassay
When *are* gram stains/cultures useful?

When is it recommended that they be use?
Large # of bact/ w/ a single morphology observed
- many PMNs
- few/no swuamous epithelial cells
--> lower airway specimin
- sample obtained before antiB
- detection of a non-colonizer (mycobacteria, endemic fungi, Legionella, PCP)

Use in hospitalized pts; but pay attn to caveats.
On CXR of suspected pneumonia, etc., what should we think when we see an upper lobe, cavitary infiltrate?

How about when the sx have an indolent course x weeks/months --> non-resolving on txt?

What should be closely investigated, in either case?
TB

Fungal or TB

Potential exposures.
If an atypical presentation pneumonia is seen in an outdoorsman, what might you think of?

How about in someone from the desert southwest?
Blastomycosis

Coccidioidomycosis
Would you expect to see cavitations with fungal pneumonias (e.g. coccidioidomycosis)?
Yes b/c they can cause necrotic granulomatous inflammation as well.
Age >60yr
comorbidities (cancer, organ failures, etc)
altered mental status
RR>30
SBP<90
T>40 or <35
HR>125
WBC>30k or <4k
hypoxemia
acidosis
multilobar involvement on CXR
fulminant progression

... what do these findings evidence in a pneumonia pt?
severity.
Are inital tx's usually based on a certain pathogen dx re: pneumonia?

How many tx categories are there?
no.
Initial treatment choices are nearly always empiric.

4
If there is structural lung dz present (e.g. bronchiectasis, CF, etc.), or if there has been recent broad spec. antiB use, malnutrition or chronic steroid use... what pathogen might you put high up on the Diff Dx?
P. aeruginosa
What are the 4 tx groups for pneumonia?
*Outpatient
1: no underlying dz or modifying fx
2: underlying comorbidities or modifying factors (CHF, COPD, alcoholism, etc...)

*Inpatient
3. Inpatients *not* needing ICU care
a. no comorbidities
b. comorbidities
4. severe dz requiring ICU care
a. low psuedomonas risk
b. @ risk for psuedomonas
What bugs would we think for Pneumonia Tx group 1? Tx?

Group two?

3?
S. pneunomia, H. influ, Mycoplasma, chlamydia, viri
- adv. macrolide (azithromycin, clarithromycin)
- fquin with good respiratory coverage: levofloxacin, moxifloxacin

Same, but w/ Aerobic GN bacilli and DRSP
- antipneumococcal fquin
- 2nd/3rd ceph + macrolide

w/Legionella
- IV 3rd cepth + macrolide
- IV antiP fquin
What bugs would we think for Pneumonia Tx group 4? Tx?
S. pneumoniae
Aerobic GN bacilli
DRSP
Legionella
S. aureus
Pseudomonas
H. influ
- IV 3rd ceph + macrolide
- IV antipneumococcal fquin
- consider Vancomycin (MRSA and PRSP)
- if @ risk for psuedomonas:
+ anti-pseudomonal B-lactam w/ ciprofloxacin.
How long can fever persist when pt is being given appropiate tx?
Patchy CXR?
~3 days
Weeks
What is the dx of HAP based on?

What might it be difficult to distinguish from?
Fever, leukocytosis
new, worsening infiltrates
new/increased respiratory secretions
Not based solely on a new culture result

CHF, PE, Pulm hemorr, ARDS
Which is more likely to be polymicrobial, CAP or HAP?
HAP
Below whichCD4+ # should we really worry about PCP in an HIV+ pt?

Is prophylactic tx in compliant pts effective?
<200

Yes: trimethoprim/sulfa, dapsone, inhaled pentamidine
What is the most likely dx in the sx HIV+ pt w/ an abnormal CXR?
Bacterial pneumonia.
What are the features of the clinical presentation of PCP?

How do we make the dx?

Tx?
dyspnea, dry cough, fever.... insidious onset

Diffuse infiltrates typical
Hypoxemia prominent feature.

Visualization: DFA/Silver stain in BAL.

Trimeth/sulfa
IV pentamidine
Coriticosteroids if pO2<70mmHg or A-a grad > 35mmHg
Is there a particular CD4# that puts HIV pts @ risk for TB?
No, susceptible @ any number; however, more typical at higher CD4 counts.
Cryptococcus neoformans is a common cause of what in HIV pts?

When it does cause pulmonary dz, is it any specific pattern?
meningitis, usually w/o pneumonia

Meh, Local or diffuse pulmonary dz; disseminates