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109 Cards in this Set
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(3) Typical Sx of Pneumonia
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Fever;
Cough w/ sputum; Pleurtic Chest pain |
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Pneumonia is the ____ leading cause of death in the United States?
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6th
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(4) Physical Exam findings w/ Pneumonia
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Dullness to Percussion;
Rales (Crackles); Egophany; Tactile Fremitus in consolidated segment |
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What organism is responsible for up to 90% of all bacterial pneumonias?
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Pneumococcus
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Bug Dx:
27-yo patient has pneumonia, bullous myringitis and a chest film that looks worse then expected |
Mycoplasma Pneumonia
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Lobar pneumonias present how?
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Signs of consolidation -- bronchial breath sounds, egophony, increased tactile and vocal fremitus, dullness to percussion, pleural friction rub and cyanosis may be present
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If a patient comes to the ER w/ consolidation and pleural effusion on CXR, what is the most important test to determine admission / Tx?
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Thoracentesis
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Lobar pneumonias are usually caused by what?
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Klebsiella and pneumococcus.
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Bug Dx:
patient w/ HIV who has a CD-4 count of 52 does not take antiretroviral meds or TMP-SMX, is hypoxic on room air, and has a diffuse bilateral infiltrate on chest film |
PCP
(Pneumocystis Carinii Pneumonia) |
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Bronchopneumonias present how?
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rales and rhonchi without consolidation
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Bug Dx:
Elderly man presents w/ pneumonia, GI Sx, bradycardia, and hypoN |
Legionella
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Organism responsible for bronchopneumonias?
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H. influenzae
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Pneumonia Bug Dx:
Currant Jelly sputum |
Klebsiella
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empyemas most common with which organisms?
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S. aureus, Klebsiella and anaerobic infections.
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Pneumonia Bug Dx:
Rusty sputum |
Pneumococcus
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Nursing Home-Acquired pneumonia displays which characteristic?
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Increased frequency of oropharyngeal colonization by gram-negative organisms.
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Pneumonia Bug Dx:
patient develops a post-influenza pneumonia |
Pneumococcus
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empiric therapy for Nursing Home-Acquired pneumonia should cover which organisms?
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- Streptococcus pneumoniae
- Staphylococcus aureus - Haemophilus influenzae - gram-negative bacteria |
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Pneumonia Bug Dx:
Buldging fissure on CXR |
Klebsiella
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What is the single best agent for broad spectrum coverage in Nursing Home-Acquired pneumonia?
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Levofloxacin
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Pneumonia Bug Dx:
No bacteria on sputum gram stain culture (2) |
Legionella
Mycoplasma |
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Pneumonia Bug Dx:
signs of pneumonia and Serum LDH is high |
PCP
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MC Community Acquired, typical pneumonia
(2) |
S. pneumoniae
H. Influenzae |
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MC Community Acquired, atypical pneumonia
(3)* |
Community Lung Mess:
Chlamydia pneumoniae; Legionella; Mycoplasma |
Community Lung Mess
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MC Hospital Acquired pneumonia
(3) |
Pseudomonas aeruginosa;
S. aureus; Enteric organisms (E. coli) |
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What is the MCC of pneumonia (bugs) in the HIV patients as the CD-4 count decreases to the following numbers
(in order of occurrence)*: 1. < 500 2. < 200 3. < 200 4. < 200 5. < 50 6. < 50 |
The Pneumonia HIV Causes Are Count-based:
1. TB (500) 2. PCP (200) 3. Histoplasma (200) 4. Cryptococcus (200) 5. Avium (mycoplasma) (50) 6. CMV (50) |
The Pneumonia HIV Causes Are Count-based
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MCC of pneumonia in the immunocompromised host w/ Neutropenia
(4)* |
Pseudomonas;
Enterobacteriaceae; S. Aureus; Aspergillus |
PESA
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MCC of pneumonia in the immunocompromised host w/ sickle cell or a splenectomy
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Encapsulated organisms
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MCC of pneumonia in the immunocompromised host w/ chronic Steroid use
(2) |
TB;
Nocardia |
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MCC of pneumonia in Alcoholics
(4) |
S. pneumoniae;
H. Influenzae; Klebsiella; TB |
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Pneumonia Bug Dx:
Small gram negative rod w/ a halo on gram stain |
H. Influenzae
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CXR pneumonia findings:
Upper lobe (2) |
TB;
Klebsiella |
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CXR pneumonia findings:
small cavities w/o air-fluid levels |
TB
(Mycobacterium) |
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CXR pneumonia findings:
Large cavities w/ air-fluid levels that do not culture (2) |
Coccidioidomycosis;
Nocardia |
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CXR pneumonia findings:
Diffuse Bilateral Infiltrates (2) |
PCP;
Mycoplasma |
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Definition:
Idiopathic Eosinophilic Pneumonia |
Loeffler's pneumonia
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Pneumonia bugs causing "Relative Bradycardia"
(slower then expected HR for Temp, but above 60bpm) (3) |
Legionella;
Salmonella; Chlamydia Psittaci |
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What drug prevents respiratory failure and improves survival in PCP pneumonia patients?
Criteria for when it is given? (2) |
Steroids
give: A-a gradient > 35 PaO2 < 75 |
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Drug of choice for:
Any Community Acquired Pneumonia w/ no risk factors |
Macrolide
(Erythromycin, Azithromycin) |
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Drug of choice for:
Any Community Acquired Pneumonia w/ risk factors (CHF, DM, etc) (2) |
1. Macrolide + 2nd generation Cephalosporin
2. FQ (Extended-spectum) |
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Drug of choice for:
Any Hospital Acquired Pneumonia (2) |
1. Cefixime
2. Piperacillin-tazobactam [both for Pseudomonas coverage] |
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Drug of choice for:
Any Immunocompromised patient w/ Pneumonia |
TMP-SMX
[for PCP coverage] |
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Dx:
Productive cough, night sweats, hemoptysis, anorexia, weight loss, chest pain, fever, chills |
TB
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(3) Dx tests for TB
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Positive PPD;
Granuloma in upper lobes of lung; Acid-fast bacilli on sputum |
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How is latent TB treated?
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INH daily for 9 months
(or Rifampin for 4 if in contact w/ INH-resistant TB) |
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How is Active TB treated?
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RIPE for 2 months:
Rifampin; INH, Pyrazinamide; Ethambutol followed w/ 4 months of: INH and Rifampin |
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How is tx of TB different w/ pregnant pt?
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No pyrazamide
(other med ok) |
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Toxicity of INH
(2)* |
INH: Infects Neuro and Hepatic:
Neruopathy; Seizures; Hepatitis |
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Dx:
patient brought by ambulance in status epilepticus. Patient says only medical history is TB How is it treated? |
INH toxicity
Tx: Pyridoxine |
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Toxicity of Rifampin
(2) |
Induces P450
Gives Red-orange secretions (tears, urine, sweat, etc) |
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Toxicity of Ethambutol
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Optic neuritis and impaired color vision
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Nosocomial pneumonia may have what significant past medical history?
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History of hospital admission within 90 days of symptoms.
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Nosocomial pneumonia requires coverage for which organisms?
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- MRSA
- Pseudomonas - Acinetobacter species |
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appropriate antibiotics for nosocomial pneumonia?
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- vancomycin
- cefepime - ciprofloxacin - ceftazidime and gentamicin |
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aspiration pneumonia often involves which organisms?
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anaerobic
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Aspiration pneumonia can be a complication of which procedure?
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upper endoscopy
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Significant physical finding for aspiration pneumonia?
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foul smelling sputum
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Poor dentition increases the risk of which type of pneumonia?
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aspiration pneumonia
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appropriate antibiotic for aspiration pneumonia?
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clindamycin for anaerobic coverage.
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What type of pneumonia tends to be the most serious?
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Community-acquired pneumonia
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What is the most common cause of community-acquired bacterial pneumonia?
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Streptococcus pneumoniae
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Gram positive diplococci (Streptococcus pneumoniae
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Gram stain for Streptococcus pneumoniae?
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Gram positive diplococci
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Vaccine for S. pneumoniae recommendations?
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23-valent capsular polysaccharide vaccine for pneumococcus recommended for healthy adults 65 and older.
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Gram positive cocci in clusters (S. aureus)
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Gram stain of S. aureus
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Gram positive cocci in clusters.
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What group of patients is S. aureus most common in?
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IV drug users
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Which type of pneumonia is most common in IV drug users?
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IV drug users
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Which patients are at risk for S. aureus pneumonia?
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- IV drug users (most common)
- elderly - recent influenza infection - cystic fibrosis |
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Recent influenza infection can lead to which type of pneumonia?
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postviral lobar pneumonia
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S.aureus can lead to which complication of pneumonia?
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severe necrotizing pneumonia
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What factors contribute to necrotizing pneumonia?
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cell wall virulence factors produced by S. aureus promote binding to mucosal cells.
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Usual presentation of atypical pneumonia
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fever, chills, malaise, dyspnea and a nonproductive cough
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Most common cause of atypical pneumonia?
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- Respiratory viruses
- Mycoplasma - Chlamydia |
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Pathognomonic feature of Mycoplasma infection?
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Bullous myringitis
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Bullous myringitis is pathgnomonic for what?
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Mycoplasma infection
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Bullous myringitis definition?
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inflammation and blistering of the tympanic membrane
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Signs of Legionella pneumonia?
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Atypical pneumonia symptoms plus gastrointestinal symptoms
- anorexia - nausea - vomiting - diarrhea - mental status changes may be present |
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What cellular features is common for atypical pneumonia?
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Organisms which lack a cell wall
- Mycoplasma pneumonia - Chlamydia pneumonia |
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Treatment of atypical pneumonia?
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treat with protein synthesis inhibitors
- macrolides - tetracycline |
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Which additional lab test is recommended for atypical pneumonia?
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Purified protein derivative (PPD)
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Which patients are more prone to atypical pneumonias?
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young adults
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what is the most common cause of atypical pneumonia in young children?
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Respiratory viruses
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By school age, what is the most common cause of atypical pneumonia?
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Mycoplasma pneumoniae
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Preventative measures for atypical pneumonia?
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- flu vaccine prevents influenza pneumonia
- Hib vaccine prevents Haemophilus influenzae type b |
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What mediates the dectruction of infected respiratory epithelial cells in influenza pneumonia?
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Cytotoxic T-cells
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treatment for parainfluenza virus
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- racemic epinephrine in acute phase (rebound can occur)
- oral or IM dexamethosone (0.6 mg/kg as a single dose) or - nebulized budesonide |
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secondary pneumotoceles are a feature of what?
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acute necrotizing pneumonia caused by S. pneumoniae
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Clinical features necrotizing pneumonia
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- blood streaked sputum
- multiple midfield lung cavities on CXR |
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Common cause of pneumonia at 4 months - 4 years old?
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Respiratory syncytial virus
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Common cause of pneumonia at 5 - 15 years old?
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Mycoplasma pneumoniae
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Which antibiotics is Mycoplasma pneumoniae sensitive to?
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macrolides
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Main diagnostic features of pneumonia?
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- presenting signs and symptoms
- examination of the sputum - chest radiograph |
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Secondary tests to consider in pneumonia?
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- WBC with diff
- pulse oximetry - blood cultures - pleural fluid examination - ABG in ill appearing patients |
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Tests to add for suspected Legionella pneumonia?
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- serum chemistry
- LFTs - urine tests for Legionelle antigen |
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Clinical findings in Legionelle pneumonia?
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- hyponatremia
- hypophosphatemia - elevated LFTs |
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Mainstay of treatment for pneumonia?
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azithromycin 500 mg PO on day one followed by 250 mg daily for 4 days
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which patients receive fluoroquinolones for pneumonia?
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highly effective, but reserved for patients who cannot tolerate or have failed other agents to prevent fluoroquinolone resistant pneumonia
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fluoroquinolone regimens for pneumonia?
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- levofloxacin 500 mg daily 10 to 14 days (each)
- moxifloxacin 400 mg - gatifloxacin 400 mg |
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Which patients require hospitalization for pneumonia?
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- immunocompromised
- pregnancy - clinical signs of toxicity - serious comorbid conditions |
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What are clinical signs of toxicity which might require hospitalization for pneumonia?
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- RR > 30
- HR > 125 - SBP < 90 Hg - hypoxemia - AMS - volume depletion |
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Patients hospitalized for pneumonia should receive which empiric antibiotics in the ER?
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- ceftriaxone 1 to 2 g IV daily
- levofloxacin 500 mg IV daily - cefotaxime 1 to 2 g IV every 8 hours - ampicillin/sulbactam 3 g IV every 6 hours piperacillin/tazobactam 3.375 g every 6 hours - cefepime 1 to 2 g every 12 hours |
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which patients are at high risk for gram-negative or Legionella pneumonia?
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- alcoholics
- diabetics - institutionalized pts. - intubated pts. |
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Empiric treatment for patients at high risk for gram-negative or Legionella pneumonia?
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- levoflozacin monotherapy
- combination of macrolide (erythromycin 1 g IV Q6) and ampicillin/sulbactam 3 g IV Q6 - ceftriaxone 1 to 2 g IV daily |
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Coverage for suspected Pseudomonas?
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- double coverage with antipseudomonal penicillin (ticarcillin) or cephalosporin (ceftaxidime) plus and antipseudomonal aminoglycoside (tobramycin) or fluoroquinolone (ciprofloxacin)
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treatment for aspiration pneumonia?
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- levofloxacin 500 mg/d IV
- PO ceftriaxone 1 to 2 g/d IV or IM |
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Suspect aspiration pneumonia in which patients?
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- severe periodontal disease
- putrid sputum - alcoholism |
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empiric treatment for suspected aspiration pneumonia?
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- piperacillin/tazobactam 3.375 g every 6 hours
- imipenem 500 mg every 8 hours - fluoroquinolone plus clindamycin 600 mg every 8 hours |
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How to manage witnessed aspirations?
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- immediate tracheal suctioning
- measure pH of aspirate - bronchoscopy for removal of large particles if needed - PEEP if intubation is required - Oxygen - steroids and prophylatic antibiotics of no value |
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