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30 Cards in this Set
- Front
- Back
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pneumonia
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-inflamm usually caused by viruses or bacteria or irritants, involving lung parenchyma
-you, elderly, and immune deficient pts are esp at risk |
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pneumonia epidemiology
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-increasing prevalent in pts with
1. COPD 2. DM 3. Malignancy 4. Heart failure 5. Neurologic diseases (aspiration problems, not able to cough) 6. Narcotic and alcohol use 7. Chronic liver disease 8. Smoking |
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Community acquired pneumonia
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-chronic disease increases the risk
-predictable pathogens sensitive to abx (strep pneumoniae, H. influenza, M. Catarrhalis) -prevention with prophylactic measure and/or vaccines -2-40% mortality -Community acquired MRSA pneumonia: causes toxic necrotizing pneumonia |
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Health care associated pneumonia
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-weakend host
-multiple abx resistance is common -partly preventable with changes in hospital/ICU practice -30-70% mortality |
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pneumonia pathophys
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-most commonly germs innoculate the lung by aspiration of oropharyngeal contents
-microaspiration occurs in otherwise healthy ppl during sleep -gross aspiration in indiv with an altered sensorium, depressed consciousness, abnormalities of protective cough or gag reflexes, or substantial gastro-esophageal reflux -lung becomes infected as a consequence of bacteremia- staph sepsis from an IV catheter; right-sided endocarditis (IV drug users); miliary TB (immuno comp host) |
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pathophys cont
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-inhalation of small suspended aeroslized droplets containing microorganisms
1. mycobacterium tuberculosis 2. legionella pneumophila 3. Yersinia pestis 4. Bacillus anthracis |
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pneumonia- clinical manisfestations
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-cough, sputum, dyspnea, chest or abd pain
-fever (not always in elderly) and crackles -loss of appetite, confusion, dehydration -worsening of symptoms or signs of other chronic illnesses -symptoms may be subtle in elderly or immunocomp -failure to thrive or abd symptoms |
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pneumonia- initial evaluation
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1. severity and duration of symptoms
2. Predisposing factors 3. Exposure to other who are ill 4. Living situation 5. Travel and occupational history 6. Exposure to pets/wild animals |
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history-clues to pathogen
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1. exposure ot sick kids: strep pneumoniae, mycoplasm
2. structural lung disease- gram - baccilli, esp pseudomonas 3. episode of unconsciousness- anaerobic abscess 4. steroid therapy- pneumocystis carinii, staph, fungi 5. COPD- H. influenza, moraxella catarrhalis 6. EtOH use - pneumococcal, gram - bacilli 7. HIV disease or IV drug abuse - TB, pneumocystic carinii 8. Recent abx use- drug-resisten gram - bacilli |
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after H&P
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-PA and lateral chest x-ray
-CBC with differential -sometimes a sputum gram stain and culture -an assessment of gas exchange- oximetry or arterial blood gas determination in the ED -hospitalization is indicated for respiratory distress, hypoxemia, dehydration, confusion |
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differential dx
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1. bronchiits, esp COPD
2. PE 3. bronchogenic embolism 4. congestive heart failure 5. drug-indced lung diseases 6. chronic interstitial lung diseases |
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"atypical pneumonias"
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-dry cough, nml WBC, LFT abnormalities, patchy CXR densities, rusty colored sputum, rigor
-mycoplasma and chlamydia most common causes -generally mild disease -legionella may be more severe and assoc with more extrapulmonary symptoms -no fever, nml pulses, no chest pain |
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viral pneumonia
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-Severe acute respiratory syndrome (SARS)
-causes by the SARS-asoc coronavirus -cause of rapidly progressive respiratory insufficiency with a case fatality rate of 4 to 15%, depending on the age and geographic location of the patient -dx depends on exposure hx -influenza (elderly) and respiratory synctial virus (RSV) (infants) can also cause severe pneumonia |
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Nosocomial pneumonia
(HCAP) |
-staph aureus
-gram neg: pseudomonas, enterobacter, klebsiella, e.coli |
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The chest x-ray
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-the extent of infx (multi-lobar)
-pleural effusion- parapneumonic effusions, empyema -loss of volume or atelectasis- an obstructing bronchial CA, mucus plugging, a foreign body in the airway -hilar lymph nodes and upper lose disease- think of TB, think of CA |
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the sputum gram stain
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-may reveal a single, predominant organism
-tells you only the class of organism not the exact species -no clear correlation between Gram stain findings and the results of deep-lung cultures in patients with community-acquired pneumonia -should be obtained if a drug-resistant germ is suspect (HCAP situation) -can be used in diagnosis if it shows fewer than 10 squamous cells and more than 25 WBCs per low-power field |
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culture data
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-cultures of normally sterile body fluids such as blood, pleural fluid are highly specific when positive
-1/4 pts with bacterial pneumonia have bacteremia -therefore in a hospitalized pt, get 2 sets of blood cultures |
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antigen-testing in urine
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Legionella:
1. a standard ELISA: result in 4hrs 2. A rapid test: result within 15 min 3. Sensitivity 80%, specificity 99% 4. still useful after therapy has begun but -detects only serogroup 1 -only do this when legionella is clinically suspected Pneumococcus: urine test is avail |
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The role of bronchoscopy
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-detection of specific pathogens (PCP)
-immunocomp hosts -pts whose conditions have worsened despite initial antimicrobial therapy -evidence of vol loss and distal consolidation suggesting an endobronchial obstruction |
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pneumonia- treatment
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-initial empiric therapy: initiated within 4 hrs
-guidelines for initial empirical therapy of CAP target: S. pneumonia and H. influenza and atypicals -for HCAP: staph and gram -, VRE, MRSA, ESBL (extended spectrum beta lactamase) |
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choosing the "right" abx
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1. first stratified the pt with respect to where tx is initiated: outpt, inpt or "sicker", ICU setting
2. identify any underlying cardiopulmonary disease |
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pneumonia- when to hospitalize
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-CURB-65: confusion, elevated Bun, ResRate >20, low BP, age >65
-Score 0-1: <2% risk of mortality, Score 4-5: 25-40% risk of mortality |
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tx of simple cases
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-advanced generation macrolide, such as azithromycin or clarithromycin
-tx for 305 days |
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tx of the sicker pt
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-IV B-lactam (ceftriaxone, ampicillin/sulbactam) plus either IV macrolide or doxyclicline
-IV anti-pneumococcal fluoroqionoline may be used alone, but NOT f or ICU pts |
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tx of pts "at risk"
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-risk of death: patients who have respiratory failure, sepsis, organ dysfunction (often in ICU)
-risk of resistant germs: *patients with structural lung disease (particularly bronchiectasis) *greater than 10 mg/day of corticosteroids *Neutropenia *Broad-spectrum antibiotics in past 3 month |
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tx of high risk pt
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-antipseudomonal drug: ceftepime, piperacillin-tazobactam PLUS
-drug for MRSA and resistant pneumococcus: vancomycin, linezolid |
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pneumonia- follow up care
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-Persistence of abnormalities on the chest radiograph or the development of recurrent pneumonia in a similar distribution should prompt a careful search for an underlying endobronchial obstruction such as an occult neoplasm, foreign body, bronchostenosis, or broncholithiasis.
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pneumonia-prevention
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-Immunization with pneumococcal vaccine (Pneumovax) for patients over 65 years old, with chronic cardiopulmonary disease, diabetes, alcoholism, or other chronic disease, or asplenia.
-Revaccination at 5 years -Children should be immunized with conjugated vaccine (Prevnar) -Annual immunization against influenza |
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pneumovax-23
-pneumococcal vaccine |
-poysacharide capsule Ag
-adults: age >65, immunosuppressed, cardiopulmonary dis., alcoholism, DM, NH resistence -not effective for CAP |
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Prevnar
-pneumococcal vaccine |
-conjugated to protein
-children, age <2yr -effective for bacteremia and CAP -Schedule: age 2,4,6 and 12 months, then follow-up Pneumovax at age 2 yr |
