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69 Cards in this Set
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Strep pneumonia
sx labs cxr |
50% CAP
shaking chills, pleuritic cp high wbc (or low if overwhelming) sputum rusty cxr lobar consolidation |
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strep pneumonia
when is mortality increased |
elderly, alcoholic, underlying illness, multilobar, WBC<5k
BACTEREMIA 30% mortality |
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strep pneumonia
gm stain diagnosis |
lancet shaped gm+diplococci w PMNs, best if orgs intracell
sputum gm st, c&S +BC pneumococc urinary AG assay+` |
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strep pneumonia
tx |
high dose amox
levofloxaxin, gatiflox, moxiflox, gemiflox azithromycin , biaxin |
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Staph aureus pneumonia
Sx labs/sputum |
usu preceding influenza or on recent abtics/staph Resist
low WBC and sepsis blood in sputum/salmon colored |
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Staph aureus pneumonia
cxr complications |
patchy infiltrates, may cavitate
empyema , IC glomerulonephritis, pericarditis |
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Staph aureus pneumonia
dx tx |
gm st sputum, C&S, Bc
nafcillin or vanco until cx back |
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enteric gram neg pneumonias
usual suspects: |
Klebsiella, proteus, e coli
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enteric gram neg pneumonias
pt population presentation |
30% of pneumonias in elderly
sepsis, rapidly fatal sputum:current jelly-blood +sputum |
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enteric gram neg pneumonias
cxr diag tx |
kleb: may show bulging fissure
usu none cavitate tx new quinalone or pip/tazobactam |
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Pseudomonas aeruginosa pneumonia
pt population tx |
mech vent, immunosuppressed, recent br spectrum abtics, malnutrition
2 synergistic antipseud drugs ie gent plus ceftazidime or cefoperazone or piperacillin or ticarcillin) |
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H flu pneumonia
pt population sputum gm stain tx |
elderly esp copd, also IgG deficient pts
gm stain: gm neg coccobacilli tx: amp or augmentin, 3rd gen ceph, doxy, quinalones, sulfa |
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Moraxella catarrhalis
pt population sputum gm stain tx |
chronic bronchitis, copd, dm, cancer or on steroids
gm st: gm neg cocci tx: doxycycline, macrolide, ceph, augmentin |
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atypical pneumonias
pt population bug/for pt who hunts/skins bug for pt works around cattle/sheep |
younger pts. may follow URi
don't look toxic hunt/skin tularemia sheep/cattle Q fever/coxiella burnetti |
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Mycoplasma pneumonia
pt population incubation, course |
20% of CAp, young pts
2-3 wk incubation, slow spread cxr worse than pt looks |
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Mycoplasma pneumonia
extrapulmonary manifestations: |
hemolytic anemia, splenomegaly, E multiforme(Stevens Johnson also), arthritis, myringitis bullosa, pharyngitis, tonsillitis, CONFUSION
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Mycoplasma pneumonia
dx tx |
dx complement fixation-meas mainly IgM ab dont use cold agglutinins
tx: Macrolide, doxy, may take 6 mo to recover! |
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Chlamydia pneumoniae
pt population presentation/course |
epidemic pneumonia in young people
similar to mycoplasma, addtl sx laryngitis biphasic: pharyngitis, then 2-3 wks later pneumonia |
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Chlamydia pneumoniae
dx tx |
dx single IgM titer using microimmunofluroscence, +cx , PCR of resp secretions or 4 fold inc in IgG titers
tx doxy or macrolides x 3 wks |
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Legionella pneumonia
where do you get it? how present? |
cool damp places, winter/summer months
multisystem dx: diarrhea and CNS sx, cxr worse than exam also low sodium/phosphate |
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Legionella pneumonia
dx tx |
dx: sputum cx on special media, urinary AG assay
tx: azithromycin or quinalones, add rifampin if ill |
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Cocciodioides immities pneumonia
pt population additional s/s |
endemic in Southwest
e nodosum and E multiforme |
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Cocciodioides immities pneumonia
dx tx |
dx: immunodiffusion gel diffusion
tx: fluconazole or amphoB if there is hemoptysis or enlargement on cxr may be self limited |
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Disseminated cocciodiomycosis
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seen w HIV
fulminant w meningitis, skin/bone involvment freq fatal |
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Histoplasma capsulatum pneumonia
endemic in: assoc w ?animals |
Mississippi and Ohio
assoc w chickens and bats |
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Histoplasma capsulatum pneumonia
CXr: |
CXR: hilar adenopathy and focal alveolar infiltrates
May have multiple nodules |
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Histoplasma capsulatum pneumonia
dx tx |
dx: systemic: Ag test of blood, BAL or urine
pneumonia:serology tx none, sometimes itraconazole, ampho B if severe |
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Blastomyces dermatitidis pneumonia
pt population cxr |
mid aged men in central SE and mid atlantic states M:f 10:1, indolent to severe
cxr shows infiltrates/masslike |
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Blastomyces dermatitidis pneumonia
dx tx |
dx sputum: koh large single budding yeast
tx observe if mild or itraconazole mod itraconazole x 6 mo or fluconazole severe ampho B HIV require chronic suppresion w itraconazole |
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Aspiration pneumonia
bugs expected |
fusobacterium nucleatum
Bacteroides melaninogenicus anaerobic strept |
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Aspiration pneumonia
tx |
don't start right away, may just be chemical, but may cavitate/pneumonia
augmentin or clindamycin |
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Nosocomial Pneumonia
3 situations in which you may see this |
1. hosp acquired if 48 hrs or more after admit
2. vent assoc more than 48-72h after intubation 3. healthcare assoc pneumonia pt in hosp for 2/more days w/in 90d of developing pneumonia, NHP, |
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Nosocomial pneumonia
MC bugs seen |
strep pneumo, staph aureus (incl MRSA), H flu
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Outpatient pneumonia tx
no risk factors |
azithromycin, clarithromycin or doxycycline
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Outpatient pneumonia tx
with risk factors |
beta lactam plus macrolide or doxycycline
or antipneumococcal quinalone gatiflox, gemiflox, levoflox, moxiflox covering for drug resist strep, and enteric GM -(also) |
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Inpt non ICU pt
no risk factors |
advanced macrolide only with betalactam
or antipneumococcal quinalone covering for DRSP, enteric GM- |
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Inpt non ICU pt
with risk factors |
IV betalactam (cefotaxime, ceftriaxone, amp/sulbactam, hi dose amp PLUS iv/oral macrolide or doxy
covering DRSP, enteric, aspiration, PCP |
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Inpt ICU pt
neg risk for pseudomonas |
IV beta lactam PLUS iv/oral macrolide or doxy or resp quinalone
or IV antipneumococcal quinalone +/- clindamycin covering drsp, enteric, staph aureus, |
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Inpt ICU pt
pos risk for pseudomonas |
iv antipseudomonal beta-lactam (cefepime, imipenem, meropenem, pip/tazo) PLUS: iv antipseudomonal quinalone(cipro)
or IV antipseudo b-l PLUS either IV azithromycin or IV nonpseudomonal quinalone covering drsp, enteric, staph, pseudomonas |
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pneumonia severity index
what comorbid illnesses affect the index? |
neoplasm +30
liver dx +20 CHF +10 cerebrovasc dx +10 renal dx +10 |
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pneumonia severity index
what physical exam findings affect the index? |
altered mental status +20
resp rate >30 + 20 systolic <90 +20 temp <35 or>40 +15 pulse >125 +10 |
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TB infection sequence
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primary infection>> latent infection>> reactivation
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TB reactivation
when does this occur in average pt? in HIV? risk of conversion in ave pt, In hiv? |
days/yrs ave pt, 5% risk of conversion w/in 2 yrs, 5% thereafter, 90% disease free
HIV 40% risk conversion w/in several months |
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primary tb where in lungs?
reactivation tb where located in lungs |
lower lobes primary
upper lobes/apices lower lobes |
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PPD high risk positive at ?induration
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5 mm
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PPD intermed risk pos at ? induration
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10 mm
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PPD low risk pos at? induration
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15 mm
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PPD high risk population is:
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known/suspected HIV
close contacts of active TB CXR suggests prev inactive TB organ transplants and immunosuppressed pts w >1 mo prednisone use |
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PPD intermediate risk population is:
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IV drug user known to be HIV-
immunosuppressive illness or pred <15 mg/d dm, renal dx or hematologic malig imigrants from hi risk countries residents of NH/correctional facilities migrant workers, homeless |
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Treatment of LTBI
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isoniazid/INH x 9 mo
if intolerant rifampin x 4 mo if exposed to inh resistant rifampin x 4 mo |
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Neg PPD but close contact of reactivation tb pt
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TX x 10-12 wks then PPD again
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reactivation TB 4 drug regimen
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INH
rifampin pyrazinamide (PZA) and either ethambutol (oral, preferred) or streptomcin (injection |
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reactivation TB 3 drug regimen
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INH
rifampin PZa pyrazinamide REST IN PEACE |
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Reactivation TB therapy
length of tx |
all get 4 drug regimen x 2 mo, then drop 4th drug if other 3 sensitive, then inh/rifampin for 4 more mos
must observe pts taking drugs unless totally sure compliant |
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reactivation TB therapy
need this vitamin to prevent periph neuropathy |
B6 pyridoxine
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TB med: ethambutol
watch for ?toxicity |
dec in visual acuity
needs baseline ophthal exam then periodic cks loss of color reception first to go |
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Mycobacterium kansaii
pt population affected: tx: |
immunocompetent esp smokers and pts w DM or silicosis
3 drugs inh/rif/ethambutol |
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Mycobacterium avium complex or MAC
pt population affected: course of illness cxr tx: |
50-80 yo women w chronic cough
indolent cxr: "tree in bud" clarithromycin/ethambutol/rifampin |
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What type of pts have humoral dysfunction?
this makes the susceptible to what types of infections? |
B cell dysfunction or decreased antibodies seen in: ALL, CLL and multiple myeloma, hypogammaglobulinemia, asplenia, sickle cell, abnl complement
susceptible to encapsulated orgs: pneumococcus, meningococcus, H flu |
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What type of pts have cell mediated infections?
this makes the susceptible to what types of infections? |
T cell defects: AIDS, lymphoma, uremia, organ transplant, steroid user
PCP, mycobacteria, viruses (CMV, HSV)fungi, legionella, nocardia |
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Organ transplant pts /T cell defects
1.infections first 30d 2. 1-4 mo 3. after 4 mo |
1.first 30d: usu nococomial, esp GM- pneumonias, legionella
2. 1-4 mo: pcp(P. jiroveci) CMV, mycobacteria 3. After 4 mo: pcp, encapsulated, fungus, viral, community acquired |
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what is the most common cause of fever after transplant?
dx: tx: |
CMV
usu 6-8 wks post transplant think if mixed bag of "itises", pneumonitis, hepatitis, adrenalitis dx: inclusion bodies on tissue sample tx: ganciclovir |
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AIDS pts pulmonary infection
highest/lowest frequency for HIV pts |
PCP>TB>MAI>Bacteria>CMV/HSV<fungal
for HIV;; MC is bacteria/TB first! |
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PCP/AIDS pts
cxr: dx tx |
cxr diffuse bilat symm interstial/alveolar infiltrates
dx: sputum IF monoclonal ab in 80% or BAL tx: IV/oral bactrim or IV pentamidine alt: atovaquone usu tx given w steroids in pts w mod/severe pneumonia--if PaO2<70 or A-a gradient >35 |
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aspergillosis/AIDS pts
also AML, ALL, hodgkins, heart/BM transplant, steroids dx course |
dx sputum worthless cuz aspergillus often found/nl sputum, can try nasal cx or lung bx
course: invades vessels:pul infarct, disseminates |
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cryptococcal pnemonia
pt population: CXR: Dx: |
seen more in Hodgkins, steroids, transplants
cxr nodules or mass lesions dx sputum, needle asp/lung bx all are ways to diag if C. neoforms found do lumbar puncture to r/o cns |
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nocardia/T cell deficient pts
and w alveolar proteinosis pulmonary picture: tx |
pulmonary lesions may cavitate
may see brain abscesses and subcutaneous lesions tx sulfonamides |
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reactivation pulmonary infections
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TB, toxoplasmosis, herpes, cryptococcosis, strongyloides all can reactivate in the immunosuppressed
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Causes of pulmonary hemorrhage:
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common in pts w AML--but must also r/o Aspergillus
others: Goodpastures, pulmonary hemosiderosis, SLE, post bone marrow transplant |
