Resp Final - Dr. Ramirez: Community Acquired Pna

Front 1

definition

Back 1

- infxn of alveoli, distal airway, and interstitium (LRT)**
- occurs outside hospital setting; prior to hosp visit

Front 2

2 types of CAP; clinical presentation

Back 2

1. typical: fever, chills, pleuritic chestp, sputum prod, CXR -> at least 1 opacity

2. atypical: *non-prod cough; *CXR -> interstitial pattern; incubation period > with bacT PNA; pt may NOT be as toxic

Front 3

differences b/w typical & atypical PNA:
1. cough
2. CXR

Back 3

1. typ = productive; atypical = non-prod

2. typ = atleast 1 opacity; atyp = interstitial pattern

Front 4

pathogenesis

Back 4

- *microaspiration of oropharyngeal colonized MOs -> MC route*

- *gross aspiration: MC of nosocomial acquired PNA*

Front 5

describe patho of nosocomial acquired PNA

Back 5

- gross aspiration = MC

- CNS disorders effect swallowing
- impaired consciousness
- anesthesia/intubation
- *G- bacilli & anaerobes

Front 6

other forms of pathogenesis

Back 6

- aerosolization
- hematogenous spread
- contiguous spread from another site

Front 7

comorbidities:
MC predisposing conditions

Back 7

-*alcoholism -> cirrhosis
- DM
- smoking
-*immunosupressed -> HIV
- sedation

Front 8

etiologies:
- MC type; specific type***
- what % of cases are caused by this?

Back 8

- bacT; strep pneumoniae***
- 50%

Front 9

other etiologies

Back 9

- H. influenza
- S. aureus
-*Mycoplasma
-*chlamydiae pneumoniae
- morexella catarrhalis
-*Legionella
-*aerobic G-
- influenza virus
- RSV

Front 10

strep pneumoniae**
1. morphology
2. transmission

Back 10

1. G+, cocci

2. direct droplet -> close contact

Front 11

Strep pneumoniae
- clinical*

Back 11

- pre-existing resp condition -> gets worse
- pt feels worse at onset -> *acute onset
- grayish-tinged skin -> anxious & ill
-*fever (MC) OR hyotermic
- shaking chil
-*sputum -> thick, yellow, green
- pleuritic chest pain

Front 12

strep pna:
- chest exam

Back 12

- splinting
-*dullness to precussion
- vocal fremitus
- bronchial breath sounds + crackles

Front 13

other things that cause consolidation

Back 13

- pleural effusion
- malignancy
- blood in the lung (hemothorax)

Front 14

strep pna:
- labs

Back 14

- Gm stain & culture -> **sputum AND blood

--**good Gm stain -> RBCs are really red

- CBC, chem profile, ABG, urine AG, sed rate

Front 15

strep pna:
- CXR

Back 15

-*multilobar ds (50%)
- air-space consolidation
-*air bronchogram (<50%)
--remember not a test but a SIGN
- pleural fluid (50%)

Front 16

strep pna:
1. PCN resistance
2. vaccine

Back 16

1 - intermed-strains (20%)
--> resistant to 1st & many 2nd gen cephalosporins
- resistant strains (15%)

2. *capsular polysaccharide
--(+) Abs: 23 most prev types of S. pna
--give to 5-15 yos

Front 17

CDC recommendations for strep pna vaccine

- indications

Back 17

-*all pts >2yoa or ALL pts admitted to hospital

- asplenia
- >65 yoa
- CSF leak
- immunocompromised
- DM, EtOHism, cirrhosis, CRF, advanced CV ds
- chronic pulm ds

Front 18

Klebsiella pna

Back 18

-**alcoholics, COPD (MC seen in)
--also neonates, nosocomial
- currant jelly PNA
-**bulging fissure (boards or TQ)
- lung necrosis -> *necrotizing PNA
--many WBC
- large G- rod and capsule

Front 19

other capsular bacT besides klebsiella PNA

Back 19

- pneumococcus, hemophilus

Front 20

H. influenzae

Back 20

1. non-typable -> MC acute tracheobronchitis or PNA in pt w/ chronic bronchitis, emphysema, COPD (always coughing)

Front 21

H influenzae
- other debilitating ds present w/ it

Back 21

- malnutrition
- lung ca
- alcoholism (**remember that this is MC a/w Klebsiella though**)

Front 22

bacT a/w atypical PNA

Back 22

- mycoplasma PNA (MC)**
- legionella
- chlamydia trachomatis
- chlamydia PNA (TWAR agent)
- chlamydia psittaci

Front 23

mycoplasma PNA
1. MCC of what
2. general
3. age of onset

Back 23

1. *atypical PNA
2. year round
- *person-person -> inhalation
- *kids and young adults
- smallest free living organism (no cell wall)
- longest incub period (2-3wks)

3. 5-20 yoa

Front 24

mycoplasma PNA
- clinical

Back 24

- fever (seldom >102-103)
- h/a
- cough -> sputum (white, may be blood tinged)
-->chest mm soreness
- paryngeal infxn
- arthralgia -> myalgia
- shaking -> chills
- GI symp
- pleuritic chestp (pleural effusions)
- bronchitis (PNA)
- cervical node enlargement
-**ear pain due to bullous myringitis** + atyp pna**
- ascultation is nL

Front 25

when you have ear pain d/t bullous myringitis + atypical PNA, what is the etiology until proven otherwise?****

Back 25

***mycoplasma until proven o/w

Front 26

myoplasma PNA:
associated syndromes (extra pulm)

Back 26

- hemolytic anemia
-*rash/erythema multiforme (can be only thing differentiates M. pna)
- hepatitis
- myocarditis
- arthritis (myelitis/encephalitis)

Front 27

what is the only thing that differentiates M. pna?

Back 27

*rash/erythema multiforme

Front 28

legionella
1. general
2. labs
3. CXR

Back 28

1. *adults; summer peak; AC/cooling towers

2. *hyponatremia (MC)*
- *hypophosphatemia
- renal insufficiency
- transiminitis (inc transaminase)
- leukocytosis

3. interstitial pattern

Front 29

what is the hyponatremia in legionalla d/t?

Back 29

*due to SIADH (syndrome of inappropriate ADH)

Front 30

legionella
- clinical

Back 30

-**is a SYNDROME: thus s/sx + atypical pna on CXR*** (different from other pna)
--mm aches, weakness, arthralgia
--general malaise
--fever/chills (f/ch)
--non-prod cough
--dyspnea
--GI symp
--ataxia
--confusion

Front 31

chlamydia pna (TWAR agent: taiwan acute resp agent)
- clinical

Back 31

- non-prod cough
-**sore throat & low grade fever
- low grade leukocytosis
- inc sed rate
- CXR - interstitial pattern
- possible *bronchitis & sinusitus (can be one or both concurrently)

Front 32

chlamydia psittaci
1. general
2. clinical

Back 32

1. year round; parrot/pigeons/ turkeys (inhalation); *adults**

2. high fever
- myalgias & h/a
-**splenomegaly** + atyp pna
- confused w/ legionella

Front 33

- what is the only clinical finding to suggest psitticosis

- what is psitticosis usually confused w/?

Back 33

-***splenomegaly + atypical pna

- legionella

Front 34

complications of pna

Back 34

- death (5th MC in US)
- abscess formation
- pleural effusion
- empyema (infxn of effusion)
- bacteremia -> sepsis
- resp failure

Front 35

tx of CAP/HAP
- outpt CAP (CDC is the most important to know but there are others in the notes if you wanna see)

Back 35

- b-lactam (1st gen cephalosporins)***
- macro ***
- doxy ***

Front 36

tx of CAP/HAP
- inpt (hospital)

Back 36

- all are given IV**
- b-lactam (3rd gen cephalosporins)**
- floroquino/macro**

Front 37

CAP
group 1

Back 37

out pt (w/ no underlying ds)
--> azithro + clarithro + doxy

Front 38

CAP
group 2

Back 38

out pt + underlying ds
--> b-lactam (1st gen) + azithro/floroquinolone

Front 39

CAP:
group 3a

Back 39

in pt w/ NO hx (IV)
--> azithro or FQ

Front 40

CAP
group 3b

Back 40

in pt w/ comorbidities
--> b-lactam (3rd gen) + FQ, macro, doxy

Front 41

tx for: (anasthasia went up to talk to him so its slightly diff from what was said in previous slides)
1. CAP
2. HAP
1. CAP
2. HAP

Back 41

1. 1st gen ceph + macrolide/FQ
2. 3nd gen ceph (antipeudomonal) + vancomycin

Front 42

possible TQ:**
Pt comes in w/ cough & heavy sputum prod
1. what can be ruled in
2. What would be the appropriate drug combo

Back 42

1. typical CAP d/t prod cough
2. 1st gen cephalosporin & macrolide
(apparently when she talked to him, he never said anything about doxy)

Front 43

nosocomial PNA (HAP)

Back 43

- #1 cause of death among nosocomial infxns
- 2nd MCC of noscomial infxns in USA
- inc in cost of care

Front 44

HAP
1. definition
2. usually includes
3. intubation patho
4. microorganism

Back 44

1. pna that occurs w/in 48 hrs (usually w/in
2. VAP (ventilator)
3. **intubation->fluid accumulation above cuff -> biofilms develop on ETT
---> staph (MRSA)
4.**MC pseudomonas & staph; G-; stenotrophomonas maltophilia is extremely resistant

Front 45

VAP

Back 45

arises 48-72 hrs after ETT

Front 46

HCAP (healthcare AP)

Back 46

hospitalized in acute care (nursing home, etc) for greater than 2 days

Front 47

risk factors for nosocomial pna

Back 47

-*underlying chronic lung, CV, renal ds
-*inc gastric pH
-*previoud abx tx

Front 48

***purulent bronchitis (TQ)

Back 48

- infxn of just upper airway (trachea, etc)***
-- purulent sputum
-- nL CXR
-- typical in ventilator pts

Front 49

why is CXR nL in purulent bronchitis?

Back 49

- b/c alveoli and LRT are NOT effected

Front 50

cell wall inhibitors

Back 50

B-lactams
glycopeptides
monobactams
carbapenems
daptomycin

Front 51

membrane permeability

Back 51

polymycins
detergents

Front 52

antimetabolites/folic acid

Back 52

sulfas
clotrimazole

Front 53

DNA inhibitor
1. repair
2. replication
3. transcription

Back 53

1. FQ
2. metronidazole; imidazole
3. rifampin; rifamycin

Front 54

protein synthesis inhibitor
1. inhibits 30s
3. inhibits 50s

Back 54

1. GOAT - glycylcyclines, oxazolidones, aminoglycosides, tetracycles
2. chloramphenicol, macrolides, lincomycins, ketolides

Front 55

combo txs

Back 55

-**cell wall inhib + something that inhibits metabolic progess
-**tx G+ & G-
- extremely resistant G- (antipseudomonal PCN, vanco)

Front 56

what should be done w/ HAP/VAP tx?

Back 56

use *optimal dose*
always IV
switch 3-4d to oral if possible

Front 57

what should be used for MDR (multi drug resis) microorganisms

Back 57

combo tx

Front 58

try for shortest tx time as possible:
1. # days
2. if necrotizing

Back 58

1. ~7d
2. 2wks

Front 59

*common problems a/w drugs
1. quinolones (levofloxacin)
2. dapto
3. linezolid
4. cefepime
5. ertapenem
6. meropenem

Back 59

1. ** inc QT intervals
2. inc CPK
3. ** serotonin syndrome
4. hypersensitivity
5. inc liver enzymes
6. hypersens + inc liver enzymes