1
Q
What are the 4 ways pneumonia (PNA) can be transmitted?
A
- Aspiration from the oropharynx
- Inhalation of contaminated droplets
- Hematogenous spread
- Extension from infected pleural or mediastinal space
(just b/c you are exposed to someone w/ PNA doesn’t mean you will get PNA)
2
Q
Pathophysiology of what?
- Proliferation of microbial pathogens at the alveolar level when the capacity of the alveolar macrophages to ingest or kill microorganisms is exceeded.
- Alveolar macrophages initiate an inflammatory response to increase the lower respiratory tract defenses
A
Pneumonia
3
Q
What are the 3 ways PNA can be classified?
A
- CAP
- HAP
- VAP
4
Q
T/F: CAP is the 2nd leading cause of death
A
FALSE
CAP is the 8th leading cause of death
5
Q
When is CAP most commonly seen?
A
Winter
(b/c there is seasonal variation)
6
Q
Which disease?
Men > women
African Americans > caucasians
A
CAP
7
Q
Risk factors for what?
- >65y/o
- Alcoholism and ALOC (due to lack of gag reflex)
- Tobacco use
- Immunosuppression/HIV
- Comorbidities (asthma, COPD, cardiac, cerebrovascular, DM, dementia, etc)
- Malnutrition
- Institutionalization
- Other underlying respiratory illness (lung cancer, cystic fibrosis, bronchogenic obstruction)
A
CAP
8
Q
Which 8 comorbidities are risk factors for CAP?
A
- Asthma
- COPD
- Cardiac
- Liver
- Cerebrovascular
- Seizure disorder
- DM
- Dementia
9
Q
Which 3 underlying respiratory illnesses are risk factors for CAP?
A
- lung cancer
- Cystic fibrosis
- Bronchogenic obstruction
10
Q
What is the MC bacterial cause of typical CAP?
A
S. pneumoniae
11
Q
What are the top 3 MC pathogens that cause atypical CAP
A
1. Mycoplasma pneumoniae
2. Chlamydophila pneumoniae
3. Legionella spp.
(these are not susceptible to B. lactams)
“CLM”
12
Q
What is the MC viral cause of CAP?
A
Influenza
13
Q
A
14
Q
What are 8 possible clinical presentations of CAP?
A
- Fever
- cough (+/- sputum/hemoptysis)
- Dyspnea
- Chest discomfort
- pleurisy
- fatigue, weakness
- GI sxs (anorexia, abd pain, N/V/D, failure to thrive)
- mental status changes (esp in elderly)
15
Q
What are 6 clinical presentation signs in CAP
A
- Fever (or hypothermia)
- Tachypnea
- Tachycardia
- Low O2 sat
- Rales
- Signs of consolidation
*clinical presentation is not super sensitive- need CXR*
16
Q
Which pathogen?
- Sudden onset of chills
- rust colored sputum
A
S. pneumoniae
17
Q
Which pathogen?
- children and adolescents
- asymptomatic or mild
- CXR- reticulonodular pattern/patchy areas of consolidation
A
M. pneumoniae
18
Q
Which pathogen?
- GI disorders (watery diarrhea)
- Confusion or encephalopathy
- Outbreaks usually from contaminated water sources
A
Legionella
19
Q
Which pathogen?
•Cavitary infiltrate or necrosis
- Gross hemoptysis
- Rapidly increasing pleural effusion
A
MRSA
20
Q
Which pathogen?
- Comorbidities usually include alcohol abuse, DM, severe COPD
- “currant jelly” sputum (thick, mucoid, blood-tinged)
A
Klebsiella pneumoniae
21
Q
What do you see on CBC w/ CAP?
A
leukocytosis w/ left shift
22
Q
What do you see on CXR in CAP?
A
Deonstratable infiltrate
- lobar
- interstitial
- cavitation
23
Q
What is the gold standard for diagnosing CAP?
A
CXR
24
Q
What can you order to help diagnose pathogen responsible for CAP if your patient is not responding to tx?
A
urine antigen tests (S. pneumonia, Legionella)
25
What is the **first step in the Pneumonia Severity Index** (used to determine if suitable for inpatient or outpatient tx of CAP)
If positive to any of the following then go to step 2:
* **\>50y/o**
* **Coexisting conditions** (neoplastic dz, HF, cerebrovascular dz, renal dz, liver dz)
* **abnormal vitals, altered mental status**
(if negative for all then outpatient)
26
What is step 2 of the Pneumonia Severity Index (used to determine if outpt or inpt tx for CAP)
Risk stratification- if score is **_\< 70_** then outpatient
\*basically- if patient is over 65ish + comorbidities, nursing home resident or crappy vitals--\> ADMIT
* Points for age in yrs; -10 for female
* (ex: 65pts for 65y/o man, 55pts for 65y/o woman)
* Nursing home resident
* comorbidities (HF, CKD, etc)
* AMS
* RR\> 30
* SBP\<90
27
What is CURB 65 and what is it used for?
Used to determine if **inpatient or outpatient** tx of CAP
## Footnote
**C**onfusion
**U**rea \> 7 mmol/L (BUN \> 20 mg/dL)
**R**espiratory Rate ≥ 30 breaths/minute
**B**lood pressure (SBP \<90 or DBP \<60)
**65**- ≥ 65 years old
28
How is CURB 65 scored (which score is outpatient vs inpatient)
Score 0-1: outpatient
Score 2: Admit
Score 3-5: assess for ICU care
29
What is different about the CRB-65 compared to the CURB-65? How is it scored?
–Removes need for labs (BUN)
–Score of 0 = low predicted mortality--\> no need for hospitalization
–Score 1-2 = consider for hospitalization (increased risk mortality)
–Score 3-4 = urgent hospitalization +/- ICU
30
What do IDSA/ATS guidelines recommend for **outpatient tx of CAP** in a pt that is **previously healthy** and has **not had abx w/in the last 3 months**
treat empirically for **at least 5 days** w/ :
**macrolide**
or
**Doxycycline**
31
What do IDSA/ATS guidelines recommend for **outpatient tx of CAP** in a pt w/ **risk factors for** **macrolide resistant S. pneumoniae or antibiotic use within the past 3 months**
Treat empirically for **at least 5 days** w/:
**Respiratory fluoroquinolone**
OR
**beta-lactam** (first line= high dose amoxicillin or amoxicillin-clavulanate)\* PLUS **macrolide**
\*alternative choice for beta lactam= ceftriaxone, cefpodoxime, cefuroxime
32
What is the duration of CAP treatment- outpatient?
* At least 5 days
33
If you have a patient with CAP that you are treating on an outpatient basis, what should you say to reassure the patient in regards to **duration of sxs?**
1. Median time to resolution:
* 3 days for fever
* 14 days for cough and fatigue
2. At least 1/3 will have at least one symptom at 28 days
34
When should you consider follow up CXRs for a pt w/ CAP that you are treating outpatient?
if they remain symptomatic
smokers
elderly
35
What is tx for CAP if **inpatient but _non-ICU_?**
**Respiratory fluoroquinolone**
OR
**beta-lactam plus a macrolide**
(tx for a min of 5 days)
36
What is tx for CAP if in the **ICU** (not PCN allergic)?
**anti-pneumococcal beta-lactam** PLUS **azithromycin**
or
**anti-pneumococcal beta-lactam** PLUS **respiratory fluoroquinolone**
37
What is tx for CAP if in the **ICU** if patient is **PCN allergic?**
**respiratory fluoroquinolone**
PLUS
**aztreonam**
38
CAP tx- inpatient (ICU):
What are the 7 risk factors for Pseudomonas?
1. Alcohol use disorder
2. Cystic fibrosis
3. Neutropenic fever
4. Recent intubation
5. Cancer
6. Organ Failure
7. Septic Shock
"CANCORS"
39
CAP tx- inpatient (ICU):
What are the 4 risk factors for MRSA?
1. ESRD
2. IV drug abuse
3. Prior antibiotic use
4. influenza
40
How do you tx CAP if pt is inpatient (**ICU**) and there is **pseudomonas** risk?
Antipneumococcal, antipseudomonal beta lactam\*
**_plus_** either ciprofloxacin or levofloxacin (750 mg)
**_OR_**
above beta-lactam\* + aminoglycoside + azithromycin
**_OR_**
above beta-lactam\* + aminoglycoside + respiratory fluoroquinolone
\*e.g. cefepime, piperacillin-tazobactam
for PCN allergic substitute aztreonam for above beta-lactam
41
How do you tx CAP inpatient **(ICU**) if **MRSA** risk?
Add vancomycin or linezolid
42
How do you tx CAP if pt is inpatient (**ICU**) and there is **pseudomonas** risk AND pt is **_PCN allergic_**?
aztreonam + either ciprofloxacin or levofloxacin (750 mg)
**_OR_**
aztreonam + aminoglycoside + azithromycin
OR
aztreonam + aminoglycoside + respiratory fluoroquinolone
(same as tx for non-PCN allergic but replacing beta lactams w/ aztreonam)
43
In a pt w/ CAP receiving IV abx- what criteria must be met in order to change to oral tx?
- overall clinical improvement
- hemodynamically stable
- able to take oral meds
- improvement in fever, respiratory status and WBC
44
What is the duration of inpatient treatment?
**•Minimum of 5 day**s and all of the following:
* Afebrile for 48-72 hours
* Supplemental O2 not needed
* Heart rate \< 100
* RR \< 24
* SBP ≥ 90 mm Hg
45
What is an important aspect of CAP treatment?
smoking cessation
46
What are 3 complications of CAP?
1. **Bacteremia**
2. **Sepsis**
3. **Cardiac complications**
* **** heart failure
* MI
* arrhythmia
47
How is CAP prevented?
Vaccinations!
48
Which vaccinations are given to prevent CAP? Who gets them?
**Influenza**: all patients
Sequential administration of **PCV13** and **PPSV23**: \>65y/o
* When possible give PCV13 first; followed by PPSV23 one year later
* If already received PPSV23, give PCV13 at least 1 year after most recent PPSV23 dose
49
What 6 conditions in an immunocompetent pt would be indications to give PPSV23 vaccine at an earlier age (19-64)?
1. alcoholism
2. chronic heart dz
3. chronic liver dz
4. chronic lung dz
5. cigarrette smoking
6. DM
"HALLD"
50
how long after receiving PCV13 is it recommended to give PPSV23 to **immunocompromised** patient that is **19-64 y/o?**
\>8 weeks after PCV13
51
how long after receiving first dose of PPSV23 is it recommended to be revaccinated w/ PPSV23 in immunocompromised patients that are 19-64 y/o?
\>5 yrs after 1st dose of PPSV23
MJ- Foundations 2 Exam 3
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