Lower RTI

Question 1

Acute bronchitis

-etiology

Answer 1

bronchitis without pneumonia is ALWAYS viral

90% viral

• influenza viruses
• RSV
• other respiratory viruses

10% bacterial

• mycoplasma pneumoniae
• chlamydophila pneumoniae
• bordetella pertussis

Question 2

The Flu

• epidemiology (what time of year, who gets it, how many of us get it)
• major epidemics result of…

Answer 2

• winter months
• everyone gets it, but death highest among elderly and infants
• 10-20% attack rate

-Major epidemics are the result of rearrangement of the segmented genome (antigenic shift)

Question 3

The Flu

• etiology
• H and N significance

Answer 3

• Influenza virus
• Hemagglutinin binds sialic acid on cell surface
• Neuraminidase cleaves new virions from cell surface

Question 4

The Flu

-course of infection

Answer 4

• shedding 24-48h before symptoms
• sudden onset symptoms: fever, headache, myalgias, malaise, cough, rhinnorhea (like the cold, but worse)
• 2-7 days of symptoms
• viral shedding stops 6-7 days after symptom onset

Question 5

The Flu

-Management

Answer 5

• supportive therapy

- antiviral therapy (oseltamivir) for high risk

Question 6

The Flu

-Prevention

Answer 6

• Immunisation
• Chemoprophylaxis in nursing homes (oseltamivir)
• Droplet precautions

Question 7

COPD

-general definition

Answer 7

• irreversible air flow limitation, usually associated with an inflammatory response
• chronic bronchitis +/- emphysema

Question 8

Acute exacerbations of chronic bronchitis

-define chronic bronchitis, and an acute exacerbation

Answer 8

• Chronic bronchitis: productive cough for at least 3/12 for 2yrs
• Acute exacerbations: increased sputum volume, purulence +/- dyspnea

Question 9

Acute exacerbation of chronic bronchitis

-prevention

Answer 9

COPD patients should receive the flu vaccine each year and pneumococcal vaccine (q6 yrs)

Question 10

Acutre exacerbation of chronic bronchitis

-etiology

Answer 10

50% viral

Mild:
Haemophilus spp.
S. pneumoniae
M. cattarhalis

Moderate:
above + enterobacteriaciae

Severe:

above + P. aeruginosa

Question 11

Acute exacerbation of chronic bronchitis

-management

Answer 11

• If antibiotics are given, amoxicillin for mild, amoxil-clav for moderate and levofloxacin for severe

Question 12

Bronchiolitis

-epidemiology (who gets it? when?

Answer 12

• Infants and children

- fall—>spring

Question 13

Bronchiolitis

-etiology

Answer 13

• RSV (50-80%)
• Influenza (6-25%)
• Rhinovirus (16-25%)
• Parainfluenza (7-18%)

Question 14

Bronchiolitis

• S/S
• Diagnosis

Answer 14

• prominent cough, lethargy, inc. RR, signs of respiratory distress
• Can be seen on CXR unlike bronchitis

Diagnosis is clinical, but can do a viral nasopharyngeal swab

Question 15

Bronchiolitis

-Management

Answer 15

-supportive care

Question 16

Pneumonia

• definition
• CAP vs. HAP vs. HCAP vs. VAP

Answer 16

• inflammation of the alveoli, usually caused by viruses or bacteria
• Communit-acquired pneumonia
• Hospital acquired pneumonia
• Health-care associated pneumonia: non-hospital health care source
• Ventilator pneumonia

Question 17

Pneumonia

• etiology in children and adults
• atypical pathogens

Answer 17

Children: RSV, Influenza, S. pneumoniae, H. influenzae, S. aureus

Adults: more often bacterial–> S. pneumoniae most common (others exist)

Typical:
S. pneumoniae
H. influenza

Atypical:
Mycoplasma penumoniae
Chlamydophila pneumoniae
Legionella pneumophila

Viral:
Influenza

Oppotunistic:
PJP
TB
fungal

Question 18

Pneumonia

-predisposing conditions

Answer 18

• alcoholism
• diabetes
• CHF
• COPD
• smokers
• aspiration prone
• post-influenza
• cystic fibrosis (pseudomonas esp

Question 19

Pneumonia

-diagnosis

Answer 19

Treatment depends on the ability to identify the pathogen!!

• Physical
• History
• Sputum smear and culture
• CXR
• CT

Question 20

Pneumonia

-empiric therapy for outpatient CAP, inpatient CAP, nursing home CAP, HAP, VAP

Answer 20

Outpatient

• must use Ab that covers S. pneumoniae
• Amoxicillin
• If concerned about atypical pathogens add doxy or clarithromycin
• NOT macrolides (resistance of S. pneumo)

Inpatient
- use ceftriaxone

Nursing home patient
-Amoxil-clavulanate

HAP
-ceftriaxone

VAP
-pipercillin-tazobactam (want to cover P. aeruginosa)

Question 21

Atypical pneumonia

-mycoplasma pneumoniae diagnosis and treatment

Answer 21

Diagnosis: serology and CXR
Treatment: erythromycin (macrolide)

Question 22

Atypical pneumonia

-legionella pneumophila diagnosis

Answer 22

Diagnosis: consider in patients not responding to B-lactams and possible exposure (A/C, hot tubs, resp equipment). Urine antigen test

Treatment: quinolones or macrolides

Question 23

Empyema

-definition

Answer 23

• collection of pus in the pleural space

Question 24

Empyema

-etiology

Answer 24

• S. pneumoniae/pyogenes/aureus

- Anaerobes

Question 25

Empyema | -management

Answer 25

- drain pleural space, gram stain and C&S this fluid | - empiric therapy: ceftriaxone +metronidazole

Question 26

Lung abscess | -definition

Answer 26

-a cavity in the lung when microbial infection leads to necrosis of lung tissue

Question 27

Lung abscess | -etiology

Answer 27

- usually mouth flora (oral anaerobes e.g. streptococci) - TB - fungi - malignancy

Question 28

Lung abscess | -treatment

Answer 28

-clindmycin OR -penicillin +metronidazole

Question 29

Chronic pneumonia | -general causative agents

Answer 29

Bacteria Mycobacteria Fungi Parasites **rarely seen**

Question 30

TB natural history | -S/S

Answer 30

- inhalation of TB - Primary active disease OR - Latent infection --> reactivation Most TB is pulmonary: - cough - hemoptysis - weight loss - night sweats - low grade fever - dypnea Can also have: - pericarditis - meningitis - SSTI - Bone and joint infection

Question 31

TB | -diagnosis

Answer 31

- Ziehl-Neelson stain of sputum | - Fluorescent stain (bacilli, bright, beaded)