Term
| Which organisms should be considered in a patient who presents with Pneumonia 72 hours after hospitalization in the context of severe disease? |
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Definition
>48 hours in hospital is HAP (greater mortality than CAP)
Strep Pneumonia is STILL most common
1) Legionella
2) Pseudomonas
3) Staph aureus |
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Term
| What native immune mechanisms maintain sterility of the lower respiratory tract? |
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Definition
1) Upper airway (colonized by virridens streptococci, Neisseria and Candida) uses filtration, mucociliarty transport and sneezing, along with antimicrobial substances.
2) Glottis
- closure and cough reflex
3) Bifurcating airway
- Mucociliary escalator and anti-microbials
4) Alveolar macrophages (recruit PMNs) and immunoglobulins |
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Term
| What is the most common cause of hematogenous seeding of the lung leading to Pneumonia? |
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Definition
| Staph aureus (IV drug users especially and in patients with right-sided bacterial endocarditis. |
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Term
| What is the chronology of infection in aspiration pneumonia? |
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Definition
Usually resolve in 2 days since aspiration contents are sterilized by gastric fluid pH
1) phase 1 (ACID) is direct effects of acid on pulmonary parenchyma and tracheobronchial tree in first 1-2h
2) Phase 2 (PMN) is 4-6h with PMN infiltration of alveoli
Fever, Leukocytosis and Short-lived infiltrate may follow
3) Inflammation usually resolves itself in 48h, unless patient is at high risk or there are high number of gram negative rods in stomach (in which case, give antibiotics). |
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Term
| How are Pneumonia categorized pathologically? |
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Definition
Lobular, Lobar or Interstitial
1) Lobular (Bronchopneumonia) refers to patchy consolidation in bronchi, bronchioles and alveoli within one or more lobes (normally bacterial)
- Usually will resolve, unless highly virulent strains (Staph Aureus) create abscess
2) Lobar usually involves an entire lobe of the lung (Strep Pneumonia is common).
- Widespread inflammatory exudate (PMN followed by fibrin in alveolar space, without wall destruction) usually resolves over several days.
3) Interstitial is inflammation largely confined to alveolar wall, with leukocyte infiltration and edema, but no filling of alveolar space (VIRAL- influenza, or Atypical Mycoplasma)
- Usually resolves, but can led to scarring and alveolar fibrosis. |
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Term
What are the most common bacterial etiologies of Pneumonia in the following contexts?
1) Outpatient- no co-morbidity
2) Outpatient- co-morbidity
3) Hospitalized
4) Hospitalized with severe disease |
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Definition
1)
- Strep. pneumoniae
- Mycoplasma pnemoniae
- Chlamydia
- Viral (adeno, RSV)
- Haemophilus influenza
2)
- Streptococcus pneumonia
- Haemophilus influenzae
- Chlamydia and Mycoplasma
- Viruses
- Legionella
3) Strep pneumoniae
- Haemophilus influenzae
- Polymicrobia
- Viruses
- Legionella
4) Strep pneumoniae
- Legionella
- Pseudomonas and other gram -
- Staph aureus
- Viruses |
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Term
True or False:
NO pathogen responsible for CAP is identifiable in up to 50% of cases |
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Definition
True!
Streptococcus pneumonia and "atypicals" like Mycoplasma, Chlamydia and Legionella are all prominent and MUST be covered by empiric therapy. |
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Term
| Under what conditions should anti-pseudomonal antibiotic therapy be considered for CAP? |
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Definition
Pseudomonas is rare for CAP.
Usually it is strep, legionella, mycoplasma or chamydia
Would need antipseudomonal beta lactam + FQ
1) Severe structural lung disease (Bronchiectasis)
2) Recent antibiotic therapy
3) Recent hospital stay (ICU) |
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Term
What organisms are characteristic in the following HAP?
1) Early VAP
2) Late VAP
3) Non VAP |
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Definition
1) 1st week with upper respiratory fauna
- S. pneumo, H. influenzae and S. aureus
- treat empirically with Ampicillin/Sulbactam
2) Micro-aspiration of resistant bacterial replacing normal upper tract species because of cross -contamination/antibiotic therapy
- Treat empirically with Vanco, Cefepime or tobramycin
- Pseudomonas
- S. aureus (MRSA)
- Enteric gram negative (Klebsiella and Enterobacter)
3) Gram negative bacilli (E. coli, Proteus and Serratia)
- Treat empirically with Piperacillin/tazobactam |
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Term
| What are the typical signs and symptoms of Pneumonia? |
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Definition
Often absent in elderly
1) Cough
2) Fever
3) Dyspnea
4) Chills and productive purent cough (bacterial)
on PE
- Tachypnea, fever and tachycardia (again, elderly are less reliable) |
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Term
| What laboratory tests are recommended for the diagnosis of VAP? |
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Definition
| Bronchoalveolar lavage (BAL) with quantitative culture (>10,000 CFU/ml is diagnostic) |
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Term
| What caveats are important to consider when using CXR to diagnose Pneumonia? |
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Definition
Considered "gold standard"
1) Quality of X ray is important
2) X-ray may lab behind clinical findings
3) Variable interpretation |
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Term
What organisms produce following CXR findings and clinical symptoms?
1) Alveolar patterns that are sometimes lobar in distribution with Rapid onset fever/chills, pleurisy and cough with sputum
2) Interstitial pattern with dry cough and subacute onset in young adults
3) Alveolar pattern with patchy, segmental distribution accompanying Upper respiratory symptoms (sore throat, hoarseness) and a dry cough
4) Alveolar pattern, from patchy to more extensive consolidation in the context of a cough and extra-pulmonary manifestations (elevated liver enzymes, CNS symptoms, hyponatremia)
5) Interstitial pattern, bilaterally with a flu-like illness (high fever, headache, myalgias) |
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Definition
1) S. pneumo, H. influenzae, Gram negative bacilli (e. coli or enterobacter)
2) Mycoplasma
3) Chlamydia pneumoniae
4) Legionella
5) Influenza |
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Term
A patient presents with rapid onset fever/chills, pleurisy, cough and sputum.
On CXR you determine an alveolar pattern of consolidation, following a lobular distribution.
What is the diagnosis? |
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Definition
| This is Pneumonia do to Strep pneumonia, H. influenza or gram-negative bacilli. |
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Term
A 13 year old boy presents with dry cough and you order a CXR, on which you notice an interstitial pattern of consolidation.
What is the diagnosis? |
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Definition
| Sounds like atypical Pneumonia from Mycoplasma pneumoniae. |
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Term
A 18 year old women presents with sore throat, hoarseness and a dry cough.
You order a CXR and notice alveolar consolidation in a patchy and segmental pattern.
What is the diagnosis? |
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Definition
| Sounds like atypical, Chlamydia pneumonia. |
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Term
A 37 year old man presents acutely with a sputum-producing cough, elevated liver enzymes and dizziness/confusion.
On CXR you see an alveolar pattern of consolidation that is patchy.
What is the diagnosis? |
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Definition
| Sounds like atypical Pneumonia from Legionella species. |
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Term
Patient presents with high fever, headache and myalgias.
A CXR reveals bilateral interstitial consolidation
What is the diagnosis? |
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Definition
| Sounds like Pneumonia due to influenza |
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Term
| When should patients being treated for CAP be switched from IV to oral antibiotic therapy? |
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Definition
As soon as fever abates and patient is clinically stable.
Saves $$ |
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Term
How is empiric therapy handled for CAP in each of the following situations.
1) Previously healthy (outpatient)
2) Patients with co-morbidity (outpatient)
3) Treatment on medical ward (inpatient)
4) Treatment in ICU w/o Pseudomonas issue
5) Treatment in ICU w/ Pseudomonas issue |
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Definition
1) Doxi or Azithromycin
2) Azithromycin or FQ
3) Azithromycin + beta-lactam
4) Macrolide + beta-lactam
5) Antipseudomonal beta-lactam + FQ |
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Term
What types of empiric therapy should be applied in each of the following cases of HAP?
1) Early VAP
2) Late VAP
3) Non-VAP |
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Definition
1) Treat empirically with Ampicillin/Sulbactam
- Gets S. pneumoniae, H. influenzae and S. aureus
2) Treat empiracilly with Vanco, Cefepime or tobramycin
- Must get MRSA, Pseudomonas and gram-negative rods
3) Treat empirically with Piperacillin/tazobactam
- Gets aerobic and anaerobic gram negative rods |
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Term
| What congenital causes of immunodeficiency predispose young patients to Pneumonia? |
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Definition
1) T lymphocyte (Viruses, PJP)
- Di George/Thymic aplasia with reduced CD4+ and CD3
2) B lymphocyte (S. pneumo and H. influenzae)
- Bruton's X_linked agammaglobulinemia (no B, plasma or IG)
- Selective IgG subclass
- IgA deficiency
3) Mixed T and B
- CVID
- SCID
- Wiskott-aldrich
4) Phagocyte (staph aureus, pseudomonas, aspergillus))
- Chronic granulomatous disease (NADPH oxidase)
- Chediak-Higashi |
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Term
| What are the 4 major categories of immunocompromised patients affected by Pneumonia? |
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Definition
1) Chemotherapy for hematologic malignancy and solid tumor
2) Immunosuppression in solid-organ transplant
3) Corticosterodis, methotraxate, anti-TNFa for Rheumatic Arthritis
4) HIV
- CD4 count <200 is key |
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Term
A patient with a hematological malignancy or solid tumor may undergo chemotherapy, splenectomy and/or treatment of graft versus host disease in case of stem cell transplant.
What sorts of infections occur in these conditions? |
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Definition
1) Chemotherapy produces Neutropenia
- Pseudomonas and Aspergillus
2) Splenectomy for lymphoma
- Encapsulated (S. pneumoniae, H. influenzae, N. meningitidis)
3) Tacrolimus/Cyclosporine
- Fungal
- Mycobacterial
- Viral (CMV) |
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Term
| Why do patients with Rheumatoid arthritis and Autoimmune disorders tend to get Pneumonia? |
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Definition
TREATMENT with corticosteroids and anti-rheumatic agents
TB is an issue and requires a PPD. |
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Term
| What organisms tend to cause pulmonary infections in HIV-infected individuals with CD4 counts <200? |
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Definition
| S. pneumoniae and M. tuberculosis. |
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Term
What do each of the following hints tell you about Pneumonia etiology in an immunocompromised patient?
1) Travel to southwestern US (New Mexico, California, Arizona)
2) Travel to Ohio River Valley (Ohio, Tennessee)
3) Construction in hospital
4) Swimming in lakes.
5) Donor:recipient serotype mismatch |
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Definition
1) Coccidiomycosis
2) Histoplasma
3) Aspergillosis
4) Legionella, Aspergilliosis or Pseudomonas
5) CMV or Toxo |
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Term
A patient presents with cutaneous nodules on their skin and a severe respiratory infection.
What is the diagnosis? |
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Definition
| Pneumonia due to Cryptococcus |
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Term
A patient who recently received a solid organ transplant presents with a pulmonary infection that you suspect in Pneumonia.
What do each of the following timepoints, post-transplant tell you about the likely organism?
1) <1 month
2) 1-6 months
3) > 6 months |
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Definition
1) **MRSA**, Gram negative bacilli, Legionella, Aspergillus
2) **CMV** Aspergillus, Legionella, Gram negative bacilli (if ventilated- E. coli)
3) Nocardia, Mycobacteria, Cryptococcus, Coccidiodes immitus |
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Term
| How does a CD4+ count of > 200 or < 200 change your diagnosis of Pneumonia etiology? |
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Definition
You don't see PJP until less than 200
1) > 200 think S. pneumonia or M. tuberculosis
2) < 200, think S. pneumonia, PJP, M. tuberculosis |
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Term
| What are the challenges associated with empiric therapy for Pneumonia in immunocompromised patients? |
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Definition
1) Broad differential
- Give Vancomycin, Cipro, Meropenem, Amphotericin, Ganciclovir and Bactrim to cover MRSA, Pseudomonas, Legionella, CMV and Pneumocystis. |
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Term
| What preventative measures can limit infection in immunocompromised patients? |
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Definition
1) VAP prevented by semi-recumbent posturing and use of sucralfate (not H2 blockers)
2) Bactrim prophylaxis (PJP)
3) Water purification (TB, Legionella and Aspergillus)
4) Prevent exposure to construction activity |
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Term
| What types of etiological agents produce interstitial Pneumonias? |
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Definition
| Viral and atypical Mycoplasma |
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Term
| What bugs to patients get after splenectomy? |
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Definition
Performed for Hodkin's Lymphoma
Encapsulated
- H. influenzae
- S. pneumo
- N. Meningidites |
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Term
When a patient with Multiple myeloma gets a stem cell transplant, they are treated prophylactly for graft versus host disease using cyclosporine/tacrolimus with corticosteroids.
What bugs are they at risk for? |
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Definition
1) Fungal
2) Mycobacterial
3) Viral (CMV) |
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Term
| What bugs to patients on chemotherapy get? |
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Definition
1) Pseudomonas
2) Aspergillus |
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