Lower Respiratory Tract Infections

What is pneumonia?

new lung infiltrate + clinical evidence that infiltrate is of infectious origin

What are some causes of pneumonia?

aspiration of upper airway microbiota, inhalation of aerosolized material, metastatic seeding from the blood to the lung (rare)

What are signs and symtpoms of pneumonia?

cough, sputum, dyspnea, fever, chills, hemoptysis, pleuritic chest pain, tachypnea, tachycardia, diminished breaths sounds, egophony, increased WBC

What are some common bacteria that cause pneumonia?

strep pneumonia, staph aureus, Hemophilus influenzae, moraxella catarrhalis, klebsiella pneumoniae, and psuedomonas aeruginosa

When are sputum cultures obtained for patiens with suspected pneumonia?

generally reserved for severe hospitalized cases

What are some diagnositic tools for penumonia?

BAL, blood cultures, procalcitonin, oxygen saturation, urinary antigen testing, viral panel, and sputum cultures

What is the CURB-65 score?

tries to determine if a pneumonia patient should be treated as an outpatient or inpaintent patient?

What is hospital acquired pneumonia?

pneumonia not incubating at the time of hospital admission and occurring 48 hours or more after admission; could also include patients coming from the community who received IV abx within 90 days of admission

What is community acquired pneumonia?

no exposure to the healthcare system

What is ventilator associated pneumonia?

pneumonia occurring > 48 hours after endotracheal intubation

What are specific risk factors for having CAP caused by S. pneumoniae?

most common cause of pneumonia, must know resistance rates in your community; usually has rusty colored sputum

What are specific risk factors for having CAP caused by haemophilus influenzae or moraxella catarrhalis?

more common in patients with COPD, alcohol abuse, cystic fibrosis, HIV, impaired humoral immunity

What are specific risk factors for having CAP caused by anaerobes?

loss of consciousness after alcohol or drug overdose; post seizure, gingival disease, esophageal motility disorder

What are specific risk factors for pneumonia that is CA-MRSA?

after influenza, cavitary lesions, severe CAP/ICU admission, empyema

What are specific risk factors for CAP caused by legionella penumphilia?

water exposure, men>women, smokers

What are specific signs/characteristics of pneumonia caused by legionella pneumophilia?

electrolyte abnormalities (hypophos, hyponatremia), confusion, LFT elevation

What specific antibiotics should be used to treat pneumonia caused by legionella pneumophilia?

fluoroquinolones, azithromycin

What characteristics are specific to pneumonia caused by mycoplasma pneumoniae?

persistent hacking cough; most common in middle aged adults

What abx would you give for pneumonia caused by mycoplasma pneumoniae or chlamydophilia pneumoniae?

macrolides, doxycycline, fluoroquinolones

What specific charcterisitics are present with pneumonia caused by chlamydophilia pneumoniae

cough may be persistent for months, hoarseness, common for extremes of age

What characterisitcs does typical penumonia have?

abrupt onset, unilateral well defined infiltrate, significant fever, chills, sweats, dyspnea, purulent sputum production

What characteristics does atypical pneumonia have?

gradual onset, diffuse infiltrates, ground glass appearance, mild fever, mild dyspnea, dry cough

What are the treatment options for outpatient CAP for a previously healthy patient with no risk factors?

PO amoxicillin

PO doxycycline

PO macrolide (azitro or clarithro)

What are the treatment options for outpatient CAP for a patient with comorbidities (extremes of ages, beta lactam within 3 months, alcohol abuse, immunosuppression, exposure to daycare, cancer, chronic respiratory disease?

PO amox/clav PLUS macrolide

PO cephalosporin PLUS macrolide

PO respiratory quinolone

What are the treatment options for inpatient CAP that is non-severe?

IV beta lactam PLUS macrolide

respiratory FQ

What are the treatment options for inpatient CAP that is severe?

IV beta lactam PLUS macrolide

IV beta lactam PLUS respiratory FQ

What is the duration of treatment for community acquired pneumonia?

treat for a min of 5 days; should be afebrile for 48-72 hours

Who should receive urinary antigen test for legionella and strep pnuemoniae?

patients with severe CAP

True or false: viral penumonia can result in co-infection with bacterial pathogens

true

What are the signs and symptoms of hospital acquired pneumonia?

same as CAP but tends to be more severe, SIRS and spesis are more common

When do you initiate limited spectrum abx therapy for HAP?

suspected HAP/VAP with no risk factors for multi drug resistant pathogens

When do you initiate broad spectrum abx therapy for HAP?

suspected HAP/VAP with late onset (more than 5 days) or risk factors for multi drug resistant pathogens

What are considered risk factors for MDR pathogens for HAP, VAP?

prior antibiotics, colonization, hospitalization, or chronic care, immunosuppressive disease or therapy

What are the recommended abx for empiric treatment of HAP/VAP?

ceftriaxone

levofloxacin, moxifloxacin

ampicillin/sulbactam

ertapenem

When to cover pseudomonas empirically?

prior IV antibiotic use within previous 90 days

severe presentation (sepsis, ventilator)

previous infection/colonization

immunosuppression

What antibiotics cover pseudomonas empirically?

one antipseudomonal antibiotic different classes:

P/T, cefepime, ceftazidime, imipenem, meropenem, aztreonam, ciprofloxacin, levofloxacin, aminoglycosides, colistin, polymyxin B

True or false: cultures are suggested for HAP and VAP to get target treatment regimens

true

What is the treatment duration for VAP and HAP?

7 days (regardless of pathogen)