Pneumonia and CAP

What is URTI?

• Nonspecific term to describe acute infx involving the nose, paranasal sinuses, pharynx, and larynx

  • common cold (viral)

  • most common reason for MD visits in U.S.

URTI is mostly caused by what? What are other causes?

• …

In Rhinosinusitis, when do we treat with ABX?

• Persistent signs or symptoms of acute rhinosinusitis, lasting for >10 days (Viral sinusitis usually lasts only 7-10 days) without any evidence of clinical improvement.

• Worsening signs or symptoms characterized by new-onset fever, headache, or increase in nasal discharge following a viral cold or flu that lasted ~7 days, and were initially improving but developed the above signs and/or symptoms

• Severe signs or symptoms; high fever (≥39°C [102°F]), purulent nasal discharge, or facial pain lasting for at 3 to 4 consecutive days at the beginning of illness
  

What is first line tx for Sinusitis?

• Amox/clav x5-7d

• Doxycycline, beta-lactam allergy

What is second line tx for sinusitis?

• High dose amoxicillin/clav x5-7 d

• Respiratory FQ (Moxifloxacin, Levofloxacin)

Pneumonia inflammation occurs where?

• within the lung tissue, bronchioles, and alveoli

• fluid/mucus build up in the alveoli and can interfere with gas exchange → decrease in O2 saturation
  

Bronchitis is inflammation of what?

• Bronchitis is inflammation of the lining of the bronchi. Rarely fluid/mucus in the alveoli.

  • Chronic bronchitis prolonged inflammation & secretions may hinder O2 exchange.

How are pathogens acquired in pneumonia?

• via aspiratio

  • Saliva (oral flora or oral colonizers)

  • Stomach contents

• via inhalation of aerosolized particles

• seeding from the bloodstream

Lung defenses protect from pneumonia but can still occur if what?

• Patient is immunosuppressed

• Celia defense mechanisms not working

• Inoculum of bacteria is too high and overwhelms the defenses

• Viral infection → weakens immune system/lung defenses

What are some risk factors on pneumonia?

• Smoking

• PPI use

• Structural lung disease

• Prolonged hosptitalization

• Contaminated water supply

• Immunosuppression (steroids, chemo, elderly)

What are signs+sx of pneumonia? What about labs need to be taken and physical exam signs?

• Sx: Dyspnea, productive cough, fever, Chest pain

• Labs: WBC with differential: PMNs, Elevated bands (“left shift”)

  • Low oxygen (O2) saturation

  • Pro-calcitontin levels (Pct)

  • C-reactive protein (CRP)

• Physical: tachypnea, tachycardia, inspiratory crackles, rales, rhonchi, wheezing

What are some ways to diagnose pneumonia?

• Chest X-Ray (CXR)

  • Presence of infiltrates, consolidation, or pleural effusions

• Sputum Gram-stain/cultures

  • Not routinely done for outpatients

  • Recommended for some inpatients (severe CAP (or MDRO risk), HAV/VAP)

  • bronchoalveolar lavage (BAL) sometimes needed

• Blood cultures – for some patients (severe infection)

• Routine lab testing – CBC, BMP, LFTs, Procalcitonin, CRP

• Pulse oximetry, ABG

In a sputum culture, what is optimal specimen vs bad specimen?

• Optimal specimen

  • < 10 epithelial cells / hpf

  • > 25 WBCs / hpf

  • A predominant organism on Gram stain

  • Heavy growth of a single species on culture

• Non-optimal (bad) specimen

  • > 10 epithelial cells / hpf

  • < 25 WBCs / hp

  • Several organisms → normal flora

  • Lack of a single predominant organism

PROCALCITONIN SLIDE

What is the PCT algorithm for stewardship of antibiotic therapy in patients with LRTI?

• Insert

What are the different classifications of pneumonia?

• Community Acquired Pneumonia (CAP)

  • Atypical Pneumonia

• Hospital Acquired Pneumonia (HAP) → nosocomial

• Ventilator Associated Pneumonia (VAP) → nosocomial

• Aspiration Pneumonia

Where does community acquired pneumonia occur?

• Non-hospitalized patient (patient in community setting)

  • Acquired infection while in the community

  • Pneumonia symptoms present < 48 hours after admission (suggests patient came in with it)

What is known about the info of CAP?

• Infection/inflammation of the pulmonary parenchyma

• Acute infection

When determining outpatient vs inpatient tx, what can it be based on?

• PSI (preferred)

• CURB65

What is the major criteria for severe CAP?

• Invasive mechanical ventilation

• Septic shock - need of vasopressors

• **One of these

What is the #1 cause of CAPB?

• Strep pneumoniae

What is the DOC for inpatient CAP?

• 3rd gen cephalosporins (ceftriaxone)