pc2 3.6 CAP

peumonia

acute infection of the pulmonary parenchyma

community-acquired pneumonia

acute infection of the pulmonary parenchyma acquired outside of the hospital setting

noscomial pneumonia

acute infection of the pulmonary parenchyma acquired in hospital settings

48 hours or more (after admission or put on ventilator)

hospital and ventilator associated nosocomial pneumonia are acquired after how much time in the hospital or on ventilator

extremes of age, chronic comorbidities, immunosuppression, viral respiratory, smoking and alcohol overuse, crowded living conditions, exposure to environmental toxins

risk factors for CAP

COPD, CF, asthma, chronic heart disease, diabetes

what chronic comorbidities are risk factors for CAP

rhinovirus, influenza, parainfluenza, SARS CoV-2, coronavirus, RSV, human metapeumovirus, adenovirus

viruses that cause CAP

strep pnemo, h flu, m cat, staph aureus

typical bacteria that cause CAP

mycoplasma pneumo, chlamydia pnuemo, legionella pnemo

atypical bacteria that cause CAP

pneumococcal vaccine

s. pneumo has been on the decline because of what

SARS-CoV-2

what has been more prominent cause of CAP since the pandemic

respiratory viral panels

what has contributed to the increased recognition of respiratory virsues

viruses, strep pneumo, h flu, mycoplasma, c. pneumoniae

common pathogens for CAP outpatient

viruses, strep pneumo, h flu, mycoplasma, c. pneumoniae, legionella pneumonphilia

common pathogens for CAP inpatient non-ICU

viruses, strep pneumo, s. aureus, legionella pneumophilia, gram negative bacilli-psuedomonas

common pathogens for CAP inpatient ICU

lungs are not sterile, impairing host defense mechanism

what pathophys contributes to CAP colonizing the nasopharynx/lungs

nasal hair, turbinates, upper airway anatomy, mucociliary apparatus

what host defense mechanisms are in the nasopharynx

saliva, sloughing of epithelial cells

what host defense mechanisms are in the oropharynx

cough, airway anatomy, mucociliary apparatus, immunoglobulins

what host defense mechanisms are in the trachea and bronchi(upper airway)

alveolar lining fluid, cytokines, alveolar macrophages, polymorphonuclear cells

what host defense mechanisms are in the terminal airway/alveoli (lower lungs)

pulmonary signs and symptoms, physical exam finding, imaging(chest x ray), systemic signs and symptoms

what is evaluated in the clinical presentation of CAP

cough, dyspnea, sputum production, pleuritic chest pain, shortness of breath

what pulmonary signs and symptoms are seen in CAP

consolidation or fuzzy/gray in lungs

(healthy is clear/black)

what to look for in chest x ray to indicate cap

fever, chills, fatigue, malaise

(systemic altogether is less common, usually pulmonary signs and symptoms are seen)

what systemic signs and symptoms are seen in CAP

fussiness, difficulty feeding, restlessness

what may neonates/infants present with instead of cough when having CAP

rales/crackles, rhonchi, wheeze, decreased breath sounds, egophony, dullness to percusion, increased work of breathing, tachypnea, tachy cardia

what is seen in a physical exam for CAP

leukocytosis (over 12k), leukopenia (under 5k), low oxygen saturation, increased inflammatory markers (ESR, CRP, procalcitonin)

what laboratory findings are seen in CAP

blood culture,

sputum culture (unreliable),

urine antigen tests,

rapid diagnostic tests

what microbiologic testing can be performed for CAP

over 70

tachypnea in infants is how many breaths per min

over 40

tachypnea in children is how many breaths per min

over 20

tachypnea in adults is how many breaths per min

pneumonia severity index, CURB-65

what is used to determine pneumo severity along with 30 day mortality and need for ICU

there's not a validated scoring tool

what is used to determine pneumo severity in pediatric patients

1

how many major criteria for clinical severity are needed for adults for admission to the ICU

respiratory failure requiring mechanical ventilation,

septic shock with need for vasopressors

what are major criteria for clinical severity of CAP in adults

3 or more

how many minor criteria for clinical severity are needed for adults for admission to the ICU

high respiratory rate

multilobar infiltrates, confusion,

uremia,

leukopenia,

thrombocyotopenia,

temperature under 36,

hypotension requiring fluid resuscitation,

low PaO3/FIO2 ratio

what are minor criteria for clinical severity of CAP in adults

30 breaths/min or more

what respiratory rate would qualify as minor criteria for CAP

20mg/dl or more

(UREMIA)

what BUN quantity would qualify as minor criteria for CAP

under 4k

what WBC would qualify as leukopenia-minor criteria for CAP

under 100k

what platelet count would qualify as thrombocytopenia-minor criteria for CAP

under 36 C

what pt temperature would qualify as minor criteria for CAP

250 or under

what PaO2/FIO2 ratio would qualify as minor criteria for CAP

confusion, uremia, respiratory rate, blood pressure, age 65 or up

CURB-65 has what categories

less than 90mm Hg

what systolic BP value gets a quantity of 1 in CURB 65

60mmHg or less

what diastolic BP value gets a quantity of 1 in CURB 65

when waiting on labs

when is CRB used

beta lactams, respiratory fluroquinolones, macrolides

outpatient tx of CAP for adults includes what classes of antibiotics

amoxicillin,

amoxicillin/clavulanate,

cefpodoxime,

cefuroxime

what beta lactams are used for outpatient tx of CAP for adults

3-5

what CURB-65 score would you admit to ward/ICU

2

what CURB-65 score would you admit to hospital

B lactam + Macrolide/doxycycline

most out pts will be put on what for CAP

ceftriaxone, ceftaroline, ampicillin/sulbactam

for in patient tx for CAP what anti pnemococcal beta lactams can be used

levofloxacin, moxifloxacin

for in patient tx for CAP what respiratory fluoroquinolones can be used

vancomycin, linezolid, ceftaroline

for in patient tx for CAP what MRSA antibiotics can be used

cefepime, meropenem, piperacillin/tazobactam, aztreonam

for in patient tx for CAP what anti-pseudomonal beta lactams can be used

levofloxacin, ciprofloxacin

for in patient tx for CAP what anti psuedomonal fluoroquinolones can be used

antipnemococcal beta lactam PLUS azithromycin or doxycycline,

or respiratory fq

if a patient is not at risk for pseudomonas or mrsa what should the tx be for inpatient NON icu

Anti-MRSA plus antipnuemococcal beta lactam plus azithromycin or doxycycline

if an in patient is at risk for only MRSA what antibiotics should they be on

anti MRSA agent, plus antipsuedomonal beta lactam, plus antipseudomonal FQ

if an in-patient patient is at risk for both MRSA and psuedomonas what antibiotics should they be put on

antipseudomonal beta lactam plus antipseudomonal FQ

if an in patient is at risk for only pseudomonas what antibiotics should they be on

antipneumococcal beta lactam w azithromycin

or

respiratory FQ monotherapy

if a patient is not at risk for pseudomonas or mrsa what should the tx be for an ICU pt

high dose amoxicillin

what is first line for pediatrics outpt for CAP

over 5 can have a second agent like FQ or doxyxcline(if over 7) to add coverage for atypicals

(under 5 are less likely to get atypicals)

what is the difference in tx for CAP outpt in kids over 5 and under 5

ampicillin

for inpatient pediatric pts with CAP that are fully immunized against h. flu and s. pneumo what antibiotic is first line

macrolide

for inpatient pediatric pts with CAP what can be added for atypical coverage

vancomycin or clindamycin

for inpatient pediatric pts with CAP what can be added if suspected MRSA

ceftriaxone,

(levo could also be used)

for inpatient pediatric pts with CAP that are NOT fully immunized what is first line

clinical response

duration of treatment for CAP is based on what

3 days

minimum duration of tx for cap in adults

7-10days

minimum duration of tx for cap in children

hemodynamically stable, clinically improving, and can take oral meds

pts can switch from IV to oral therapy inpt when what is seen

disease severity, age, risk of multidrug resistant pathogen

what pt factors are assessed to guide antibiotic choice