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Pneumonia
infection/ inflammation of the alveoli, distal airways, and interstitium of the lung
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Types of Pneumonia
- Lobar Pneumonia
- -Entire lung lobe
- Bronchopneumonia
- - Patchy consolidation involving one or several lobes
- Interstitial Pneumonia
- -Patchy or diffuse inflam. Process involving the interstitium, including the alveolar walls and connective tissue around the bronchovascular tree
- Miliary pneumonia
- -Numerous discrete lesions that are diffusely distributed
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Innate defense mech
- Upper resp tact (nose to larynx)
- -Curved to prevent things from going down into lungs
- (Anatomical structure, nonpathogenic bacteria, glottis (valve))
- -Lower resp tract (below trachea)
- (Coughing)
- -Mucocilary transport system w mucus layer
- (Mucins trap microorganizms, decrease mucosal pH, secretory IgA, shedding of epithelial cells)
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Acquired mechanism
- Macrophages
- Fibronectin
- Lysozymes
- Lactoferrin
- IgG
- Defensins
- Cathelicidins
- Collectins
- Complement¨
- Surfactant
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Modes of Transmission
- Microaspiration- most common
- Gross aspiration- postoperative/swallowing disorder
- Aerosolization
- -M. tuberculosis
- -Fungi
- -Legionella
- -Resp virus
- Hematogenous spread
- -Endocarditis
- -Iv catheter infection
- -UTI
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Risk Factors For CAD
- >70 y/o
- m>f
- African>caucasions
- Alcoholism
- -They tend to change diet.. mal nourish
- -Tend to replace healthy meals with alcohol
- - More at risk for aspiration pneumonia
- Asthma/COPD, CF
- CHF, CAD
- Diabetes
- -And infection rate are high bc sugar levels are high.. pathogens like sugar and have kidney damage
- Dementia, stroke, altered level of consciousness
- -Mental status change.. have a hard time swallowing
- Immunosuppresion
- -Solid organ transplants
- -HIV/AIDS
- -Asplenia
- Renal failure, chronic liver disease
- Smoking
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Poor Prognosis for CAD
- Advanced age
- Comobidities- ex cardiopulmonary disease
- Poor nutritional status
- Hyponaturemia
- Azotemia
- High fever
- Bacteremia
- Immunosuppression
- Acoholism
- Staph. Aureus pneumonia (MRSA)
- Ø High mortatlity
- G- bacilli pneumonia
- Ø Pseudomonas
- Ø High mortality rate
- Aspiration pneumonia
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Clinical manifestations (Signs)
- Fever
- Cough
- Pleuritic
- Chest pain
- Chills
- Rigors
- SOB
- Headache
- N/V/D
- Myalgia
- Fatigue
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Clinical manifestations (Symptoms)
- Tachypnea
- Tachycardia
- Hypotension
- Poor o2 saturation
- Dullness to percussion
- Increase tacile
- Increase tacile
- Vocal fremits
- Egophony/bronchophony
- Whispering pectoriloquy
- Crackles/rales/diminished breath sounds
- Pleural friction rub
- Radiographic evidence
- Elevated wbc w “left shift”
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CAP diagnosis
- Screeen tools
- -Chest radiography
- -CT
- Blood culture**
- Sputum sample
- Urine antigen (Elisa)
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CAP common pathogens Out pt
- Strep pneumoniae-- common**
- Mycoplasma pneumoniae--common atypical
- Haemophilus influenzae--big in the out pt setting*
- Chlyamydia pneumoniae
- Resp virus (Influenza A/b, Adenovirus, Resp syncytial virus (RSV)- parainfluenza)
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CAP common pathogens Hospital non-ICU
- S. pneumoniae
- M. pneumoniae
- C. pneumoniae
- H. influenzae
- Legionella epp.
- Resp. virus
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CAP common pathogens Hospital ICU
- S. pneumoniae
- Staph aureus *MRSA
- Legionella spp.
- G- bacilli
- H. influenzae
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High mortality rate by pathogens
- P. aeruginosa
- K. pneumoniae
- S. aureus
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Risk Factors for Drug Resistance PCN
- Age <5 or >65 y/o
- Beta-lactam therapy within the last 3 months
- Alcoholism
- Immunocompromised pts
- Multiple comorbidities
- Exposure to a child in daycare
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S. pneumoniae treatment
- PCN sensitive
- IV/PO PCN
- PO amoxicillin
- ALT: Macrolides, cephalosporin’s, clindamycin, doxycycline, fluroquinolones
- PCN resistant
- Fluroquinoloes
- Doxycycline
- Clindamycin
- Cefepime
- Imipenem/ meropenems
- Linezolid
- Vanco
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Haemophilus influenzae
- -Common from a cold
- -Invasive disease in children and adults
- -Common organism that colonizes the upper resp tract (Pathogenic in pt with COPD/ smoker)
- Treatment:
- 2nd or 3rd gen cephalosporin’s
- -Cefuroxime, ceftriaxone, cefotaxime, ceftizoxime, cefixime
- -Amoxilicillin/ clavulanate
- -Alt: doxy, fluroquinolones, azith
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Atypical Pathogens and treatments for them
- Mycoplasma and Chlamydia pneumonia
- Doxycyline
- Macrolides
- Alt: Fluroquinolones
- Legionella
- -Azith
- -Fluroquinolones
- -Alt: Doxy
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How to determine site of care
- PORT severity index (PSI)
- CURB-65
- CRB-65
- Social circumstances
- Comorbid medical conditions
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CAP: Hospitalization should be considered when
- Pt have pre- existing conditions that may compromise safety at home
- Pt have hypoxemia.. low o2
- Pt are unable to tolerate oral med
- Pt has psychosocial factors that may impact treatment
- Pt have poor mortality predictors
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Pneumonia Severity Index
- Class 1- out pt <1% mortality
- Class 2- out pt <1% mortality
- Class 3- out pt/ observation until/ short hospital stay <5% mortality
- Class 4- hospital stay 8-30% mortality
- Class 5- hospital 8-30% mortality, require icu care
- Includes 20 variables
- -Scored based on age, comorbid conditions, s/s
- -Impracticable in busy ED
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CURB-65 assessment of severity
- Confusion
- Specific mental test
- Disorientation to person/place/time
- Uremic
- BUN>7 mmol/L (20mg/dL)..To see if they are dehydrated
- Respiration Rate
- RR >30 breaths/min
- BP (hypotensive)
- Systolic <90 mmHg or diastolic <60mmHg
- Age >65
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CRB-65 score
- 0- out pt treatment
- 1- hospital admin
- >2 - hospitalization, possible ICU admin
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Empiric ABX therapy Out PT
-healthy and no abx within 3 monhts
-coverage: typical and atypical (S. pneumoniae, H. influenzae- prefer azith, M. pneumoniae, C. pneumoniae)
- Macrolides and Doxycycline
- Erythromycin: 250-500mg po q6h or 1g IV q6h
- Clarithromycin: 500mg po q12h
- **Azith
: 500mg po, then 250 po qd x4days or 2g po x 1dose (suspension) or 500mg IV x2 days, then 500mg po q24h for 5-8 more days... longest 1/2 life- Doxycycline
: 100mg po q 12 h or 100mg IV q 12h
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Empiric ABX therapy Out PT
-comorbidities or abx within 2 months
-Need to treat with more broad sprectrum
- Resp fluroquinolones OR Beta-lactam+macrolides
- -Doxycycline is a alt for macrolides
- Fluroquinolones
- -Levofloxacin- 750mg po q24h
- -Moxifloxacin- 400mg po q24h
- -Gemifloxacin- 320mg po q24 h
- Beta-lactam + macrolides (erithy, clarith, azith) for broader spectrum
- -high dose amox- 1g po q8h
- -Aug- 2g po q12h
- -Ceftriaxone- 1-2g IV q24 h
- -Cefpodoxine-200mg po q12h
- -Cefuroxime- 500mg po q12h
- if fail with macrolides give doxycycline
- NO FLUROQUINOLONES for kids
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Empiric ABX therapy Out PT
-macrolide resistant S. pneumoniae
Fluroquinolone or Beta-lactam
if they have PCN allergy can give
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Empiric ABX hospital, non-ICU
- -resp fluroquinolone (same ones)
- or
- -beta-lactam + macrolide (Eryth, clarith, azith)-Etrapenem (for selected pt)
- -Doxycycline (alt for macrolide)
- -Fluroquinolone (pcn allergy)
- -Cefotaxime- 1-2g IV q6-8h
- -Ceftriaxone- 1-2g IV q24h
- -Ampicillin- 500mg po QID or 1-2g IV q6h
- -Ertapenem- 1g IM/IV q24h
- --For highly immunosuppressed pt but contraindicated in seizures, or a lot of comorbidity
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Ceftaroline IV (Teflaro)
- -5th generation cephalosporin
- -prodrug
For: CAP, SSTIs (Skin and Soft Tissue infection)
- active against (bacterialcidal)
- -G+ (VISA, VRSA, MRSA), strep pneumonia
- -G- Moraxella catarrhalis, h. influenzae
no better than ceftriaxone
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Empiric Abx Hospital ICU treatment
- ***IV
- Beta-lactam + azith OR Fluroquinolone
- -Cefotaxime
- -Ceftriaxone
- -Ampicillin-sulbactam
- -same Azith and fluroquinolone doses
- -For PCN allergy: Fluroquinolones + aztreoman (no cross sens.) is recc
give cipro?? NO its not a resp
- Cefotaxime- 1-2g IV q6-8h
- Ceftriaxone- 1-2g IV q24h
- Ampicillin/Sulbactam 1.5-3g IV q6h
- Aztreonam 1-2g IV q8-12h or 2g IV q6-8h
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Empiric Abx Hospital ICU treatment
Psuedomonas Infection or beta-lactam allergy
- Psuedomonas Infection (double coverage)
- Antipsuedomonas beta lactam+cipro or levofloxacin
- Antipsuedomonas beta lactam+ aminoglycoside + azith
- Antipsuedomonas beta lactam+ aminoglycoside + fluroquinolone
- Beta-lactam allergy
- Aztreonam
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- .Piperacillin/tazo- 3.375-4.5g IV q4-8h
- .Cefepime-1-2g IV q12h
- .Imipenem- 500-1000mg IV q6-8h
- .Meropenem- 500-1000mg IV q8h
- .Cipro- 500-750 po q12h or 200-400mg IV q12h
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Empiric Therapy- Hospital ICU
CA-MRSA infection
- add vanco 1g IV q12h or per hospital guidlines
- -dosing adjustments per therapeutic levels OR
- add linezolid 600mg IV/PO q12h
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Therapy
Organism has been ID-ed, antimicrobial therapy should be directed at that pathogen (we want a narrow spectrum to prevent resistance)
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CAP: Duration of therapy
- Min of 5 days, up to 7-14 days
- -fever for 48-72 hours
- -CAP associated s/s improve (hr, rr, sbp, o2 stat, tolerating orals, normal mental status)
- ->5 days may be necessary if therapy was ineffective or extrapulmonary infection occur
IV to PO switch: >24h before discharge must swtich over** - -hemodynamically stable and improving
- -tolerating orals (meds or food)
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Additional supportive care
- Supplemental oxygen
- fluid hydration
- fever control
- nutritional support
- -Septic shock despite fluid resuscitation
- -hypotensive, fluid resuscitated pt w severe CAP should be screened for adrenal insufficieny
- -hypoxemia or repiratory distress
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Preventive measures
- Influenza Virus vaccines
- Pneumococcal vaccine
- smoking cessation
- proper hygiene
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CAP Key Points: Empiric Therapy
- Clinical Features: Severity of illness, treat t as out/in pt
- exposures and comorbidities
- pt's age
- previous or concurrent meds
- major organ function
- sputum gram stain
- resistance patter
- drug allergy and intolerances
- SE and potential interactions
- Cost
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Aspiration Pneumonia
Pneumonia that is a result of abnormal entry significant volumes (via macroaspiration) of oropharyngeal or gastrointestinal contents into the lower resp tract
- need to think about GUT FLORES ANAEROBES** (flagyl, clindamycin)
- Aspiration pneumonia vs pneumonitis
- -pneumonitis= sequelae from sterile gastric contents; noninfectious
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Aspiration pneumonia: Clinical presentation
- Presents similar to any other pneumonia
- -can progress into ling absesses, empyema, or lung necrosis
- -CXR indicate infiltrates in dependent pulmonary segments of the lungs
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Aspiration Pneumonia: Risk Factors
- Conditions of decreased consciousness
- -Alcoholics
- -Seizure disorders (harder to swallow)
- -Head trauma (have low seizure threshold)
- -Sedation or anesthesia
- Neurologic disorders: dysphasia
- -stroke
- -Parkinson's disease
- GERD or vomiting
- Instrumentation of the airway
- -Intubation
- -Bronchoscopy
- -NG Tube
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Aspiration Pneumonia: Pathogens
- Anaerobic bacterial from gingival crevices and GI flora
- -peptostreptococcus
- -Bacteroides
- -Fusobacterium
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Aspiration Pneumonia: Treatment
- target: anaerobes
- -clindamycin
- -metronidazole + pcn
- -beta-lactam/beta-lactamase inhibitor combo
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