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Name some findings suggestive of pneumonia
- Pleurisy, Dyspnea, Hemoptysis
- High fever or hypoothermia, tachypnea, tachycardia
- Bronchial breath sounds
- Tactile fremitus
- Lung consolidation findings (dullness to percussion, egophony, whispered pectoriloquoy, bronchophony, bronchial breath sounds)
How should you treat patient with the presence of delierium or confusion?
Admit to the hospital (there is an increased liklihood of pneumonia, especially in the elderly)
How is pneumonia diagnosed?
- Chest Xray (visible infiltrates)
- CBC, BMP, BNP
- Pulse Oximetry
For inpatient: blood gasses & sputum culture
How is community acquired pneumonia defined?
Pneumonia acquired outside of hospital or extended care facility
Acute infection of the pulmonary parenchyma that is asssociated with at least two symptoms of acute infection (ex: fever, cough, dyspena) and accompanied by an acute infiltrate on chest x-ray
What is the criteria for health care associated pneumonia?
- Hospitalized >2 days in past 3 months
- Resident of skilled nursing facility
- Receiving IV antibiotics, chemotherapy or wound care
- Receiving hemodialysis
Who is at risk for community acquired pneumonia?
- HIV disease
- Any immune deficiencies
What are the goals for diagnosis and treatment of pneumonia?
Determine which patients can be treated at home
Provide empiric treatment based on likely pathogens uncovered in patient’s history
How does classic pneumonia (pneumococcal or staphloccal) present?
Sudden chill followed by a fever, pleuritic pain, and productive cough
How does atypical pneumonia (mycoplasma or chlamydia) present?
Begins with a sore throat and headache followed by a non-productive cough and dyspnea
What does the presence of infiltrates inthe right middle lobe indicate?
How does strep pneumonia present?
Classic presentaton - abrupt onset fever, cough wth rusty sputum, pleuritic chest pain
What are the complications of strep pneumoniae?
What typically precipitates Staph Aureus Pneumonia?
- Respiratory tract infection (especially influenza)
- Common nosocomial infection
How does staph aureus pneumonia present?
patients are extremely ill, produces lung necrosis and multiple small lung abcesses.
- Common nosocomial infection
- IV drug users
What are the complications of staph aureus pneumonia?
- Can cause bacteremia with metastatic seeding of distant sites such as the endocardium, bone, joints, liver, and meninges
- Pt often left with residual pulmonary fibrosis
How does haemophilus influenza present?
X-ray shows a typical bronchopneumia pattern
Sputum: abundant polymorphonuclear leukocytes and small pleomorphic gram- coccobaccili
Pleural Effusion 30%
What are the risk factors for haemophilus influenza?
Klebsiella pneumonia is cased by _____ (bacteria) and is commonly seen in _____ patients.
Klebsiella pneumonia is cased by gram negative bacilli and is commonly seen in debilitated or alcoholic patients.
Klebsiella pneumonia x-ray findings show ____
dense lobar consolidation
Klebsiella pneumonia causes
tissue necrosis (hemoptysis) - sputum maybe dark red and mucoid (like currant jelly)
high incidence of abcess formation
How does mycoplasma pneumia present?
- Often begins with headache,malaise,sore throat and progresses to non-productive cough
- Common in late summer/early fall
- Spread by respiratory droplets
- Long incubation period
- 50% Household spread
- 5-25 Years old; Increasing age prevalence
- Ear pain 30%
- Myringitis/bullae 15%
- Skin exam may show erythema multiform
- WBC <10,000 80% cases
What do X-ray findings show for mycoplasma pneumonia?
Patchy / Broncho-pneumonia
What tests are used to diagnose mycoplasma pneumonia?
- Cold Agglutinins titer >1:64. Present in 50% cases
- New PCR test—not widely available
What is the treatment for mycoplasma pneumonia?
Treat with macrolide or tetracycline
What is the leading cause of atypical pneumonia syndrome?
presents with fever, dry cough, non-specific chest film
How is chlamydia pneumonia treated?
treat with tetracycline or macrolide
How does moraxella catarrhalis pneumonia present?
- Low grade fever, productive cough
- more common in winter months
What do X-ray findings show in moraxella catarrhalis pneumonia?
What are the risk factors for moraxella catarrhalis pneumonia?
- underlying pulmonary disease
Whar are the risk factors for legionella pneumonia?
- male sex
What are the clinical features of legionella pneumonia? (include initial, intermediate and extrapulmonary features)
Initial - Fever, Nonproductive cough, N/V, Myalgias, dyspnea, pleuritic chest pain
Intermediate - CHEST PAIN, CONFUSION, DIARRHEA & RELATIVE BRADYCARDIA
Extrapulmonary findings: Myocarditis, pericarditis, rhabdomyolysis, renal dysfunction
What clinical findings can you expect wth legionella pneumonia?
- Sputum - Many PMNs & No Bugs
- Hyponatremia <130; Chest pain (30%)
- Diarrhea; Neurological symptoms
- Rapid progression
What do X-ray findings show in legionella pneumonia?
X-ray-interstitial infiltrates, or areas of patchy consolidation
How is legionella pneumonia diagnosed?
Cultures poorly (needs buffered charcoal yeast extract agar)
Urinary antigen 80% sensitive
SEROLOGY IgG 1:256 DIAGNOSTIC
Epidemics traced to contaminated cooling systems, whirlpool baths, and potable water
Some authorities feel that the following constellation of clinical features suggests this diagnosis: high fever, hyponatremia, CNS manifestations, lactate dehydrogenase levels of >700 U/mL, or severe disease
How is legionella pneumonia treated?
For patients who do not require hospitalization, acceptable antibiotics include:
DO NOT Treat with Penicillins
What are predisposing factors for aspiration pneumonia?
Drugs, anesthesia, alcohol, head trauma, diminution of gag reflex, edentulous patients
What bacteria causes aspiration pneumonia?
Usually a mixed infection caused by anerobic and aerobic organisms—normal flora of mouth
What do X-ray findings show in aspiration pneumonia?
right middle lobe infiltrates
Headache typically indicates
Diarrhea typically indicates
Myalgia typically indicates
Bullous myringitis typically indicates
blood tinged sputum typically indicates
What is the treatment for moderate serverity pneumonia in patients <60 with no comorbidity?
ZITHROMAX 500MG QD OR BIAXIN 500mg BID OR ERYTHOMYCIN 500mg QID (for 7-14 days)
Doxycycline 100mg po BID
- 3rd or 4th generation quinolone (some resistances)
- Ketek (telithromycin)
Consider daily injection (1gm) of rocephin (ceftriaxone) until cultures are back
What is the treatment for mild to moderate serverity pneumonia in patients >60 or with comorbidity?
- Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or Levaquin)
- Beta lactam **PLUS** Macrolide
What symptomatic and supportive measures may be used?
- Adequate hydration essential
- Increased fluid intake, local airway humidification
- Expectorants may help loosen sputum (Guaifenesin)
- Cough suppression not recommended
- Fever controlled with aspirin or tylenol
Name some indications for admission
- AGE > 65?; Temp >101
- Physical exam findings: Change in level of consciousnessSYSTOLIC B/P 90mmHg; PULSE >120; RESP >30Dehydration, vomitingHypothermia
- Laboratory or radiographic findings: Bilateral infiltrates, pulmonary edema, pleural effusion
- Sodium <130; BUN >50; CREAT >2.0; K+>5.5/<3.2, glucose >250, PO2 <60mm Hg ON R.A., WBC < 5,000 / > 20,000; HCT <30 PLTs <100,000
- Abrupt onset of illness
- Significant comorbid illness
- Neoplastic disease, liver disease, renal disease, CHF Impaired host defense - COPD, HIV, diabetes, alcoholism
- Suppurative pneumonia related infection - Empyema, septic arthritis, meningitis, endocarditis
- Failure to respond to outpatient treatment within 24-48 hours
- Medical or psychosocial needs:
- Cognitive dysfunction Psychiatric disease, Homelessness, Drug abuse, Lack of outpatient resources, Poor overall functional status
Name the Curb-65 Criteria
- BUN >20
- Respiratory rate > 30 breaths/min
- Blood pressure <90/60
- Age <65
- Patients with 0-1 criterion should be treated as outpatients
- Patients with 2 criteria should be hospitalized on a general medical floor
- Pts with 3 or more criterion should be admitted to ICU
What are standards for outpatient follow-up?
All patients should be re-evaluated within 48-72 hours for improvement
Decreased fever, tachypnea, WBC
If patient admitted, should be followed up 48 hours after discharge
Follow up chest x-ray in 2-3 months weeks for all over age 40, all smokers or ex-smokers
Name some strategies for prevention of pneumonia
- Pneumovax > age 65 or any chronic illness
- Influenza vaccine yearly
- Smoking cessation
- Avoid proton pump inhibitors
Compare typical vs. atypical neumonia. What is the main differentiating factor between the two.
typical pneumonia is usually caused by bacteria such as streptococcus pneumonia. Atypical pneumonia is usually caused by the influenza virus, mycoplasma, chlamydia, legionella, adenovirus or other unidentified microorganism.
Age is the main differentiating factor between typical and atypical pneumonia. Young adults are more prone to atypical causes, very young and older persons are more perdisposed to typical causes