Viral/ pneumonia

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cindyx88
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71632
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Viral/ pneumonia
Updated:
2011-03-08 17:46:44
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pneumonia treatments
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exam 3 viral
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  1. Pneumonia
    infection/ inflammation of the alveoli, distal airways, and interstitium of the lung
  2. 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
  3. 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)
  4. Acquired mechanism
    • Macrophages
    • Fibronectin
    • Lysozymes
    • Lactoferrin
    • IgG
    • Defensins
    • Cathelicidins
    • Collectins
    • Complement¨
    • Surfactant
  5. 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
  6. 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
  7. 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
  8. Clinical manifestations (Signs)
    • Fever
    • Cough
    • Pleuritic
    • Chest pain
    • Chills
    • Rigors
    • SOB
    • Headache
    • N/V/D
    • Myalgia
    • Fatigue
  9. 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”
  10. CAP diagnosis
    • Screeen tools
    • -Chest radiography
    • -CT
    • Blood culture**
    • Sputum sample
    • Urine antigen (Elisa)
  11. 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)
  12. CAP common pathogens Hospital non-ICU
    • S. pneumoniae
    • M. pneumoniae
    • C. pneumoniae
    • H. influenzae
    • Legionella epp.
    • Resp. virus
  13. CAP common pathogens Hospital ICU
    • S. pneumoniae
    • Staph aureus *MRSA
    • Legionella spp.
    • G- bacilli
    • H. influenzae
  14. High mortality rate by pathogens
    • P. aeruginosa
    • K. pneumoniae
    • S. aureus
  15. 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
  16. 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
  17. 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
  18. Atypical Pathogens and treatments for them
    • Mycoplasma and Chlamydia pneumonia
    • Doxycyline
    • Macrolides
    • Alt: Fluroquinolones

    • Legionella
    • -Azith
    • -Fluroquinolones
    • -Alt: Doxy
  19. How to determine site of care
    • PORT severity index (PSI)
    • CURB-65
    • CRB-65
    • Social circumstances
    • Comorbid medical conditions
  20. 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
  21. 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
  22. 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
  23. CRB-65 score
    • 0- out pt treatment
    • 1- hospital admin
    • >2 - hospitalization, possible ICU admin
  24. 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
  25. 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
  26. Empiric ABX therapy Out PT
    -macrolide resistant S. pneumoniae
    Fluroquinolone or Beta-lactam

    if they have PCN allergy can give
  27. 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
  28. 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
  29. 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
  30. 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
    • .
    • .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
  31. 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
  32. Therapy
    Organism has been ID-ed, antimicrobial therapy should be directed at that pathogen (we want a narrow spectrum to prevent resistance)
  33. 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)
  34. 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
  35. Preventive measures
    • Influenza Virus vaccines
    • Pneumococcal vaccine
    • smoking cessation
    • proper hygiene
  36. 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
  37. 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
  38. 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
  39. 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
  40. Aspiration Pneumonia: Pathogens
    • Anaerobic bacterial from gingival crevices and GI flora
    • -peptostreptococcus
    • -Bacteroides
    • -Fusobacterium
  41. Aspiration Pneumonia: Treatment
    • target: anaerobes
    • -clindamycin
    • -metronidazole + pcn
    • -beta-lactam/beta-lactamase inhibitor combo

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