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bacterial Pneumonia
bacterial pneumonia
| Question | Answer |
|---|---|
| Why are rate of pneumonia increasing by 60% over past 20 years? | more immunocompromised patients; pneumonia/infleuzna is most common infectious cause of death, seventh most common cause of death in US |
| What is the epidemiology of pneumonia ? | 1-most common infectious cause of hospitalization and death 2-highest rates in extreme ages 3-Winter seasonality like influenza 4-microbe depends on pt risk factors 5-Influenza predisposes to secondary pneumonia w/strep pneumo or staph aureus |
| What are the clinical characteristics of pneumonia? | 1-Inflammation of lung parenchyma (often infectious cause) 2-respiratory ract symptoms 3-Abnormal breath sounds on ausculcatory exam 4-dullness to percussion 5-Abnormal Infiltrate on CXR (REQUIRED!!) 6-extra-pulmonary symp possible |
| What are some extra-pulmonary symptoms of pneumonia? | gastrointestinal symptoms, especially in the elderly |
| How do you diagnose pneumonia pathogens (7 ways)? | 1-sputum gram stain/culture 2-Pleural fluid culture if effusion 3-Blood culture 4-Pneumococcal and Legionella Urine Antigen tests 5-HIV tests 6-Acid-fast stain/culture if TB mycobacterium 7-Antibody titers for atypical organisms (research setting) |
| How do you diagnose pneumonia? | CHEST X RAY—PosteroAnterior + Lateral view; or CT w/better resolution; Note: Resolution lags behind clinical improvement by 2-4 weeks |
| What could cause false negative on CXR for pneumonia? | Neutropenia, Severe dehydration, PCP infection (AIDS/HIV pt) |
| What causes 50% of pneumonia? | Unknown etiology (idiopathic)! |
| What should empiric antibiotic treatment always cover? | S. pneumonia and atypical organisms |
| Why do we determine pathogen? | Start with broad therapy but then narrow to target pathogenic cause and prevent antibiotic-resistant strains |
| What are the THREE SYNDROMES of Pneumonia? | 1-Typical (bacterial) 2-Atypical |
| (bacterial or viral) 3-Chronic (Fungal, non-infectious causes, or bacterial—brucellosis, mycobacterium TB) | |
| What are the features of TYPICAL pneumonia? | acute, hi fever, ill appearance, Productive cough, dyspnea, Pleuritic chest pain, Consolidation, Gram stain sputum w/many PMNs and PYOGENIC bacteria, Defined opacity on CXR |
| What are the features of ATYPICAL pneumonia? | Subacute, lo grade fever, well appearance “walking pneumonia”, nonproductive cough, dyspnea, gram stain rare w/no PMNs or bacteria, CXR w/ill-defined infiltrate usually in BOTH lungs |
| What are 3 causes of ATYPICAL pneumonia? | 1Mycoplasma pneumoniae 2-Chlamyophila pneumoniae 3-Legionella pneumophila (also mycobacterium TB, anaerobes (aspiration pneumonia), viral (influenza), parasitic, fungal could be chronic or atypical) |
| Why are Mycoplasa, Chlamydophila and Legionella called Atypical pathogens? | 1-CanNOT be cultured w/routine methods 2-CanNOT be treated w/Beta-lactam antibiotics 3-mild subacute course w/mycoplasma & chlamydophila 4-Atypical CXR—usually bilateral interstitial or reticular infiltrates; not lobar consolidation |
| What are five causes of Typical pneumonia? | St.pneumo, Staph aureus, H. influenzae, Klebsiella, Moraxalla catarrhalis |
| What 3 gram positive bacteria cause pneumonia? | 1-Streptococcus pneumonia, 2-Staphylococcus aureus 3-Bacillus anthracis |
| What four gram negative bacteria cause pneumonia? | 1-Haemophilus influenzae 2-Chalmydophila pneumoniae (TWAR strain, not visible on gram stain bc of thin cell wall) 3-Francisella tularensis (causes tularemia) 4-Yersinia Pestis (causes plague!) |
| What six gram negative bacteria cause NOSOCOMIAL UTI and pneumonia? | Pseudomonas (in CF pt), Klebsiella (encapsulated), serratia, enterobacter, proteus (morganella/providencia), Legionella pneumonphila (too faint to be seen on gram stain) |
| What bacterium without cell wall causes pneumonia? | mycoplasma pneumoniae |
| What does chlamydophila psittaci cause? | psittacosis |
| What does coxiella burnetti cause? | Q or Query fever which leads to atypical pneumonia; is a Rickettsia |
| What are the six common categories of pneumonia? | 1-Community Acquired Pneumonia 2-Nosocomial pneumonia→Hospital Acquired Pneumonia, Ventilator Associated Pneumonia,Healthcare-Associated pneumonia 4-Aspiration Pneumonia 5-Opportunistic Pneumonia in an immunocompromised host 6-Non-infectious “pneumonia” |
| What is the largest category of pneumonia? | Community acquired pneumonia |
| What is Non-infectious pneumonia? | Eosinophilic pneumonia, lipid pneumonia, bronchiolitis, obliterans organizing pneumonia, chemical pneumonia, etc |
| Who is affected by Community Acquired Pneumonia—CAP? | healthy and immunocompromised children and adults |
| What are the TEN most common causes of CAP? | Strep p., Mycoplasma p, Chlamydophila p, Legionella pneumophila, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus (and MRSA), Coxiella burnetti, Chlamydia psittaci, Viral (influenza, parainfluenza, RSV), Fungal or TB |
| What is the MOST common cause of CAP? | streptococcus pneumonia |
| What are the three types of CAP? | Mild (outpatient), moderate (non-icu inpatient), Severe (ICU inpatient) |
| What is hospital acquired pneumonia? | occurs >48h after admission to hospital, NOT incubating at time of admission; problem w/multi-drug resistance strains |
| What are the EIGHT most common causes of Hospital Acquired Pneumonia HAP? | Klebsiella, Enterobacter, Serratia, Ecoli, Pseudomonas aeruginosa, Acinetobacter, Staphylococcus aureus (MRSA), Anaerobic bacteria |
| What is Ventilator Associated Pneumonia? | pneumonia that develops 48-72h after endotracheal intubation; pathogens often multi-drug resistance and hospital-acquired; hi risk for noninfectious causes of fever & pulmonary infiltrates |
| What is Aspiration pneumonia? | Pneumonia caused by aspiration of enteric gm - rods or anaerobes from oropharynx and gastric juice; Cause acute lung injury and abscess; Characterized by cough, fever and foul smelling sputum; Risk factors—chronic alcoholism, unconsciousness, intubation |
| What types of organisms cause aspiration pneumonia? | enteric gram negative rods or anaerobes, usually oropharynx |
| What are the risk factors for aspiration pneumonia? | alcoholism, unconsciousness, intubation |
| What is the most commonly used diagnostic technique? | Expectorated sputum—must have <10 squamous epithelial cells (eg saliva); must have >25 PMNs (eg from focal infection); acquire BEFORE trtmt w/antibiotics; gram test and culture of cells |
| What is gram stain of streptococcus pneumoniae? | gram + diplococci |
| What is gram stain of staphylococcus aureus? | gram + cocci clusters |
| What is gram stain of Haemophilus influenzae? | gram – coccobacilli |
| What is gram stain of Klebsiella pneumoniae? | gram – encapsulated rod |
| Which organisms gram stain POORLY? | Mycobacterium TB, Chlamydophila pneumoniae, Chlamydophila psittaci, Coxiella burnetti (Rickettsia), Mycoplasma pneumo, Legionella (light gm – stain), Viruses |
| What test is best for mycobacterium TB? | Acid Fast Bacillus (AFB) test |
| What medium is used to culture aerobic bacteria for pneumonia? | Sheep’s blood agar, MacConkey (gram - ), Chocolate agar (H.infl) |
| Are blood and sputum cultures high yield for pneumonia? | NO, not specific or sensitive; Thus only recommended for specific patients w/severe pneumo/ICU or failed antibiotics, chronic liver/lung disease, asplenia, pleural effusion, recent travel |
| What are common lower respiratory pathogens in neonates? | Ecoli, Streptococcus agalactiae (group B strep) |
| What are common lower respiratory pathogens in Infants? | Chlamydia, RSV |
| What are common lower respiratory pathogens in Children? | Viruses like parainfluenza, influenza, RSV, adenovirus |
| What are common lower respiratory pathogens in Teens/young adults? | mycoplasa, s.pneumoniae, Bordetella pertussis |
| What are common lower respiratory pathogens in Adults? | S. pneumoniae, Chlamydia, mycoplasma, viruses |
| What are common lower respiratory pathogens in Elderly? | E coli, Klebsiella, Staph aureus, Legionella, Haemophilus influenzae type B |
| What are common lower respiratory pathogens in Immunocompromised patients(hint: mostly nonbacterial)? | HIV/AIDS→S. pneumonia, Crytpococcus neoformans, Pneumocstis jiroveci; Organ transplant pt→CytoMegaloVirus; Pt on chemo or immunosuppressants→Aspergillus or fungi |
| What are three complications of pneumonia? | Parapneumonic effusion, Empyema, Pulmonary Abscess |
| What is Parapneumonic Effusion? | pleural effusion occurring secondary to pneumonia in 40% of cases; more common in Staph aureus inf (90%) and gram – rod (60%); Meniscus sign on CXR; Responds to antibiotics unless huge (thoracentesis) |
| What is Empyema? | purulent effusion (ie. pus in pleural space) due to spread of pneumonia from infected lung parenchyma or parapneumonic effusion; + gram stain in fluid; Trt w/Percutaneous drainage AND antibiotics (2-4wk) |
| What is pulmonary Abscess? | rare complication; due to inf Anaerobes in Right Middle or lower lobe bc vertical (aspiration pneumonia) or bacteremia w/Staph aureus septic emboli; trt w/percutaneous or surgical drainage & long antibiotic(4-6wk) |
| What Vaccines exist for pneumonia (though underutilized)? | 2 Pneumococcal vaccinations, Influenza vaccination |
| What is pneumococcal vaccination? | 1-Vaccine w/23 capsular antigens; Blocks inf w/strep pneumoniae→Give to people >65 y and <65y w/alcoholism, CVD, diabetes, immunocompromised, nursing home→Revaccinate in 5 yrs; 2-Conjugate vaccine (7-valent)→give to BABIES @ 2,4,6,12 months |
| What is the MOST common cause of Community Acquired Pneumonia (CAP)? | Streptococcus pneumonia! |
| What 4 Diseases develop from infection w/streptotcoccus pneumoniae? | 1-Pneumonia (adults), 2-Meningitis (adults) 3-Otitis Media (kids) 4-Sepsis |
| What is the virulence factor for Streptococcus pneumoniae? | capsule with 84 serotypes! |
| What is the mechanism for Strep pneumoniae inf? | massive multiplication leads to inflammation; anti-phagocytic capsule |
| What is the transmission for S.pneumoniae? | normal flor of Oropharynx |
| How do you diagnose s.pneumoniae? | Gram stain (diplococc), Alpha hemolytic, Culture—does not grow in presence of bile or Optochin |
| What is the treatment for infection w/streptococcus pneumoniae? | Penicillin G |
| What are the virulence factors of Staphylococcus aureus? | Protein A, enzymes, Exotoxin |
| What is the mechanism of staph aureus infection? | 1-Disable Host Immune Response w/Protein A, coagulase, hemolysins, penicillinase 2-Tunnel thru tissue w/hyaluronidase, staphylokinase, lipase |
| What is the transmission of staph aureus? | ubiquitous in environment, hospital, normal skin flora |
| How do you diagnose staph aureus? | Gram + clusters of cocci, Catalase +, Coagulase + (blood clots thru prothrombin activation) |
| What 8 diseases are caused by direct organ invasion by staph aureus? | 1-Skin inf 2-Bacteremia/sepsis 3-Pneumonia w/Pulmonary Abscess 4-Meningitis 5-Acute bacterial endocarditis 6-Osteomyelitis 7-Urinary tract infections 8-Abscess formation in any organ |
| What 3 diseases are caused by staph aureus Exotoxin? | 1-Food poisoning (enterotoxin) 2-Scalded skin syndrome (exfoliation exotoxin) 3-Toxic Shock Syndrome (TSS toxin) |
| What is the treatment for Staph aureus infection? | Penicillinase resistant antibiotics→Methicillin, Nafcillin; Staph aureus may be MRSA in hospital |
| What are the virulence factors of Legionella Pneumophila? | Beta lacamase, Endotoxin—affects elderly, smokers, alcoholics; 24 serotypes |
| What is transmission for Legionella pneumophila? | Aersolization of respiratory droplets from environmental water sources; Legionella parasitizes fresh-water amoebas that live in air conditioners and water towers; Can be Community Acquired or nosocomial |
| What diseases does Leigonella pneumophila cause? | Atypical pneumonia (Legionnaire’s disease), either community-acquired or nosocomial but it is HIGH morbidity so should test for it frequently |
| Who is at risk for infection with Legionella pneumophila? | smokers, immunosuppressed pt, pt on ventilators—Very high mortality rate! |
| How do you diagnose Legionella pneumophila infection? | Gram – rod stains faintly; Dieterle Silver Stain; Cysteine required for culture, serology, fluorescent tests; rapid Legionella Antibody Urine Test! |
| What is the treatment for legionnaire’s disease? | Macrolide antibiotics (+/- Rifampin); Resistant to B-lectam antibiotics due to presence to beta lactamase bc gram negative |
| What are the virulence factors of Klebsiella Pneumoniae? | thick polysaccharide capsule (70 serotypes of K antigens) prevents phagocytosis; LPS endotoxin |
| What is the mechanism of pathogenesis of klebsiella pneumoniae? | Septic shock caused by Endotoxins in cell wall (LPS) |
| What is the transmission for Klebsiella pneumoniae? | aspiration of respiratory droplets; normal flora of Colon! |
| What are the diseases caused by Klebsiella pneumoniae? | Pneumonia, Nosocomial pneumonia/UTI (urinary catherters), Septic shock |
| How do you diagnose Klebsiella pneumoniae? | gram – rod, large polysaccharide capsule; Lactose-fermenting; Clincal—Currant jelly sputum often in alcoholics (think kelly’s currant jelly sputum!); tends to be nosocomial/opportunistic urinary catheters or in alcoholics |
| What is the treatment for klebsiella pneumonia infection? | Cephalosporins; hi antibiotic resistance is a problem |
| What are the virulence factors for Mycoplasma pneumoniae? | Protein P1→adheres to epithelium of respiratory tract |
| What is the mechanism of Mycoplasma pneumonia infection? | adhere to respiratory tract epithelium and inhibit cilia movement→necrosis of respiratory epithelium |
| How many serotypes exist for mycoplasma pneumonia? | one! But immunity is incomplete and reinfection is possible |
| What is the transmission for Mycoplasma pneumoniae? | respiratory droplets; community-acquired, usually |
| How do you diagnose mycoplasma pneumonia infection? | Serology—cold agglutintion test, slow special agar culture—looks like fried eggs (pleomorphic), NO gram stain bc NO cell wall, very small (tiniest bac able to grow outside a cell; ~ same size as virus), polarized |
| What disease does Mycoplasma pneumoniae cause? | Atypical “walking” pneumonia |
| What are the symptoms associated with Atypical walking pneumonia caused by mycoplasma pneumonia? | Fever w/dry nonproductive cough, CXR looks worse than symptoms, Common in 10-15yo teens, Can be chronic & spread w/in families |
| What lipid does Mycoplasma pneumoniae require for membrane formation? | Cholesterol! |
| How do you assess the severity of infection? | Systemic inflammatory Response Syndrome (SIRS) vs Sepsis vs Septic shock |
| What is Systemic inflammatory response syndrome SIRS? | Two or more are true: 1-Temp >38C or <36C 2-Pulse >90 beats/min 3-Resp rate >20breaths/min 4-WBC >12000 or <4000 mm |
| How do you define Sepsis? | SIRS plus documented infection (eg positive bacterial culture) |
| How do you define septic shock? | sepsis-induced organ dysfunction or failure; REFRACTORY HYPOTENSION causes end organ damage |
| How does sterile lung get infected to cause pneumonia? | 1-aspirate oropharyngeal—most common (S.pneum, H.infl) 2-Aspirate gastric juice w/enteric Gm – rods & anaerobes 3-aerosolize (M.TB, Legionella, Viral) 4-Hematogenous spread (staph aureus) 5-contiguous spread (heart valve inf.touches lung→emboli form) |
| What is the pathogenesis of pneumonia? | 1-bacteria cause inflammatory response in alveoli 2-increase vascular leakage of immune cells and serum into alveoli 3-macrophages destroy tissue 4-thick septae bc of fluid in interstitial space |
| What are the 6 main risk factors for pneumonia? | Extremes of age, Smoking, Alcoholic, Poor dentition, Contact w/kids in daycare, Chronic comorbid conditions like COPD, CVD, Diabetes, Malnutrition, Cancer, Stroke/seizure/CNS disorders that impair swallowing reflex |
| What 6 risk factors increase likelihood of infection with S.Pneumo? | Extremes of age, Recent antibiotics/hospitalization, Alcoholism, Immunosuppressed, Comorbid Cardiopulonary disease, kid in daycare |
| What 3 risk factors increase likilhood of infection with enteric gram negative rods like Ecoli, Klebsiella, proteus, etc? | Nursing home resident, Comorbid cardiopulmonary disease, Recent antibiotics |
| What 4 risk factors increase likelihood of inf with Pseudomonas Aeruginosa? | Bronchiectasis (due to CF or COPD), Steroids, Recent antibiotics, Malnutrition |
| What 2 risk factors increase likelihood of inf with S. Aureus? | Recent influenza 2-comorbid cardiopulmonary disease |
| What pathogens are associated with Asplenia? | Streptococcus pneumonia, Hemophilus influenzae |
| What 2 pathogens are associated with cystic fibrosis? | Pseudomonas aeruginosa, Burkholderia cepacia |
| What 2 bacterial pathogens are associated with influenza outbreak? | Streptococcus pneumonia, staphylococcus aureus |
| What are some epidemiological clues to rare etiologies of pneumonia? | Travel history, animal contact, activities |
| What rare etiologies of pneumonia are associated with travel history? | 1-SE Asia—Melloidosis 2-Tropics S America/Far east—Paragonimiasis (worm inf) 3-Ohio/MissR—Histoplasmosis, Blastomycosis fungi 4-CA Central Valley, Arizona Mexico—Coccidiodomycosis 5-Martha’s Vineyard—Tularemia (francisella T.) |
| What rare etiologies of pneumonia associated with Animal contact? | 1-sick pet birds—psittacosis 2-chickens in SE asia—Avan influenza 3-Prairie dogs—Plague 4-Parturient cats/cattle—Q fever 5-rabbits—tularemia 6-Bats—Hitoplasmosis 7-Mice droppings—Hantavirus pulmonary syndrome |
| What rare etiologies of pneumonia are associated with activities? | 1-Lawn mow-Tularemia; Hotel/cruise AC H2O—Legionellosis; Farmer—Q fever;Alcohol—asp. pneumonia, Klebsiella; Wool/hides—inhalational Anthrax; Butcher—Brucellosis; White-water rafting—Leptospirosis; Crawl under a house/mouse poo—Hantavirus pulmonary syn. |
| An elderly patient is more likely to get which type of CAP in home versus a nursing home? | Home—S pneumo, GNR, Legionella vs. Nursing home—Staph aureus, GNR, S. Pneumo |
| What is severe CAP? | life-threatening community acquired pneumonia requiring hospitalization in intensive care, prolonged antibiotics, possibly surgery |
| Which pathogen causes severe CAP (ie requires Intensive care)? | S pneumo, legionella, PCP, H.infl, P.aeruginosa |
| Which severe CAP has highest mortality? | Pseudomonas aeruginosa (88%), Staph aureus (40%), PCP (40%) |
| How do you treat Severe CAP? | 1-IV antibiotics—anti-pseudomonal B-lactam + fluoroquinolone or macrolide; Vancomycin to cover MRSA 2-Cover Legionella, Staph aureus, Pseudomonas aeruginosa and Strep pneumo 3-Supportive care—O2, ventilation, BP support, Cardiovascular monitoring |
| When do you consider the complications of pneumonia? | Pt failing w/antibiotics or w/severe pneumonia, repeated diagnostic testing; bacteremia, sepsis, pleural effusion, empyema, lung abscess; May require surgery or long antibiotics course |
| What is etiology of Mild CAP? | 1-Young healthy pt 2-Mycoplasma p. (“walking pneumonia”), Chlamydophila P, Respiratory viruses >> Spneumo 3-RARELY S. aureus, Legionella or P.aeuruginosa |
| What is treatment for Mild CAP? | SHORT course antibiotics in OUTpatient setting→macrolides, fluoroquinolones, tetracyclines |
| How do you determine to hospitalize a patient? | PORT score (Pneumonia Severity Index) |
Created by:
matthewthomp