CMN 568 - Exam 2 covering McPhee readings
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| For previously healthy pt who has not taken abx within the past 3 mo, what will you RX for outpatient management of CAP? | a. A macrolide (Clarithromycin 500 mg PO BID; or azithromycin, 500 mg PO 1st dose followed by 250 mg PO QD X 4 d, or 500 mg PO QD X 3d) OR
b. doxycycline, 100 mg PO BID
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| In the patient with suspected CAP, it is essential that you order what diagnostic test? | CXR
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| Patient presents with an acute or subactue onset of fever, cough with or without sputum production, and dyspnea. You suspect what? Upon exam, you expect to find? | 1. CAP
2. Tachypnea, tachycardia and arterial O2 desat, insp crackles and bronchial breath sounds
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| Common viral causes of CAP | Influenza virus, RSV, adenovirus and parainfluenza virus
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| Most common bacterial pathogen identified in CAP? Other common causes? | 1.S pneumoniae
2. M pneumoniae; C pneumoniae; Viruses
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| What are the essentials of diagnosis for CAP? | 1. Fever or hypothermia, tachypnea, cough with or without sputum, dyspnea, chest discomfort, sweats or rigors (or both)
2. Bronchial breath sounds or insp crackles
3. CXR shows parenchymal opacity
4. Outside of hosp or within 48 hrs of admit
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| Risk factors for the development of CAP | Advanced age; tobacco use; comorbid medication conditions, esp asthma or COPD; and immunosuppresion
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| Pt with CAP is at risk for drug resistance, What is the appropriate outpt management? | a. resp fluoroquinolone
b. macrolide plus a B-lactam
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| You have decided to RX respiratory fluoroquinolone for CAP, what are appropriate medications/dosages? | moxifloxacin, 400 mg PO QD
gemifloxacin, 320 mg PO QD
levofloxacin 750 mg PO QD
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| You have decided to RX a macrolide in combination with a B-lactam to treat CAP, what medications/dosages does this include? | Macrolide: (Clarithromycin 500 mg PO BID; or azithromycin, 500 mg PO 1st dose followed by 250 mg PO QD X 4 d, or 500 mg PO QD X 3d)
B-lactam: amoxicillin, 1g PO TID; augmentin 2g PO BID; cefpodoxime, 200 mg PO BID; cefuroxime, 500 mg PO BID
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| What puts a patient at risk for drug resistance in CAP? | 1. Abx therapy in past 90 days
2. Age > 65 years
3. Comorbid illness
4. Exposure to a child in daycare
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| What is the appropriate duration of treatment in CAP? | Most experts recommend a minimum of 5 days of therapy and to continue abx until the patient is afebrile for 48 to 72 hours
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| The most common etiologies of CAP in patients who require hospitalization (not ICU) | S pneumoniae, M pneumoniae, C pneumoniae, H influenza, Legionella species, and viruses
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| Most common etiologies of CAP in patients who require ICU stay | S pneumoniae, Legionella species, H influenza, Enterobacteriaceae species, S aureus, and Pseudomonas species
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| What are indications for the pneumococcal vaccine? | Age >/= 65 years
Any chronic illness that increases risk of CAP
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| Who should receive a revaccination of the pneumococcal vaccine? | Immunocompromised pts should receive 2nd dose 6 years after the first; Immunocompetent persons 65 or older that received the first dose prior to age 65 should get a 2nd dose 6 years after the 1st
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| Name two clinical prediction tools available to guide hospital admission decisions R/T CAP. | Pneumonia severity index (PSI)
CURB - 65
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| 3 factors that distinguish nosocomial pneumonia from CAP | 1. Different infectious causes
2. Higher incidence of drug resistance
3. Patient's underlying health status puts them at risk for more severe infections
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| What is the most important step in the pathogenesis of nosocomial pneumonia? | Colonization of the pharynx and possibly the stomach with bacteria
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| Organisms prevalent in nosocomial pneumonias | Streptococcus Pneumoniae
Staph aureus
MRSA
Gram-neg rods, non-ESBL
ESBL-producing gram neg rods (Klebsiella pneumonia, E. coli and Enterobacter species
Psuedomonas aeruginosa
Acinetobacter species
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| What are the signs and symptoms of nosoc |
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| 3 factors that distinguish nosocomial pneumonia from CAP | 1. Different infectious causes
2. Higher incidence of drug resistance
3. Patient's underlying health status puts them at risk for more severe infections
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| What is the most important step in the pathogenesis of nosocomial pneumonia? | Colonization of the pharynx and possibly the stomach with bacteria
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| Organisms prevalent in nosocomial pneumonias | Streptococcus Pneumoniae
Staph aureus
MRSA
Gram-neg rods, non-ESBL
ESBL-producing gram neg rods (Klebsiella pneumonia, E. coli and Enterobacter species
Psuedomonas aeruginosa
Acinetobacter species
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| What are the signs and symptoms of nosocomial pneumonias? | At least 2 of the following: fever, leukocytosis, purulent sputum
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New or progressive parenchymal opacity on CXR
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| Differential diagnosis of new lower resp tract ssx | Nosocomial pneumonias
CHF
Atelectasis
Aspiration
ARDS
Pulmonary thromboembolism
Pulmonary hemorrhage
Drug reactions
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| Diagnostic evaluation for suspected nosocomial pneumonia | Blood cultures from two different sites
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| Essentials of diagnosis for anaerobic pneumonia and lung abscess | Hx of or predisposition to aspiration
Indolent symptoms (fever, wt loss, malaise)
Poor dentition
Foul-smelling purulent sputum (Most pts)
Infiltrate in dependent lung zone
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| Most aspiration patients with necrotizing pneumonia, lung abcess, and empyema are found to be infected with... | Multiple species of anaerobic bacteria including: Prevotella melaninogenica, Peptostreptococcus, Fusobacterium nucleatum, and Bacteroides species
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| Identify acceptable methods of collecting representative material for culture with suspected anaerobic pneumonia | Transthoracic aspiration
Thoracentesis
Bronchoscopy with a protected brush
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| Different types of anaerobic pleuropulmonary infections are distinguished on the basis of... | X-ray appearance
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| Describe the appearance of lung abcess on CXR | Thick-walled solitary cavity surrounded by consolidation
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| How does necrotizing pneumonia look on CXR? | Multiple areas of cavitation within an area of consolidation
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| Viewing the CXR of a patient with an empyema, you expect to see.. | Presence of purulent pleural fluid, possibly in combination with findings suggestive of lung abcess or necrotizing pneumonia
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| Drugs of Choice for Anaerobic pneumonia and lung abcess | Clindamycin, 600 mg IV Q8H until improvement, then 300 mg PO Q6H or
Augmentin, 875 mg PO Q12H
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| Patient with defect in humoral immunity is predisposed to? | Bacterial infections
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| Defects in cellular immunity lead to infections with... | Viruses, fungi, mycobacteria, and protozoa
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| Neutropenia & impaired granulocyte formation predispose to | infections from S aureus, Aspergillus, gram neg bacilli, and Candida.
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| Fulminant pneumonia is often caused by | Bacterial infection
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| Insidious pneumonia is likely caused by | Viral, fungal, protozoal, or mycobacterial infection
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| What are the essentials of diagnosis of pulmonary venous thromboembolism? | -Predisposition to venous thrombosis
-At least one: dyspnea, chest pain, hemoptysis, syncope
-Tachypnea & widened alveolar-arterial PO2 difference
-Elevated D-Dimer, characteristic defects on CT arteriogram, VQ scan, or pulmonary angiogram
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| What is Virchow's Triad? Why is it significant? | -Venous stasis, injury to the vessel wall, & hypercoagulability
-Risk factors for PE
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| Profound hypoxia with a normal CXR in the absence of preexisting lung disease leads one to suspect what condition? | Highly suspicious for PE
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| What is Westermark sign? | Sign that represents a focus of oligemia (vasoconstriction)distal to a PE
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| What is Hampton hump? | Wedge-shaped opacity that represents intraparenchymal hemorrhage; in combination with Westermark sign, indicates PE
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