Pneumonia

ACUTE BRONCHITIS:

Definition

  • Infection of trachea and bronchi due to spread of URI or exposure to irritants

MCC:

  • Non-smokers: Mycoplasma pneumoniae (Dx: high agglutinin titer)
  • Smokers: S. pneumoniae + H. influenza

Clinical features

  • Productive cough, sore throat, fever, wheeze

CXR:

  • Mild congestion

Treatment

  • Most cases are viral -> self-limited, if suspecting bacteria -> give abx

 


PNEUMONIA:

Definition

Infection of the bronchoalveolar tree

Types:

a. Community acquired pneumonia (CAP):

  • From the community or w\ in the first 72 hrs of hospitalization
  • MCC pathogen: Pneumococcus

b. Nosocomial pneumonia:

  • After the first 72 hrs of hospitalization
  • MCC pathogen: Gram neg (E. coli, pseudomonas) and Staph aureus

Pneumonia 1

Pneumonia 2Pneumonia 3Pneumonia 4

Diagnosis:

CXR:

  • PA + lateral. Sensitive (if neg  -> don’t treat)
  • Once URI is excluded, CXR is done to differentiate between acute bronchitis and pneumonia, which are both LRI
  • False negative -> neutropenia, dehydration, PCP infection, early ds
  • Changes after treatment take up to 6 weeks

Sputum:

  • Gram stain: in all pts
  • Culture: in pts requiring hospitalization
  • Acid-fast stain -> for mycobacterium
  • Silver stain -> for fungi (PCP) in HIV\immunocompromised pts
  • Legionella -> urinary Ag assay. Very sensitive, remains for wks even after treatment
  • PCP -> Broncho-alveolar lavage
  • Mycoplasma -> cold agglutins
  • “Consider” two Pretreatment blood cultures from diff sites

Thoracentesis:

  • PH < 7.2: empyema -> chest tube drainage
  • LDH > 0.6 or protein > 0.5: exudate; infection or cancer

 

Treatment:

Outpatients:

  • Continue treatment for 5 days. Don’t stop until pt is afebrile for 48 hrs
  • < 60 yo -> 1st Macrolides (azithromycin or clarithromycin) or doxycycline. 2nd fluoroquinolone
  • > 60 yo OR those treated w\ antibiotic in the last 3 mo -> 1st fluoroquinolone (levofloxacin, moxifloxacin). 2nd third-gen cephalosporin

Hospitalized:

  1. Fluoroquinolone
  2. Third-gen cephalosporin + macrolides (ceftriaxone + azithromycin)

HAP: tailored towards gram-neg rods

  • Cefrazidime or cefepime (cephalosporin w\ pseudomonal coverage)
  • Carbapenems: imipenem
  • Piperacillin\tazobactam

 

When to admit?Pneumonia 5

Based on pneumonia severity (index, CURB65)

  • Hypotension (sys <90)
  • RR > 30, or pO2 <60 mmHg, PH <7.35
  • BUN > 30 mg\dL, Na < 130 mmol\L, glucose > 250 mg\dL
  • Pulse > 125
  • Confusion
  • Temprature > 40 c
  • > 65 yo, or w\ comorbid: ca, COPD, CHF, renal failure, liver ds

 

Pneumococcal vaccinations given to?

  • Pts > 65 yo
  • Younger pt w\ risk: CSF leak, cochlear implant, sickle cell, DM, alcoholic cirrhosis, asplenic, pulmn\cardiac ds
  • NOT healthcare workers

 

Complications:

  • Pleural effusion (50%). If significant (>1cm on lateral) -> thoracocentesis
  • Pleural empyema (2% of CAP, 7% hospitalized CAP)
  • Acute respiratory failure

 

 

 Random notes:

  • Nursing home residents -> nosocomial pathogens + prefer upper lobes (Pseudomonas)
  • Legionella –> transplant recipients, renal failure pts, chronic lung ds, smokers: present w\ GI sx + hyponatremia

 

Pneumonia 6

 


Download the PDF version: here


References:

  • Step up to medicine
  • Master the boards
  • Kaplan step 2 videos

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