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  • 20% need to be hospitalized
  • On the top we see the cilia, labeled (H). They are attached to columnar cells, labeled (I). The cilia sweep the mucous produced in the goblet cells, labeled (J) as well as mucous coming from deeper glands within the lungs and the particulate matter trapped in the mucous. The bottom layer of cells, labeled (L) are the basal cells
  • Lemierre’s syndrome retropharyngeal abscess and jugular venous thrombophlebitis
  • Pneumococcal assay is an immunochromatographic membrane
  • pneumococcus
  • Fine classes
  • c
  • c
  • a
  • d
  • C.
  • D
  • Transcript

    • 1. PneumoniaPneumonia Tammy Wichman MDTammy Wichman MD Assistant Professor of MedicineAssistant Professor of Medicine Pulmonary-Critical CarePulmonary-Critical Care Creighton University Medical CenterCreighton University Medical Center
    • 2.  The #1 cause of death in the UnitedThe #1 cause of death in the United States from infectious disease is:States from infectious disease is:  A. MeningitisA. Meningitis  B. PneumoniaB. Pneumonia  C. GastroenteritisC. Gastroenteritis  D. Urinary Tract InfectionsD. Urinary Tract Infections  E. Toe fungusE. Toe fungus
    • 3. PneumoniaPneumonia  Most deadly infectious disease in the U.S.Most deadly infectious disease in the U.S.  66thth leading cause of deathleading cause of death  Average mortality 14%Average mortality 14%  $20 billion/year in U.S.$20 billion/year in U.S.11  Community acquired pneumonia affectsCommunity acquired pneumonia affects ~4 million patients and results in 10 million~4 million patients and results in 10 million physician visits, 1 million hospitalizations,physician visits, 1 million hospitalizations, and >50,000 deaths annuallyand >50,000 deaths annually 1 File Chest 2004; 125:1888-1901
    • 4. Defense MechanismsDefense Mechanisms  80% of cells lining central airways are ciliated,80% of cells lining central airways are ciliated, pseudostratified,pseudostratified, columnar epithelial cellscolumnar epithelial cells  Each ciliated cell containsEach ciliated cell contains about 200 cilia that beat inabout 200 cilia that beat in coordinated waves aboutcoordinated waves about 1000x/minute1000x/minute  So the lower respiratory tractSo the lower respiratory tract is normally sterileis normally sterile
    • 5. Pneumonia PathophysiologyPneumonia Pathophysiology  Microbial pathogens enter the lung by:Microbial pathogens enter the lung by:  AspirationAspiration of organisms from oropharynxof organisms from oropharynx  More common in patients with impaired level of consciousness:More common in patients with impaired level of consciousness: alcoholics, IVDA, seizures, stroke, anesthesia, swallowing disorders,alcoholics, IVDA, seizures, stroke, anesthesia, swallowing disorders, NG tubes, ETTNG tubes, ETT  Gram positive and anaerobes: Strep pneumo, H flu, Mycoplasma,Gram positive and anaerobes: Strep pneumo, H flu, Mycoplasma, Moraxella, ActinomycesMoraxella, Actinomyces  Gram negatives:Gram negatives: • more likely with hospitalization, debility, alcoholism, DM, and advanced agemore likely with hospitalization, debility, alcoholism, DM, and advanced age • Source may be stomach which can become colonized with these organismsSource may be stomach which can become colonized with these organisms with use of H2blockerswith use of H2blockers  InhalationInhalation of Infectious Aerosolsof Infectious Aerosols  Influenza, Legionella, Psittacosis, Histoplasmosis, TBInfluenza, Legionella, Psittacosis, Histoplasmosis, TB  HematogenousHematogenous DisseminationDissemination  Staph aureusStaph aureus  Fusobacterium infections of the retropharyngeal tissues: Lemierre’sFusobacterium infections of the retropharyngeal tissues: Lemierre’s syndromesyndrome  Direct inoculation and Contiguous SpreadDirect inoculation and Contiguous Spread  Tracheal intubation, stab woundsTracheal intubation, stab wounds
    • 6. At the left the alveoli are filled with a neutrophilic exudate that corresponds to the areas of consolidation seen grossly with the bronchopneumonia. This contrasts with the aerated lung on the right of this photomicrograph.
    • 7. What is pneumonia?What is pneumonia?  Infection of the lower respiratory tractInfection of the lower respiratory tract  Which of the following isWhich of the following is NOTNOT a symptom of pneumonia?a symptom of pneumonia?  A. CoughA. Cough  B. Shortness of breathB. Shortness of breath  C. FeverC. Fever  D. Abdominal painD. Abdominal pain  E. Chest tightnessE. Chest tightness  F. ConfusionF. Confusion  G. Hot, erythematous 1G. Hot, erythematous 1stst toetoe
    • 8. Clinical presentationClinical presentation  Pneumonia should be considered in any patientPneumonia should be considered in any patient who has newly acquired respiratory symptoms:who has newly acquired respiratory symptoms: cough, sputum production, dyspnea, especially ifcough, sputum production, dyspnea, especially if accompanied by fever and abnormal breathaccompanied by fever and abnormal breath sounds and cracklessounds and crackles  In elderly or immunocompromised, pneumoniaIn elderly or immunocompromised, pneumonia may present with confusion, failure to thrive,may present with confusion, failure to thrive, worsening of underlying chronic illness, fallingworsening of underlying chronic illness, falling
    • 9. Pneumonia SymptomsPneumonia Symptoms  ““Typical” pneumonia: sudden onset ofTypical” pneumonia: sudden onset of fever, cough productive of purulentfever, cough productive of purulent sputum, pleuritic chest painsputum, pleuritic chest pain  ““Atypical”: gradual onset, dry cough,Atypical”: gradual onset, dry cough, prominence of extrapulmonary symptoms:prominence of extrapulmonary symptoms: headache, myalgias, fatigue, sore throat,headache, myalgias, fatigue, sore throat, nausea, vomitingnausea, vomiting  Includes diverse entities and has limitedIncludes diverse entities and has limited clinical valueclinical value
    • 10. PneumoniaPneumonia  Which of the following isWhich of the following is NOTNOT a sign ofa sign of pneumonia?pneumonia?  A. Dullness to percussionA. Dullness to percussion  B. Tracheal deviationB. Tracheal deviation  C. Bronchial breath soundsC. Bronchial breath sounds  D. Egophany, increased tactile fremitusD. Egophany, increased tactile fremitus  E. Late inspiratory cracklesE. Late inspiratory crackles
    • 11. Pneumonia DiagnosisPneumonia Diagnosis  Radiography: CXRRadiography: CXR  confirm the presence and location of the pulmonaryconfirm the presence and location of the pulmonary infiltrateinfiltrate  assess the extent of the infectionassess the extent of the infection  detect pleural involvement, pulmonary cavitation, ordetect pleural involvement, pulmonary cavitation, or lymphadenopathylymphadenopathy  May be normal when the patient is unable toMay be normal when the patient is unable to mount an inflammatory responsemount an inflammatory response (immunocompromised) or is in the early stage of(immunocompromised) or is in the early stage of an infiltrative process (hematogenous S. aureusan infiltrative process (hematogenous S. aureus pneumonia)pneumonia)
    • 12.  A 64 year old female with DM and HTN isA 64 year old female with DM and HTN is admitted to 4600 with RLL pneumonia. T 39.3admitted to 4600 with RLL pneumonia. T 39.3 HR 118 R 28 BP 110/60 Sats 92% on 4 L NC.HR 118 R 28 BP 110/60 Sats 92% on 4 L NC. She has crackles in her RLL. You should:She has crackles in her RLL. You should:  A. Order a sputum gram stain and culture. WaitA. Order a sputum gram stain and culture. Wait for the results before ordering antibiotics.for the results before ordering antibiotics.  B. Order a sputum gram stain and culture.B. Order a sputum gram stain and culture. Empirically start Ceftriaxone and Azithromycin.Empirically start Ceftriaxone and Azithromycin.  C. Order a sputum gram stain and culture.C. Order a sputum gram stain and culture. Empirically start Vancomycin and Zosyn.Empirically start Vancomycin and Zosyn.  D. Start Ceftriaxone and Azithromycin.D. Start Ceftriaxone and Azithromycin.
    • 13. Pneumonia DiagnosisPneumonia Diagnosis  Sputum gram stain and culture:Sputum gram stain and culture:  Controversial: no rapid, easily done, accurate,Controversial: no rapid, easily done, accurate, cost-effective method to allow immediate resultscost-effective method to allow immediate results  Expectorated sputum is frequently contaminatedExpectorated sputum is frequently contaminated by oropharyngeal floraby oropharyngeal flora  Low power magnification to assess squamous epithelial cells  Culture and sensitivity are only accurate if there are <10 epi’s per low power field  Best results if the specimen contains >25 WBCs per LPF  If patient has a productive cough, send sputumIf patient has a productive cough, send sputum for gram stain and culture: could be of use infor gram stain and culture: could be of use in directing treatment if patient fails to respond todirecting treatment if patient fails to respond to empiric therapyempiric therapy
    • 14.  Same patient. What other tests do you want?Same patient. What other tests do you want?  Blood cultures.Blood cultures.  Urine cultures.Urine cultures.  Urine for Legionella antigen.Urine for Legionella antigen.  Urine for pneumococcal antigen.Urine for pneumococcal antigen.  Urine for chlamydia antigen.Urine for chlamydia antigen.  HIV test.HIV test.  Bronchoscopy with culture of respiratoryBronchoscopy with culture of respiratory secretions.secretions.
    • 15. Pneumonia DiagnosisPneumonia Diagnosis  Blood cultures are positive in 11% of patientsBlood cultures are positive in 11% of patients with CAP, more commonly in patients withwith CAP, more commonly in patients with severe illnesssevere illness  Urine antigen assays for L pneumophilaUrine antigen assays for L pneumophila serogroup 1 can be done easily and rapidly.serogroup 1 can be done easily and rapidly. Sensitivity 70% Specificity >90%Sensitivity 70% Specificity >90%  Assay for pneumococcal urinary antigen :Assay for pneumococcal urinary antigen : sensitivity 50-80% and specificity 90%sensitivity 50-80% and specificity 90%  Responsible pathogen is not defined in as manyResponsible pathogen is not defined in as many as 50% of patientsas 50% of patients
    • 16.  In February, a 55yo F with rheumatoid arthritisIn February, a 55yo F with rheumatoid arthritis and chronic bronchitis presents to the office withand chronic bronchitis presents to the office with a cough productive of green sputum, a fever anda cough productive of green sputum, a fever and generalized myalgias x 2 days. T 101.6 HR 110generalized myalgias x 2 days. T 101.6 HR 110 R 24 BP 125/80. On exam, she has crackles inR 24 BP 125/80. On exam, she has crackles in her LLL and dullness to percussion. You shouldher LLL and dullness to percussion. You should  A. Give her a presciption for AzithromycinA. Give her a presciption for Azithromycin  B. Check her O2 sats and order a CXRB. Check her O2 sats and order a CXR  C. Check her for Influenzae AC. Check her for Influenzae A  D. Order a CBC, BMP, LFTsD. Order a CBC, BMP, LFTs  E. A, B, and CE. A, B, and C  F. B, C, and DF. B, C, and D  G. B and CG. B and C
    • 17. Pneumonia DiagnosisPneumonia Diagnosis  Routine laboratory tests: CBC, electrolytes,Routine laboratory tests: CBC, electrolytes, hepatic enzymes) are of little value inhepatic enzymes) are of little value in determining the etiology of pneumonia, but maydetermining the etiology of pneumonia, but may have prognostic significance and influence thehave prognostic significance and influence the decision to hospitalization. Should bedecision to hospitalization. Should be considered in patients who may needconsidered in patients who may need hospitalization, >65 yr, or with coexisting illness.hospitalization, >65 yr, or with coexisting illness.  All admitted patients should have oxygenAll admitted patients should have oxygen saturation assessed by oximetrysaturation assessed by oximetry
    • 18. Pneumonia DiagnosisPneumonia Diagnosis  Invasive testing: percutaneousInvasive testing: percutaneous transthoracic needle aspiration ortransthoracic needle aspiration or bronchoscopy are not routinelybronchoscopy are not routinely recommended.recommended.  May be helpful in:May be helpful in: • immunocompromised hostsimmunocompromised hosts • suspected tuberculosis in the absence ofsuspected tuberculosis in the absence of productive coughproductive cough • non-resolving pneumonianon-resolving pneumonia • pneumonia associated with suspected neoplasmpneumonia associated with suspected neoplasm or foreign bodyor foreign body • suspected Pneumocystis cariniisuspected Pneumocystis carinii
    • 19.  Which of the following findings would indicate anWhich of the following findings would indicate an increased risk of death in patients withincreased risk of death in patients with community-acquired pneumonia?community-acquired pneumonia?  A. BUN <8 mmol/LA. BUN <8 mmol/L  B. Diastolic blood pressure >70 mm HgB. Diastolic blood pressure >70 mm Hg  C. Respiratory rate >30 breaths per minuteC. Respiratory rate >30 breaths per minute  D. Unilobar lung infiltrateD. Unilobar lung infiltrate  E. PO2 = 65 mm Hg while breathing room airE. PO2 = 65 mm Hg while breathing room air
    • 20.  PneumoniaPneumonia  SeveritySeverity  IndexIndex
    • 21. Pneumonia Severity Index
    • 22. Site of TreatmentSite of Treatment  Class I or II: Outpatient treatmentClass I or II: Outpatient treatment  Class III: Potential outpatient or briefClass III: Potential outpatient or brief inpatient observationinpatient observation  Class IV and V: InpatientClass IV and V: Inpatient  Physician decision making: medical andPhysician decision making: medical and psychosocial comorbidities, ability to takepsychosocial comorbidities, ability to take po, substance abuse, ability to do ADLspo, substance abuse, ability to do ADLs
    • 23. CURB 65CURB 65  ConfusionConfusion  Urea level (>19)Urea level (>19)  Respiratory rate (>30)Respiratory rate (>30)  Blood Pressure SBP< 90 or DBP <60Blood Pressure SBP< 90 or DBP <60  AgeAge  Excellent indicator for mortalityExcellent indicator for mortality
    • 24.  All of the following are reasons to admit aAll of the following are reasons to admit a patient with pneumonia to the ICUpatient with pneumonia to the ICU EXCEPT:EXCEPT:  A. Need for mechanical ventilationA. Need for mechanical ventilation  B. Shock requiring pressorsB. Shock requiring pressors  C. High WBC count with bandemiaC. High WBC count with bandemia  D. Decreased urine outputD. Decreased urine output
    • 25. ICU AdmissionICU Admission  Minor CriteriaMinor Criteria  RR>30/minRR>30/min  PaOPaO22/F/FiiOO22 <250<250  Multilobar pneumoniaMultilobar pneumonia  Systolic BP <90Systolic BP <90  Diastolic BP <60Diastolic BP <60  Major CriteriaMajor Criteria  Need for mechanical ventilationNeed for mechanical ventilation  Increase in the size of infiltrates by >50% within 48hrsIncrease in the size of infiltrates by >50% within 48hrs  Septic shockSeptic shock  Acute renal failure (uop <80ml in 4 h or serumAcute renal failure (uop <80ml in 4 h or serum Cr>2.0)Cr>2.0)
    • 26.  In April, a 45yo F with HTN presents to the officeIn April, a 45yo F with HTN presents to the office with fever x 3 days and a cough. T 102.5 HR 95with fever x 3 days and a cough. T 102.5 HR 95 R 22 BP 130/80 Sats 94% on RA. CXR showsR 22 BP 130/80 Sats 94% on RA. CXR shows RUL infiltrate.RUL infiltrate.  A. You should check a CBC, BMP, and LFTsA. You should check a CBC, BMP, and LFTs and consider admitting her based on the resultsand consider admitting her based on the results  B. You should admit her for 24 hour observationB. You should admit her for 24 hour observation  C. You should check for Influenzae AC. You should check for Influenzae A  D. The most likely organisms are StrepD. The most likely organisms are Strep pneumonia, Mycoplasma, Chlamydia, and H. flupneumonia, Mycoplasma, Chlamydia, and H. flu and she should be treated with Azithromycin orand she should be treated with Azithromycin or DoxycyclineDoxycycline
    • 27. Group I: OutpatientsGroup I: Outpatients No cardiopulmonary diseaseNo cardiopulmonary disease No modifying factorsNo modifying factors Organism:Organism: Streptococcus pneumoniaStreptococcus pneumonia Mycoplasma pneumoniaMycoplasma pneumonia Chlamydia pneumoniaChlamydia pneumonia Hemophilus influenzaeHemophilus influenzae MiscellaneousMiscellaneous LegionellaLegionella MycobacteriumMycobacterium FungiFungi Treatment:Treatment: Advanced generationAdvanced generation macrolide(azithromycin ormacrolide(azithromycin or clarithromycin)clarithromycin) OR doxycyclineOR doxycycline
    • 28.  All of the following have been identified asAll of the following have been identified as risk factors for community-acquiredrisk factors for community-acquired Legionella pneumonia EXCEPT:Legionella pneumonia EXCEPT:  A. Cigarette smokingA. Cigarette smoking  B. Chronic pulmonary diseaseB. Chronic pulmonary disease  C. Acquired immunodeficiency syndromeC. Acquired immunodeficiency syndrome  D. Advanced ageD. Advanced age  E. Chronic illness, including diabetes,E. Chronic illness, including diabetes, liver disease, and renal diseaseliver disease, and renal disease
    • 29.  A 68 yo M with DM, HTN, CAD, is admitted toA 68 yo M with DM, HTN, CAD, is admitted to the hospital with community acquiredthe hospital with community acquired pneumonia. He is recently retired from thepneumonia. He is recently retired from the insurance industry and has been caring for hisinsurance industry and has been caring for his grandson several mornings a week. He doesn’tgrandson several mornings a week. He doesn’t smoke but he does drink 2-3 cocktails everysmoke but he does drink 2-3 cocktails every night. T 101.6 HR 85 R 22 BP 95/60 Sats 92%night. T 101.6 HR 85 R 22 BP 95/60 Sats 92% on 3L NC. CXR shows an infiltrate in the lingula.on 3L NC. CXR shows an infiltrate in the lingula. He is at risk forHe is at risk for  A. Penicillin resistant pneumococusA. Penicillin resistant pneumococus  B. PseudomonasB. Pseudomonas  C. MRSAC. MRSA  D. Enteric gram negativesD. Enteric gram negatives
    • 30. Modifying Factors that Increase theModifying Factors that Increase the Risk of infection with SpecificRisk of infection with Specific PathogensPathogens Penicillin-resistant pneumococciPenicillin-resistant pneumococci  Age >65Age >65  B-lactam therapy within the past 3 monthsB-lactam therapy within the past 3 months  AlcoholismAlcoholism  Immune suppressive illness (including tx with corticosteroids)Immune suppressive illness (including tx with corticosteroids)  Multiple medical comorbidities: DM, CRI, CHF, CAD, malignancy,Multiple medical comorbidities: DM, CRI, CHF, CAD, malignancy, chronic liver diseasechronic liver disease  Exposure to a child in a day care centerExposure to a child in a day care center  Enteric gram negativesEnteric gram negatives  Residence in a nursing homeResidence in a nursing home  Underlying cardiopulmonary diseaseUnderlying cardiopulmonary disease  Multiple medical comorbiditiesMultiple medical comorbidities  Recent antibiotic therapyRecent antibiotic therapy  Pseudomonas aeruginosaPseudomonas aeruginosa  Structural lung disease (bronchiectasis)Structural lung disease (bronchiectasis)  Corticosteroid therapy (>10mg prednisone/day)Corticosteroid therapy (>10mg prednisone/day)  Broad spectrum antibiotic therapy for > 7 days in past monthBroad spectrum antibiotic therapy for > 7 days in past month  MalnutritionMalnutrition
    • 31.  The mortality rate for patients with nursingThe mortality rate for patients with nursing home-acquired pneumonia is:home-acquired pneumonia is:  A. 10%A. 10%  B. 20%B. 20%  C. 40%C. 40%  D. 60%D. 60%  E. 80%E. 80%
    • 32. Group II: Outpatient, withGroup II: Outpatient, with cardiopulmonary disease, and/orcardiopulmonary disease, and/or other modifying factorsother modifying factors Organism:Organism:  Strep pneumoniaStrep pneumonia  MycoplasmaMycoplasma  ChlamydiaChlamydia  Mixed infectionMixed infection  Hemophilus influenzaeHemophilus influenzae  Enteric gram-negativesEnteric gram-negatives  VirusesViruses  MiscellaneousMiscellaneous  Moraxella, Legionella,Moraxella, Legionella, anaerobes, TB, fungianaerobes, TB, fungi  Therapy:Therapy:  ΒΒ -lactam (oral-lactam (oral cefpodoxime, cefuroxime,cefpodoxime, cefuroxime, high-dose amoxicillin,high-dose amoxicillin, amoxicillin/clavulanate oramoxicillin/clavulanate or parenteral ceftriaxoneparenteral ceftriaxone PLUSPLUS  Macrolide or doxycyclineMacrolide or doxycycline OROR  AntipneumococcalAntipneumococcal fluoroquinolonefluoroquinolone
    • 33. Group III: InpatientsGroup III: Inpatients  OrganismOrganism  Strep pneumoniaStrep pneumonia  Hemophilus influenzaeHemophilus influenzae  MycoplasmaMycoplasma  ChlamydiaChlamydia  Mixed infectionMixed infection  Enteric gram-negativesEnteric gram-negatives  AspirationAspiration  VirusVirus  MiscellaneousMiscellaneous Therapy:Therapy:  1. Intravenous1. Intravenous ΒΒ -lactam:-lactam: cefotaxime, ceftriaxone,cefotaxime, ceftriaxone, ampicillin/sulbactam,ampicillin/sulbactam, high-dose amipicillinhigh-dose amipicillin  PLUSPLUS  Intravenous or oralIntravenous or oral macrolide or doxycyclinemacrolide or doxycycline  OROR  2. Antipneumococcal2. Antipneumococcal fluoroquinolonefluoroquinolone
    • 34.  A 45 year old female with lupus is admitted toA 45 year old female with lupus is admitted to the ICU with community acquired pneumoniathe ICU with community acquired pneumonia and septic shock. She was intubated in the ERand septic shock. She was intubated in the ER due to hypoxemic respiratory failure. Currently,due to hypoxemic respiratory failure. Currently, T 102 HR 125 R 28 BP 90/60 on Dopamine.T 102 HR 125 R 28 BP 90/60 on Dopamine. She should be started on:She should be started on:  A. Vancomycin and ZosynA. Vancomycin and Zosyn  B. LevofloxacinB. Levofloxacin  C. Ceftriaxone and LevofloxacinC. Ceftriaxone and Levofloxacin  D. Doxycycline and GentamicinD. Doxycycline and Gentamicin
    • 35. ICU PatientsICU Patients  Organisms:Organisms:  Strep pneumoniaStrep pneumonia  LegionellaLegionella  Hemophilus influenzaeHemophilus influenzae  Enteric gram-negativeEnteric gram-negative bacillibacilli  Staphylococcus aureusStaphylococcus aureus  MycoplasmaMycoplasma  Respiratory VirusesRespiratory Viruses  MiscellaneousMiscellaneous  Therapy:Therapy:  1. Intravenous1. Intravenous ΒΒ -lactam:-lactam: cefotaxime, ceftriaxone,cefotaxime, ceftriaxone, ampicillin/sulbactam,ampicillin/sulbactam, high-dose amipicillinhigh-dose amipicillin  PLUS eitherPLUS either  Intravenous or oralIntravenous or oral macrolide or doxycyclinemacrolide or doxycycline  oror  AntipneumococcalAntipneumococcal fluoroquinolonefluoroquinolone
    • 36. ICU Patients with Risks forICU Patients with Risks for Pseudomonas aeruginosaPseudomonas aeruginosa  1. Selected iv1. Selected iv antipseudomonalantipseudomonal ΒΒ -lactam-lactam (cefepime, imipenem,(cefepime, imipenem, meropenem,meropenem, piperacillin/tazobactam)piperacillin/tazobactam)  PLUS iv antipseudomonalPLUS iv antipseudomonal quinolonequinolone  OROR  2. Selected iv2. Selected iv antipseudomonalantipseudomonal ΒΒ -lactam-lactam PLUS iv aminoglycoside PLUSPLUS iv aminoglycoside PLUS either iv macrolide or iveither iv macrolide or iv nonpseudomonalnonpseudomonal fluoroquinolonefluoroquinolone
    • 37.  The organism(s) most commonly found inThe organism(s) most commonly found in patients with nosocomial pneumonia ispatients with nosocomial pneumonia is (are):(are):  A. Aerobic Gram-negative rodsA. Aerobic Gram-negative rods  B. Staphylococcus aureusB. Staphylococcus aureus  C. Legionella speciesC. Legionella species  D. Streptococcus pneumoniaeD. Streptococcus pneumoniae  E. Haemophilus influenzaeE. Haemophilus influenzae
    • 38. Hospital-Acquired PneumoniaHospital-Acquired Pneumonia  Enteric aerobic gramEnteric aerobic gram negative bacillinegative bacilli  PseudomonasPseudomonas aeruginosaaeruginosa  Staphylococcus aureusStaphylococcus aureus  Oral anaerobesOral anaerobes  AntipseudomonalAntipseudomonal cephalosporin (cefepime,cephalosporin (cefepime, ceftazidime) ORceftazidime) OR AntipseudomonalAntipseudomonal carbepenem ORcarbepenem OR ΒΒ -- lactam/lactam/ΒΒ -lactamase-lactamase inhibitorinhibitor  PLUSPLUS  AntipseudomonalAntipseudomonal fluoroquinolone ORfluoroquinolone OR aminoglycosideaminoglycoside  PLUSPLUS Vancomycin or LinezolidVancomycin or Linezolid
    • 39.  The mechanism thought to account for mostThe mechanism thought to account for most cases of nosocomial pneumonia includes:cases of nosocomial pneumonia includes:  A. Inhalation of infected aerosols fromA. Inhalation of infected aerosols from respiratory equipmentrespiratory equipment  B. Hematogenous spread from another infectedB. Hematogenous spread from another infected site outside the lungsite outside the lung  C. Spread from a contiguous infected siteC. Spread from a contiguous infected site  D. Aspiration of pathogen-laden oropharyngealD. Aspiration of pathogen-laden oropharyngeal secretionssecretions  E. Inhalation of infected droplet nuclei fromE. Inhalation of infected droplet nuclei from other patients in the areaother patients in the area
    • 40.  Which of the following has beenWhich of the following has been demonstrated to reduce the incidence ofdemonstrated to reduce the incidence of nosocomial pneumonia?nosocomial pneumonia?  A. Nasogastric tubesA. Nasogastric tubes  B. Enteral feedingsB. Enteral feedings  C. Hand washingC. Hand washing  D. Isolation of patients with pneumoniaD. Isolation of patients with pneumonia  E. AntacidsE. Antacids
    • 41.  Staph aureusStaph aureus  HistoplasmaHistoplasma  LegionellaLegionella  MycoplasmaMycoplasma  NocardiaNocardia  TBTB  Metastasis to skin andMetastasis to skin and CNSCNS  Hyponatremia, AMS,Hyponatremia, AMS, renal and hepaticrenal and hepatic dysfunctiondysfunction  Night sweats, weightNight sweats, weight lossloss  Erythema multiforme,Erythema multiforme, hemolytic anemia,hemolytic anemia, encephalitis, transverseencephalitis, transverse myelitismyelitis  Erythema nodosumErythema nodosum  Increased risk afterIncreased risk after Influenzae pneumoniaInfluenzae pneumonia
    • 42.  The organism most commonly associatedThe organism most commonly associated with life-threatening community acquiredwith life-threatening community acquired pneumonia is:pneumonia is:  A. Streptococcus pneumoniaeA. Streptococcus pneumoniae  B. Legionella pneumophilaB. Legionella pneumophila  C. Klebsiella pneumoniaeC. Klebsiella pneumoniae  D. Pseudomonas aeruginosaD. Pseudomonas aeruginosa  E. Staphylococcus aureusE. Staphylococcus aureus
    • 43. Strep pneumoniaStrep pneumonia  Encapsulated lancet shaped diplococcusEncapsulated lancet shaped diplococcus  Causes up to 50% of community acquiredCauses up to 50% of community acquired pneumoniapneumonia  Patients present with acute onset of hard,Patients present with acute onset of hard, shaking chills and pleuritic chest painshaking chills and pleuritic chest pain  Usually have high WBC, however may have veryUsually have high WBC, however may have very low WBC if overwhelming infectionlow WBC if overwhelming infection  Sputum may be rusty coloredSputum may be rusty colored  CXR often shows lobar consolidationCXR often shows lobar consolidation  If bacteremic, mortality is 30%If bacteremic, mortality is 30%
    • 44. Drug Resistant Strep pneumoniaDrug Resistant Strep pneumonia  Prevalence continues to increase worldwide:Prevalence continues to increase worldwide:  PCN resistant 18-22%PCN resistant 18-22%  macrolide resistant 24-32%macrolide resistant 24-32%  Patients with high level resistance (penicillin MCIPatients with high level resistance (penicillin MCI >4>4µµg/mL) showed an increased risk ofg/mL) showed an increased risk of suppurative complicationssuppurative complications  Most common mechanisms of resistance toMost common mechanisms of resistance to macrolides are methylation of a ribosomal targetmacrolides are methylation of a ribosomal target encoded by erm gene and efflux of theencoded by erm gene and efflux of the macrolides by cell membrane proteinmacrolides by cell membrane protein transporter, encoded by mef genetransporter, encoded by mef gene
    • 45. Predicting Antimicrobial ResistancePredicting Antimicrobial Resistance in Invasive Pneumococcalin Invasive Pneumococcal InfectionsInfections Clinical Infectious Diseases 2005;40:1288-97Clinical Infectious Diseases 2005;40:1288-97  3339 patients3339 patients  Risk factors for penicillin-resistance orRisk factors for penicillin-resistance or macrolide resistance: antibiotic use (PCN,macrolide resistance: antibiotic use (PCN, TMP-SMX, and azithro) in last 3 monthsTMP-SMX, and azithro) in last 3 months  Risk factors for fluoroquinolone resistance:Risk factors for fluoroquinolone resistance: previous use of fluoroquinolones,previous use of fluoroquinolones, residence in a NH; nosocomial acquisitionresidence in a NH; nosocomial acquisition
    • 46. Kyaw, M. H. et al. N Engl J Med 2006;354:1455-1463 Percentage of Pneumococcal Isolates That Were Nonsusceptible to Various Antibiotics from Children under Two Years of Age (Panel A) and Adults 65 Years of Age or Older (Panel B) with Invasive Disease, 1999 to 2004
    • 47. Clinical CourseClinical Course  Target time for appropriate initiation ofTarget time for appropriate initiation of antimicrobials within 4 hours of admissionantimicrobials within 4 hours of admission  Fever x 2-4 daysFever x 2-4 days  Leukocytosis usually resolves by Day 4Leukocytosis usually resolves by Day 4  Abnormal physical findings (crackles) persistAbnormal physical findings (crackles) persist beyond 7 d in 20-40%beyond 7 d in 20-40%  CXR clears by 4 weeks in 60% patientsCXR clears by 4 weeks in 60% patients  Delayed resolution with increasing age, multipleDelayed resolution with increasing age, multiple coexisting illness, alcoholism, bacteremiacoexisting illness, alcoholism, bacteremia
    • 48. When to switch to oral therapyWhen to switch to oral therapy  Oral = iv: doxycycline, linezolid,Oral = iv: doxycycline, linezolid, quinolonesquinolones  Improvement in cough and dyspneaImprovement in cough and dyspnea  AfebrileAfebrile  WBC decreasingWBC decreasing  Functioning GI tractFunctioning GI tract  Patient can be discharged home the samePatient can be discharged home the same day that clinical stability occurs and oralday that clinical stability occurs and oral therapy is initiated.therapy is initiated.
    • 49. PreventionPrevention  Recommendations by CDC:Recommendations by CDC:  Pneumococcal vaccine:Pneumococcal vaccine: age >65 or ifage >65 or if chronically ill: CHF, COPD, DM, ETOH,chronically ill: CHF, COPD, DM, ETOH, cirrhosis, asplenia, long-term care facilities.cirrhosis, asplenia, long-term care facilities. Revaccinate after 5 years.Revaccinate after 5 years.  Influenzae vaccineInfluenzae vaccine: age >65, residents of: age >65, residents of long-term care facilities, chronic pulmonarylong-term care facilities, chronic pulmonary or cardiovascular disease, hospitalization inor cardiovascular disease, hospitalization in the preceding year, immunosuppression,the preceding year, immunosuppression, pregnant women in 2pregnant women in 2ndnd or 3or 3rdrd trimestertrimester during flu seasonduring flu season  Patients should be counseled duringPatients should be counseled during hospitalization regarding smoking cessationhospitalization regarding smoking cessation
    • 50. Kyaw, M. H. et al. N Engl J Med 2006;354:1455-1463 Annual Incidence of Invasive Disease Caused by Penicillin-Susceptible and Penicillin- Nonsusceptible Pneumococci among Children under Two Years of Age, 1996 to 2004
    • 51. Kyaw, M. H. et al. N Engl J Med 2006;354:1455-1463 Annual Incidence of Invasive Disease Caused by Penicillin-Nonsusceptible Pneumococci in Persons Two Years of Age or Older, 1996 to 2004
    • 52.  In immunocompetent adults for whom theIn immunocompetent adults for whom the pneumococcal vaccine is indicated, thepneumococcal vaccine is indicated, the protection efficacy is:protection efficacy is:  A. 0%A. 0%  B. 10%B. 10%  C. 30%C. 30%  D. 60%D. 60%  E. 80%E. 80%
    • 53.  A 34yo F with JRA presents to the office with aA 34yo F with JRA presents to the office with a 3 day history of a cough productive of yellow3 day history of a cough productive of yellow sputum, fever, and myalgias. On physical exam,sputum, fever, and myalgias. On physical exam, she is mildly tachypneic but not in distress T 104she is mildly tachypneic but not in distress T 104 HR 115 R 28 BP 105/60 Saturations 94% RA.HR 115 R 28 BP 105/60 Saturations 94% RA. Physical exam reveals rales in her LLL. She hasPhysical exam reveals rales in her LLL. She has dullness to percussion at her left base anddullness to percussion at her left base and increased tactile fremitus. The next step in herincreased tactile fremitus. The next step in her management is:management is:  A. Sputum gram stainA. Sputum gram stain  B. Chest radiographB. Chest radiograph  C. Give her a prescription for AugmentinC. Give her a prescription for Augmentin  D. Admit her to the hospitalD. Admit her to the hospital
    • 54.  What should she be treated with?What should she be treated with?  A. Vancomycin and ImepenemA. Vancomycin and Imepenem  B. KeflexB. Keflex  C. AzithromycinC. Azithromycin  D. CeftriaxoneD. Ceftriaxone  E. LevofloxacinE. Levofloxacin
    • 55.  A 55yo with CHF presents to the ER withA 55yo with CHF presents to the ER with a 1 day history of cough, fever, shakinga 1 day history of cough, fever, shaking chills, and weakness. She is obviouslychills, and weakness. She is obviously uncomfortable, with mildly increased workuncomfortable, with mildly increased work of breathing. T 100.8 HR 125 R 32 BPof breathing. T 100.8 HR 125 R 32 BP 100/55 Saturations 86% on RA. Lungs100/55 Saturations 86% on RA. Lungs have crackles in her right upper lobe. Shehave crackles in her right upper lobe. She has 1+ edema bilaterally. She is alert andhas 1+ edema bilaterally. She is alert and oriented.oriented.
    • 56.  You should now obtain all of the followingYou should now obtain all of the following labslabs EXCEPTEXCEPT::  A. CBCA. CBC  B. ElectrolytesB. Electrolytes  C. PT, PTTC. PT, PTT  D. ABGD. ABG  E. Sputum cultureE. Sputum culture  F. Blood culturesF. Blood cultures
    • 57.  ABG: pH 7.36 pCO2 42 pO2 50ABG: pH 7.36 pCO2 42 pO2 50  Na 134 K 4.3 Cl 95 HCO3 20 BUN 42 Cr 1.4Na 134 K 4.3 Cl 95 HCO3 20 BUN 42 Cr 1.4 glucose 145glucose 145  WBC 18.3 Hgb 10.3 Hct 32 Plt 130WBC 18.3 Hgb 10.3 Hct 32 Plt 130  She should be:She should be:  A. Given a prescription for Azithromycin andA. Given a prescription for Azithromycin and sent homesent home  B. Admitted to the hospital. Start CeftriaxoneB. Admitted to the hospital. Start Ceftriaxone and Azithromycin after she coughs up a sputumand Azithromycin after she coughs up a sputum sample.sample.  C. Admitted to the hospital. Start LevofloxacinC. Admitted to the hospital. Start Levofloxacin immediatelyimmediately  D. Admitted to the ICU and started onD. Admitted to the ICU and started on mechanical ventilationmechanical ventilation
    • 58. PORT ScorePORT Score  Age 55-10=45Age 55-10=45  CHF +10CHF +10  RR +20RR +20  HR 124 +10HR 124 +10  BUN +20BUN +20  pO2 +10pO2 +10 115 Class IV Mortality 8-9%
    • 59.  A 70yo F resident of a nursing home is evaluated in theA 70yo F resident of a nursing home is evaluated in the ER due to decreased mental status and hypothermia.ER due to decreased mental status and hypothermia. She has a history of stroke and is currently taking onlyShe has a history of stroke and is currently taking only aspirin. She has been able to eat on her own and thereaspirin. She has been able to eat on her own and there have been no witnessed aspirations. She has not beenhave been no witnessed aspirations. She has not been treated recently with antibiotics. WBC 12 Hgb 12treated recently with antibiotics. WBC 12 Hgb 12 Electrolytes are normal and she has mild chronic renalElectrolytes are normal and she has mild chronic renal insufficiency. CXR shows small interstitial infiltrate ininsufficiency. CXR shows small interstitial infiltrate in RLL. She receives empiric treatment for community-RLL. She receives empiric treatment for community- acquired pneumonia. Therapy for which of the followingacquired pneumonia. Therapy for which of the following should also be considered?should also be considered?  A. Pseudomonas aeruginosaA. Pseudomonas aeruginosa  B. Anaerobic bacteriaB. Anaerobic bacteria  C. Enteric gram-negative organismsC. Enteric gram-negative organisms  D. Aspergillus fumigatusD. Aspergillus fumigatus  E. Mycobacterium tuberculosisE. Mycobacterium tuberculosis
    • 60.  A 28yo M presents to the ER withA 28yo M presents to the ER with increasing shortness of breath andincreasing shortness of breath and subjective fever and chills. In the ER,subjective fever and chills. In the ER, patient is in moderate respiratory distress.patient is in moderate respiratory distress. T 102 HR 140 R 38 BP 85/55 Sats 80%T 102 HR 140 R 38 BP 85/55 Sats 80% on RA. Lungs have rales throughout. Heon RA. Lungs have rales throughout. He has no peripheral edema. He knows hishas no peripheral edema. He knows his name and knows he is in the ER but he isname and knows he is in the ER but he is unsure of the date (thinks it is 2003).unsure of the date (thinks it is 2003).
    • 61.  You should do all of the followingYou should do all of the following EXCEPTEXCEPT::  A. Start IVF wide openA. Start IVF wide open  B. Get an ABGB. Get an ABG  C. Wait on ABG before starting oxygenC. Wait on ABG before starting oxygen  D. Order a CXRD. Order a CXR  E. Admit to the ICUE. Admit to the ICU
    • 62.  In carefully performed prospective studies on theIn carefully performed prospective studies on the etiology of community-acquired pneumonia, theetiology of community-acquired pneumonia, the organism most often identified in patients illorganism most often identified in patients ill enough to require hospitalization is:enough to require hospitalization is:  A. Streptococcus pneumoniaeA. Streptococcus pneumoniae  B. UnknownB. Unknown  C. Chlamydia pneumoniaeC. Chlamydia pneumoniae  D. Mycoplasma pneumoniaeD. Mycoplasma pneumoniae  E. Haemophilus influenzaeE. Haemophilus influenzae
    • 63.  In patients with bacteremic pneumonia theIn patients with bacteremic pneumonia the organism most likely to be found is:organism most likely to be found is:  A. Staphylococcus aureusA. Staphylococcus aureus  B. Klebsiella pneumoniaeB. Klebsiella pneumoniae  C. Haemophilus influenzaeC. Haemophilus influenzae  D. Streptococcus pneumoniaeD. Streptococcus pneumoniae  E. Pseudomonas aeruginosaE. Pseudomonas aeruginosa
    • 64.  A 65 yo M develops bilateral lower lobeA 65 yo M develops bilateral lower lobe pneumonia and is treated as an outpatient withpneumonia and is treated as an outpatient with amoxicillin/clavulanic acid for 72hours. Despiteamoxicillin/clavulanic acid for 72hours. Despite this treatment, he deteriorates and is admitted tothis treatment, he deteriorates and is admitted to the hospital. Within 12 hours of admission, hethe hospital. Within 12 hours of admission, he develops respiratory failure requiring admissiondevelops respiratory failure requiring admission to the ICU, intubation, and mechanicalto the ICU, intubation, and mechanical ventilation. The organism most likely to accountventilation. The organism most likely to account for the severity of disease despite treatment withfor the severity of disease despite treatment with Augmentin is:Augmentin is:  A. Moraxella catarrhalisA. Moraxella catarrhalis  B. Chlamydia pneumoniaeB. Chlamydia pneumoniae  C. Klebsiella pneumoniaeC. Klebsiella pneumoniae  D. Legionella pneumophilaD. Legionella pneumophila  E. Streptococcus pneumoniaeE. Streptococcus pneumoniae
    • 65. PneumoniaPneumonia  Common infectionCommon infection  PathophysiologyPathophysiology  Clinical presentationClinical presentation  Risk factors for mortalityRisk factors for mortality  TreatmentTreatment

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