Fusobacterium infections of the retropharyngeal tissues: Lemierre’s syndrome
Direct inoculation and Contiguous Spread
Tracheal intubation, stab wounds
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.
What is pneumonia?
Infection of the lower respiratory tract
Which of the following is NOT a symptom of pneumonia?
B. Shortness of breath
D. Abdominal pain
E. Chest tightness
G. Hot, erythematous 1 st toe
Pneumonia should be considered in any patient who has newly acquired respiratory symptoms: cough, sputum production, dyspnea, especially if accompanied by fever and abnormal breath sounds and crackles
In elderly or immunocompromised, pneumonia may present with confusion, failure to thrive, worsening of underlying chronic illness, falling
“ Typical” pneumonia: sudden onset of fever, cough productive of purulent sputum, pleuritic chest pain
Includes diverse entities and has limited clinical value
Which of the following is NOT a sign of pneumonia?
A. Dullness to percussion
B. Tracheal deviation
C. Bronchial breath sounds
D. Egophany, increased tactile fremitus
E. Late inspiratory crackles
confirm the presence and location of the pulmonary infiltrate
assess the extent of the infection
detect pleural involvement, pulmonary cavitation, or lymphadenopathy
May be normal when the patient is unable to mount an inflammatory response (immunocompromised) or is in the early stage of an infiltrative process (hematogenous S. aureus pneumonia)
A 64 year old female with DM and HTN is admitted to 4600 with RLL pneumonia. T 39.3 HR 118 R 28 BP 110/60 Sats 92% on 4 L NC. She has crackles in her RLL. You should:
A. Order a sputum gram stain and culture. Wait for the results before ordering antibiotics.
B. Order a sputum gram stain and culture. Empirically start Ceftriaxone and Azithromycin.
C. Order a sputum gram stain and culture. Empirically start Vancomycin and Zosyn.
D. Start Ceftriaxone and Azithromycin.
Sputum gram stain and culture:
Controversial: no rapid, easily done, accurate, cost-effective method to allow immediate results
Expectorated sputum is frequently contaminated by 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 sputum for gram stain and culture: could be of use in directing treatment if patient fails to respond to empiric therapy
Same patient. What other tests do you want?
Urine for Legionella antigen.
Urine for pneumococcal antigen.
Urine for chlamydia antigen.
Bronchoscopy with culture of respiratory secretions.
Blood cultures are positive in 11% of patients with CAP, more commonly in patients with severe illness
Urine antigen assays for L pneumophila serogroup 1 can be done easily and rapidly. Sensitivity 70% Specificity >90%
Assay for pneumococcal urinary antigen : sensitivity 50-80% and specificity 90%
Responsible pathogen is not defined in as many as 50% of patients
In February, a 55yo F with rheumatoid arthritis and chronic bronchitis presents to the office with a cough productive of green sputum, a fever and generalized myalgias x 2 days. T 101.6 HR 110 R 24 BP 125/80. On exam, she has crackles in her LLL and dullness to percussion. You should
A. Give her a presciption for Azithromycin
B. Check her O2 sats and order a CXR
C. Check her for Influenzae A
D. Order a CBC, BMP, LFTs
E. A, B, and C
F. B, C, and D
G. B and C
Routine laboratory tests: CBC, electrolytes, hepatic enzymes) are of little value in determining the etiology of pneumonia, but may have prognostic significance and influence the decision to hospitalization. Should be considered in patients who may need hospitalization, >65 yr, or with coexisting illness.
All admitted patients should have oxygen saturation assessed by oximetry
Invasive testing: percutaneous transthoracic needle aspiration or bronchoscopy are not routinely recommended.
May be helpful in:
suspected tuberculosis in the absence of productive cough
pneumonia associated with suspected neoplasm or foreign body
suspected Pneumocystis carinii
Which of the following findings would indicate an increased risk of death in patients with community-acquired pneumonia?
A. BUN <8 mmol/L
B. Diastolic blood pressure >70 mm Hg
C. Respiratory rate >30 breaths per minute
D. Unilobar lung infiltrate
E. PO2 = 65 mm Hg while breathing room air
Pneumonia Severity Index
Site of Treatment
Class I or II: Outpatient treatment
Class III: Potential outpatient or brief inpatient observation
Class IV and V: Inpatient
Physician decision making: medical and psychosocial comorbidities, ability to take po, substance abuse, ability to do ADLs
Urea level (>19)
Respiratory rate (>30)
Blood Pressure SBP< 90 or DBP <60
Excellent indicator for mortality
All of the following are reasons to admit a patient with pneumonia to the ICU EXCEPT:
A. Need for mechanical ventilation
B. Shock requiring pressors
C. High WBC count with bandemia
D. Decreased urine output
PaO 2 /F i O 2 <250
Systolic BP <90
Diastolic BP <60
Need for mechanical ventilation
Increase in the size of infiltrates by >50% within 48hrs
Acute renal failure (uop <80ml in 4 h or serum Cr>2.0)
In April, a 45yo F with HTN presents to the office with fever x 3 days and a cough. T 102.5 HR 95 R 22 BP 130/80 Sats 94% on RA. CXR shows RUL infiltrate.
A. You should check a CBC, BMP, and LFTs and consider admitting her based on the results
B. You should admit her for 24 hour observation
C. You should check for Influenzae A
D. The most likely organisms are Strep pneumonia, Mycoplasma, Chlamydia, and H. flu and she should be treated with Azithromycin or Doxycycline
Group I: Outpatients No cardiopulmonary disease No modifying factors
Advanced generation macrolide(azithromycin or clarithromycin)
All of the following have been identified as risk factors for community-acquired Legionella pneumonia EXCEPT:
A. Cigarette smoking
B. Chronic pulmonary disease
C. Acquired immunodeficiency syndrome
D. Advanced age
E. Chronic illness, including diabetes, liver disease, and renal disease
A 68 yo M with DM, HTN, CAD, is admitted to the hospital with community acquired pneumonia. He is recently retired from the insurance industry and has been caring for his grandson several mornings a week. He doesn’t smoke but he does drink 2-3 cocktails every night. T 101.6 HR 85 R 22 BP 95/60 Sats 92% on 3L NC. CXR shows an infiltrate in the lingula. He is at risk for
A. Penicillin resistant pneumococus
D. Enteric gram negatives
Modifying Factors that Increase the Risk of infection with Specific Pathogens
B-lactam therapy within the past 3 months
Immune suppressive illness (including tx with corticosteroids)
A 45 year old female with lupus is admitted to the ICU with community acquired pneumonia and septic shock. She was intubated in the ER due to hypoxemic respiratory failure. Currently, T 102 HR 125 R 28 BP 90/60 on Dopamine. She should be started on:
Risk factors for penicillin-resistance or macrolide resistance: antibiotic use (PCN, TMP-SMX, and azithro) in last 3 months
Risk factors for fluoroquinolone resistance: previous use of fluoroquinolones, residence in a NH; nosocomial acquisition
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
Target time for appropriate initiation of antimicrobials within 4 hours of admission
Fever x 2-4 days
Leukocytosis usually resolves by Day 4
Abnormal physical findings (crackles) persist beyond 7 d in 20-40%
CXR clears by 4 weeks in 60% patients
Delayed resolution with increasing age, multiple coexisting illness, alcoholism, bacteremia
When to switch to oral therapy
Oral = iv: doxycycline, linezolid, quinolones
Improvement in cough and dyspnea
Functioning GI tract
Patient can be discharged home the same day that clinical stability occurs and oral therapy is initiated.
Recommendations by CDC:
Pneumococcal vaccine: age >65 or if chronically ill: CHF, COPD, DM, ETOH, cirrhosis, asplenia, long-term care facilities. Revaccinate after 5 years.
Influenzae vaccine : age >65, residents of long-term care facilities, chronic pulmonary or cardiovascular disease, hospitalization in the preceding year, immunosuppression, pregnant women in 2 nd or 3 rd trimester during flu season
Patients should be counseled during hospitalization regarding smoking cessation
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
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
In immunocompetent adults for whom the pneumococcal vaccine is indicated, the protection efficacy is:
A 34yo F with JRA presents to the office with a 3 day history of a cough productive of yellow sputum, fever, and myalgias. On physical exam, she is mildly tachypneic but not in distress T 104 HR 115 R 28 BP 105/60 Saturations 94% RA. Physical exam reveals rales in her LLL. She has dullness to percussion at her left base and increased tactile fremitus. The next step in her management is:
A. Sputum gram stain
B. Chest radiograph
C. Give her a prescription for Augmentin
D. Admit her to the hospital
What should she be treated with?
A. Vancomycin and Imepenem
A 55yo with CHF presents to the ER with a 1 day history of cough, fever, shaking chills, and weakness. She is obviously uncomfortable, with mildly increased work of breathing. T 100.8 HR 125 R 32 BP 100/55 Saturations 86% on RA. Lungs have crackles in her right upper lobe. She has 1+ edema bilaterally. She is alert and oriented.
You should now obtain all of the following labs EXCEPT :
C. PT, PTT
E. Sputum culture
F. Blood cultures
ABG: pH 7.36 pCO2 42 pO2 50
Na 134 K 4.3 Cl 95 HCO3 20 BUN 42 Cr 1.4 glucose 145
WBC 18.3 Hgb 10.3 Hct 32 Plt 130
She should be:
A. Given a prescription for Azithromycin and sent home
B. Admitted to the hospital. Start Ceftriaxone and Azithromycin after she coughs up a sputum sample.
C. Admitted to the hospital. Start Levofloxacin immediately
D. Admitted to the ICU and started on mechanical ventilation
HR 124 +10
115 Class IV Mortality 8-9%
A 70yo F resident of a nursing home is evaluated in the ER due to decreased mental status and hypothermia. She has a history of stroke and is currently taking only aspirin. She has been able to eat on her own and there have been no witnessed aspirations. She has not been treated recently with antibiotics. WBC 12 Hgb 12 Electrolytes are normal and she has mild chronic renal insufficiency. CXR shows small interstitial infiltrate in RLL. She receives empiric treatment for community-acquired pneumonia. Therapy for which of the following should also be considered?
A. Pseudomonas aeruginosa
B. Anaerobic bacteria
C. Enteric gram-negative organisms
D. Aspergillus fumigatus
E. Mycobacterium tuberculosis
A 28yo M presents to the ER with increasing shortness of breath and subjective fever and chills. In the ER, patient is in moderate respiratory distress. T 102 HR 140 R 38 BP 85/55 Sats 80% on RA. Lungs have rales throughout. He has no peripheral edema. He knows his name and knows he is in the ER but he is unsure of the date (thinks it is 2003).
You should do all of the following EXCEPT :
A. Start IVF wide open
B. Get an ABG
C. Wait on ABG before starting oxygen
D. Order a CXR
E. Admit to the ICU
In carefully performed prospective studies on the etiology of community-acquired pneumonia, the organism most often identified in patients ill enough to require hospitalization is:
A. Streptococcus pneumoniae
C. Chlamydia pneumoniae
D. Mycoplasma pneumoniae
E. Haemophilus influenzae
In patients with bacteremic pneumonia the organism most likely to be found is:
A. Staphylococcus aureus
B. Klebsiella pneumoniae
C. Haemophilus influenzae
D. Streptococcus pneumoniae
E. Pseudomonas aeruginosa
A 65 yo M develops bilateral lower lobe pneumonia and is treated as an outpatient with amoxicillin/clavulanic acid for 72hours. Despite this treatment, he deteriorates and is admitted to the hospital. Within 12 hours of admission, he develops respiratory failure requiring admission to the ICU, intubation, and mechanical ventilation. The organism most likely to account for the severity of disease despite treatment with Augmentin is: