Pneumonia Tammy Wichman MD Assistant Professor of Medicine Pulmonary-Critical Care Creighton University Medical Center.

PneumoniaPneumonia

Tammy Wichman MDTammy Wichman MDAssistant Professor of MedicineAssistant Professor of Medicine

Pulmonary-Critical CarePulmonary-Critical CareCreighton University Medical CenterCreighton University Medical Center

The #1 cause of death in the United States The #1 cause of death in the United States from infectious disease is: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

PneumoniaPneumonia

Most deadly infectious disease in the U.S.Most deadly infectious disease in the U.S. 66thth leading cause of death leading 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 affects Community 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 annually and >50,000 deaths annually

1 File Chest 2004; 125:1888-1901

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 contains Each ciliated cell contains about 200 cilia that beat in about 200 cilia that beat in coordinated waves about coordinated waves about 1000x/minute1000x/minute So the lower respiratory tract So the lower respiratory tract is normally sterileis normally sterile

Pneumonia PathophysiologyPneumonia Pathophysiology Microbial pathogens enter the lung by:Microbial pathogens enter the lung by: AspirationAspiration of organisms from oropharynx of 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 organisms Source may be stomach which can become colonized with these organisms

with use of H2blockerswith use of H2blockers InhalationInhalation of Infectious Aerosols of Infectious Aerosols

Influenza, Legionella, Psittacosis, Histoplasmosis, TBInfluenza, Legionella, Psittacosis, Histoplasmosis, TB HematogenousHematogenous Dissemination Dissemination

Staph aureusStaph aureus Fusobacterium infections of the retropharyngeal tissues: Lemierre’s Fusobacterium infections of the retropharyngeal tissues: Lemierre’s

syndromesyndrome Direct inoculation and Contiguous SpreadDirect inoculation and Contiguous Spread

Tracheal intubation, stab woundsTracheal 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?What is pneumonia?

Infection of the lower respiratory tractInfection of the lower respiratory tract

Which of the following is Which 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 toe toe

Clinical presentationClinical presentation Pneumonia should be considered in any patient Pneumonia should be considered in any patient

who has newly acquired respiratory symptoms: who has newly acquired respiratory symptoms: cough, sputum production, dyspnea, especially if cough, sputum production, dyspnea, especially if accompanied by fever and abnormal breath accompanied by fever and abnormal breath sounds and cracklessounds and crackles

In elderly or immunocompromised, pneumonia In elderly or immunocompromised, pneumonia may present with confusion, failure to thrive, may present with confusion, failure to thrive, worsening of underlying chronic illness, falling worsening of underlying chronic illness, falling

Pneumonia SymptomsPneumonia Symptoms

““Typical” pneumonia: sudden onset of Typical” pneumonia: sudden onset of fever, cough productive of purulent fever, 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 limited Includes diverse entities and has limited clinical valueclinical value

PneumoniaPneumonia

Which of the following is Which of the following is NOTNOT a sign of a sign of pneumonia?pneumonia?

A. Dullness to percussion A. Dullness to percussion B. Tracheal deviation B. 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

Pneumonia DiagnosisPneumonia Diagnosis

Radiography: CXR Radiography: CXR confirm the presence and location of the pulmonary confirm the presence and location of the pulmonary

infiltrate infiltrate assess the extent of the infection assess the extent of the infection detect pleural involvement, pulmonary cavitation, or detect pleural involvement, pulmonary cavitation, or

lymphadenopathylymphadenopathy May be normal when the patient is unable to May be normal when the patient is unable to

mount an inflammatory response mount an inflammatory response (immunocompromised) or is in the early stage of (immunocompromised) or is in the early stage of an infiltrative process (hematogenous S. aureus an infiltrative process (hematogenous S. aureus pneumonia)pneumonia)

A 64 year old female with DM and HTN is A 64 year old female with DM and HTN is admitted to 4600 with RLL pneumonia. T 39.3 admitted 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. Wait A. 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.

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 contaminated Expectorated 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 sputum If patient has a productive cough, send sputum

for gram stain and culture: could be of use in for gram stain and culture: could be of use in directing treatment if patient fails to respond to directing treatment if patient fails to respond to empiric therapyempiric therapy

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 respiratory Bronchoscopy with culture of respiratory

secretions.secretions.

Pneumonia DiagnosisPneumonia Diagnosis

Blood cultures are positive in 11% of patients Blood cultures are positive in 11% of patients with CAP, more commonly in patients with with CAP, more commonly in patients with severe illnesssevere illness

Urine antigen assays for L pneumophila Urine 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 many Responsible pathogen is not defined in as many as 50% of patientsas 50% of patients

In February, a 55yo F with rheumatoid arthritis In February, a 55yo F with rheumatoid arthritis and chronic bronchitis presents to the office with and chronic bronchitis presents to the office with a cough productive of green sputum, a fever and a cough productive of green sputum, a fever and generalized myalgias x 2 days. T 101.6 HR 110 generalized myalgias x 2 days. T 101.6 HR 110 R 24 BP 125/80. On exam, she has crackles in R 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

Pneumonia DiagnosisPneumonia Diagnosis

Routine laboratory tests: CBC, electrolytes, Routine laboratory tests: CBC, electrolytes, hepatic enzymes) are of little value in hepatic enzymes) are of little value in determining the etiology of pneumonia, but may determining the etiology of pneumonia, but may have prognostic significance and influence the have prognostic significance and influence the decision to hospitalization. Should be decision to hospitalization. Should be considered in patients who may need considered in patients who may need hospitalization, >65 yr, or with coexisting illness.hospitalization, >65 yr, or with coexisting illness.

All admitted patients should have oxygen All admitted patients should have oxygen saturation assessed by oximetrysaturation assessed by oximetry

Pneumonia DiagnosisPneumonia Diagnosis

Invasive testing: percutaneous Invasive testing: percutaneous transthoracic needle aspiration or transthoracic needle aspiration or bronchoscopy are not routinely bronchoscopy are not routinely recommended. recommended. May be helpful in: May be helpful in:

• immunocompromised hostsimmunocompromised hosts• suspected tuberculosis in the absence of suspected tuberculosis in the absence of

productive cough productive cough • non-resolving pneumonia non-resolving pneumonia • pneumonia associated with suspected neoplasm pneumonia associated with suspected neoplasm

or foreign body or foreign body • suspected Pneumocystis cariniisuspected Pneumocystis carinii

Which of the following findings would indicate an Which of the following findings would indicate an increased risk of death in patients with increased 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

PneumoniaPneumonia SeveritySeverity IndexIndex

Pneumonia Severity

Index

Site of TreatmentSite of Treatment

Class I or II: Outpatient treatmentClass I or II: Outpatient treatment Class III: Potential outpatient or brief Class III: Potential outpatient or brief

inpatient observationinpatient observation Class IV and V: InpatientClass IV and V: Inpatient Physician decision making: medical and Physician decision making: medical and

psychosocial comorbidities, ability to take psychosocial comorbidities, ability to take po, substance abuse, ability to do ADLspo, substance abuse, ability to do ADLs

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

All of the following are reasons to admit a All of the following are reasons to admit a patient with pneumonia to the ICU patient 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

ICU AdmissionICU Admission Minor CriteriaMinor Criteria

RR>30/minRR>30/min PaOPaO22/F/FiiOO22 <250 <250 Multilobar pneumonia Multilobar 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 serum Cr>2.0)Acute renal failure (uop <80ml in 4 h or serum Cr>2.0)

In April, a 45yo F with HTN presents to the office In April, a 45yo F with HTN presents to the office with fever x 3 days and a cough. T 102.5 HR 95 with fever x 3 days and a cough. T 102.5 HR 95 R 22 BP 130/80 Sats 94% on RA. CXR shows R 22 BP 130/80 Sats 94% on RA. CXR shows RUL infiltrate. RUL infiltrate.

A. You should check a CBC, BMP, and LFTs A. 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 Strep D. The most likely organisms are Strep

pneumonia, Mycoplasma, Chlamydia, and H. flu pneumonia, Mycoplasma, Chlamydia, and H. flu and she should be treated with Azithromycin or and she should be treated with Azithromycin or DoxycyclineDoxycycline

Group I: OutpatientsGroup I: Outpatients No cardiopulmonary disease No cardiopulmonary disease

No modifying factorsNo modifying factorsOrganism:Organism:

Streptococcus pneumoniaStreptococcus pneumonia

Mycoplasma pneumoniaMycoplasma pneumonia

Chlamydia pneumoniaChlamydia pneumonia

Hemophilus influenzaeHemophilus influenzae

MiscellaneousMiscellaneous

LegionellaLegionella

Mycobacterium Mycobacterium

FungiFungi

Treatment:Treatment:

Advanced generation Advanced generation macrolide(azithromycin or macrolide(azithromycin or clarithromycin) clarithromycin)

OR doxycyclineOR doxycycline

All of the following have been identified as All of the following have been identified as risk factors for community-acquired risk 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, liver E. Chronic illness, including diabetes, liver

disease, and renal diseasedisease, and renal disease

A 68 yo M with DM, HTN, CAD, is admitted to A 68 yo M with DM, HTN, CAD, is admitted to the hospital with community acquired the hospital with community acquired pneumonia. He is recently retired from the pneumonia. He is recently retired from the insurance industry and has been caring for his insurance industry and has been caring for his grandson several mornings a week. He doesn’t grandson several mornings a week. He doesn’t smoke but he does drink 2-3 cocktails every smoke 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 for He is at risk for

A. Penicillin resistant pneumococusA. Penicillin resistant pneumococus B. PseudomonasB. Pseudomonas C. MRSAC. MRSA D. Enteric gram negativesD. Enteric gram negatives

Modifying Factors that Increase the Modifying Factors that Increase the Risk of infection with Specific Risk 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

The mortality rate for patients with nursing The 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%

Group II: Outpatient, with Group II: Outpatient, with cardiopulmonary disease, and/or cardiopulmonary 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: -lactam (oral -lactam (oral

cefpodoxime, cefuroxime, cefpodoxime, cefuroxime, high-dose amoxicillin, high-dose amoxicillin, amoxicillin/clavulanate or amoxicillin/clavulanate or parenteral ceftriaxoneparenteral ceftriaxone

PLUSPLUS Macrolide or doxycyclineMacrolide or doxycycline

OROR Antipneumococcal Antipneumococcal

fluoroquinolonefluoroquinolone

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. Intravenous 1. Intravenous -lactam: -lactam:

cefotaxime, ceftriaxone, cefotaxime, ceftriaxone, ampicillin/sulbactam, ampicillin/sulbactam, high-dose amipicillinhigh-dose amipicillin

PLUSPLUS Intravenous or oral Intravenous or oral

macrolide or doxycyclinemacrolide or doxycycline OROR 2. Antipneumococcal 2. Antipneumococcal

fluoroquinolonefluoroquinolone

A 45 year old female with lupus is admitted to A 45 year old female with lupus is admitted to the ICU with community acquired pneumonia the ICU with community acquired pneumonia and septic shock. She was intubated in the ER and 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

ICU PatientsICU Patients

Organisms:Organisms: Strep pneumoniaStrep pneumonia LegionellaLegionella Hemophilus influenzaeHemophilus influenzae Enteric gram-negative Enteric gram-negative

bacillibacilli Staphylococcus aureusStaphylococcus aureus MycoplasmaMycoplasma Respiratory VirusesRespiratory Viruses MiscellaneousMiscellaneous

Therapy:Therapy: 1. Intravenous 1. Intravenous -lactam: -lactam:

cefotaxime, ceftriaxone, cefotaxime, ceftriaxone, ampicillin/sulbactam, ampicillin/sulbactam, high-dose amipicillinhigh-dose amipicillin

PLUS eitherPLUS either Intravenous or oral Intravenous or oral

macrolide or doxycyclinemacrolide or doxycycline oror Antipneumococcal Antipneumococcal

fluoroquinolonefluoroquinolone

ICU Patients with Risks for ICU Patients with Risks for Pseudomonas aeruginosaPseudomonas aeruginosa

1. Selected iv 1. Selected iv antipseudomonal antipseudomonal -lactam -lactam (cefepime, imipenem, (cefepime, imipenem, meropenem, meropenem, piperacillin/tazobactam) piperacillin/tazobactam)

PLUS iv antipseudomonal PLUS iv antipseudomonal quinolonequinolone

OR OR 2. Selected iv 2. Selected iv

antipseudomonal antipseudomonal -lactam -lactam PLUS iv aminoglycoside PLUS PLUS iv aminoglycoside PLUS either iv macrolide or iv either iv macrolide or iv nonpseudomonal nonpseudomonal fluoroquinolonefluoroquinolone

The organism(s) most commonly found in The organism(s) most commonly found in patients with nosocomial pneumonia is patients 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

Hospital-Acquired PneumoniaHospital-Acquired Pneumonia

Enteric aerobic gram Enteric aerobic gram negative bacillinegative bacilli

Pseudomonas Pseudomonas aeruginosaaeruginosa

Staphylococcus aureusStaphylococcus aureus Oral anaerobesOral anaerobes

Antipseudomonal Antipseudomonal cephalosporin (cefepime, cephalosporin (cefepime, ceftazidime) OR ceftazidime) OR Antipseudomonal Antipseudomonal carbepenem OR carbepenem OR --lactam/lactam/-lactamase -lactamase inhibitor inhibitor

PLUSPLUS Antipseudomonal Antipseudomonal

fluoroquinolone OR fluoroquinolone OR aminoglycosideaminoglycoside

PLUSPLUSVancomycin or LinezolidVancomycin or Linezolid

The mechanism thought to account for most The mechanism thought to account for most cases of nosocomial pneumonia includes:cases of nosocomial pneumonia includes:

A. Inhalation of infected aerosols from A. Inhalation of infected aerosols from respiratory equipmentrespiratory equipment

B. Hematogenous spread from another infected B. 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 oropharyngeal D. Aspiration of pathogen-laden oropharyngeal

secretionssecretions E. Inhalation of infected droplet nuclei from E. Inhalation of infected droplet nuclei from

other patients in the areaother patients in the area

Which of the following has been Which of the following has been demonstrated to reduce the incidence of demonstrated 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

Staph aureusStaph aureus

HistoplasmaHistoplasma

LegionellaLegionella

MycoplasmaMycoplasma

NocardiaNocardia

TBTB

Metastasis to skin and Metastasis to skin and CNSCNS

Hyponatremia, AMS, Hyponatremia, AMS, renal and hepatic renal and hepatic dysfunctiondysfunction

Night sweats, weight Night sweats, weight lossloss

Erythema multiforme, Erythema multiforme, hemolytic anemia, hemolytic anemia, encephalitis, transverse encephalitis, transverse myelitismyelitis

Erythema nodosumErythema nodosum Increased risk after Increased risk after

Influenzae pneumoniaInfluenzae pneumonia

The organism most commonly associated The organism most commonly associated with life-threatening community acquired with 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

Strep pneumoniaStrep pneumonia

Encapsulated lancet shaped diplococcusEncapsulated lancet shaped diplococcus Causes up to 50% of community acquired Causes 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 very Usually 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%

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 MCI Patients with high level resistance (penicillin MCI >4>4g/mL) showed an increased risk of g/mL) showed an increased risk of suppurative complicationssuppurative complications

Most common mechanisms of resistance to Most common mechanisms of resistance to macrolides are methylation of a ribosomal target macrolides are methylation of a ribosomal target encoded by erm gene and efflux of the encoded by erm gene and efflux of the macrolides by cell membrane protein macrolides by cell membrane protein transporter, encoded by mef genetransporter, encoded by mef gene

Predicting Antimicrobial Resistance Predicting Antimicrobial Resistance in Invasive Pneumococcal in Invasive Pneumococcal

InfectionsInfectionsClinical Infectious Diseases 2005;40:1288-97Clinical Infectious Diseases 2005;40:1288-97

3339 patients3339 patients Risk factors for penicillin-resistance or Risk 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

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

Clinical CourseClinical Course

Target time for appropriate initiation of Target 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 4 Leukocytosis usually resolves by Day 4 Abnormal physical findings (crackles) persist Abnormal 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, multiple Delayed resolution with increasing age, multiple

coexisting illness, alcoholism, bacteremiacoexisting illness, alcoholism, bacteremia

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 same Patient can be discharged home the same

day that clinical stability occurs and oral day that clinical stability occurs and oral therapy is initiated.therapy is initiated.

PreventionPrevention Recommendations by CDC:Recommendations by CDC: Pneumococcal vaccine:Pneumococcal vaccine: age >65 or if age >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 pulmonary long-term care facilities, chronic pulmonary or cardiovascular disease, hospitalization in or cardiovascular disease, hospitalization in the preceding year, immunosuppression, the preceding year, immunosuppression, pregnant women in 2pregnant women in 2ndnd or 3 or 3rdrd trimester trimester during flu seasonduring flu season

Patients should be counseled during Patients should be counseled during hospitalization regarding smoking cessationhospitalization 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 In immunocompetent adults for whom the pneumococcal vaccine is indicated, the pneumococcal 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%

A 34yo F with JRA presents to the office with a A 34yo F with JRA presents to the office with a 3 day history of a cough productive of yellow 3 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 104 she 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 has Physical exam reveals rales in her LLL. She has dullness to percussion at her left base and dullness to percussion at her left base and increased tactile fremitus. The next step in her increased 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

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

A 55yo with CHF presents to the ER with a A 55yo with CHF presents to the ER with a 1 day history of cough, fever, shaking 1 day history of cough, fever, shaking chills, and weakness. She is obviously chills, and weakness. She is obviously uncomfortable, with mildly increased work uncomfortable, with mildly increased work of breathing. T 100.8 HR 125 R 32 BP of breathing. T 100.8 HR 125 R 32 BP 100/55 Saturations 86% on RA. Lungs 100/55 Saturations 86% on RA. Lungs have crackles in her right upper lobe. She have crackles in her right upper lobe. She has 1+ edema bilaterally. She is alert and has 1+ edema bilaterally. She is alert and oriented. oriented.

You should now obtain all of the following You should now obtain all of the following labs labs 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

ABG: pH 7.36 pCO2 42 pO2 50 ABG: pH 7.36 pCO2 42 pO2 50 Na 134 K 4.3 Cl 95 HCO3 20 BUN 42 Cr 1.4 Na 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 and A. Given a prescription for Azithromycin and

sent homesent home B. Admitted to the hospital. Start Ceftriaxone B. Admitted to the hospital. Start Ceftriaxone

and Azithromycin after she coughs up a sputum and Azithromycin after she coughs up a sputum sample.sample.

C. Admitted to the hospital. Start Levofloxacin C. Admitted to the hospital. Start Levofloxacin immediatelyimmediately

D. Admitted to the ICU and started on D. Admitted to the ICU and started on mechanical ventilationmechanical ventilation

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%

A 70yo F resident of a nursing home is evaluated in the A 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 only She has a history of stroke and is currently taking only aspirin. She has been able to eat on her own and there aspirin. She has been able to eat on her own and there have been no witnessed aspirations. She has not been have been no witnessed aspirations. She has not been treated recently with antibiotics. WBC 12 Hgb 12 treated recently with antibiotics. WBC 12 Hgb 12 Electrolytes are normal and she has mild chronic renal Electrolytes are normal and she has mild chronic renal insufficiency. CXR shows small interstitial infiltrate in insufficiency. 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 following acquired 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

A 28yo M presents to the ER with A 28yo M presents to the ER with increasing shortness of breath and increasing 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. He on RA. Lungs have rales throughout. He has no peripheral edema. He knows his has no peripheral edema. He knows his name and knows he is in the ER but he is name 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).

You should do all of the following You 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

In carefully performed prospective studies on the In carefully performed prospective studies on the etiology of community-acquired pneumonia, the etiology of community-acquired pneumonia, the organism most often identified in patients ill organism 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

In patients with bacteremic pneumonia the In 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

A 65 yo M develops bilateral lower lobe A 65 yo M develops bilateral lower lobe pneumonia and is treated as an outpatient with pneumonia and is treated as an outpatient with amoxicillin/clavulanic acid for 72hours. Despite amoxicillin/clavulanic acid for 72hours. Despite this treatment, he deteriorates and is admitted to this treatment, he deteriorates and is admitted to the hospital. Within 12 hours of admission, he the hospital. Within 12 hours of admission, he develops respiratory failure requiring admission develops respiratory failure requiring admission to the ICU, intubation, and mechanical to the ICU, intubation, and mechanical ventilation. The organism most likely to account ventilation. The organism most likely to account for the severity of disease despite treatment with for 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

PneumoniaPneumonia

Common infectionCommon infection PathophysiologyPathophysiology Clinical presentationClinical presentation Risk factors for mortalityRisk factors for mortality TreatmentTreatment