Pneumonia Pneumonia

Tammy Wichman MD Tammy Wichman MD

Assistant Professor of Medicine Assistant Professor of Medicine
Pulmonary Pulmonary- -Critical Care Critical Care
Creighton University Medical Center Creighton 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. Meningitis A. Meningitis
B. Pneumonia B. Pneumonia
C. Gastroenteritis C. Gastroenteritis
D. Urinary Tract nfections D. Urinary Tract nfections
E. Toe fungus E. Toe fungus
Pneumonia Pneumonia
Most deadly infectious disease in the U.S. Most deadly infectious disease in the U.S.
6 6
th th
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.
1 1
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 Mechanisms Defense Mechanisms
80% of cells lining central airways are ciliated, 80% of cells lining central airways are ciliated,
pseudostratified, pseudostratified,
columnar epithelial cells columnar 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/minute 1000x/minute
So the lower respiratory tract So the lower respiratory tract
is normally sterile is normally sterile
Pneumonia Pathophysiology Pneumonia Pathophysiology
Microbial pathogens enter the lung by: Microbial pathogens enter the lung by:
Aspiration Aspiration 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, VDA, seizures, stroke, anesthesia, swallowing disorders, alcoholics, VDA, seizures, stroke, anesthesia, swallowing disorders,
NG tubes, ETT NG tubes, ETT
Gram positive and anaerobes: Strep pneumo, H flu, Mycoplasma, Gram positive and anaerobes: Strep pneumo, H flu, Mycoplasma,
Moraxella, Actinomyces Moraxella, Actinomyces
Gram negatives: Gram negatives:
more likely with hospitalization, debility, alcoholism, DM, and advanced age more 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 H2blockers with use of H2blockers
nhalation nhalation of nfectious Aerosols of nfectious Aerosols
nfluenza, Legionella, Psittacosis, Histoplasmosis, TB nfluenza, Legionella, Psittacosis, Histoplasmosis, TB
Hematogenous Hematogenous Dissemination Dissemination
Staph aureus Staph aureus
Fusobacterium infections of the retropharyngeal tissues: Lemierre's Fusobacterium infections of the retropharyngeal tissues: Lemierre's
syndrome syndrome
Direct inoculation and Contiguous Spread Direct inoculation and Contiguous Spread
Tracheal intubation, stab wounds 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? What is pneumonia?
nfection of the lower respiratory tract nfection of the lower respiratory tract
Which of the following is Which of the following is NOT NOT a symptom of pneumonia? a symptom of pneumonia?
A. Cough A. Cough
B. Shortness of breath B. Shortness of breath
C. Fever C. Fever
D. Abdominal pain D. Abdominal pain
E. Chest tightness E. Chest tightness
F. Confusion F. Confusion
G. Hot, erythematous 1 G. Hot, erythematous 1
st st
toe toe
Clinical presentation Clinical 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 crackles sounds and crackles
n elderly or immunocompromised, pneumonia n 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 Symptoms Pneumonia Symptoms
"Typical pneumonia: sudden onset of "Typical pneumonia: sudden onset of
fever, cough productive of purulent fever, cough productive of purulent
sputum, pleuritic chest pain sputum, 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, vomiting nausea, vomiting
ncludes diverse entities and has limited ncludes diverse entities and has limited
clinical value clinical value
Pneumonia Pneumonia
Which of the following is Which of the following is NOT NOT 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 sounds C. Bronchial breath sounds
D. Egophany, increased tactile fremitus D. Egophany, increased tactile fremitus
E. Late inspiratory crackles E. Late inspiratory crackles
Pneumonia Diagnosis Pneumonia 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
lymphadenopathy lymphadenopathy
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 Diagnosis Pneumonia Diagnosis
Sputum gram stain and culture: Sputum gram stain and culture:
Controversial: no rapid, easily done, accurate, Controversial: no rapid, easily done, accurate,
cost cost- -effective method to allow immediate results effective method to allow immediate results
Expectorated sputum is frequently contaminated Expectorated sputum is frequently contaminated
by oropharyngeal flora 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
f patient has a productive cough, send sputum f 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 therapy empiric 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.
HV test. HV test.
Bronchoscopy with culture of respiratory Bronchoscopy with culture of respiratory
secretions. secretions.
Pneumonia Diagnosis Pneumonia 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 illness severe 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 sensitivity 50- -80% and specificity 90% 80% and specificity 90%
Responsible pathogen is not defined in as many Responsible pathogen is not defined in as many
as 50% of patients as 50% of patients
n February, a 55yo F with rheumatoid arthritis n 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 should her LLL and dullness to percussion. You should
A. Give her a presciption for Azithromycin A. Give her a presciption for Azithromycin
B. Check her O2 sats and order a CXR B. Check her O2 sats and order a CXR
C. Check her for nfluenzae A C. Check her for nfluenzae A
D. Order a CBC, BMP, LFTs D. Order a CBC, BMP, LFTs
E. A, B, and C E. A, B, and C
F. B, C, and D F. B, C, and D
G. B and C G. B and C
Pneumonia Diagnosis Pneumonia 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 oximetry saturation assessed by oximetry
Pneumonia Diagnosis Pneumonia Diagnosis
nvasive testing: percutaneous nvasive 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 hosts immunocompromised hosts
suspected tuberculosis in the absence of suspected tuberculosis in the absence of
productive cough productive cough
non non- -resolving pneumonia resolving pneumonia
pneumonia associated with suspected neoplasm pneumonia associated with suspected neoplasm
or foreign body or foreign body
suspected Pneumocystis carinii suspected 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 community- -acquired pneumonia? acquired pneumonia?
A. BUN <8 mmol/L A. BUN <8 mmol/L
B. Diastolic blood pressure >70 mm Hg B. Diastolic blood pressure >70 mm Hg
C. Respiratory rate >30 breaths per minute C. Respiratory rate >30 breaths per minute
D. Unilobar lung infiltrate D. Unilobar lung infiltrate
E. PO2 = 65 mm Hg while breathing room air E. PO2 = 65 mm Hg while breathing room air
Pneumonia Pneumonia
Severity Severity
ndex ndex
Pneumonia
Severity
Index
Site of Treatment Site of Treatment
Class or : Outpatient treatment Class or : Outpatient treatment
Class : Potential outpatient or brief Class : Potential outpatient or brief
inpatient observation inpatient observation
Class V and V: npatient Class V and V: npatient
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 ADLs po, substance abuse, ability to do ADLs
CURB 65 CURB 65
Confusion Confusion
Urea level (>19) Urea level (>19)
Respiratory rate (>30) Respiratory rate (>30)
Blood Pressure SBP< 90 or DBP <60 Blood Pressure SBP< 90 or DBP <60
Age Age
Excellent indicator for mortality Excellent 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 CU patient with pneumonia to the CU
EXCEPT: EXCEPT:
A. Need for mechanical ventilation A. Need for mechanical ventilation
B. Shock requiring pressors B. Shock requiring pressors
C. High WBC count with bandemia C. High WBC count with bandemia
D. Decreased urine output D. Decreased urine output
CU Admission CU Admission
Minor Criteria Minor Criteria
RR>30/min RR>30/min
PaO PaO
2 2
/F /F
i i
OO
2 2
<250 <250
Multilobar pneumonia Multilobar pneumonia
Systolic BP <90 Systolic BP <90
Diastolic BP <60 Diastolic BP <60
Major Criteria Major Criteria
Need for mechanical ventilation Need for mechanical ventilation
ncrease in the size of infiltrates by >50% within 48hrs ncrease in the size of infiltrates by >50% within 48hrs
Septic shock Septic shock
Acute renal failure (uop <80ml in 4 h or serum Acute renal failure (uop <80ml in 4 h or serum
Cr>2.0) Cr>2.0)
n April, a 45yo F with HTN presents to the office n 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 results and consider admitting her based on the results
B. You should admit her for 24 hour observation B. You should admit her for 24 hour observation
C. You should check for nfluenzae A C. You should check for nfluenzae 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
Doxycycline Doxycycline
Group : Outpatients Group : Outpatients
No cardiopulmonary disease No cardiopulmonary disease
No modifying factors No modifying factors
Organism: Organism:
Streptococcus pneumonia Streptococcus pneumonia
Mycoplasma pneumonia Mycoplasma pneumonia
Chlamydia pneumonia Chlamydia pneumonia
Hemophilus influenzae Hemophilus influenzae
Miscellaneous Miscellaneous
Legionella Legionella
Mycobacterium Mycobacterium
Fungi Fungi
Treatment: Treatment:
Advanced generation Advanced generation
macrolide(azithromycin or macrolide(azithromycin or
clarithromycin) clarithromycin)
OR doxycycline OR doxycycline
All of the following have been identified as All of the following have been identified as
risk factors for community risk factors for community- -acquired acquired
Legionella pneumonia EXCEPT: Legionella pneumonia EXCEPT:
A. Cigarette smoking A. Cigarette smoking
B. Chronic pulmonary disease B. Chronic pulmonary disease
C. Acquired immunodeficiency syndrome C. Acquired immunodeficiency syndrome
D. Advanced age D. Advanced age
E. Chronic illness, including diabetes, liver E. Chronic illness, including diabetes, liver
disease, and renal disease disease, 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 smoke but he does drink 2- -3 cocktails every 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 pneumococus A. Penicillin resistant pneumococus
B. Pseudomonas B. Pseudomonas
C. MRSA C. MRSA
D. Enteric gram negatives D. Enteric gram negatives
Modifying Factors that ncrease the Modifying Factors that ncrease the
Risk of infection with Specific Risk of infection with Specific
Pathogens Pathogens
Penicillin Penicillin- -resistant pneumococci resistant pneumococci
Age >65 Age >65
BB- -lactam therapy within the past 3 months lactam therapy within the past 3 months
Alcoholism Alcoholism
mmune suppressive illness (including tx with corticosteroids) mmune suppressive illness (including tx with corticosteroids)
Multiple medical comorbidities: DM, CR, CHF, CAD, malignancy, Multiple medical comorbidities: DM, CR, CHF, CAD, malignancy,
chronic liver disease chronic liver disease
Exposure to a child in a day care center Exposure to a child in a day care center
Enteric gram negatives Enteric gram negatives
Residence in a nursing home Residence in a nursing home
Underlying cardiopulmonary disease Underlying cardiopulmonary disease
Multiple medical comorbidities Multiple medical comorbidities
Recent antibiotic therapy Recent antibiotic therapy
Pseudomonas aeruginosa Pseudomonas 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 month Broad spectrum antibiotic therapy for > 7 days in past month
Malnutrition Malnutrition
The mortality rate for patients with nursing The mortality rate for patients with nursing
home home- -acquired pneumonia is: acquired pneumonia is:
A. 10% A. 10%
B. 20% B. 20%
C. 40% C. 40%
D. 60% D. 60%
E. 80% E. 80%
Group : Outpatient, with Group : Outpatient, with
cardiopulmonary disease, and/or cardiopulmonary disease, and/or
other modifying factors other modifying factors
Organism: Organism:
Strep pneumonia Strep pneumonia
Mycoplasma Mycoplasma
Chlamydia Chlamydia
Mixed infection Mixed infection
Hemophilus influenzae Hemophilus influenzae
Enteric gram Enteric gram- -negatives negatives
Viruses Viruses
Miscellaneous Miscellaneous
Moraxella, Legionella, Moraxella, Legionella,
anaerobes, TB, fungi anaerobes, TB, fungi
Therapy: Therapy:
- -lactam (oral lactam (oral
cefpodoxime, cefuroxime, cefpodoxime, cefuroxime,
high high- -dose amoxicillin, dose amoxicillin,
amoxicillin/clavulanate or amoxicillin/clavulanate or
parenteral ceftriaxone parenteral ceftriaxone
PLUS PLUS
Macrolide or doxycycline Macrolide or doxycycline
OR OR
Antipneumococcal Antipneumococcal
fluoroquinolone fluoroquinolone
Group : npatients Group : npatients
Organism Organism
Strep pneumonia Strep pneumonia
Hemophilus influenzae Hemophilus influenzae
Mycoplasma Mycoplasma
Chlamydia Chlamydia
Mixed infection Mixed infection
Enteric gram Enteric gram- -negatives negatives
Aspiration Aspiration
Virus Virus
Miscellaneous Miscellaneous
Therapy: Therapy:
1. ntravenous 1. ntravenous - -lactam: lactam:
cefotaxime, ceftriaxone, cefotaxime, ceftriaxone,
ampicillin/sulbactam, ampicillin/sulbactam,
high high- -dose amipicillin dose amipicillin
PLUS PLUS
ntravenous or oral ntravenous or oral
macrolide or doxycycline macrolide or doxycycline
OR OR
2. Antipneumococcal 2. Antipneumococcal
fluoroquinolone fluoroquinolone
A 45 year old female with lupus is admitted to A 45 year old female with lupus is admitted to
the CU with community acquired pneumonia the CU 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 Zosyn A. Vancomycin and Zosyn
B. Levofloxacin B. Levofloxacin
C. Ceftriaxone and Levofloxacin C. Ceftriaxone and Levofloxacin
D. Doxycycline and Gentamicin D. Doxycycline and Gentamicin
CU Patients CU Patients
Organisms: Organisms:
Strep pneumonia Strep pneumonia
Legionella Legionella
Hemophilus influenzae Hemophilus influenzae
Enteric gram Enteric gram- -negative negative
bacilli bacilli
Staphylococcus aureus Staphylococcus aureus
Mycoplasma Mycoplasma
Respiratory Viruses Respiratory Viruses
Miscellaneous Miscellaneous
Therapy: Therapy:
1. ntravenous 1. ntravenous - -lactam: lactam:
cefotaxime, ceftriaxone, cefotaxime, ceftriaxone,
ampicillin/sulbactam, ampicillin/sulbactam,
high high- -dose amipicillin dose amipicillin
PLUS either PLUS either
ntravenous or oral ntravenous or oral
macrolide or doxycycline macrolide or doxycycline
or or
Antipneumococcal Antipneumococcal
fluoroquinolone fluoroquinolone
CU Patients with Risks for CU Patients with Risks for
Pseudomonas aeruginosa Pseudomonas 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
quinolone quinolone
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
fluoroquinolone fluoroquinolone
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 A. Aerobic Gram- -negative rods negative rods
B. Staphylococcus aureus B. Staphylococcus aureus
C. Legionella species C. Legionella species
D. Streptococcus pneumoniae D. Streptococcus pneumoniae
E. Haemophilus influenzae E. Haemophilus influenzae
Hospital Hospital- -Acquired Pneumonia Acquired Pneumonia
Enteric aerobic gram Enteric aerobic gram
negative bacilli negative bacilli
Pseudomonas Pseudomonas
aeruginosa aeruginosa
Staphylococcus aureus Staphylococcus aureus
Oral anaerobes Oral anaerobes
Antipseudomonal Antipseudomonal
cephalosporin (cefepime, cephalosporin (cefepime,
ceftazidime) OR ceftazidime) OR
Antipseudomonal Antipseudomonal
carbepenem OR carbepenem OR - -
lactam/ lactam/ - -lactamase lactamase
inhibitor inhibitor
PLUS PLUS
Antipseudomonal Antipseudomonal
fluoroquinolone OR fluoroquinolone OR
aminoglycoside aminoglycoside
PLUS PLUS
Vancomycin or Linezolid Vancomycin 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. nhalation of infected aerosols from A. nhalation of infected aerosols from
respiratory equipment respiratory equipment
B. Hematogenous spread from another infected B. Hematogenous spread from another infected
site outside the lung site outside the lung
C. Spread from a contiguous infected site C. Spread from a contiguous infected site
D. Aspiration of pathogen D. Aspiration of pathogen- -laden oropharyngeal laden oropharyngeal
secretions secretions
E. nhalation of infected droplet nuclei from E. nhalation of infected droplet nuclei from
other patients in the area other 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 tubes A. Nasogastric tubes
B. Enteral feedings B. Enteral feedings
C. Hand washing C. Hand washing
D. solation of patients with pneumonia D. solation of patients with pneumonia
E. Antacids E. Antacids
Staph aureus Staph aureus
Histoplasma Histoplasma
Legionella Legionella
Mycoplasma Mycoplasma
Nocardia Nocardia
TB TB
Metastasis to skin and Metastasis to skin and
CNS CNS
Hyponatremia, AMS, Hyponatremia, AMS,
renal and hepatic renal and hepatic
dysfunction dysfunction
Night sweats, weight Night sweats, weight
loss loss
Erythema multiforme, Erythema multiforme,
hemolytic anemia, hemolytic anemia,
encephalitis, transverse encephalitis, transverse
myelitis myelitis
Erythema nodosum Erythema nodosum
ncreased risk after ncreased risk after
nfluenzae pneumonia nfluenzae pneumonia
The organism most commonly associated The organism most commonly associated
with life with life- -threatening community acquired threatening community acquired
pneumonia is: pneumonia is:
A. Streptococcus pneumoniae A. Streptococcus pneumoniae
B. Legionella pneumophila B. Legionella pneumophila
C. Klebsiella pneumoniae C. Klebsiella pneumoniae
D. Pseudomonas aeruginosa D. Pseudomonas aeruginosa
E. Staphylococcus aureus E. Staphylococcus aureus
Strep pneumonia Strep pneumonia
Encapsulated lancet shaped diplococcus Encapsulated lancet shaped diplococcus
Causes up to 50% of community acquired Causes up to 50% of community acquired
pneumonia pneumonia
Patients present with acute onset of hard, Patients present with acute onset of hard,
shaking chills and pleuritic chest pain shaking 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 infection low WBC if overwhelming infection
Sputum may be rusty colored Sputum may be rusty colored
CXR often shows lobar consolidation CXR often shows lobar consolidation
f bacteremic, mortality is 30% f bacteremic, mortality is 30%
Drug Resistant Strep pneumonia Drug Resistant Strep pneumonia
Prevalence continues to increase worldwide: Prevalence continues to increase worldwide:
PCN resistant 18 PCN resistant 18- -22% 22%
macrolide resistant 24 macrolide resistant 24- -32% 32%
Patients with high level resistance (penicillin MC Patients with high level resistance (penicillin MC
>4 >43 3g/mL) showed an increased risk of g/mL) showed an increased risk of
suppurative complications suppurative 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 gene transporter, encoded by mef gene
Predicting Antimicrobial Resistance Predicting Antimicrobial Resistance
in nvasive Pneumococcal in nvasive Pneumococcal
nfections nfections
Clinical nfectious Diseases 2005;40:1288 Clinical nfectious Diseases 2005;40:1288- -97 97
3339 patients 3339 patients
Risk factors for penicillin Risk factors for penicillin- -resistance or resistance or
macrolide resistance: antibiotic use (PCN, macrolide resistance: antibiotic use (PCN,
TMP TMP- -SMX, and azithro) in last 3 months 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 acquisition residence in a NH; nosocomial acquisition
Kyaw, M. H. et aI. N EngI J Med 2006;354:1455-1463
Percentage of PneumococcaI IsoIates That Were NonsusceptibIe to Various Antibiotics from
ChiIdren under Two Years of Age (PaneI A) and AduIts 65 Years of Age or OIder (PaneI B) with
Invasive Disease, 1999 to 2004
Clinical Course Clinical Course
Target time for appropriate initiation of Target time for appropriate initiation of
antimicrobials within 4 hours of admission antimicrobials within 4 hours of admission
Fever x 2 Fever x 2- -4 days 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 beyond 7 d in 20- -40% 40%
CXR clears by 4 weeks in 60% patients CXR clears by 4 weeks in 60% patients
Delayed resolution with increasing age, multiple Delayed resolution with increasing age, multiple
coexisting illness, alcoholism, bacteremia coexisting illness, alcoholism, bacteremia
When to switch to oral therapy When to switch to oral therapy
Oral = iv: doxycycline, linezolid, Oral = iv: doxycycline, linezolid,
quinolones quinolones
mprovement in cough and dyspnea mprovement in cough and dyspnea
Afebrile Afebrile
WBC decreasing WBC decreasing
Functioning G tract Functioning G 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.
Prevention Prevention
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 cirrhosis, asplenia, long- -term care facilities. term care facilities.
Revaccinate after 5 years. Revaccinate after 5 years.
nfluenzae vaccine nfluenzae vaccine: age >65, residents of : age >65, residents of
long long- -term care facilities, chronic pulmonary 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 2 pregnant women in 2
nd nd
or 3 or 3
rd rd
trimester trimester
during flu season during flu season
Patients should be counseled during Patients should be counseled during
hospitalization regarding smoking cessation hospitalization regarding smoking cessation
Kyaw, M. H. et aI. N EngI J Med 2006;354:1455-1463
AnnuaI Incidence of Invasive Disease Caused by PeniciIIin-SusceptibIe and PeniciIIin-
NonsusceptibIe Pneumococci among ChiIdren under Two Years of Age, 1996 to 2004
Kyaw, M. H. et aI. N EngI J Med 2006;354:1455-1463
AnnuaI Incidence of Invasive Disease Caused by PeniciIIin-NonsusceptibIe Pneumococci in
Persons Two Years of Age or OIder, 1996 to 2004
n immunocompetent adults for whom the n 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 stain A. Sputum gram stain
B. Chest radiograph B. Chest radiograph
C. Give her a prescription for Augmentin C. Give her a prescription for Augmentin
D. Admit her to the hospital D. Admit her to the hospital
What should she be treated with? What should she be treated with?
A. Vancomycin and mepenem A. Vancomycin and mepenem
B. Keflex B. Keflex
C. Azithromycin C. Azithromycin
D. Ceftriaxone D. Ceftriaxone
E. Levofloxacin E. 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 EXCEPT EXCEPT::
A. CBC A. CBC
B. Electrolytes B. Electrolytes
C. PT, PTT C. PT, PTT
D. ABG D. ABG
E. Sputum culture E. Sputum culture
F. Blood cultures F. 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 145 glucose 145
WBC 18.3 Hgb 10.3 Hct 32 Plt 130 WBC 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 home sent 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
immediately immediately
D. Admitted to the CU and started on D. Admitted to the CU and started on
mechanical ventilation mechanical ventilation
PORT Score PORT Score
Age 55 Age 55- -10=45 10=45
CHF +10 CHF +10
RR +20 RR +20
HR 124 +10 HR 124 +10
BUN +20 BUN +20
pO2 +10 pO2 +10
115
Class V 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 aeruginosa A. Pseudomonas aeruginosa
B. Anaerobic bacteria B. Anaerobic bacteria
C. Enteric gram C. Enteric gram- -negative organisms negative organisms
D. Aspergillus fumigatus D. Aspergillus fumigatus
E. Mycobacterium tuberculosis E. 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. n the ER, subjective fever and chills. n 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
EXCEPT EXCEPT::
A. Start VF wide open A. Start VF wide open
B. Get an ABG B. Get an ABG
C. Wait on ABG before starting oxygen C. Wait on ABG before starting oxygen
D. Order a CXR D. Order a CXR
E. Admit to the CU E. Admit to the CU
n carefully performed prospective studies on the n carefully performed prospective studies on the
etiology of community etiology of community- -acquired pneumonia, the 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 pneumoniae A. Streptococcus pneumoniae
B. Unknown B. Unknown
C. Chlamydia pneumoniae C. Chlamydia pneumoniae
D. Mycoplasma pneumoniae D. Mycoplasma pneumoniae
E. Haemophilus influenzae E. Haemophilus influenzae
n patients with bacteremic pneumonia the n patients with bacteremic pneumonia the
organism most likely to be found is: organism most likely to be found is:
A. Staphylococcus aureus A. Staphylococcus aureus
B. Klebsiella pneumoniae B. Klebsiella pneumoniae
C. Haemophilus influenzae C. Haemophilus influenzae
D. Streptococcus pneumoniae D. Streptococcus pneumoniae
E. Pseudomonas aeruginosa E. 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 CU, intubation, and mechanical to the CU, 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 catarrhalis A. Moraxella catarrhalis
B. Chlamydia pneumoniae B. Chlamydia pneumoniae
C. Klebsiella pneumoniae C. Klebsiella pneumoniae
D. Legionella pneumophila D. Legionella pneumophila
E. Streptococcus pneumoniae E. Streptococcus pneumoniae
Pneumonia Pneumonia
Common infection Common infection
Pathophysiology Pathophysiology
Clinical presentation Clinical presentation
Risk factors for mortality Risk factors for mortality
Treatment Treatment