Pneumonia

http://www.erwize.com/Quick_Reference/Professionatls/...

PNEUMONIA

Etiology/S&S/Diagnosis/Treatment:

1.

TYPICAL
a.

Strep. Pneumonia: Frequent cause of CAP (Community Acquired Pneumonia). Especially common in COPD, asplenism, SC. Pt c/o fever, chills, cough. On CXR - typically a lobar appearance. PCN G IV or IM, Ampicillin or Amoxicillin, Erythromycin, PCN V po x 10-14 d. are all accepted treatment modalities. Also effective are many other synthetic penicillins, 2d and 3d generation cephalosporins (Cefotaxime, Ceftriaxone), and the new macrolides. Some strains are now resistant to PCN. The resistance to commonly prescribed antibiotics is as follows: TMP/SMX = 18% resistance to S. Pneumonia, Macrolides = 10% resistance to S. Pneumonia Quinolones = 0.2 % resistance to S. Pneumonia Staph. aureus: Affects pt with DM, IVDA or recent viral URI. On CXR - patchy appearance. Pt is treated with b -lactamase resistant PCN (nafcillin) or, if risk of MRSA, Vancomycin. High risk of forming abscess and empyema. H. Flu: COPDers are very susceptible. CXR - patchy infiltrate. Generally responds to ampicillin or amoxicillin, but given resistant strains, 2nd or 3d generation cephalosporin are commonly used. TMP/SMX is an alternative, as are azithromycin or clarithromycin. Moraxella catarrhalis: Common in COPDers or/and geriatric population. Treated with Erythromycin, TMP/SMX, or amoxicillin-clavulanate (Augmentin). Klebsiella: COPDers, ETOH, nursing home pts are the common targets. Jelly-red sputum is characteristic. Treated with aminoglycoside + 3d generation cephalosporin. P. aureginosa: Pt with CF, neutropenic pts and nosocomial pts are susceptible. Aminoglycoside + anti-pseudomonal PCN (e.g., Timentin).

b.

c.

d.

e.

f.

2.

ATYPICAL
a.

Mycoplasma: Common cause of CAP. Also called "walking pneumonia" . Pt looks better than the CXR. Pt c/o myalgias, dry cough. On exam bullous myringitis, pericarditis, hepatitis may be found. CXR typically shows bilateral interstitial infiltrate. If the antibodies (complement fixation) in acute or convalescent phase are high, it is diagnostic. The cold agglutinins are not specific for dx. Treated with Erythromycin x 10 - 14 d, or the newer macrolides.

1 of 3

3/11/13 10:07 PM

Pneumonia

http://www.erwize.com/Quick_Reference/Professionatls/...

Chlamydia (psittaci, trachomatis, TWAR): Presents like other atypical pneumonias (dry, prolonged and chronic cough, URI). Many pts may present with S & S of pharyngitis, tracheobronchitis, and "new onset asthma". Chlamydia represents 5-15% of CAP. CXR looks like any atypical pneumonia. Only serological studies can confirm the dx. Treated with Erythromycin or the newer macrolides. Viral (influenza, RSV, Coxackie, Varicella): Some occur as epidemics, some occur predominantly in children. Yet, sporadic cases can occur. Pt c/o cough, SOB, myalgias, malaise, URI, +/- GI symptoms. On labs - WBC with lymphocytic predominance.CXR looks like any other atypical pneumonia. Fourfold viral titer increase from acute to convalescent stage is diagnostic. Treatment is supportive. In cases of influenza A - Amantadine within 48 hours. In case of RSV - Ribavirin. In case of Herpes and Varicella - Acyclovir. New medications and guidelines are put on the market frequently and it is advisable to check updated publications.
3.

PCP
a.

Pneumocystis carinii - Acutely ill Occurs in HIV pt with low CD count < 200/mm3, or other immunocompromised patients, and in pts who are treated with steroids and immunocompromised. No risk of acquiring PCP by person-to-person spread. Pt generally c/o dyspnea, cough (generally not productive), hiccups and fever. CXR shows butterfly wing appearance. Presence of normal CXR (10%) doesn't r/o PCP pneumonia. Pts often have ( LDH (> 450 IU). ABG should be performed not for documenting A-a gradient, which can be normal, but to see the pO2. If the latter is < 75 mmHg, steroids are instituted as part of treatment. The absolute dx is done on the floor by way of fiberoptic broncoscopy, biopsy and lavage. Culture or examination of induced sputum by indirect immunofuorescence are also floor diagnostic tests. In the ER pt is treated with TMP/SMX as 15-20mg/kg/day (TMP component) divided q6 - q8 hrs IV or Pentamidine 4 mg/kg qd TMP 20 mg/kg/day administered in 4 divided doses and given PO q6 -q8 hrs. If the pO2 is < 70 mmHg on RA or A-a gradient is >30, 40mg Prednisone bid is started in ER. Pneumocystis carinii - Not acutely ill TMP/SMX 2 DS tabs po q8h (total of 15-20mg/kg/day basesd on TMP) po x 21 days or Dapson 100 mg po qd + TMP 5 mg/kg po q8h x 21 days Pneumocystis carinii - prophylaxis TMP/SMX DS 1 tab po qd

b.

c.

4.

ASPIRATION PNEUMONIA
a.

Not to be confused with aspiration pneumonitis, which presents hours after aspiration, with SOB and fever secondary to chemical reaction. Aspiration Pneumonia occurs days after the episode. Presents with fever, SOB, tachypnea. CXR typically shows infiltrate in inferior part of RUL. Ticarcillin clavulanate (Timentin) 3.1 g q4-6 hrs is a good choice for treatment. Clindamycin 600 mg IV q6 hr is an alternative to cover anaerobes. Intubation

2 of 3

3/11/13 10:07 PM

Pneumonia

http://www.erwize.com/Quick_Reference/Professionatls/...

and PEEP are instituted if there is no adequate oxygenation.

5.

NOSOCOMIAL PNEUMONIA
a.

Affects hospitalized and nursing home patients. Often due to aspiration. CXR shows infiltrate in inferior part of RUL. Broad coverage for G (+), G (-) and coverage for anaerobic oral flora with Ticarcillin clavulanate (Timentin) + Gentamicin is indicated. Consider Legionella if S & S are suggestive.

6.

LEGIONELLA a. Water born sources. Pt presents with GI symptoms, LFTs, bradycardia, cough ( nonproductive). Pt may also have AMS. Hyponatremia may be present. CXR - bilateral infiltrates. Sputum tested with DFA (Direct Fluorescent AB) and rise in serum titers from acute to convalescent phase are used for diagnosis. Treated with Erythromycin IV or newer macrolides. TB
a.

7.

Pts present with cough, fever, night sweats, weight loss. CXR most commonly will be abnormal (shows infiltrate, cavitation, pl. effusion or miliary pattern). In ER one can only suspect TB and put pt in isolation. Following are some medications that pts are started on: INH 5 - 10 mg/kg up to 300 mg PO / qd (adverse effects: neuritis, hepatitis, sz) Ethambutol 20 mg/kg PO / qd (causes optic neuritis) Rifampin 600 mg PO / qd (can cause hepatitis) PZA 1-2 gm PO / qd (causes hepatitis). At least two medication regimen is used to avoid drug resistance.

8.

FUNGAL
a.

Seen in immunocompromised host. Common pathogens are Cryptococcus, Histoplasmosis, Coccidioidomycosis, Aspargillosis. CXR classically shows fungoid mass. Treatment is generally Amphotericin. Doses may vary according to etiology. [BACK]

3 of 3

3/11/13 10:07 PM