Infectious Disease [PNEUMONIA]

Organisms and Disease Typing

Whenever there’s a fever and a cough consider a lung infection.
There are three lung infections: 1) Abscess, 2) Bronchitis, and 3)
Pneumonia. When learning about Typical Pneumonias and
Atypical Pneumonias for Step 1, the symptoms and CXR
findings may be misleading (neither is specific enough), and
“Pneumonia” is treated on its severity - not by which “type” it is.
Instead, use: exposure, the history, and risk factors to orient the
treatment goals. That means the Step 1 studying you did (this
organism leads to that presentation) should be ignored. Rather,
the thinking should be along the lines of, “given the patient’s risk-
factors, what bug could this be?” If there’s no association with
healthcare the community bugs (not virulent or resistant) are CAP Strep pneumo Most Common
more likely (Community Acquired Pneumonia). Within CAP M. catarrhalis
there are bugs more likely to cause disease. Strep pneumo is H. flu COPD / Smoker
Klebsiella and Aspiration
always the most common; the #2 disease is based on risk factors Anaerobes (EtOH, CVA, MS)
(see the table). If the patient has been near healthcare the S. Aureus Post Viral
virulence and resistance increase; the bugs are more hostile. Treat Legionella Immuno ↓
for HCAP (Health Care Associated Pneumonia). To be HAP Pseudomonas
considered HCAP (which also means HAP and VAP), there must MRSA
be exposure to a healthcare facility within 90 days (HCAP), be Immuno ↓ TB
admitted and acquire the pneumonia after 48 hours of admission Fungal
PCP
(HAP), or be on a ventilator (VAP). While HCAP, HAP, and
VAP are different bureaucratically, they carry the same
microbiologic risk - MRSA and Pseudomonas – so they’re treated Fever + Cough…….with
the same. If the patient is Immunocompromised the weird bugs Bronchitis Sputum Production, Nrml CXR
can cause infections (TB, Fungus, MAC, and PCP). Finally, if Abscess Foul Breath, Cavitation CXR
there’s a risk for aspiration (MS, Stroke, Diabetic, Alcoholic, Pneumonia Sputum production, Consolidation on CXR
Intubated, Seizures), the oral flora /anaerobes are at ↑ risk. PCP Immunocompromised, Hypoxemia, elevated LDH
Flu Myalgias, Arthralgias, body aches
Workup
Everybody who presents with a fever and a cough will get a
CXR. They’ll also get an SpO2. Even though the best test is a
culture, sometimes in the lung it doesn’t work out. So beyond
CXR + SpO2, there’s no clear algorithm.

Sputum Gram Stain and Culture rarely has utility unless obtained
by bronchoscopy (contaminated by floral organisms, useful only
when <10 Squamous and >25 Polys /hpf). Blood Cultures rarely
yield anything, and if positive represent septicemia, but should be
obtained on any patient being admitted to the hospital.
Bronchoalveolar lavage is reserved for acutely ill patients or
those who do not improve after 72 hours of empiric therapy.
Serum, urine antigen, or PCR can be used to identify certain
organisms (legionella, strep pneumo), but these advanced tests are
often not needed. Empiric treatment is usually sufficient to
direct us.

Pneumonia
Fever, productive cough, and consolidation on chest x-ray is
classic for pneumonia. In this constellation, one must only decide
between HCAP and CAP; use empiric therapy from there. Be able
to differentiate Pneumonia from Abscess and Bronchitis, as well
as HCAP from CAP. See first section.

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 Infectious Disease [PNEUMONIA]

Bronchitis Other Bugs to consider
Bronchitis presents as a fever and a cough with a Normal CXR. S. pneumoniae Most Common
This presentation might be a viral pneumonia or an Legionella GI + CNS Sxs Urine Ag
extrapulmonary process, but with a sputum production that can Klebsiella EtOH
Chlamydia Placenta/Sheep Serum Ab
be treated as an ambulatory pneumonia. This means outpatient
Haemophilus COPD/Smoker
therapy with a macrolide (Azithromycin), doxycycline, or
moxifloxacin. Chronic Bronchitis is a productive cough for 2-3
months in 2 consecutive years.

Atypical Pneumonia Bottom Line 1st Line Alternate

This isn’t a thing in clinical medicine, but it still comes up on Ambulatory Pneumonia Azithromycin Doxycycline
tests. Atypical pneumonia presents as an insidious onset fever (“Bronchitis”) Moxifloxacin
and cough with bilateral infiltrates on CXR. These patients Inpatient Community Pneumonia Ceftriaxone + Moxifloxacin
(“CAP”) Azithromycin
typically don’t present as acutely ill - the so called “walking
Inpatient Health Care Pneumonia Vancomycin Many
pneumonia.” Treat this like a bronchitis, but know the association (“HCAP”) + Pip/Tazo
between Mycoplasma Pneumonia and IgM cold agglutinin PCP Bactrim None
disease. +/- Steroids
Influenza Oseltamivir None
Abscess / Aspiration Pneumonia
An abscess is going to present as a fever and a cough, plus
cavitation and foul breath. Because of cavitation, lung cancer,
TB, and fungus must be considered. Obtain a CT scan to
facilitate. Clindamycin is crucial to the therapy because oral flora
has anaerobes, but often additional therapy is initiated with the
clindamycin as it still represents “a pneumonia.” Aspiration
causes abscesses. Aspiration risk essentially means patients with
seizure, alcoholics, and MS/CVA patients with dysphagia
(include PEG tube patients in here too).

HIV and PCP

If the patient has a subacute pneumonia with bilateral fluffy
infiltrates, give consideration to PCP. An elevated LDH is often
associated with PCP. The diagnosis is made with a silver stain on
induced sputum or bronchoalveolar lavage. The treatment is with
IV Bactrim. If the patient is hypoxemic, add steroids.
CURB-65
Who Needs to be admitted? PORT Score / PSI and CURB-65
Confusion of new Onset A 5-point system. The more
You shouldn’t memorize the Pneumonia Severity Index (PSI) nor Urea > 7 (BUN > 19) points, the more severe the
the CURB-65, but since pneumonia is so common at least be Respiratory Rate > 30 patient’s condition + and
aware of what these are and what they mean. The CURB-65 is an Blood pressure < 90 / < 60 the more fatal it is. Used to
ED Triage Tool, whereby the patient likely needs admission if 65 years or older determine if the patient
any one of the CURB-65 are met. The PSI is an Internal needs to be admitted
Medicine Triage Tool that’s quite complex – it requires an online
calculator to complete. The higher the score, the more likely the
Pneumonia Severity Index
need for ICU. The lower the score the more likely the person can
I Discharge from ED
be discharged. While clinical acumen is equivalent to these II < 70 Floor Admission (probably)
scores, they provide object evidence for documentation and can III 71-90 Floor Admission (Definitely)
be used to gauge clinical reasoning on severity of disease. THIS IV 91-130 ICU Admission (Probably)
IS NOT FOR THE SHELF. V > 130 ICU Admission (Definitely)

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