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Questions and Answers
Which cell type predominates during the resolution phase of pneumonia?
Which cell type predominates during the resolution phase of pneumonia?
What is the initial phase of classic lobar pneumonia characterized by?
What is the initial phase of classic lobar pneumonia characterized by?
Which phase corresponds to the successful containment of infection with improved gas exchange?
Which phase corresponds to the successful containment of infection with improved gas exchange?
In the context of pneumonia, what is the dominant cell type during the red hepatization phase?
In the context of pneumonia, what is the dominant cell type during the red hepatization phase?
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What is the typical radiograph pattern observed in bacterial community-acquired pneumonia (CAP)?
What is the typical radiograph pattern observed in bacterial community-acquired pneumonia (CAP)?
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Which vital sign indicates a risk factor for High-Risk Community Acquired Pneumonia (CAP)?
Which vital sign indicates a risk factor for High-Risk Community Acquired Pneumonia (CAP)?
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Which of the following pathogens is classified under Low Risk for CAP?
Which of the following pathogens is classified under Low Risk for CAP?
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What condition must be met for moderate-risk CAP to be considered?
What condition must be met for moderate-risk CAP to be considered?
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Which symptom is least likely associated with Community Acquired Pneumonia?
Which symptom is least likely associated with Community Acquired Pneumonia?
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Which physical examination finding is indicative of severe CAP?
Which physical examination finding is indicative of severe CAP?
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What is a common clinical finding that helps differentiate CAP from other infections?
What is a common clinical finding that helps differentiate CAP from other infections?
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Which of the following scenarios increases the risk for anaerobic infection in pneumonia?
Which of the following scenarios increases the risk for anaerobic infection in pneumonia?
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What is the recommended action for a patient presenting with severe sepsis due to pneumonia?
What is the recommended action for a patient presenting with severe sepsis due to pneumonia?
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What is the most common cause of community-acquired pneumonia (CAP)?
What is the most common cause of community-acquired pneumonia (CAP)?
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Which of the following characteristics is typical of atypical pneumonia?
Which of the following characteristics is typical of atypical pneumonia?
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Which organism is often associated with pneumonia following influenza infections?
Which organism is often associated with pneumonia following influenza infections?
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What diagnostic test is considered the best initial evaluation for pneumonia?
What diagnostic test is considered the best initial evaluation for pneumonia?
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Which of the following biomarkers is NOT mentioned as useful in assessing pneumonia severity?
Which of the following biomarkers is NOT mentioned as useful in assessing pneumonia severity?
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Which of the following statements about atypical organisms of CAP is correct?
Which of the following statements about atypical organisms of CAP is correct?
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What respiratory condition is associated with the pathogen Pseudomonas aeruginosa?
What respiratory condition is associated with the pathogen Pseudomonas aeruginosa?
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Which agent is associated with pneumonia in individuals who have been exposed to birds?
Which agent is associated with pneumonia in individuals who have been exposed to birds?
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What is the drug of choice for low-risk patients with no co-morbid illness?
What is the drug of choice for low-risk patients with no co-morbid illness?
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In moderate-risk patients without a risk for Pseudomonas, which combination of treatments is appropriate?
In moderate-risk patients without a risk for Pseudomonas, which combination of treatments is appropriate?
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What should be expected as the first sign of response to treatment?
What should be expected as the first sign of response to treatment?
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Which of the following is NOT a reason for lack of response to treatment?
Which of the following is NOT a reason for lack of response to treatment?
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For most bacterial pneumonias except enteric Gram-negative pathogens, what is the recommended duration of therapy?
For most bacterial pneumonias except enteric Gram-negative pathogens, what is the recommended duration of therapy?
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What is the recommended treatment addition for high-risk patients with suspected MRSA?
What is the recommended treatment addition for high-risk patients with suspected MRSA?
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How long should most symptoms resolve within effective treatment?
How long should most symptoms resolve within effective treatment?
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Which of the following could be a reason for treating with a B-lactam/BLIC combination in stable co-morbid patients?
Which of the following could be a reason for treating with a B-lactam/BLIC combination in stable co-morbid patients?
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How long should a patient with MSSA/Staph aureus pneumonia be treated?
How long should a patient with MSSA/Staph aureus pneumonia be treated?
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Which of the following characteristics should be monitored for a patient before discharge?
Which of the following characteristics should be monitored for a patient before discharge?
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What is the maximum treatment duration for atypical pneumonia using Azithromycin?
What is the maximum treatment duration for atypical pneumonia using Azithromycin?
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Which treatment should be given for a patient at risk for Pseudomonas in CAP-MR?
Which treatment should be given for a patient at risk for Pseudomonas in CAP-MR?
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What could be a reason for a lack of response to treatment of CAP?
What could be a reason for a lack of response to treatment of CAP?
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If a patient is bacteremic, how should the duration of treatment be adjusted?
If a patient is bacteremic, how should the duration of treatment be adjusted?
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For a patient with comorbidities in CAP-LR and no Pseudomonas risk, which is the preferred treatment?
For a patient with comorbidities in CAP-LR and no Pseudomonas risk, which is the preferred treatment?
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What is a potential cause for persistent fever despite appropriate treatment for CAP?
What is a potential cause for persistent fever despite appropriate treatment for CAP?
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Study Notes
Risk Stratification
- Patients with any of these features are considered High Risk for Community Acquired Pneumonia (CAP) and require ICU admission:
- Respiratory rate (RR) ≥30/min
- Pulse rate (PR) ≥125/min
- Temperature (T) ≥40°C or ≤36°C
- Systolic blood pressure (SBP) <90mmHg or Diastolic blood pressure (DBP) ≤60mmHg
- Altered mental status with acute onset
- Suspected aspiration
- Unstable co-morbid conditions
- Chest X-ray findings: multilobar pleural effusion, abscess
- If patients present with Severe sepsis or septic shock they are also considered High Risk for CAP and require ICU admission.
- Patients with either High or Moderate risk CAP require a ward admission.
Etiology/Pathogens
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Low-risk pathogens are the most common etiologies of CAP. These are:
- Streptococcus pneumoniae
- Haemophilus influenzae
- Chlamydophila pneumoniae
- Mycoplasma pneumoniae
- Moraxella catarrhalis
- Enteric gram-negative bacilli (in those with co-morbid illness)
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Moderate risk pathogens are those found in Low-risk group plus:
- Legionella pneumophila
- Anaerobes (in individuals with aspiration risk)
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High-risk pathogens are those found in Moderate-risk group plus:
- Staphylococcus aureus
- Pseudomonas aeruginosa
Clinical Manifestation
- CAP most commonly presents with:
- Fever
- Tachycardia
- Chills and sweats
- Non-productive to productive cough with different secretions
- Pleuritic chest pain
- Nausea, vomiting, or diarrhea
- Fatigue, headache, myalgia, arthralgia
- Physically, patients may present with:
- Inability to speak in full sentences
- Increased respiratory rate
- Use of accessory muscles of respiration
- Increased or decreased tactile fremitus
- Dull to flat percussion note
- Crackles
Diagnostics
- Chest X-ray is the best initial test.
- Sputum gram stain and culture help identify the pathogen.
- Urinary antigen tests are helpful in detecting pneumococcal and Legionella antigens.
- Polymerase chain reaction tests are used to detect specific DNA sequences, such as bacterial or viral DNA.
- Serology, a test that detects antibodies, may also be helpful in identifying the pathogen and determining the course of the infection.
- Biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) are useful in the following:
- Identification of worsening disease or treatment failure.
- Distinguishing bacterial from viral infections.
- Determining the need for antibacterial therapy.
- Making decisions about when to discontinue treatment.
Pathology
- The typical histopathological changes during bacterial pneumonia are:
- Edema: The initial phase where the lung tissue swells.
- Red Hepatization: The stage where the lung becomes red and firm due to an influx of red blood cells and fibrin.
- Gray Hepatization: The stage where the lung tissue turns gray due to the accumulation of neutrophils and cellular debris.
- Resolution: The final stage where the inflammation resolves, and the lung tissue returns to its normal state.
- Edema is rare in biopsy samples.
- The resolution phase corresponds to successful containment of the infection and improved gas exchange.
- The dominant cell in each stage is:
- Edema (initial): Bacteria
- Red Hepatization: RBCs
- Gray Hepatization: Neutrophils
- Resolution (final): Macrophages
- Different types of pneumonia present with unique radiograph patterns:
- Bacterial CAP: Lobar pneumonia
- Nosocomial Pneumonia: Bronchopneumonia
- Viral, Pneumocystis pneumonia: Interstitial pneumonia
Treatment Based on CAP Guidelines 2016
-
Low-risk:
- No co-morbid illness:
- Amoxicillin (drug of choice)
- Extended macrolides (Azithromycin, Clarithromycin)
- Stable co-morbid illness:
- B-lactam/BLIC combination (Co-amoxiclav, Sultamicillin), or
- 2nd gen Cephalosporins (Cefuroxime)
-
- Extended macrolides
- No co-morbid illness:
-
Moderate-risk:
- IV non-antipseudomonal B-lactam (Ampicillin-sulbactam, Ceftriaxone, Ertapenem) PLUS either extended macrolide or fluoroquinolone (Levofloxacin, Moxifloxacin)
- If no risk of Pseudomonas:
- IV non-antipseudomonal B-lactam (BLIC, Cephalosporins, Carbapenem) PLUS IV Extended macrolide or Fluoroquinolone
- If risk of Pseudomonas:
- IV antipneumococcal/antipseudomonal B-lactam (Pip-Tazo, Cefepime, Meropenem, Imipenem-Cilastatin) PLUS extended macrolide and aminoglycoside (gentamicin, amikacin) or
- IV antipneumococcal + antipseudomonal B-lactam (BLIC, Cephalosporins or Carbapenem) PLUS IV ciprofloxacin or IV levofloxacin
-
High-risk:
- If MRSA is suspected, add any of the following:
- Vancomycin, Linezolid or Clindamycin
- If MRSA is suspected, add any of the following:
-
Response to Treatment:
- 1 week: Fever should have resolved.
- 4 weeks: Chest pain and sputum production should have substantially reduced.
- 6 weeks: Cough and breathlessness should have substantially reduced.
- 3 months: Most symptoms should have resolved; fatigue may still be present.
- 6 months: Most people will feel back to normal.
-
Lack of Response to Treatment:
- Resistant pathogen
- Sequestered focus (Lung abscess or empyema)
- Wrong treatment
- Correct drug but wrong dose or frequency
Duration of Antibiotic Use Based on Etiology
-
Common bacterial pneumonias:
- 5-7 days (excluding enteric Gram-negative pathogens, S.aureus, and P.aeruginosa)
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Enteric Gram-negative pathogens, S.aureus, and P.aeruginosa:
- 3-5 days (azalides) for S.pneumoniae
-
Mycoplasma and Chlamydophila:
- 10-14 days
-
Legionella:
- 14-21 days; 10 days (azalides)
-
Shortcuts:
- **MSSA/*Staph aureus: 10-14 days
-
Gram-negative (enteric/non-enteric): 7 days
- If using Azithromycin, 5 days
- Pseudomonas or MRSA/MSSA: 14 days
- Bacteremic: Double the usual duration
- Atypical: Double the usual duration
CAP-HR / CAP-MR / CAP-LR
- Always assess for MRSA in CAP-HR patients.
-
CAP-MR treatment varies based on Pseudomonas risk:
- No risk for Pseudomonas: IV non-antipseudomonal B-lactam (Ampicillin-sulbactam, Ceftriaxone, Ertapenem) + Extended macrolide/ Fluoroquinolone (Levofloxacin, Moxifloxacin)
- Risk for Pseudomonas: IV antipneumococcal/antipseudomonal B-lactam (Pip-Tazo, Cefepime, Meropenem, Imipenem-Cilastatin) + extended macrolide and aminoglycoside (gentamicin, amikacin)
-
CAP-LR treatment depends on co-morbidity:
- No co-morbid illness: Amoxicillin (drug of choice); Extended Macrolides (Azithromycin, Clarithromycin).
- Stable co-morbid illness: B-lactam/BLIC combination (Co-amoxiclav, Sultamicillin), or 2nd gen Cephalosporins (Cefuroxime) + Extended macrolides
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Description
This quiz assesses the knowledge of risk stratification for Community Acquired Pneumonia (CAP). Focused on identifying high-risk features and understanding pathogen etiologies, the quiz will enhance your understanding necessary for patient management. Suitable for medical students and healthcare professionals.
