S1E29 Pneumonia

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All right, so let's do pneumonia today. So this is definitely one you'll get at least a few questions on on the pants. I can't imagine you won't. It's a pretty popular topic because there are so many different questions they can ask you about all the different organisms that you see and hospital acquired.

community acquire there's there's just a bunch of things that you need to know for pneumonia so I did my best to really break it down and just boil it down into the things that you really need to know and you know I tried to simplify it as best I can because it can get a little overwhelming so let's get started with pneumonia Thank you as always, guys. You really, I just really appreciate all the comments, the people reaching out to me.

Just letting me know that it's helping you. I really do appreciate that. So thank you so much for that. And as always, if you haven't checked out the YouTube channel, please do. It's cram the pants on YouTube. So let's go ahead and get started with pneumonia. Pneumonia, as you know, is an infection of the lungs with consolidation. or these interstitial lung infiltrates so clinically pneumonia is very simple it's a fever cough and consolidation seen on chest x-ray boom there's pneumonia so

It's very simple, but it's when you get into all the different organisms that makes it a little bit more tricky, the different types. So the first thing I want to start with. is just to familiarize you with community-acquired pneumonia versus hospital-acquired pneumonia. So it's an important distinction to make, and it's going to guide your empiric treatment because the organism is acquired walking around at the local grocery store.

going to be much different than the ones in the hospital. Hospital organisms are obviously going to be more resistant. They're going to be more virulent strains. So community acquired pneumonia, that's pneumonia acquired outside of the hospital setting. That's pretty obvious. And then also you can make the distinction if they develop pneumonia under 48 hours of hospital admission, it's still considered.

Community acquired due to the incubation period so hospital acquired pneumonia is pneumonia acquired 48 hours or more After hospital admission, so if it's been 48 hours or more After they've been admitted to the hospital, that's considered hospital acquired pneumonia. The organisms that you're looking for, that you're worried about in hospital acquired pneumonia is going to be Pseudomonas and MRCEP. Those are the most common organisms you'll see in hospital acquired pneumonia.

That's what you really need to know for those two just to know the difference. There's also something known as ventilator associated pneumonia. It's just pneumonia acquired 48 or more hours after endotracheal intubation. Don't worry so much about that. Just know your community-acquired pneumonia and hospital-acquired pneumonia. And just know hospital-acquired is 48 hours or more after hospital admission. That's hospital-acquired. Okay, so this is the tough part. Your organisms.

Um, the organism seen in pneumonia. they're really important there's a good amount that you need to know about them the way the patients are going to present with different types of organisms versus others the treatment options it's just an important component of pneumonia that you kind of need to know i really tried again to Focus on the little tiny bits that you need to know about each but there's a lot of organisms So let's let's break it down first. I want to go over

What your typical organisms are and then you're a typical organism. So let's go over that first So you take your typical organisms and community acquired pneumonia is going to be strep pneumo Haemophilus influenzae, and M. catterhalus, Staph aureus, and Klebsiella. Those are the main ones. Now, if you only want to remember one of those, it's definitely going to be Strep pneumo. It's the most common bacterial pathogen overall.

And luckily, though, in the U.S., it's actually decreasing in incidence because of the pneumococcal vaccine, which targets strep pneumo. So strep pneumonia, that's the one you really need to know for your typical organisms in CAP. I'm going to start calling it CAP instead of saying community core. pneumonia over and over so strep pneumo is the main one but you also have H influenza and Caterhallis Staph aureus and Klebsiello so those are your typical organisms

Clinically, you're going to have classic signs on clinical presentation with your typical organism. So fever. productive cough, purulent sputum, pleuritic chest pain, something known as rigors. And if you're not familiar with this, rigors is not just chills, rigors is like this full-on violent shaking. And it's something that you very well may see in a vignette.

or hear about in the clinical history of a patient. So it's just violent shaking that patients can have bacterial infections like with pneumonia. And you'll see these symptoms compared with the presentation and atypical organisms is different We're gonna go over that next. So next is your atypical organisms. So first you have mycoplasma pneumoniae so in typical organisms you should just remember strep pneumo if you're going to remember one in atypicals

You should just remember your mycoplasma pneumoniae. That's really the most common atypical organism, and it's the one you'll always have an exam question on. It's just a really common atypical organism. So mycoplasm pneumoniae, that's the one you should focus on. There's also Legionella.

chlamydia pneumonia as well as your viruses so you're like influence a and b rhinovirus adenovirus don't worry so much about those so if those are your atypical organisms so why are they called atypical what's atypical about these organisms so One, the main thing is the presentation. These patients that have these atypical organisms compared to the patients with typical organisms, they're going to have a much...

more indolent and less severe course. So you may have heard of walking pneumonia. Well, that's your a typical organisms. A lot of times these patients are just going to have these mild symptoms. Um, and it turns out they have pneumonia. You never expected. They just going to have like this mild cough and may be productive. They may have a fever. They're not going to feel that.

um terrible though compared to some of those symptoms i went over with the typical organisms so that's the first thing they may have this less severe symptoms a more indolent course with these atypical organisms

The other thing is that with atypical organisms, you can often have these unique extra pulmonary manifestations that are not commonly seen in typical organisms. So you may have... diarrhea like with Legionella you may have otalgia with mycoplasma all of these extra pulmonary things that aren't commonly seen in your typical organisms and then the third reason not so important for the exam but

Another reason they're known as atypical is due to the resistance of these organisms to the beta-lactam antibiotic class and the fact that they can't be visualized on gram stain. So that's the third thing. But mainly... focus on their their presentation that they're less severe in symptoms generally and then also the fact that they have all these unique extra pulmonary symptoms so

To make it easy for a vignette, just remember if it kind of sounds like pneumonia, but they have some weird stuff thrown in, an earache, diarrhea, or it's a young patient and they don't really feel that bad. then you should be thinking of atypical. And that's, it's really that simple for an exam question. Okay, so that's your atypical versus your typical organisms.

Now let's break down the important organisms and discuss just the stuff that you need to know about each one. So just so you know, as I go over these, I'm going to give you the likely clinical manifestations or presentation for the organisms. None of these are like...

100 exclusive or specific so like chronicle chronic alcoholism that's commonly seen in club siela can also be seen in strep pneumo so know that these are commonly seen in these organisms but it's not like 100 specific so Let's go over the ones I think you should know and the couple things that I think I really tried to break it down as best I can into things You just really need to know about each so strep pneumo

Of course, you have to know this is your most common cause of community acquired pneumonia. That's one. And then the other thing I think you should know is that you may see on a clinical vignette on a vignette that. They describe the sputum as either rusty or blood tinged. So strep pneumo supposedly the.

the sputum can sometimes be blood-tinged or rusty, and a lot of times they'll describe it that way in a vignette. I've seen that multiple times. In real life, I don't know how common it really is, but it's definitely a popular way to describe it on a vignette. So Strap Pneumo. Most common cause of community-acquired pneumonia. And then blood-tinged or rusty sputum. Next one, H-influenza or Haemophilus influenza. So the one...

The one you'll most likely hear about in a vignette when it comes to H flu is the fact that this patient has an underlying pulmonary disorder. And the one that you'll most commonly hear about is COPD. So when you see haemophilus influenza, think COPD. or other underlying pulmonary disorders, asthma, bronchiectasis, but COPD is the one you'll most commonly hear about.

haemophilus influenza copd and i say it that way because this is the way that i used to remember it so haemophilus influenza like ham hamophilus influenza ham comes from a pig. COPD has the word cop in it. COPD. Um, and I have, I'm not like stating any opinion about cops, but this is just how I remembered it. So I'm not trying to offend anybody, but, um,

I'm sure we've all heard that cops are called pigs or people have stated that. So COPD has the word cop in it. Hamophilus influenzae. I just used to think of ham and a pig. So that just helped me associate the two. So COPD cop.

Hamophilus, pig, and then you kind of can remember the two. So as soon as you see Hamophilus influenza, and they say what likely is associated with this, or that you have a patient with COPD, and they say what organism is most common, you see Hamophilus, you're like, okay, ham, pig.

COPD cop and then you can hopefully make the association all right, so haemophilus influenza COPD next Klebsiella so the vignette i always remember seeing for club ciella was an alcoholic presenting with this um This sputum that they described as blood-tinged thick they call it current jelly sputum And that's Klebsiella So the three things you need to know about Klebsiella and the way that I used to remember them was Klebsiella is spelled with a K

But I used to remember Klebsiella as spelled with a C because for Klebsiella, it's all about the C's. So one, chronic alcoholism. chronic illness it's most frequently seen in hospitalized patients and in those with impaired host defenses like diabetes alcoholism malignancy but the one you're always going to hear about is chronic alcoholism so that's your first seat chronic alcoholism or chronic illness

Second C is current jelly sputum. So do the increased inflammation necrosis seen in patients with Klebsiella and it can lead to this thick blood tinge sputum and it's referred to as current jelly sputum. That's your second C. The third C is cavitary lesions. I kind of say this like plus or minus. Used to be thought that around 30 to 50% of patients with club CL would have these cavitary lesions on imaging.

I'd say take it with a grain of salt. This data is kind of outdated. You know, a few sources are still kind of making that association, but it's still probably going to be on an exam question. It's just a popular thing to ask. So remember. Klebsiella, spell it with a C instead of a K, and remember chronic alcoholism, currant jelly sputum, and cavitary lesions. Those are your three Cs. Next one, Staph aureus. All you should know about Staph aureus post-flu. That's it.

Staph aureus post viral infection flu in particular, so staph aureus pneumonia That's community acquired is usually seen in patients who are recovering from influenza. So post influenza pneumonia, that's really the only thing I'd say to waste your time knowing about Staph aureus post flu. That's it. Make it nice and simple.

All right, next one, one of your atypicals, your mycoplasma pneumoniae. So if they give you a vignette and it sounds like atypical pneumonia or walking pneumonia, like mild symptoms, young patient, healthy otherwise. Definitely be thinking mycoplasma again. This is going to be your most common cause of your atypical so Mycoplasma, as soon as you see young and healthy patients living in a close proximity, this is key here because M pneumonia is spread via respiratory droplets.

So you'll see infection arise among individuals living in close quarters. So families living in the same household, schools, healthcare facilities. And the one you should really kind of put in your head because this is the...

popular way that i always remember seeing in vignettes is military barracks that's for some reason the one they always like to to mention so military barracks because they're all living close together so young and healthy patients close proximity thinking you should be thinking mycoplasma the other thing too is the

Extrapulmonary symptoms, of course, so cough, sore throat, rhinorrhea, choriza, ear pain. It's common to have these upper respiratory symptoms with mycoplasma infection. One that I want to point out. Not because you should know it but

because that it used to be something that a lot of people heard about and thought it was associated with mycoplasma, and it's kind of found out that it wasn't true, was something known as bullous smerangitis. So this is this fluid-filled blisters on the tympanic membrane. And when I was in school, it used to be...

said that this was commonly seen with mycoplasma pneumonia but it's actually found out that a lot of the new studies are saying there's really no association between the two so hopefully you won't get a vignette about it because like I said I remember learning about it in school but it's turned out that that wasn't really a true you know they're not commonly associated together a lot of the studies have found there was no association between the two so if you hear it

Maybe the exam questions might be a little outdated, but otherwise you should know the most up-to-date sources are saying there's no association between the two. And then the last thing. is something known as cold autoimmune hemolytic anemia. So it's possible to get something known as cold autoimmune hemolytic anemia with mycoplasma infection. I don't want you to go too deep into this. Just know if you've seen it in a vignette.

know that it can be seen with mycoplasma it's just a type of hemolysis where the antibodies they attack the blood group antigens and it's it's these it's only in temperatures lower than the normal body temp so they're called cold glutens so just remember cold autoimmune hemolytic anemia You should be thinking of mycoplasma. So those are the things that I'd say focus on. Young and healthy patient living in close proximity.

Those extra extra pulmonary symptoms and then cold autoimmune hemolytic anemia Mycoplasma should be on your list of differentials. All right, let's move on to Legionella Legionella cough and diarrhea

you can almost stop there. You see a cough and you see diarrhea. They mention like pneumonia type symptoms and then they also mention GI like diarrhea. See these two symptoms combined in the vignette, right away you should be thinking of Legionella. In real life, there's a million things that can cause both, but in the vignette...

You should be looking for Legionella in the answer choices. So that's the first thing. That's probably the most important thing. Then also look in the history that they mentioned some sort of outbreak with contaminated water sources. So they're probably going to mention.

a hot tub in the vignette a humidifier an ac symptom ac system something that can lead to the transmission of legionella via inhalation of aerosolized mist from water sources that's your key in a vignette it can also be transmitted through soil but

You're not commonly going to hear about that. It's mostly through inhalation through water sources. So look for them to mention a hot tub, like I said, an AC system in like a hotel or something, and all these people got infected. That's what you're going to look for in the vignette. And then lab finding, there's a couple unique...

thing. So you're going to see hyponatremia and then elevated hepatic transaminases. So your AST or ALT, um, those are of course not specific, but if you see these lab findings combined with a patient with diarrhea, cough, proper history. Legionella right away should be high on your list of differentials. So again, Legionella, cough and diarrhea, that's your big one. And then anytime they mention any kind of contaminated water source, and then if lab findings with hyponatremia.

where elevated hepatic transaminases are mentioned. Those are all things that can be commonly seen on Legionella. All right, so that's probably the hardest part about pneumonia is just knowing those little key things about each organism. Diagnosis.

I'm going to make it pretty brief because pneumonia diagnosis, it's really made using like a clinical spectrum with your diagnostic findings your clinical findings there's no like one best test to diagnose of course chest x-ray is great but even that there's a lot of

problems with. So diagnostic tests are pretty low yield for the exam. Let's just quickly go through them and kind of talk about a little bit that you'll see with each. So chest x-ray, you'll generally see lobar pneumonia with typical organisms. And then your atypical are going to be more like

hazy, patchy infiltrates with atypicals. That may not come up on the exam, but just know that your atypicals, again, is gonna be atypical. It's gonna be more of like a hazy kind of... patchy infiltrate rather than that lobar pneumonia seen with typical organisms cbc of course you have an infection so it could show leukocytosis um Another one that's kind of important just because of a scoring system we're going to go over later with Curb 65 is your BUN.

Also your serum electrolytes you can get as well and then you can do blood cultures and sputum gram stains and cultures sputum cultures But it's really only for your patients with moderate and severe pneumonia. You're not really going to be getting a sputum culture routinely in a patient you're treating in the outpatient setting.

Remember, they do have a place. You can do those things, but it's not commonly used unless you have your hospitalized patients more severe, that you do your cultures, your blood cultures, your sputum and gram stain and cultures and things like that. um the last test diagnostic test i want to go over is something uh your pcr testing you're really only going to do those in legionella and mycoplasma

So you can use PCR testing in those. That's really your diagnostic tests. Do not waste a lot of time on that because there's really not much that's very high yield in there. So the other thing I want to go over, kind of related to the diagnosis, is these different severity index tools and calculators.

It's really only one that I'm going to focus on. So these are calculators used in patients with pneumonia to determine how severe the infection is and how they need to be handled, whether it's going to be inpatient, outpatient, ICU. The one you're going to be tested on is CURB-65. So it's easy to memorize.

There's really only a few things you need to know the more accurate tests though Just so you know this the one that's commonly used in clinical settings is known as the pneumonia severity index or the PCI Luckily, they're not gonna ask you any questions on it because there's just way too much to memorize it's like over 20 different components So it's one of those things that you'll use out in you know when you're

out on your rotations you're going to get the app like your med um md calc or go to the website and actually do it that way but they're never going to ask you on an exam that would just be cruel there's just too many components but like i said you can be asked about curb 65 because there's only a few things you need to know so let's just

quickly go over CURB65 so you're familiar with it because I did get a question. So you should probably just know it. It's not that hard. So CURB65 stands for confusion, urea, respiratory rate, blood pressure, and age over 60. 65 or older so what you do is you give one point for each

thing that they're positive for and I'll go over each individual one and then you take your your points calculated and that helps you decide whether they're going to be treated in an outpatient setting inpatient or ICU so confusion And the C in Curb 65 stands for confusion. So if they have any type of altered mental status, that's one point. Urea, the U in Curb 65 stands for your urea or your BUN, your blood urea nitrogen, either over seven millimoles or.

over 19 mgs so that's your urea respiratory rate 30 or more breaths per minute that's a that's another point Blood pressure, either your systolic less than 90 or your diastolic 60 or less for diastolic. And then age 65 or older is another point. So. If you get zero points, the patients, none of those things are going to treat them in an outpatient setting. If they get up to two points, then you want to admit them. You want to treat them, you know, in the hospital.

three or more, you should be considering ICU. So zero points outpatient, two points admitted. three or more icu um that between one and two it's kind of one of those things that you make your clinical judgment on um up to date kind of has more of a persistence like they feel like as soon as you get one point you should probably admit them but all of the other calculators don't really say to admit until about two points so kind of know that in between one to two is kind of questionable but

two definitely inpatient, three ICU, and then zero is going to be your outpatient. So that's curb 65. If you wanna waste like a minute or two to memorize it, cause you might get one question right. I don't know if it's 100% worth it, but all right, let's move on to some more higher yield things. So treatment. So before I start with the meds, I need to add the disclaimer that there's a lot to know with the meds for pneumonia.

Tried to boil down as best I could, but don't kill yourself on meds. Know the basics. and just don't waste a lot of time beyond that because it can become a little bit overwhelming so let's break down each individual one so first let's start with the the least severe of all and that's going to be your community acquired pneumonia in an outpatient setting how are you going to treat these patients well you're going to treat them with macrolides amoxicillin or augmentin or doxycycline

Now, the last option, the fourth option is going to be a respiratory fluoroquinolone, moxifloxacin, levofloxacin. But this is something that you should only use as your last line option. You can use it, but you should. try any of these other options first, just because of the adverse effect profile, the potential of promoting fluoroquinolone resistance. It's really only for patients that have contraindications to the above meds that I went over, the preferred agents.

or any, any, if, or if they have comorbidities, then a lot of times we'll use respiratory fluoroquinolones, but otherwise stick to your amoxicillin doxy macrolides like azithromycin. You may see these drugs being used as monotherapy, sometimes combined. The way that I remember that is you got community-acquired pneumonia, you're effing mad. You're effing mad because you got community-acquired pneumonia. So effing, the F stands for fluoroquinolones.

M stands for macrolides, A stands for amoxicillin or augmentin, and then D stands for doxycycline. You're effing mad, you got community acquired pneumonia. Alright, next. Now we have community acquired pneumonia, but now we're treating them in an inpatient setting. So first, you were effing mad that you got pneumonia, but now you have to be hospitalized. So now you realize things are getting pretty effing bad. So...

What does that stand for? So first, respiratory fluoroquinolones. That's your effing effing bad. So that can be used as monotherapy. So either levofloxacin, moxifloxacin, gemfloxacin. Again, though. Avoid if possible. They're tempting because they're only a once a day med and like, you know, they can be used as monotherapy and that's why they're commonly used, but resist the temptation unless there's a compelling reason to use it. Respiratory fluoroquinolones, kind of like your last line.

Unless they have all those comorbidities and everything. The other option is your B. Because remember, things are getting effing bad. So your beta-lactam. So ceftriaxone is the one you'll probably see most commonly used. Ampicillin, sobactam, ceftaroline, or dependem, any of those beta-lactams, combined with... either azithromycin so that's from your macrolide class you can also use chlorithromycin or doxy

So the main treatment option here for community acquired inpatient is going to be your beta-lactam. So you can use ceftriaxone, ceftaroline, any one of those combined with either azithro. and or doxy so you combine those two any one of those two beta lactams combined with azithro or doxy you can also use chlorithromycin instead of azithromycin but that doesn't make the mnemonic work and azithromycin is actually used more commonly in the chlor

clarithromycin anyways. And then the other option is your fallback, which would be respiratory fluoroquinolones. So remember community acquired inpatient. Now you are realizing that things are getting pretty effing bad, effing. F, fluoroquinolones, B, beta-lactams, A, azithromycin, and D, doxy. So that's your treatment for that. Now we move on to hospital acquired.

Now we potentially need coverage for our hospital bugs, our Pseudomonas and our MRSA. So with hospital acquired pneumonia, the impaired treatment is going to cover those bugs. Of course, you have to make sure that there's a risk for MRSA. You have to look at the... The the organisms seen in the hospital and the resistance etc So with hospital acquired pneumonia, you're almost always going to cover Pseudomonas right away though. Merces kind of if there is a risk so

how do you cover your pseudomonas in hospital acquired? You're going to use your anti-pseudomonas beta-lactam. So that's piptazo, piperacillin, tazobactam, cefepime, ceftazidine, any one of those, any one of those anti-pseudomonas. lactams and then if there is a risk for MRSA you're going to use either linazolid or vancomycin.

So really, uh, Pseudomonas is going to be covered almost all the time. And then, so you're going to use your Piptazosefbim, Ceftazidim. And then if there's a risk for MRSA, you tack on either Linazolib or Vancomycin. Now, you're only going to add your anti-pseudomonal fluoroquinolones or aminoglycosides.

if the patient has risk factors for gram negative bacilli like patient with structural lung disease like bronchiectasis cystic fibrosis or if a gram stain should positive for that um or if they had iv antibiotic treatment in the last 90 days anyways

This is beyond what you're going to be tested on, and it's further than you should go. So if you're treating hospital-acquired pneumonia, assume coverage of pseudomonas with anti-pseudomonas, beta-lactams, peptazo, etc. And then if they mention MRSA, add on your linazolid or vanco. Try not to overcomplicate it. It's complicated as it is. I'm sorry. I tried to make that easy. It's just not. But I tried my best. All right. So remember.

Let's really quickly go through it again. So you have community acquired outpatient. You are effing mad fluoroquinolones. but try not to. And then MAD stands for your macrolides, like your azithromycin, amoxicillin or augmentin, and then doxy. Remember, you're trying to combine amoxicillin or augmentin with either macrolide and doxy and then, or doxy, and then of course your fluoroquinolone.

can be used as monotherapy but last line because of all the problems with those now community acquired inpatient now you're no longer effing mad you're just realizing things are getting effing bad so respiratory fluoroquinolones can be used as monotherapy, or BAD stands for beta-lactam, so your ceftriaxone, ampicillin-sobactam, ceftaroline, plus either azithromycin or doxy.

And then of course, hospital acquired, you're treating Pseudomonas or MRSA. Pseudomonas can be with your anti-pseudomonal beta-lactams, Piptazosefepime, and then MRSA with Linazolid or Vanco. All right. So I guess, you know, try your best. Hopefully you won't get any questions on that because it's just a lot. All right. Now I just want to go over a few more miscellaneous topics. If you're still with me at this point.

Just a few things that I think are pretty easy to remember and there's not a lot to know. So let's just try to go through those and then we'll wrap it up. So one thing, miscellaneous topic, aspiration pneumonia. So you're just going to see this in chronically ill patients, patients with reduced consciousness, like patients that are on sedatives, antipsychotics, alcohol, drug use, basically patients that have...

Whatever the reason is, they aspirate their stomach contents into their lungs. They can't protect their airway and it leads to this infection and pneumonia in the lungs. It's most commonly caused by anaerobes. and the key to the vignette is going to be a foul-smelling sputum. It's the sputum that has this putrid odor, and this finding is consistent with an anaerobic infection, which they, like I just said, it's most commonly caused by. Treatment.

ampicillin solbactem if they're hospitalized because you give that iv or augmentin which is amoxicillin clavulonate it's good for your outpatient setting since it can be given po so again aspiration pneumonia it's a patient

You can't really protect their airway. They're going to vomit. They're going to aspirate the content into their lungs. It's most commonly caused by anaerobes. Vignette's going to be a foul-smelling sputum. Treatment is going to be with ampicillin solbactam or amoxicillin clavulonate. You're augmenting. All right, so the last two, they're really kind of infectious disease more than they're pulmonary, but they can easily be lumped into a clinical medicine exam on pulmonology.

and they're easy there's only only a couple things to know about them so and i'll give you a couple of mnemonics to memorize the important things let's just go over them really quick so first histoplasmosis It's a fungal infection caused by breathing in spores of a fungus often found in bird and bat droppings that can lead to pneumonia. All I want you to know about histoplasmosis is the word bird.

it can be caused like i said by bird and bat droppings so just remember bird and you remember basically all you really need to know about it so bird stands for the b stands for bird or bat droppings b bird B bat droppings. The I stands for itraconazole. Itraconazole is going to be your first line treatment for outpatient and patients with mild or moderate disease. So that's your I in bird.

R stands for River Valley. And that's because the Mississippi and Ohio River Valleys is where you're most commonly going to see this and probably what they'll list in a vignette. And that's because the soil in this area is rich in bird and bat dropping. So you may have also heard about this illness sometimes in people that explore caves. And again, same thing due to the bat droppings. But that's the main thing. Mississippi, Ohio River Valley is one of the highest.

rates of um histoplasmosis is seen there and then the d stands for defining illness for aids because this is an aids defining illness if you're not familiar with that what that is um certain diseases

patient has hiv and gets one of these diseases like histoplasmosis they're now considered to have aids and that's why they're called aids defining illnesses they're diseases you're not really going to see in a healthy immunocompetent individual so histoplasmosis is one of those aids defining illnesses

you see it, they had HIV, well now they have AIDS because it's usually only going to occur if the CD4 count is less than or equal to 150. So remember histoplasmosis, BIRD, B stands for bird or bat droppings, I stands for etroconazole. R stands for River Valley, the Mississippi, Ohio River Valley, and then D stands for defining illness for AIDS. All right, last one.

Pneumocystis pneumonia, also known as PCP. So PCP pneumocystis pneumonia. So this is a yeast-like fungal infection and it's most commonly caused by Pneumocystis gyrovicii. or gyrovecchii however you want to pronounce it it's just a fungal infection that leads to pneumonia there's really only four things you need to know about it one

It's another AIDS defining illness. This case, it's going to be a CD4 less than or equal to 200 that you'll generally see this. The second thing is you may see an increased LDH on labs. So that's your serum lactate dehydrogenase. So LDH. are elevated in around 90% of patients with PCP who are infected with with HIV so increased LDH third one this is probably the one you'll see in a vignette it's these

bilateral interstitial infiltrates that you'll see on chest x-ray in a patient with PCP. It's also described as a batwing pattern. It's just how the infiltrates kind of line up on the sides of the lungs. And then finally, treatment. This is really important too. Treatment of both prophylaxis are both with Bactrim. So Bactrim, of course, is trimethoprene, sulfamethoxazone.

That's how you're going to treat and prophylax in a patient with PCP. And you prophylax in an HIV patient with a CD4 count less than or equal to 200. That's when you start giving them Bactrim. So the way, because probably the most important thing is the Bactrim for this. for the vignette because it's probably what you'll get asked. The way that I used to remember that Bactrim is the treatment of choice for PCP or pneumocystis pneumonia is because your PCP

Your posterior is coarse and prickly. PCP, posterior coarse prickly. You need your back trimmed. Back trim. So that's how I used to remember it. So PCP, PCP pneumonia. Posterior is coarse and prickly. PCP. You need your back trimmed back trim. I don't know. Hopefully that's that's helpful for you. It's a really nice visual. All right. So that's it. That was.

Tough so hopefully you guys are still with me. Those meds are really just a killer So let's do five quick questions and then we will be done. So question one What is the most common cause of community acquired pneumonia?

it's an easy one that one's going to be strep pneumonia so streptococcus pneumonia is most common cause of community acquired pneumonia two homeless patient presents to the er with a productive cough foul smelling sputum and amidst the blacking out last night due to excessive alcohol use which antibiotic classes should be cons or which antibiotics should be considered in this patient for the likely diagnosis

So looking at that vignette, it's a classic presentation, aspiration pneumonia, his foul-smelling sputum. He had reduced consciousness due to the alcohol, the blackout he had, so he likely vomited and aspirated. So you're going to use either amoxicillin clavulonate, your augmentin, or ampicillin. 3. What organism should be considered when prescribing empiric antibiotic treatment in a patient with hospital-acquired pneumonia?

What organisms should be considered when prescribing empiric antibiotic treatment in a patient with hospital-acquired pneumonia? It's going to be Pseudomonas and MRSA. So not in every patient, of course, but those are the ones you're going to be most concerned about in hospital-acquired pneumonia. Four, 17-year-old male presents to the office today with pharyngitis, nonproductive cough, and an earache. On chest x-ray, Apache Infiltrate is visualized.

what is the likely organism causing this patient's symptoms so this one you should know that's going to be mycoplasma pneumonia remember that's your atypical organism your quote-unquote walking pneumonia young healthy patient those extra pulmonary symptoms That is going to be likely mycoplasma pneumonia causing those symptoms.

And then question five, what antibiotics are commonly used in the treatment of community acquired pneumonia in an outpatient setting? So which antibiotics are commonly used in the treatment of community acquired pneumonia in an outpatient setting? Remember.

you are effing mad you got community acquired pneumonia but you're an outpatient yet so you're not realizing things are effing bad yet so effing mad that's going to be fluoroquinolones remember only in patients with comorbidities or risk factors and then mad Macrolides like azithromycin, amoxicillin, and doxycycline. Remember, you're generally using amoxicillin combined with either a macrolide or a doxy. And then fluoroquinolones, if need be, can be used as monotherapy.

All right, guys, that was pneumonia. Um, hopefully again, like I always say, I really hope that's helping you and hopefully that was helpful. Um, please leave me a comment if it's helping. Please check out my YouTube page if you haven't yet. I would really appreciate that. And thank you so much, as always, for listening and for, you know, leaving me these really nice, great comments. So good luck on your pants, your panery, your EORs, and good luck in PA school.

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