BRONCHITIS
Dx: Acute wheezes, rhonchi, &/or prolonged expiratory phase- No fever or rales (would = pneumonia)
- Normal CXR (if obtained)
- Viral (most likely)
- Asthma (if Hx recurrent episodes)
- COPD Exacerbation (if COPD + new purulent sputum)
-
Pertussis (clear lungs, paroxysmal cough)
- Tx Pertussis if contact w/ unimmunized infant
- Treat w/ inhalers
- If really considering Pertussis: Azithromycin
-
COPD Exacerbation: Macrolide, Amoxicillin, Cefuroxime, OR Doxycycline
- If frequent recurrences, vary antibiotic
See postings Acute Cough – 1 (re: Pertussis); Acute Cough – 2 (re: Bronchitis)
COMMUNITY-ACQUIRED PNEUMONIA
Dx: Fever with Focal Rales- Get CXR in adults & children <5 y.o.; empiric Dx in other kids
Empiric Out-Patient Antibiotic Treatment
DiagnosisDude recommends:- Doxycycline (if >8 y.o.); OR
- Amoxicillin-clavulanate, high-dose (4 gm/d) ± a macrolide
- Levofloxacin for adults w/ multiple comorbidities
- Otherwise-Healthy: Macrolide (Doxycycline acceptable)
-
Patients with Risk of Drug-Resistant Pneumococcus ¶
- Levofloxacin; OR
- Amoxicillin-clavulanate (high-dose) plus a macrolide
- Amoxicillin 500 mg – 1,000 mg T.I.D. (90 mg/kg/d)
- Pen-Allergic: a Macrolide
Microbiology of Community-Acquired Pneumonia
- Pyogenic: Abrupt onset, Purulent Sputum, Rales (focal), Consolidation (CXR)
- Atypical: Gradual onset, Interstitial Infiltrates
- NOTE: Lots of overlap; can’t differentiate easily
- NOTE: “Atypical” can be equally serious
Pyogenic Pneumonia — the Bugs
Common • Pneumococcus • H. flu Uncommon • Strep pyogenes • Staph aureus • E. coli & other enterics • Klebsiella pneumoniae • Pseudomonas VERY Rare (hopefully) • Anthrax, plague, tularemia, hantavirus, Q fever, SARS | Comments > Community Acquired Pneumonia (CAP) > CAP > CAP, Complication of Influenza > IV drug user; Complication of Influenza > Nosocomial; debilitated > Diabetes, cancer, alcoholics > Underlying lung disorder; nosocomial; immunocompromomised > Agents of Bioterrorism (Very ill; CXR variable) |
“Atypical” Pneumonia — the Bugs
Common • Mycoplasma pneumoniae • Chlamydophila pneumoniae – aka Chlamydia pneumoniae • Viral influenza Less Common • Legionnaires’ • Tuberculosis • Endemic fungi – histoplasmosis, blastomycosis – coccidioidomycisis • Psittacosis • Pneumocystis | Comments > Usually youngish > Usually middle-aged or older > Anybody > Common-source outbreaks (e.g. water coolers) [Usually ill enough to need admission] > Lived in endemic areas > Lived in endemic areas – Ohio River Valley, 3rd World – Calif. Central Valley, Arizona > Parrot exposure > AIDS, organ transplants, etc. |
See posting Infectious Disease – 3.