S1E29 Pneumonia

I drive my bus in a busy city. That's why road safety is so important to me. I know that I must slow down and be extra careful when I make a wide turn. Buses need more room than cars. Everyone can help keep our road safe. Next time you're driving, remember to give buses plenty of time and space to finish turning before driving ahead. Let's all plan to share the road safely. Learn how at www.sharetheroadsafely.gov All right, so let's do pneumonia today. So this is definitely one you'll get at least a few questions on the pants. I can't imagine you won't. It's a pretty popular topic because there's so many different questions they can ask you about all the different organisms that you see in hospital acquired, community acquired. 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 crammed the pants on YouTube. So let's go ahead and get started with pneumonia. Nomonia 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 scene 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 a familiarize you with community acquired pneumonia versus hospital acquired pneumonia. So that's an important distinction to make and it's going to guide your and pure treatment because the organisms acquired walking around at the local grocery store are 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 strain. 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 merceph. Those are the most common organisms you'll see in hospital acquired pneumonia. So that's what you really need to know for those two, just to know the difference. There's also something known as ventilator ventilator associated pneumonia. It's just pneumonia acquired 48 or more hours after endotracheal innovation. 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. 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 burst in with different types of organs. Of course, others, the treatment options. It's just an important component of pneumonia that you kind of need to know. I really try it again to only 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 your atypical organisms. So let's go over that first. So your typical your typical organisms in community acquired pneumonia is going to be strep pneumo, hemophilus influenza, and m-catarhalus, staphoreus, and clepsiala. 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 US, it's actually decreasing an 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 a cap instead of saying community acquired pneumonia over and over. So strep pneumo is the main one, but you also have h-involuenza, m-catarhalus, staphoreus, and clepsiala. So those are your typical organisms. Clinically you're going to have classic signs on clinical presentation with your typical organisms. So fever, productive cough, periodulence butum, pleuritic chest pain, something known as riggers. And if you're not familiar with this, riggers is not just chills, riggers. It's like this full-on violent shaking. And it's something that you very well may see in a vignette or hear about in a clinical history of a patient. So it's just violent shaking that patients can have in bacterial infections like with pneumonia. And you'll see these symptoms compared with the presentation in atypical organisms is different. We're going to go over that next. So next is your atypical organisms. So first you have microplasma pneumonia. So in typical organisms, you should just remember strep pneumo, if you're going to remember one in atypicals, you should just remember your microplasma pneumonia. That's really the most common atypical organism. And it's the one you'll always have an exam question on. It's just the really common atypical organism. So microplasma pneumonia, 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, rhino virus, adenovirus. Don't worry so much about those. So 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 indolin and less severe course. So you may have heard of walking pneumonia. Well, that's your atypical organisms. A lot of times these patients are just going to have these mild symptoms. And it turns out they have pneumonia. You never expected they're just going to have like this mild cough, maybe productive. They may have a fever. They're not going to feel that 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 indolin 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 microplasma. 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 do the resistance of these organisms to the beta-lactin antibiotic class and the fact that they can't be visualized on gram stain. So that's the best of their 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 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 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 chronic alkyl holism that's commonly seen in club Ciella 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 and to 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 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 strep pneumo, most common cause of community acquired pneumonia, and then blood tinged or rusty sputum. Next one, H influenza or hemophilus 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 hemophilus influenza, think COPD or other lying or other underlying pulmonary disorders as my bronchiactasis, but COPD is the one you'll most commonly hear about. So hemophilus influenza COPD. And I say it that way because this is the way that I used to remember it. So hemophilus influenza, like ham, ham, hemophilus influenza, ham comes from a pig. COPD has the word "copenit" COPD. 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 I'm sure we've all heard that cops are called pigs or people have stated that. So COPD has the word "copenit". Hamophilus influenza, 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 hemophilus influenza and they say what likely is associated with this or you have a patient with COPD and they say what? 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 hemophilus influenza, COPD. Next, Klebsiella. So the vignette I always remember seeing for Klebsiella was an alcoholic presenting with this, this sputum that they described as blood tinged, thick, they call it crantjelly 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 is spelled with a C because for Klebsiella it's all about the Cs. So one, chronic alcoholism or 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 gonna hear about is chronic alcoholism. So that's your first C, chronic alcoholism or chronic illness. Second C is crantjelly sputum. So do the increased inflammation across the cina patients with Klebsiella, and likely to this thick blood tinged sputum and it's referred to as crantjelly sputum. That's your second C. The third C is cavitary lesions. I kinda say this like plus or minus, used to be thought that around 30 to 50% of patients with Klebsiella would have these cavitary lesions on imaging. I'd say take it with a grain of salt. This data is kinda outdated. A few sources are still kinda making that association, but it's still probably gonna be on an exam question. It's just a popular thing to ask. So remember, Klebsiella, spelled with a C instead of a K and remember chronic alcoholism, crantjelly sputum and cavitary lesions. Those are your three C's. Next one, staphoreus. All you should know about staphoreus post flu, that's it. Staphoreus post viral infection, flu in particular. So staphoreus 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 staphoreus post flu. That's it. Make it nice and simple. All right, next one, one of your atypicals, your microplasma pneumonia. 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 microplasma. Again, this is gonna be your most common cause of your atypical. So microplasma, 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 see infection of rise 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 a vignette is military barracks. That's for some reason the one they always like to mention. So military barracks are all living close together. So young and healthy patients, close proximity thinking, you should be thinking microplasma. The other thing too is the extra pulmonary symptoms, of course, so coughs or throat, rhinorrhea, cariza, ear pain. It's common to have these upper respiratory infection symptoms with microplasma 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 microplasma. It's kind of found out that it wasn't true, was something known as bolus smear and gytus. 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 microplasma 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, 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 microplasma infection. I don't want you to go too deep into this. Just know if you've seen an event yet, know that it can be seen with microplasma. It's just a type of hemolysis where the antibodies, they attack the blood group antigens, and it's only in temperatures lower than the normal body temp, so they're called cold agglutants. So just remember, cold autoimmune hemolytic anemia, it should be thinking of microplasma. So those are the things that I'd say focus on, young and healthy patient living close proximity, those extra pulmonary symptoms, and then cold autoimmune hemolytic anemia, microplasma 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 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 and the answer choices. So that's the first thing, that's probably the most important thing. Then also look in the history that they mention some sort of outbreak with contaminated water sources. So they're probably gonna mention a hot tub of 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 gonna 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 and like a hotel or something and all these people got infected. That's what you're gonna look for in the vignette. And then lab finding, there's a couple unique things. So you're gonna see hyponatremia and then elevated hepatic transamination. So your AST or ALT. Most of course not specific, but if you see these lab findings combined with the 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 or 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 gonna 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-rays 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 low-bar pneumonia with typical organisms. And then your A-tipical are gonna be more like hazy, patchy infiltrates with A-tipicals. That may not come up on the exam, but just know that your A-tipicals again is gonna be A-tipical. It's gonna be more of like a hazy kind of patchy infiltrate rather than that low-bar pneumonia seen with typical organisms. CBC of course, you have an infection, so it could show lococytosis. Another one that's kind of important just because of a scoring system we're gonna go over later with Curb 65 as your BUN. Also you see them electrolytes, you can get as well. And then you can do blood cultures and sputum grahamstains and cultures, a sputum cultures. But it's really only for your patients with moderate severe pneumonia, you're not really gonna be getting a sputum culture routinely in a patient, you're treating in the outpatient setting. So 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 grahamstains and cultures and things like that. The last test, diagnostic tests I wanna go over is something, your PCR testing. You're really only gonna do those in Legionella and Michael Plasma. So you can use PCR testing in those. That's really your diagnostic tests do not waste a lot of time on that 'cause it's really not much, that's very high yield in there. So the other thing I wanna go over, kind of related to the diagnosis, is these different severity index tools and calculators. It's really only one that I'm gonna 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 gonna be inpatient, outpatient ICU. The one you're gonna be tested on is Curb 65. So it's easier 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 for 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 when you're out on your rotations, you're gonna get the app, like your MDCoc, or go to the website and actually do it that way, but they're never gonna 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 Curb 65, 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 Curb 65 stands for confusion, urea, respiratory rate, blood pressure, and age over 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 points calculated and that helps you decide whether they're gonna be treated in an outpatient setting, inpatient, or ICU. So confusion, and the C for Curb 65 stands for confusion. So if they have any type of. of altered mental status, that's one point. Yuria, the UN Curb 65, stands for your Yuria or your BUN, your blood, Yuria, nitrogen, either over seven millimoles or over 19 MGs. So that's your Yuria. Respiratory rate, 30 or more breaths per minute. 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 gonna treat them in an outpatient setting. If they get up to two points, then you wanna admit them. You wanna treat them in the hospital. Three or more, you should be considering ICU. So zero points, outpatient, two points, admitted, three or more ICU. That between one and two, it's kind of one of those things that you make your clinical judgment on. Up to date kinda 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 too admit until about two points. So kinda know that in between one to two is kinda questionable, but two definitely inpatient, three ICU, and then zero is going to be your outpatient. So that's curbs 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% more good, 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 just a lot to know with the meds for pneumonia. I 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, 'cause it can become a little bit overwhelming. So let's break down each individual one. So first let's start with the least severe of all, and that's gonna be your community acquired pneumonia in an outpatient setting. How are you gonna treat these patients? Well, you're gonna treat them with macrolides, amoxicillin or augmentin, or doxyscycline. Now, the last option, the fourth option, is going to be a respiratory fluoraquinolone. Amoxicilloxicin, leave afloxicin, but this is something 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, or if they have comorbidities, then a lot of times we'll use respiratory fluoraquinolones. But otherwise, stick to your amoxicillin doxysmacrolides, 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 f-ing mad. You're f-ing mad because you got community acquired pneumonia. So f-ing, the f stands for chloroquinolones, m stands for macrolides, a stands for amoxicillin, or augmentin, and then d stands for doxyscycline. You're f-ing mad, you got community acquired pneumonia. All right, next, now we have community acquired pneumonia, but now we're treating them in an inpatient setting. So first, you were f-ing mad, they got pneumonia, but now you have to be hospitalized. So now you realize things are getting pretty f-ing bad. So what does that stand for? So first, respiratory fluoraquinolones, that's your f-ing, f-ing bad. So that can be used as monotherapy. So either a levofloxicin, moxifloxicin, gemfloxicin, again, though, avoid if possible. They're tempting because they're only once a day mad, and 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 fluoraquinolones, 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 f-ing bad. So your beta lactam. So seftriaxone is the one you'll probably see most commonly used, ampacillin, so backdamp, sefteriline, or dependent any of those beta lactam, combined with either azithromycin, so that's from your macrolite class. You can also use chlorethromycin or doxy. So the main treatment option here for a community acquired inpatient is gonna be your beta lactam, so you can use seftriaxone, sefteriline, any one of those, combined with either azithromycin instead of azithromycin, but that doesn't make the mnemonic work. And azithromycin is actually used more commonly than chlorethromycin anyways. And then the other option is your fallback, which would be respiratory fluoraquinolones. So remember community acquired inpatient. Now you are realizing that things are getting pretty f' bad, f' f' chlorachquinolones, 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 organism seen in the hospital and the resistance, et cetera. So with hospital acquired pneumonia, you're almost always going to cover pseudomonas right away though, MRSA is kind of if there is a risk. So how do you cover your pseudomonas in hospital acquired? You're going to use your anti-sutomonal beta lactams. So that's piptazo, pipa-silin, tasobactam, sefapeme, septazide, any one of those, anti-sutomonal beta lactams. And then if there is a risk for MRSA, you're going to use either a linesolid or vancomycin. So really pseudomonas is going to be covered almost all the time. And then so you're going to use your piptazo, sefapeme, septazide, and then if there's a risk for MRSA, you tack on either linesolid or vancomycin. Now you're only going to add your anti-sutomonal fluoroquinal bones or amino glycosides. If the patient has risk factors for a gram-negative bacilli, like patient with structural lung disease, like bronchietic cystic fibrosis, or if a gram-stain should positive for that. Or if they had IV antibiotic treatment in the last 90 days. Anyways, this is beyond what you're going to be tested on as, and it's further than you should go. So if you're treating hospital acquired pneumonia, assume coverage of pseudomonas with anti-sutomonal beta lactams, piptazo, et cetera. And then if they mention MRSA, add on your linesolid or vancom. Try not to over-complicate 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. Alright, so remember, let's really quickly go through it again. So you have community acquired outpatient. You're f-ing mad, fluoroquinal bones, but try not to. And then mad stands for your macrolise, like your zytheromycin, moxicillin or augmentant, and then doxy. Remember you're trying to combine a moxicillin or augmentant with either macrolite and doxy. And then or doxy. And then of course, your fluoroquinal bones can be used as monotherapy, but last line because of all the problems with those. Now, community acquired inpatient. Now you're no longer f-ing mad. You're just realizing things are getting f-ing bad. So respiratory fluoroquinal bones can be used as monotherapy or bad stands for beta-lactam, so you're septraaxone, ampicillin, so bactam, so teriline, plus either zytheromycin or doxy. And then of course, hospital acquired. You're treating pseudomonas or MRSA. pseudomonas can be with your anti-suitomonal beta-lactam, piptezocephapine, and then MRSA with linesolid or vancom. All right, so I guess 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. 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 anerobs, and the key to them in yet 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, ampacillin-sulbactin, if they're hospitalized, because you give that IV, or augmentin, which is a moxacillin clavulane. It's good for your outpatient settings, since it can be given PO. So again, aspiration pneumonia, it's a patient, 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 anerobs, then yet it's going to be a foul smelling sputum. Treatment is going to be with ampacillin-sulbactin, or a moxacillin clavulane, your augmentin. All right, so the last two, they're really kind of infectious disease, more than their pulmonary, but they can easily be lumped into a clinical medicine exam on pulmonology, and they're easy. There's only a couple of things to know about them, so, and I'll give you a couple of themonics to memorize the important things. So let's just go from really quick. So first, histoplasmosis, it's a fungal infection caused by breathing in spores of a fungus often found in bird and bat dropings, that can lead to pneumonia. All I want you to know about histoplasmosis is the word bird. So it can be caused, like I said, by bird and bat dropping, 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 dropings, B bird, B bat dropings. The I stands for itchoconizol. Itchoconizol is going to be your first line treatment for outpatient, in patients with mild or moderate disease. So that's your I in bird. our 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 the list of them yet. 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 dropings, but that's the main thing. Mississippi, Ohio River Valley is one of the highest rates of histoplasmosis is seen there. And then the D stands for defining illness for AIDS because this isn't AIDS defining illness. If you're not familiar with what that is, certain diseases, the 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. Their 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. Remember histoplasmosis bird, B stands for bird or bat dropings, I stands for heteroconisol, R stands for river valley, the Mississippi, Ohio River Valley and then D stands for defining illness for AIDS. All right, last one, Numerosysthus pneumonia, also known as PCP. So PCP, Numerosysthus pneumonia. So this is a yeast-like fungal infection and it's most commonly caused by Numerosysthus Jiro VTI or Jiro Vecchiye, 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 lab. So that's your serum lactate dehydrogenase. So LDH levels are elevated in around 90% of patients with PCP who are infected 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 or in a patient with PCP. It's also described as a bat wing 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 to treatment. Both prophylaxis are both with backdrum. So backdrum, of course, is trimetoprin. So from a thox is all, 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 backdrum. So the way, because probably the most important thing is the backdrum for this, for the vignette. Because this is probably where you'll get asked. The way that I used to remember that backdrum is the treatment of choice for PCP or Numosysthus pneumonia is because your PCP, your posterior is coarse and prickly, PCP, posterior, coarse prickly. You need your backdream, backdream. So that's how you just remember it. So PCP, PCP, pneumonia, posterior is coarse and prickly, PCP. You need your back trimmed, backdream. I don't know. Hopefully, that's how it will 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 strep docococcus pneumonia is most common cause of community acquired pneumonia. Two, homeless patient presents to the ER with a productive cough, foul smelling sputum. And it meets the blacking out last night due to excessive alcohol use, which antibiotic classes should be cons, which antibiotics should be considered. And 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 that black out he had. So he likely vomited and aspirated. So you're going to use either a moxasillin clavulonate, or a gmentin or ampacillin, so backdream. Three, what organisms should be considered when prescribing empiric antibiotic treatment and a patient with hospital acquired pneumonia? What organisms should be considered when prescribing empiric antibiotic treatment and a patient with hospital acquired pneumonia? It's going to be pseudomonas and merse. 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 pharyngeitis, non-productive cough, and an earache. And chest x-ray, a patchy infiltrate is visualized. What is the likely organism causing this patient's symptoms? So this one, you should know that's going to be microplasma pneumonia. Remember, that's your atypical organism. You're quote unquote, walking pneumonia, young healthy patient, those extra pulmonary symptoms. That is going to be likely microplasma 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 f-ing mad. You got community acquired pneumonia, but you're an outpatient yet, so you're not realizing things are f-ing bad yet. So f-ing mad, that's going to be fluoroquine loans. Remember, only in patients with comorbidities or risk factors. And then mad, macrolytes like azithromycin, moxacillin and doxyscycline. Remember, you're generally using a moxacillin combined with either a macrolite or doxy. And then fluoroquine loans, if need be, can be used as monotherapy. All right, guys, that was pneumonia. Hopefully, again, like I say, I really hope that's helping you. And hopefully that was helpful. 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 leaving me these really nice great comments. So good luck on your pants, your pantry, your EORs and good luck in PA school. (upbeat music)