Strep Pneumonia Ever Nosocomial?? please help

[medInUSA]

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Hi question:

A 67-year-old alcoholic man is admitted to the hospital for evaluation of hepatic cirrhosis. 5 days into his hospital stay he develops dyspnea, shortness of breath, and coughs up thick red sputum. Physical exam reveals dullness to percussion and increased tactile fremitus over both lung fields. This patient has most likely acquired an infection by which of the following types of organism?

A. gram negative cocci

B. gram positive rod

C. negative single-stranded RNA virus

D. gram negative rod

E. fungus


Answer:
D) gram negative rod The description is classic for Klebsiella pneumonia, a particularly common nosocomial infection seen in alcoholics. The sputum of such patients is often referred to as "red currant jelly" due to its thick consistency and blood-tinged color. Klebsiella pneumonia is a gram negative rod. Note, choice D also covers E. Coli, another major cause of nosocomial-acquired pneumonia. "Gram positive cocci" would also have been a correct answer here (since, in addition to klebsiella, alcoholics are certainly also susceptible to strep pneumoniae), but it is not one of the choices. A is incorrect because Neisseria does not present as pneumonia. B is incorrect because gram positive rods do not typically cause pneumonia, with the exception of Listeria Monocytogenes, which primary affects young children. C and E are incorrect because the patient's physical findings (increased tactile fremitus and dullness to percussion) and symptoms (coughing up thick red sputum) are consistent with pneumonia and not influenza (C) or a fungal infection (E).

The bolded part of the explanation confuses me. According to Robbins, the strep pneumonia is community aquired while Staph aureus is nosocomial. How can strep pneumonia be right if the patient aquired the disease in the hospital should it not be staph aureus??

thank you in advance.

 

[medInUSA]

One more thing.

Is klebsiella a typical nosocomial pathogen? or should we only suspect it if patient is alcoholic??
Robbins does not list Klebsiella as a cause of nosocomial pneumonia.

 

[dynx]

One more thing.

Is klebsiella a typical nosocomial pathogen? or should we only suspect it if patient is alcoholic??
Robbins does not list Klebsiella as a cause of nosocomial pneumonia.

You are quite right. It should be staph...its a little known fact that strep pneumo is instantly killed upon entering a hospital making it impossible to get a pneumococ pneumonia while admitted. Amazing isnt it?

Klebsiella is pretty rare, suspect more in ETOH users.

 

[medInUSA]

You are quite right. It should be staph...its a little known fact that strep pneumo is instantly killed upon entering a hospital making it impossible to get a pneumococ pneumonia while admitted. Amazing isnt it?

Klebsiella is pretty rare, suspect more in ETOH users.

Hi Dynx, are you trying to be clever and sarcastic? No need to be such, in an environment where colleages of a ancient and respectful profession should be able to share knowledge and experience in a spirit of fraternity.

Yes we all know that anything is possible! It is even possible for a twenty year old non smoker to get malignant cancer of the lungs, but it is improbable. However we are talking about odds here, thats what we think of when we are thinking of differential diagnosis. In general pneumonia due to staph is more common in hospitals while pneumonia due to strep is more common in the community.So would everybody here agree that that part of the explanation is wrong?

 

[mendel121]

Hi question:

A 67-year-old alcoholic man is admitted to the hospital for evaluation of hepatic cirrhosis. 5 days into his hospital stay he develops dyspnea, shortness of breath, and coughs up thick red sputum. Physical exam reveals dullness to percussion and increased tactile fremitus over both lung fields. This patient has most likely acquired an infection by which of the following types of organism?

A. gram negative cocci

B. gram positive rod

C. negative single-stranded RNA virus

D. gram negative rod

E. fungus


Answer:
D) gram negative rod The description is classic for Klebsiella pneumonia, a particularly common nosocomial infection seen in alcoholics. The sputum of such patients is often referred to as "red currant jelly" due to its thick consistency and blood-tinged color. Klebsiella pneumonia is a gram negative rod. Note, choice D also covers E. Coli, another major cause of nosocomial-acquired pneumonia. "Gram positive cocci" would also have been a correct answer here (since, in addition to klebsiella, alcoholics are certainly also susceptible to strep pneumoniae), but it is not one of the choices. A is incorrect because Neisseria does not present as pneumonia. B is incorrect because gram positive rods do not typically cause pneumonia, with the exception of Listeria Monocytogenes, which primary affects young children. C and E are incorrect because the patient's physical findings (increased tactile fremitus and dullness to percussion) and symptoms (coughing up thick red sputum) are consistent with pneumonia and not influenza (C) or a fungal infection (E).

The bolded part of the explanation confuses me. According to Robbins, the strep pneumonia is community aquired while Staph aureus is nosocomial. How can strep pneumonia be right if the patient aquired the disease in the hospital should it not be staph aureus??

thank you in advance.

The key is the sputum description - thick red sounds like the classic "currant jelly" appearance of Klebseilla pneumonia.

 

[dynx]

where colleages of a ancient and respectful profession should be able to share knowledge and experience in a spirit of fraternity.

This little dream is going to end in tears about 2 weeks into your third year.

edit: btw, staph = GPC too. Sorry if im rude but I suffer from a disorder where I think sarcasm (particularly my own) is extremely amusing.

 

[mules05]

Hi question:

A 67-year-old alcoholic man is admitted to the hospital for evaluation of hepatic cirrhosis. 5 days into his hospital stay he develops dyspnea, shortness of breath, and coughs up thick red sputum. Physical exam reveals dullness to percussion and increased tactile fremitus over both lung fields. This patient has most likely acquired an infection by which of the following types of organism?

A. gram negative cocci

B. gram positive rod

C. negative single-stranded RNA virus

D. gram negative rod

E. fungus


Answer:
D) gram negative rod The description is classic for Klebsiella pneumonia, a particularly common nosocomial infection seen in alcoholics. The sputum of such patients is often referred to as "red currant jelly" due to its thick consistency and blood-tinged color. Klebsiella pneumonia is a gram negative rod. Note, choice D also covers E. Coli, another major cause of nosocomial-acquired pneumonia. "Gram positive cocci" would also have been a correct answer here (since, in addition to klebsiella, alcoholics are certainly also susceptible to strep pneumoniae), but it is not one of the choices. A is incorrect because Neisseria does not present as pneumonia. B is incorrect because gram positive rods do not typically cause pneumonia, with the exception of Listeria Monocytogenes, which primary affects young children. C and E are incorrect because the patient's physical findings (increased tactile fremitus and dullness to percussion) and symptoms (coughing up thick red sputum) are consistent with pneumonia and not influenza (C) or a fungal infection (E).

The bolded part of the explanation confuses me. According to Robbins, the strep pneumonia is community aquired while Staph aureus is nosocomial. How can strep pneumonia be right if the patient aquired the disease in the hospital should it not be staph aureus??

thank you in advance.

I don't know that I would expect to see the thick red sputum described associated with a staph infection (am I remembering this right?)...I'd lean toward strep pneumo over staph because strep pneumo classically causes a "rust colored" sputum, and I guess rust-colored is kind of red. I doubt, though, that you'd ever see a (fair) test question with this stem that would ask you to differentiate the two without extra information (catalase tests and such).

 

[Gut Shot]

The bolded part of the explanation confuses me. According to Robbins, the strep pneumonia is community aquired while Staph aureus is nosocomial. How can strep pneumonia be right if the patient aquired the disease in the hospital should it not be staph aureus??

The explanation doesn't rule out Staph, it just mentions Strep's association with alcoholism.

From Vices Increase Risk of Pneumonia:

Researcher Professor Martha Gentry-Nielsen, of Creighton University School of Medicine, said there were several reasons why alcoholics were more susceptible to an infection called streptococcus pneumoniae, which can cause pneumonia.

"They have a decreased gag reflex," she said. This means it is easier for mucus from the nose and fluid from the gut, such as vomit, to go down into the lung, particularly when they lose consciousness, she said.

 

[medInUSA]

thank you

 

[Radiohead]

When you get to the wards, your answer to that question will be...get cultures and then lets start Vancomycin, Levaquin, and Cefepime to cover gram positives, and double cover gram negatives. You never really know for sure until the cx/sensitivities come back. It is funny how little thinking there is when it comes down to it.

 

[turkleton]

\No need to be such, in an environment where colleages of a ancient and respectful profession should be able to share knowledge and experience in a spirit of fraternity.\
QUOTE]

HAHAHA! I think this is funny and great at the same time. Glad to see that there is some idealism, but man oh man is this a corny way of putting it. Oh lord will SDN change that fraternity bit of yours. You're alright medInUSA! Keep it up kid!

 

[jdh71]

Anything is possible - like unicorns, pixies, and gnomes - however, Strep. pneumo as a nosocomial pnemonia - nope - and you'll get the question wrong every time if you insist. Nosocomial pneumonias are staph and gram neg rods, and while klebsiella is a much less likely cause of nosocomial pneumonia . . . thick red sputum . . . it's classic (although how much of medicine is "classic" - HA!)

 

[Wizard of Oz]

When you get to the wards, your answer to that question will be...get cultures and then lets start Vancomycin, Levaquin, and Cefepime to cover gram positives, and double cover gram negatives. You never really know for sure until the cx/sensitivities come back. It is funny how little thinking there is when it comes down to it.

Trudat. 👍

Just be wary of a lab that either over-calls mouth contaminants or ignores too much stuff. If you suspect a particular organsim, be sure to put a comment in on the order. Some labs I've worked for don't respect S. aureus as much as they should.

Also be careful with some of the newer fluoroqunilones. I saw a case once where moxifloxacin was prescribed for pneumonia, it wiped out the lady's colon flora, and within a couple of days she had a bag on her hip (colostomy due to pseudomembranous colitis). C. diff's a mofo. 👎

 

[Gut Shot]

Anything is possible - like unicorns, pixies, and gnomes - however, Strep. pneumo as a nosocomial pnemonia - nope - and you'll get the question wrong every time if you insist. Nosocomial pneumonias are staph and gram neg rods, and while klebsiella is a much less likely cause of nosocomial pneumonia . . . thick red sputum . . . it's classic (although how much of medicine is "classic" - HA!)

Indeed.

Nosocomial pneumonia : rationalizing the approach to empirical therapy.
Andriesse GI, Verhoef J. Treat Respir Med. 5(1):11-30, 2006.

Nosocomial pneumonia or hospital-acquired pneumonia (HAP) causes considerable morbidity and mortality. It is the second most common nosocomial infection and the leading cause of death from hospital-acquired infections. In 1996 the American Thoracic Society (ATS) published guidelines for empirical therapy of HAP. This review focuses on the literature that has appeared since the ATS statement. Early diagnosis of HAP and its etiology is crucial in guiding empirical therapy. Since 1996, it has become clear that differentiating mere colonization from etiologic pathogens infecting the lower respiratory tract is best achieved by employing bronchoalveolar lavage (BAL) or protected specimen brush (PSB) in combination with quantitative culture and detection of intracellular microorganisms. Endotracheal aspirate and non-bronchoscopic BAL/PSB in combination with quantitative culture provide a good alternative in patients suspected of ventilator-associated pneumonia. Since culture results take 2-3 days, initial therapy of HAP is by definition empirical. Epidemiologic studies have identified the most frequently involved pathogens: Enterobacteriaceae, Haemophilus influenzae, Streptococcus pneumoniae and Staphylococcus aureus ('core pathogens'). Empirical therapy covering only the 'core pathogens' will suffice in patients without risk factors for resistant microorganisms. Studies that have appeared since the ATS statement issued in 1996, demonstrate several new risk factors for HAP with multiresistant pathogens. In patients with risk factors, empirical therapy should consist of antibacterials with a broader spectrum. The most important risk factors for resistant microorganisms are late onset of HAP (>/=5 days after admission), recent use of antibacterial therapy, and mechanical ventilation. Multiresistant bacteria of specific interest are methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, Acinetobacter calcoaceticus-baumannii, Stenotrophomonas maltophilia and extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. Each of these organisms has its specific susceptibility pattern, demanding appropriate antibacterial treatment. To further improve outcomes, specific therapeutic options for multiresistant pathogens and pharmacological factors are discussed. Antibacterials developed since 1996 or antibacterials with renewed interest (linezolid, quinupristin/dalfopristin, teicoplanin, meropenem, new fluoroquinolones, and fourth-generation cephalosporins) are discussed in the light of developing resistance.Since the ATS statement, many reports have shown increasing incidences of resistant microorganisms. Therefore, one of the most important conclusions from this review is that empirical therapy for HAP should not be based on general guidelines alone, but that local epidemiology should be taken into account and used in the formulation of local guidelines.

 

[Tired]

Do not confuse board questions with the real world.

Board Questions: Strep pneumo is a community-acquired pathogen.

Real World: The word "nosocomial" has strict definitions (see CDC guidelines) depending on the location of the infection. None of the definitions of nosocomial infections rely on the identity of the organism. We call them "nosocomial" because they are acquired in the course of medical treatment (usually in the hospital), and therefore may have antibiotic resistance patterns different from those found in the community.

Here is the CDC definition of a "nosocomial pneumonia" (also referred to as a "Hospital-Acquired Pneumonia" or CAP)

"Infection not present or incubating on admission, which meets one of the following:
• Rales or dullness on chest percussion and new onset of purulent sputum, or pathogen isolated from blood, transtracheal specimen, bronchial brushing or biopsy
• New lung infiltrate, consolidation, cavitation or pleural effusion on chest radiograph and one of above criteria, or positive direct or serologic diagnostic test for respiratory pathogen, or histopathologic diagnosis of pneumonia"

So yes, of course strep pneumo can be a nosocomial pathogen.

 

[Gut Shot]

Do not confuse board questions with the real world.

Perhaps the best point made on this thread. Although, in this case, it's the apparent departure from board question dogma that's causing the difficulty.