[11] Pneumonia Flashcards
What is pneumonia?
Pneumonia is a general term denoting inflammation of the gas-exchanging region of the lung, usually due to infection (bacterial or viral). It is therefore an infection of the lung parenchyma
What is pneumonitis?
Inflammation of the lung parenchyma due to other causes, such as physical or chemical damage
What are the different types of pneumonia?
- Lobar pneumonia
- Bronchopneumonia
- Aspiration pneumonia
- Interstital pneumonia
- Chronic pneumonia
What is lobar pneumonia?
Pneumonia that is localised to a particular lobe of the lung
What is lobar pneumonia most commonly due to?
Streptococcus pneumoniae
What is bronchopneumonia?
Pneumonia that is diffuse and patchy
How does bronchopneumonia develop?
It starts in the airways, and spreads to adjacent alveoli and lung tissue
What organisms cause bronchopneumonia?
- Streptococcus pneumoniae
- Haemophilus influenza
- Staphylococcus aureus
- Anaerobes
- Coliforms
What is aspiration pneumonia?
When aspiration of food, drink, saliva, or vomit causes pneumonia
What organisms cause aspiration pneumonia?
- Oral flora
- Anaerobes
What is interstitial pneumonia?
Inflammation of the intersticium of the lung
What does the intersticium of the lung consist of?
- Alveolar epithelium
- Pulmonary capillary endothelium
- Basement membrane
- Perivascular and perilymphatic tissue
What is chronic pneumonia?
Inflammation of the lungs that persist for an extended period of time
What are the common bacteria causing pneumonia?
- Streptococcus pneumoniae
- Haemophilus influenzae
- Klebsiella pneumoniae
What are the atypical bacteria causing pneumonia?
- Chlamydia pneumophilia
- Mycoplasma pneumoniae
- Legionella pneumophilia
What hospital acquired bacteria cause pneumonia?
- Gram -ve enteric bacteria
- Pseudomonas
- Staphylococcus aureus/MRSA
What features are associated with S. Pneumoniae pneumonia?
- Elderly
- Co-morbidities
- Acute onset
- High fever
- Pleuritic chest pain
What features are associated with H. Influenzae pneumonia?
COPD
What features are associated with legionella pneumonia?
- Recent travel
- Younger patient
- Smoker
- Illness
- Multi-system involvement
What features are associated with mycoplasma pneumonia?
- Young
- Prior antibiotics
- Extra-pulmonary involvement, e.g. haemolysis, skin and joint problems
What features are associated with S. Aureus pneumonia?
- Post-viral
- IV drug users
What features are associated with chlamydia pneumonia?
Contact with birds
What features are associated with klebsiella pneumonia?
- Thrombocytopenia
- Leucopenia
What viruses can cause pneumonia?
- Most commonly RSV
- Influenza type A or B
What % of pneumonia cases are caused by viruses?
About 15%
What groups are at higher risk of pneumonia?
- Babies and very young children
- Elderly
- Smokers
- Co-morbidities
- Immunocompromised
What co-morbidities can increase the risk of pneumonia?
- Asthma
- CF
- Heart, kidney, or liver conditions
What can cause immunocompromisation?
- Recent illness such as flu
- Infection with HIV/AIDS
- Chemotherapy
- Anti-organ transplant rejection medication use
What are the risk factors for aspiration pneumonia?
- Altered level of conciousness
- Problems swallowing
What can cause altered level of consciousness increasing the risk of aspiration pneumonia?
- Anaesthesia
- Alcohol
- Drug abuse
What can cause problems swallowing increasing the risk of aspiration pneumonia?
Nerve or oesophageal damage, e.g after stroke
Is the presentation of pneumonia consistent?
It can be variable, however there is almost always malaise, fever, and a productive cough
How quickly is the onset of pneumonia?
Can be of very rapid onset, particularly if pneumococcal or staphylococcal
What are the symptoms of pneumonia?
- Malaise
- Fever
- Productive cough
- Dyspnoea
- Pleuritic chest pain
- Malaise
- Anorexia and vomiting
- Headache
- Myalgia
- Diarrhoea
- Sweats or chills
What is pleuritic chest pain?
A sharp pain when you breathe, cough, or sneeze
What is involved in the diagnosis of pneumonia?
- History and examination, including percussion and auscultation
- Chest x-ray
- Oxygen testing
- Microbiological testing
- Blood tests
What is the CURB 65 score used for?
To assess the severity of pneumonia
How is the CURB score interpreted?
A score of 2 or more is an indication for hospital treatment, and higher scores may require ICU treatment
What is C in the CURB 65 score?
New mental confusion
What is U in CURB 65?
Urea >7mmol/L
What is R in CURB 65?
Respiratory rate >30/min
What is B in CURB 65?
Blood pressure < 90/60mmHg
What is 65 in CURB 65?
Over 65 years old
What are the chest signs of pneumonia?
- Bronchial breath sounds
- Crackles
- Wheeze
- Dullness to percussion
- Reduced vocal resonance
What are the CXR findings in pneumonia?
- Lobar or multilobar infiltrates
- Cavitation
- Pleural effusion
What samples can be collected in pneumonia?
- Sputum
- Nose and throat swabs
- Endotracheal aspirates
- Broncho-alveolar-lavage fluid (BAL)
- Open lung biopsy
- Blood culture, preferably before antibiotics
- Urine
- Serum
What is the purpose of microbiological testing in pneumonia?
- To confirm a diagnosis
- Isolate the causative organism to guide treatment
What microbiological testing can be done in pneumonia?
- Macroscopic examination
- Microscopy
- Culture
- PCR
- Antigen detection
- Antibody detection
What is done in macroscopic examination of sputum in pneumonia?
Look to see if sputum is purulent or blood stained
What is included in microscopy in pneumonia?
Gram staining and acid fast
What is the purpose of culture in pnuemonia?
To isolate bacteria and viruses
What is the purpose of PCR in pneumonia?
To identify respiratory viruses
What is the purpose of antigen detection in pneumonia?
To look for Legionella
What blood tests are done in pneumonia?
- FBC
- U&E
- LFT
- CRP
What is included in the management of pneumonia?
- Antibiotics
- Oxygen therapy
- Fluids
- Analgesia if pleurisy
When should ITU be considered in the management of pneumonia?
If shock, hypercapnia, or persistent hypoxia
What antibiotic regime is used in the treatment of pneumonia when the CURB score is 0-1 and the causative organism is S. Pneumoniae or H. influenza?
Oral amoxicillin, clarithromycin, or doxycycline for 5 days
What antibiotic regime is used in the treatment of pneumonia when the CURB score is 2 and the causative organism is S. pneumoniae, H. influenza, or mycoplasma pneumoniae?
- Oral amoxicillin and clarithromycin or doxycycline
- If IV required, amoxicillin and clarithromycin for 7 days
What antibiotic regime is used in the treatment of pneumonia when the CURB score is 3+ and the causative organism is S. pneumoniae, H. influenzae, or mycoplasma pneumoniae?
IV Co-amoxiclav or cephalosporin, and
IV clarithromycin for 7 days
What antibiotic regime is used in the treatment of pneumonia when the CURB score is 3+ and the causative organism is suspected to be S. Aureus?
- IV co-amoxiclav or cephalosporin, and
- IV clarithromycin for 7 days, and
- Flucoxacillin and/or rifampicin for 10 days
What antibiotic regime is used in the treatment of pneumonia when the CURB score is 3+ and the causative organism is suspected to be MRSA?
- IV Co-amoxiclav or cephalosporin for 7 days, and
- IV clarithromycin for 7 days, and
- Vancomycin for 10 days
What antibiotic regime is used in the treatment of pneumonia when the causative organism is legionella pneumophilia?
Fluroquinolone combined with clarithromycin, or rifampicin if severe
What antibiotic regime is used in the treatment of pneumonia when the causative organism is chlamydial species?
Tetracycline
What antibiotic regime is used in the treatment of pneumonia when the causative organism is pneumocystis jiroveci?
High dose co-trimoxazole
What antibiotic regime is used in the treatment of pneumonia when the causative organism is gram -ve bacilli, Pseudomonas, or anaerobes?
IV aminoglycosides, and antipseudomodal penicillin, or 3rd generation cephalosporin
What antibiotic regime is used in the treatment of pneumonia when the causative organism is S. pneumoniae or anaerobes?
IV cephalosporin and metronidazole
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What is the aim of oxygen therapy in pneumonia?
Aim to keep PaO2 >8.0, and/or saturations >94%
What should you explain to patients recovering from community-acquired pneumonia>
That after starting treatment, their symptoms should steadily improve
What should people be told to expect regarding their symptoms after 1 week of treatment?
Fever should have resolved
What should people be told to expect regarding their symptoms after 4 weeks?
Chest pain and sputum production should have substantially reduced
What should people be told to expect regarding their symptoms after 6 weeks/
Their cough and breathlessness should have substantially reduced
What should people be told to expect regarding their symptoms after 3 months?
Most symptoms should have resolved, but fatigue may still be present
What should people be told to expect regarding their symptoms after 6 months?
Most people should feel back to normal
What should patients be advised to do if they feel that their symptoms are deteriorating, or not improving as expected after treatment?
Consult their HCP
What are the potential complications of pneumonia?
- Pleural effusion
- Empyema
- Lung abscess
- Respiratory failure
- Septicaemia
- Brain abscess
- Pericarditis
- Myocarditis
- Cholestatic jaundice
What can cause pneumonia in immunocompromised patients?
Immunocompromised patients might have a virulent infection with a common organism, or might be infected by an opportunistic pathogen, for example;
- Cytomegalovirus
- Mycobacterium avium intracellulare
- Aspergillus
- Candida
- Pneumocystis jiroveci
- Cryptosporidia
- Toxoplasma
