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Y3 Medicine > 7 - Lung Infections > Flashcards

7 - Lung Infections Flashcards

1
Q

What are the most likely organisms causing the following types of pneumonia:

  • Community acquired
  • Hospital acquired (>48h post admission)
  • Aspiration
  • Immunocompromised
A

Community: S.Pneumoniae, Haemophilus influenzae, Moraxella cattarhalis (atypical include Mycoplasma pneumoniae, S.Aureus, Legionella, Chlamydia)

Hospital: Gram -ve enterobacteria, Staph Aureus, Pseudomonas, Klebsiella

Aspiration: oropharyngeal anaeorobes

Immunocompromised: fungi, viruses (CMV, HSV), Pneumocystis jirovecii, S.Pneumoniae, S.Aureus

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2
Q

What are some signs and symptoms of pneumonia?

A

Symptoms: fever, rigors, malaise, dyspnea, cough, purulent sputum, pleuritic pain, haemoptysis

Signs: pyrexia, consolidation on CXR, crackles, dull to percussion, reduced expansion, confusion, increased vocal resonance, pleural rub

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3
Q

What investigations should you do if a patient comes in with suspected pneumonia and what will they show?

A

- O2 sats and ABGs if <92%

- Blood tests: FBC, U+Es, LFTs, CRP

- Blood cultures: if febrile

- CXR: consolidation, cavitation or pleural effusion

- Sputum culture and microscopy

- Check legionella/pneumonococcal urinary antigens

- ?Pleural effusion aspiration and culture

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4
Q

What are some causes of consolidation on a CXR?

A
  • Pneumonia
  • TB
  • Lung cancer
  • Lobar collapse
  • Haemorraghe
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5
Q

How is pneumonia severity graded?

A

CURB-65

Higher mortality with higher score

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6
Q

If someone has a high CURB65 score, what do you need to screen for?

A

Atypical pneumonia screen by doing serology and urine legionella test

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7
Q

How is pneumonia managed in hospital?

A
  • Antibiotics
  • Oxygen to keep sats>94% and PaO2>8
  • IV fluids if dehydration, shock or anorexia
  • Paracetamol for pleurisy
  • VTE prophylaxis
  • ITU referral if high CURB65
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8
Q

What antibiotics are generally used for community acquired pneumonia in UHL?

A

Mild/CURB 1: amoxicillin or doxycycline

Moderate/CURB2: amoxicillin + doxycycline (or clarithromycin) or higher dose doxycycline

Severe/CURB3 upwards: co-amoxiclav and clarithromycin

PROPHYLACTIC DALTEPARIN FOR VTE PREVENTION

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9
Q

What antibiotics are generally used for hospital acquired pneumonia in UHL?

A

Mild/Moderate: Co-amoxiclav for 5 days or Doxycyline

Severe: Co-amoxiclav higher strength for 5 days or Meropenem

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10
Q

What antibiotics are generally used for aspiration pneumonia in UHL?

A

Mild/Moderate: co-amoxiclav, if atypical pathogen suspected add doxycycline or clarithromycin

Severe: co-amoxiclav or penicillin

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11
Q

How is pneumonia followed up?

A

Need a repeat CXR and CRP in 6 weeks to check full resolution and no underlying malignancy/complications

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12
Q

What are some causes of non-resolving pneumonia?

A

CHAOS

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13
Q

What are some complications of pneumonia?

A

- Pleural effusion

  • Empyema
  • Lung abscess
  • Respiratory failure
  • Septic shock
  • Pericarditis/myocarditis
  • AFib
  • Jaundice secondary to sepsis or antibiotic therapy
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14
Q

What are some features of a lung abscess and how is it treated?

A
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15
Q

Who should be offered a pneumoncoccal vaccine and which patients is it contraindicated in?

A
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16
Q

Who are more likely to suffer from the following pneumonias:

  • Pneumococcal
  • Staphylococcal
  • Klebsiella
A
  • Most common. More prevalent in elderly, alcoholics, post-splenectomy, immunosupressed, heart failure
  • IVDU, CF, lymphoma, leukaemia. Causes bilateral cavitating bronchopneumonia
  • Rare. In elderly, diabetics, alcoholics. Usually drug resistant
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17
Q

How does legionella pneumophilia present and how is it treated?

A

Presentation: flu like symptoms (malaise, fever, myalgia) then dry cough and dyspnea. Can have D+V, hepatitis, renal failure

Treatment: diagnose with urine antigen/culture and give fluoroquinolone or clarithromycin for 2-3 weeks

Colonises water tanks kept at <60 degrees, e.g hotel air conditioning and hot water systems

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18
Q

What is chlamydophila psittaci and how is it treated?

A

Causes psittacosis and comes from infected birds (often parrots)

Symptoms: headache, dry cough, fever, lethargy, arthralgia, D+V

Diagnosis: chlamydophila serology

Treatment: Doxycycline or Clarithromycin

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19
Q

What are some causes of viral pneumonia?

A
  • Influenza (most common)
  • Swine flu
  • Measles
  • CMV
  • Varicella zoster

Treat with oseltamivir, zanamivir, nebulisers and high flow oxygen

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20
Q

How do you diagnose and treat pneumoncystis pneumonia?

A
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21
Q

What are the clinical features of respiratory TB?

A
  • Low grade fever
  • Drenching night sweats
  • Cough that starts dry then becomes purulent
  • Haemoptysis
  • Fever
  • Weight loss
  • Malaise
  • Clubbing
  • Pleural effusion
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22
Q

What are some non-respiratory manifestions of TB?

A
  • Erythema nodosum
  • Lymphadenopathy
  • Bone/joint tenderness
  • Abdominal (colicky pain)
  • Meningitis
  • Milliary (disseminated)
  • Cardiac (pericardial effusion)
  • Genitourinary
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23
Q

What are some differentials for haemoptysis?

A
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24
Q

What are some risk factors for TB?

A
  • Past history of TB
  • Known history of TB contact
  • Born in a coutry with high TB incidence
  • Foreign travel to area with high TB levels

- Immunosuppression e.g IVDU, HIV, Diabetes, low BMI, dialysis, alcoholism

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25
Q

How is latent TB diagnosed?

A
  • Tuberculin skin testing Mantoux
  • Interferon gamma release assays
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26
Q

How is active TB diagnosed?

A
  • CXR
  • Sputum smear (Ziehl-Neelsen Acid fast)
  • Sputum culture
  • NAAT (rapid diagnosis in 8 hrs and can detect drug resistance)
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27
Q

If TB is diagnosed, what further testing is offered?

A

HIV

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28
Q

If a patient with suspected TB is admitted to hospital, how should you manage them before the definitive management?

A

- Admit to side room and use infection control measures (PPE)

- Notify public health and TB nurses

- CXR

- 3 early morning sputum samples for AFB and TB culture

- Routine bloods (LFTs) and Vitamin D

- HIV test

  • Consider CT chest if CXR not typical
  • Start anti-TB therapy as culture can take 6-8 weeks
29
Q

What are some features of TB on a CXR?

A

Usually in upper lobes:

  • Cavitation
  • Pleural effusion
  • Mediastinal or hilar lymphadenopathy
  • Parenchymal infiltrates
30
Q

If you suspect miliary TB, what investigation do you need to carry out?

A
  • MRI Spine/Brain
  • Lumbar puncture
31
Q

If there is a doubt whether a diagnosis is TB or pneumonia, what should you do?

A

Treat as pneumonia using CURB65 score whilst investigating posibility of TB

32
Q

What is the antibiotic regime for active TB?

A

- Rifampicin 6 months

- Isoniazid 6 months

- Pyrazinamide 2 months

- Ethambutol 2 months

33
Q

What monitoring is needed whilst on anti-TB therapy?

A

- Patient’s weight as dose is weight dependent

- Check baseline LFTs and monitor

- Check visual acuity before ethambutol

- Pyridoxine should be given with Isoniazid as prophylaxis for peripheral neuropathy

DIRECTLY OBSERVED THERAPY THE WHOLE TIME!!!!!!

34
Q

What are the major side effects of TB treatment?

IMPORTANT TO COUNSEL ON

A

Check visual acuity, LFTs and give pyroxidine for Isoniazid

35
Q

How is latent TB managed?

A

Need to balance risk of development of active disease with possible side effects of treatment

Usually 3 months of Isoniazid (with pyroxidine) and Rifampicin

OR

6 months of isoniazid

36
Q

What people with latent TB should you treat as they are at increased risk of developing active disease?

A
  • HIV
  • Transplantation
  • Chemotherapy
  • Bioloical agents (TNF-a inhibitors)
  • Diabetes
  • CKD

Treat for 3-6 months with follow up CXR at 12 months

37
Q

What is bronchiectasis?

A

Chronic dilatation of one or more bronchi. They have poor mucus clearance so there is a predisposition to recurrent chronic bacterial infections

38
Q

What are the causes of bronchiectasis?

A

- Post infective: whooping cough, TB

- Congenital: CF, Young;s, Kartagener’s,

- Obstructive: foreign body, tumour, lymph node

- Immune deficiency: hypogammaglobulinaemia

- Secondary immune deficiency: HIV, malignancy

  • RA
  • IBD
39
Q

What is Kartagener and Young’s syndrome?

A

Kartagener: bronchiectasis, sinusitis, situs invertus

Young’s: bronchiectasis, infertility, sinusitis

40
Q

What are the common infectious organisms in bronchiectasis?

A
  • Haemophilus influenzae
  • Pseudomonas aeruginosa
  • Moraxhella catarrhalis
  • Strep pneumonia
  • Staph Aureus
41
Q

What are the signs and symptoms of bronchiectasis?

A

Symptoms: persistent cough, copious purulent sputum, intermitten haemoptysis

Signs: finger clubbing, coarse inspiratory crepitations, wheeze

42
Q

What are some complications of bronchiectasis?

A
  • Pneumonia
  • Pleural effusion
  • Pneumothorax
  • Haemoptysis
  • Amyloidosis
43
Q

What is the gold standard diagnostic test for bronchiectasis? What are the signs?

A

High resolution CT

Signet ring appearance and Tram track signs

44
Q

What other tests can you do for a patient with suspected bronchiectasis?

A

- Sputum culture (P.Aeruginosa and Non TB mycobacterium)

- CXR (tramline and ring shadows and look for pneumonia)

- Spirometry (obstructive pattern)

  • Bronchoscopy to locate site of haemoptysis and exclude obstruction
  • CF sweat test
45
Q

How is bronchiectasis managed?

A

- Treat underlying cause

- Chest physiotherapy for mucus clearance

- Antibiotics accord to cultures/sensitivity

- Bronchodilators if required

  • Steroids for allergic bronchopulmonary aspergilliosis or asthma

- Flu vaccine

- Pulmonary rehab if MRC dyspnea score 3 or more

46
Q

What should you give as antibiotic prophylaxis to bronchiectasis patients?

A

Azithromycin on 3 days a week

47
Q

If bronchiectasis patients are known to culture Pseudomonas, what antibiotics should you give them?

A

Oral ciprofloxacin OR azithromycin

If 3 or more exacerbations a year consider long term antibiotics

48
Q

What antibiotics are recommended for an acute exacerbation of bronchiectasis?

A

Stop any long term antibiotics before giving

No Pseudomonas: co-amoxiclav or doxycycline

Pseudomonas: ciprofloxacin

MRSA: doxycycline

49
Q

When is surgery indicated in bronchiectasis patients?

A

Severe haemoptysis

50
Q

What is the pathophysiology of CF?

A

Autosomal reccesive disease that leads to a mutation in CFTR

Chromosome 7

Defective chloride secretion and excess Na absorption across epithelium. Leads to excessive mucus. Predisposes them to bronchiectasis and lung infections

51
Q

What are some of the clinical features of CF?

A

Neonate: meconium ileus, failure to thrive, rectal prolapse

Children and Young adults: cough, wheeze, recurrent infections, pneumothorax, diabetes mellitus, steatorrhea, distal intestinal obstruction syndrome, male infertility, osteoporosis, gallstones

52
Q

How is CF diagnosed?

A

- Sweat test

- Genetic testing

  • Can look at faecal elastase for pancreas exocrine dysfunction
53
Q

How is CF most commonly picked up?

A
  • Meconium ileus
  • Intestinal malabsorption
  • Newborn heelprick screening
  • Recurrent chest infections
54
Q

What are some common complications of CF and how are they managed?

A

Respiratory Infections: Physiotherapy and prophylactic antibiotics

Low Body Weight: Due to pancreatic insufficiency, meed to give pancreatic enzyme replacement therapy with high calorie intake. May need NG or PEG

DIOS: Due to insufficienct pancreatic enzymes or hot weather or salt deficiency. Replace salts, drink fluids, give laxatives

CF related diabetes: give insulin

55
Q

What is DIOS and how is it diagnosed?

A

Faecal obstruction in ileocaecum (not whole bowl like constipation) due to faeces being thick and dehydrated. From insufficient pancreatic enzymes, hot weather or salt deficiency

Often palpable faeces in right iliac fossa

Diagnosis: symptoms, palpable mass in right iliac fossa, AXR showing faecal loading at junction of small and large bowel

56
Q

How is CF managed through the MDT?

A

Chest: physiotherapy and prophylactic antibiotics. Can give mucolytics and bronchodilators. Do annual CXR

GI: pancreatic enzyme replacement, fat soluble vitamin supplements (ADEK), if cirrhosis consider liver transplant

Advanced lung disease: oxygen, non-invasive ventilation, heart/lung transplant

57
Q

What will a spirometry show in CF?

A

Obstructive pattern

58
Q

What blood tests should you do regularly for a CF patient?

A
  • FBC
  • U+Es
  • LFTs
  • Clotting
  • Vit A,D, E
  • Annual oral glucose tolerance test

Also do sputum cultures

59
Q

What lifestyle advice should you give to CF patients?

A
  • Clean and dry nebs properly
  • Avoid other CF patients
  • Avoid jacuzzis
60
Q

What are some new gene therapies for CF treatment and how do they work?

A

Ivacaftor: increases the probability of CFTR channels to open

Lumacaftor: CFTR corrector so increases amount of CFTR channels

Gene therapy: transferring CFTR gene using liposome or adenovirus vectors

61
Q

What are the common pathogens seen in the sputum of patients with bronchiestasis?

A
  • H.Influenzae
  • S.Pneumoniae
  • Pseudomonas aeruginosa
62
Q

What are the principles of treating bronchiectasis?

A
63
Q

How common is CF?

A

1 in 2500 births

1 in 25 people carry the autosomal recessive gene

64
Q

How is TB managed?

A
  • Notify PHE
  • Multi drug treatment
  • Await culture results for sensitivities
65
Q

Which patients may not adhere to TB treatment?

A
  • Homeless
  • Alcohol/substance users
  • Mental health issues

Best treated with DOT or 3 supervised meetings for medications a week

66
Q

What is the pathophysiology of TB?

A

The macrophages often migrate to regional lymph nodes, the lung lesion plus affected lymph nodes is referred to as a Ghon complex.

This leads to the formation of a granuloma which is a collection of epithelioid histiocytes. There is the presence of caseous necrosis in the centre.

The inflammatory response is mediated by a type 4 hypersensitivity reaction.

In healthy individuals the disease may be contained, in the immunocompromised disseminated (miliary TB) may occur.

67
Q

What is the discharge criteria for a patient with pneumonia?

A
  • Normalised O2 sats and obs
  • Improving symptoms
  • Significantly improved CRP
68
Q

How do the antibiotics for community and hospital acquired pneumonia differ?

A

Y3 Medicine (24 decks)

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