77. Pneumonia

Question 1

In a patient with a diagnosis of pneumonia, assess the risks for unusual pathogens. Name risks (5)

Answer 1

• a history of tuberculosis
• exposure to birds
• travel
• HIV infection
• aspiration

Question 2

In a patient who is receiving treatment for pneumonia and is not responding, do what? (3)

Answer 2

• Revise the diagnosis (e.g., identify other or contributing causes, such as cancer, chronic obstructive pulmonary disease, or bronchospasm)
• consider atypical pathogens (e.g., Pneumocystis carinii, TB)
• diagnose complications (e.g., empyema, pneumothorax).

Question 3

Name TYPICAL pathogens : Pneumonia (3)

Answer 3

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis

Question 4

Name ATYPICAL pathogens : Pneumonia (3)

Answer 4

• Mycoplasma pneumoniae
• Chlamydophila pneumoniae
• Legionella spp

Question 5

Name ASPIRATION pathogen for pneumonia (1)

Answer 5

Bacteroides (anaerobes)

Question 6

Describe : Community-Acquired pneumonia (2)

Answer 6

• No hospitalization within 14d of onset
• OR <4d prior to onset

Question 7

Describe dx : Pneumonia (3)

Answer 7

• Two symptoms (fever, rigors, cough change, pleuritic chest pain, SOB)
• AND auscultatory findings (localized crackles, bronchial breath sounds)
• AND X-ray opacity

Question 9

Name symptoms : Pneumonia (6)

Answer 9

• Fever/chills
• New or change in cough
• Pleuritic chest pain
• N/V
• Urine/Stools
• Fatigue, Myalgias

Question 10

Name risk factors : Pneumonia (2)

Answer 10

• Smoker, comorbid
• Antibiotics or hospitalization in past 3 months

Question 11

Adults with an acute respiratory infection and normal vital signs/pulmonary exam are likely/unlikely to have pneumonia

Answer 11

unlikely (~0.4%)

Question 12

Describe investigations : Pneumonia

Answer 12

• Chest X-ray (PA and lateral) required for diagnosis according to IDSA. Highly suggested in children as well according to CPS
• Labs : CRP (most accurate), procalcitonin, leukocytosis (was only modestly, if at all, accurate)

Question 13

If severe pneumonia, what labs to consider (4)

Answer 13

• Urine legionella/pneumococcal Ag. Positive even after days of antibiotic therapy
• Sputum gram stain and culture (r/o MRSA, P. aeruginosa). Legionella Culture
• Nasopharyngeal swab viral PCR (influenza, coronavirus, etc…)
• If not improving can monitor CRP / Procalcitonin

Question 14

____ more evidence than CURB-65 to determine outpatient vs inpatient treatment of pneumonia

Answer 14

Pneumonia Severity Index (PSI)

Question 15

Describe tx : Pneumonia (2)

Answer 15

• Supportive : Oxygen + Drain large pleural effusions or if suspect empyema
• Antibiotics

Question 16

Describe ATB for pneumonia (4)

Answer 16

If no antibiotics in past three months

• Clarithromycin 500mg PO BID x7d or Azithromycin 500mg PO daily x1 day then 250mg PO daily x 4 days or Doxycycline 100mg PO BID x 7 days. Promote less resistance to macrolides by using clarithromycin
• Amoxicillin 1g PO TID x7d (less emphasis on covering atypicals)
• Pediatrics - Amoxicillin 90 mg/kg/d PO divided TID x7-10d (consider atypical coverage in children ≥5 years old)
• May consider shorter courses in children with community-acquired pneumonia (3d or 5d) as per recent studies CAP-IT, SAFER, SCOUT-CAP.

Question 17

Describe ATB if comorbidities or recent antibodies (3)

Answer 17

• Amoxicillin with atypical coverage (Clarithromycin or Azithromycin or Doxycycline)
• If non-anaphylactic penicillin allergy = Cefuroxime or Cefadroxil + atypical coverage (consider monitor in office 1-2h)
• Anaphylactic penicillin allergy = Levofloxacin or Moxifloxacin as below

Question 19

Describe second-line tx : Pneumonia ()

Answer 19

(after failed 72-96h)
Levofloxacin 750mg PO daily x 5 days or Moxifloxacin 400mg PO daily x 7d

Question 20

Describe tx pneumonia if hospitalized and intensive care ()

Answer 20

Cefotaxime 1-2g IV q8h or Ceftriaxone 1-2g IV q12-24h AND Levofloxacin or Moxifloxacin or Azithromycin

Note: Ceftriaxone superior to Pip/Tazo (as 15% Strep pneumo resistant to Pip/Tazo in community-acquired pneumonia)

Question 21

Consider covering for legionella if risk factors. Name ris factors (7)

Answer 21

• Elderly, immunosuppression, smoker, lung disease
• T>39ºC
• Neurological (Confusion/Weakness/Gen det)
• GI (diarrhea)
• Electrolytes (Hyponatremia. hypophosphatemia, renal/hepatic dysfunction, thrombocytopenia, leukococytosis)
• Hematuria
• Hotel, cruise ships, residence (water reservoir contamination)

Question 22

Describe follow-up : Pneumonia ()

Answer 22

• Return if no improvements after 72h of treatment (fever should not return after 3d)
• IDSA recommends not routinely obtaining follow-up imaging if symptoms resolve within 7 days (low quality evidence)

Repeat CXR in 6w (r/o underlying disease) if
* >50yo or immunosuppressed, lung disease, alcohol, smoker, >5% weight loss in past month
* Extensive/necrotizing pneumonia

Question 23

Describe prevention : Pneumonia (3)

Answer 23

• Smoking cessation
• Hygiene (handwashing)

Vaccination
* Influenza
* Pneumococcal >65yo or comorbidity. Prevents invasive pneumococcal disease (bacteremia)