Acute pneumonia

Question 1

How do patients with acute pneumonia classically present?

Answer 1

Cough, fever, SOB, CP, abnormal CXR, prodromal Sx (coryza, headache, muscle ache)

Immunocompromised –> agitation, fever, tachypnoea, red. SpO₂, CXR signs may be more subtle

Question 2

What are some common causative organisms of community-acquired and atypical pneumonia?

Answer 2

CAP –> Strep. pneumoniae, Influenza A / B, Haemophilus, Staph. aureus, Moraxella catarrhalis

Atypical –> Mycoplasma, Chlamydia pneumoniae, Legionella

Question 3

What does the CURB-65 consist of, and how is it used?

Answer 3

Confusion –> AMTS < 9
Urea > 7
RR > 30
BP < 90 / 60
Age = 65+

Score 3+ –> admit with severe pneumonia
Score 2 –> short-stay inpatient or hospital-supervised OP
Score 0-1 –> home treatment

Question 4

How would you resuscitate a patient with acute pneumonia?

Answer 4

ABCDE, involve senior, urgent CXR

Venous access –> IV crystalloids unless overloaded

ABG –> correct hypoxia with at least 35% O₂ unless in T2RF (controlled therapy)

Culture blood + sputum

Analgesia –> paracetamol / NSAID

Question 5

What investigations would you order for a patient with acute pneumonia?

Answer 5

Bedside –> ECG, sputum culture (Gram stain +- ZN stain)

ABG on air and O2

Bloods –> FBC, U&E, LFT, ESR, CRP

Pleural fluid aspiration (if present) –> MCS, protein, pH

Misc. –> Pneumococcal antigen, Legionella antigen, cold agglutinins (Mycoplasma), and serology

Question 6

Answer 6

Question 7

After initial resusciation and investigation, how would you manage the patient with acute pneumonia?

Answer 7

Initiate ‘blind’ treatment after cultures sent using local hospital guidelines.

Oxygen therapy –> aim for 94-98% (88-92% if COPD)

Continue IV fluids + VTE prophylaxis

Monitor response –> FBC, CRP, ABGs, CXR at day 3-5

Follow up –> CXR 4-6 weeks to exclude underlying endobronchial lesion

Question 8

What is the empirical therapy for community-acquired pneumonia?

Answer 8

Mild –> AMOXICILLIN 500mg tds PO

Moderate –> AMOXICILLIN 500mg-1g tds plus CLARITHROMYCIN or DOXYCYCLINE

Severe –> CO-AMOXICLAV 1.2g tds plus CLARITHROMYCIN 500mg bd IV or CEFUROXIME / CEFOTAXIME plus CLARITHROMYCIN 500mg bd IV

Question 9

What is the empirical therapy for hospital-acquired pneumonia?

Answer 9

CEFOTAXIME +- METRONIDAZOLE

Question 10

What is the empirical therapy for post-influenza pneumonia?

Answer 10

AMOXICLLIN plus CLARITHROMYCIC plus FLUCLOXACILLIN

S. aureus more likely after influenza

Question 11

What is the empirical therapy for MRSA pneumonia?

Answer 11

AMOXICILLIN plus CLARITHROMYCIN plus VANCOMYCIN

Question 12

What is the empirical therapy for aspiration pneumonia?

Answer 12

CERUFOXIME plus METRONIDAZOLE

Question 13

What are some possible complications of acute pneumonia?

Answer 13

Respiratory failure
Hypotension
Atrial fibrillation (transient)
Pleural effusion
Empyema
Abscess
Septicaemia
Jaundice (cholestatic, septic, 2⁰ to abx)