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CAP Flashcards

1
Q

Bob presents to primary care with symptoms of a LRTI. A point of care CRP is done, which is 18. Should he be given abx?

A

No - NICE guideline. For pts presenting in primary care with symptoms of LRTI, consider point of care CRP if diagnosis of pneumonia not made and not clear whether abx should be given.
- <20 = no
- 20-100 = consider delayed prescription (they can cash if symptoms worsen)
- >100 = give abx

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2
Q

Sue presents to GP with CAP. She is lucid, has a RR of 30 and is 72. BP 120/80. What is her mortality?

A

1-10% (intermediate risk)

Primary care: CRB65 score
Confusion, RR ≥30, BP≤ sys90 or dias 60, ≥65

0 (low risk) <1% mortality
1-2 (intermediate) 1-10%
3-4 (high) >10%

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3
Q

For the primary care CRB65 score, where should care be considered?

A

Confusion, RR ≥30, BP≤ sys90 or dias 60, ≥65

0 = home based care
1-2 consider hospital referral
3+ urgent hospital admission

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4
Q

Bob has a CAP. He is confused, has a urea of 7.5, RR 20, BP 120/70, age 42. What is his mortality? What is his CURB-65 score?

A

CURB 2 = 3-15% mortality (intermediate risk)

CURB-65: confusion, urea >7, RR ≥30, BP ≤60(dias) ≤90(sys), age ≥65

0-1: low risk (<3% mortality)
2: intermediate (3-15%)
3-5: high (>15-40%)

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5
Q

Sue has a CAP. She is not confused, has a urea of 6.5, RR 40, BP 90/60, age 72. What is her CURB-65 score? What is her mortality?

A

CURB = 3. Mortality >15%

CURB-65: confusion, urea >7, RR ≥30, BP ≤60(dias) ≤90(sys), age ≥65

0-1: low risk (<3% mortality)
2: intermediate (3-15%)
3-5: high (>15%)

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6
Q

Where should patient with CURB score 3 be managed?

A

Reviewed early by senior physician. Usually should be managed as high severity

0-1: consider home based care
2+: consider hospital
3+: hospital. review by senior physician
4+: need assessment for specific consideration of ITU

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7
Q

What microbiological tests should be done in patient with low severity CAP?

A

None

Low - none
Moderate/high - blood + sputum cultures, consider pneumococcal and legionella antigen

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8
Q

Carl presents with CAP. He is not confused and has normal obs. He has had an XR. Should any further tests be done?

A

No - doesn’t need micro.

Low - none
Moderate/high - blood + sputum cultures, consider pneumococcal and legionella antigen

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9
Q

How quickly should patients with CAP be treated when present to hospital?

A

Within 4 hours (treatment and diagnosis)

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10
Q

How often should CRP be monitored in patients with CAP and in hospital?

A

Consider baseline and repeat if clinical progress uncertain after 48-72 hours.

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11
Q

Bob has CAP. He is on abx. He wants to go home. His obs are: T38, HR80, RR 18, BP 100/80. Can he safely be discharged?

A

Could be considered for discharge but likely delay.
Do not routinely discharge if 2 or more of:
- T > 37.5 (consider delaying if this even without other features)
- RR ≥24
- HR >100
- Sys BP ≤90
- O2 SATS <90% on RA
- abnormal mental status
- inability to eat without assistance

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12
Q

Jane is being discharged from hospital where she was treated for CAP. How long before she can expect to be back to normal?

A

Up to 6 months

1 week: fever
4 weeks: chest pain and sputum production reduced
6 weeks: cough and SOB substantially reduced
3 months: most symptoms gone but may be fatigued
6 months: feel back to normal

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13
Q

Jane is being discharged from hospital where she was treated for CAP. How long before she can expect the cough to last?

A

Should be substantially reduced by 6 weeks

1 week: fever
4 weeks: chest pain and sputum production reduced
6 weeks: cough and SOB substantially reduced
3 months: most symptoms gone but may be fatigued
6 months: feel back to normal

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14
Q

Jane is being discharged from hospital where she was treated for CAP. How long before she can expect the fatigue to last?

A

Should be back to normal by 6 months.

1 week: fever
4 weeks: chest pain and sputum production reduced
6 weeks: cough and SOB substantially reduced
3 months: most symptoms gone but may be fatigued
6 months: feel back to normal

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15
Q

Bay has CAP. His CURB score is 0. What abx should he be given?

A

NOTE, BTS SAYS 7 DAYS FOR DURATIONS AND 7-10 FOR HIGH

CURB65 0-1/low severity:
- Amoxicillin 500mg TDS for 5d.
- Pen allergy/aytpical suspected: Doxycycline 200mg for 1d then 100mg for 4d OR Clarithromycin 500mg BD 5d OR Erythromycin 500mg QDS 5d (pregnancy)

CURB 2/moderate severity:
- Amoxicillin 500mg TDS for 5d +/- Clarithromycin (if atypical suspected) OR Erythmycin (pregnancy)
- Pen allergy: Doxycycline 200mg for 1d then 100mg for 4d OR Clarithromycin 500mg BD (or Levo or Moxi)

nb. if already tried amoxicillin, consider monotherapy macrolide
nb. if PO not possible, IV amox/benpen + clari, or in pen allergy mono levo or clari + cefuoxime/cefotaxime/ceftriaxone

CURB 3-5/high severity:
- Co-Amoxiclav 500/126 TDS or 1.2g IV TDS for 5d + Clarithromycin 500mg (oral or IV) OR Erythromycin 500mg QDS 5d (pregnancy)
– Pen allergy: Clari + Cefuoxime/Cefotaxime/Cetriaxone (NICE say Levofloxacin 500mg (oral or IV) BD for 5d)

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16
Q

Bay has CAP. His CURB score is 3. What abx should he be given?

A

NOTE, BTS SAYS 7 DAYS FOR DURATIONS AND 7-10 FOR HIGH

CURB65 0-1/low severity:
- Amoxicillin 500mg TDS for 5d.
- Pen allergy/aytpical suspected: Doxycycline 200mg for 1d then 100mg for 4d OR Clarithromycin 500mg BD 5d OR Erythromycin 500mg QDS 5d (pregnancy)

CURB 2/moderate severity:
- Amoxicillin 500mg TDS for 5d +/- Clarithromycin (if atypical suspected) OR Erythmycin (pregnancy)
- Pen allergy: Doxycycline 200mg for 1d then 100mg for 4d OR Clarithromycin 500mg (or Levo or Moxi)

nb. if already tried amoxicillin, consider monotherapy macrolide
nb. if PO not possible, IV amox/benpen + clari, or in pen allergy mono levo or clari + cefuoxime/cefotaxime/ceftriaxone

CURB 3-5/high severity:
- Co-Amoxiclav 500/126 TDS or 1.2g IV TDS for 5d + Clarithromycin 500mg (oral or IV) OR Erythromycin 500mg QDS 5d (pregnancy)
- Pen allergy: Clari + Cefuoxime/Cefotaxime/Cetriaxone (NICE say Levofloxacin 500mg (oral or IV) BD for 5d)

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17
Q

Bay has CAP. His CURB score is 2. What abx should he be given?

A

NOTE, BTS SAYS 7 DAYS FOR DURATIONS AND 7-10 FOR HIGH

CURB65 0-1/low severity:
- Amoxicillin 500mg TDS for 5d.
- Pen allergy/aytpical suspected: Doxycycline 200mg for 1d then 100mg for 4d OR Clarithromycin 500mg BD 5d OR Erythromycin 500mg QDS 5d (pregnancy)

CURB 2/moderate severity:
- Amoxicillin 500mg TDS for 5d +/- Clarithromycin (if atypical suspected) OR Erythmycin (pregnancy)
- Pen allergy: Doxycycline 200mg for 1d then 100mg for 4d OR Clarithromycin 500mg BD (or Levo or Moxi)

nb. if already tried amoxicillin, consider monotherapy macrolide
nb. if PO not possible, IV amox/benpen + clari, or in pen allergy mono levo or clari + cefuoxime/cefotaxime/ceftriaxone

CURB 3-5/high severity:
- Co-Amoxiclav 500/126 TDS or 1.2g IV TDS for 5d + Clarithromycin 500mg (oral or IV) OR Erythromycin 500mg QDS 5d (pregnancy)
- Pen allergy: Clari + Cefuoxime/Cefotaxime/Cetriaxone (NICE say Levofloxacin 500mg (oral or IV) BD for 5d)

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18
Q

Mr Blob is at the GP. He has symptoms consistent with pneumonia? He has no co-morbidities. What investigations should he have?

A

Pulse oximeter
- XR only needed if diagnostic doubt, unsatisfactory progress on treatment, or at risk of underlying lung pathology e.g. cancer

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19
Q

When should CXR be repeated for CAP?

A

6 weeks if: (whether admitted to hospital or not)
- persistent symptoms or signs
- high risk of underlying malignancy (smoker, >50)

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20
Q

What investigations should be considered if persistent signs, symptoms and radiology, 6 weeks after CAP?

A

Bronchoscopy

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21
Q

What investigations should be done in pt admitted to hospital with CAP?

A

SATS +/- arterial blood gas
CXR to confirm diagnosis
U&E for severity assessment
CRP to aid diagnosis and provide baseline
FBC
LFTs

Micro if mod-severe CAP or low severity + epidemiological/co-morbidity/prior abx reasons
- mod: blood +/- sputum (if can expectorate and haven’t had abx)
- sev: blood + sputum

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22
Q

What microbiological investigations for CAP should be carried out in the community?

A

Not routine.
Sputum if not responding to empirical therapy
TB if associated symptoms/risk factors
Urine Ag, PCR tests or serology may be considered during an outbreak/epidemic/epidemiological/clinical reasons

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23
Q

When should blood cultures be done for CAP?

A

Mod-High severity in hospital

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24
Q

When should sputum cultures be done for CAP??

A

High severity.
Moderate + expectorating with no abx yet given
Community if failure to respond

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25
Q

When should sputum Legionella be sent?

A

If legionella Ag positive (in order to get isolates for epidemiological typing and comparison to environmental sources)
OR if bronch samples

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26
Q

When should gram stain be done on sputum?

A

High severity CAP or complications.

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27
Q

When should pneumococcal Ag be sent?

A

Mod-high severity CAP

28
Q

When should legionella Ag be sent?

A

High severity CAP (note NICE say mod-high)

29
Q

How should mycoplasma pneumonia be tested for?

A

PCR on sputum if possible.
If clinical /epidemiological suspicion and no sputum, can do on throat swab

30
Q

How do you test for Chlamydophila?

A

Ag or PCR on BAL in high severity CAP or where strong suspicion of psittacosis

31
Q

What is psittacosis?

A

Mild illness caused by chlamydophila species, found in birds (particularly parrots, parakeets, budgies, cockatiels)
- rare: endocarditis, hepatitis, neurologic complications

Tx: doxycyline

32
Q

Mr Fox as moderate severity CAP. What microbiological investigations should be carried out?

A

Blood, sputum if not received abx, pneumococcal Ag, pleural fluid, PCR for mycoplasma/viruses if periods of high activity, legionella Ag if suspected

33
Q

When and how should test for viral causes of CAP?

A

Viral PCR in periods of high viral activity.
Can do paired serology if high severity CAP and no other microbiological diagnosis made or during periods where surveillance by hospital needed

34
Q

How often should high risk CAP patient be reviewed?

A

Every 12 hours until improving

35
Q

What pain killer should be given to manage pleuritic pain?

A

Paracetamol

36
Q

When should pt with CAP being managed in community be reviewed?

A

48hrs or earlier. If not improvement, consider CXR or hospital assessment

37
Q

If person has uncomplicated CAP, when should they get out of bed?

A

At least 20min in first 24 hours

38
Q

When should CRP be repeated in hospital patient?

A

Repeat at day 3 with CXR if not progressing

39
Q

Can a patient with CAP and a temp of 37.9 be discharged home?

A

Maybe suitable if not more than one of: (unless baseline)
T>37.8, HR>100, RR>24, BP<90, O2<90, inability to maintain oral intake, abnormal mental status

40
Q

Where should pt with CAP requiring NIV be managed?

A

HDU/ITU

41
Q

Should steroids be given for CAP?

A

Not routine

42
Q

Should granulocyte colony stimulating factor be given in CAP?

A

Not routine

43
Q

When should pt discharged after CAP be followed up?

A

6 weeks by GP or hospital clinic. Should be given information/leaflet on discharge.

44
Q

When/what should GP administer abx in suspected CAP where illness high severity?

A

If life-threatening or delays >6hrs expected, then should give Penicillin G 1.2g IV or amoxicillin1g PO

45
Q

When should first dose of abx be given to pt in hospital with suspected CAP?

A

Ideally get CXR first, but if life threatening then give presumptive dose
All should have within 4 hours

46
Q

Pt is on IV treatment for CAP. When should step down to oral?

A

If clinically improved and temp normal for 24hrs

47
Q

How should empirical therapy for CAP be changed if no positive micro?

A

Add in macrolide if not already done.
Otherwise change to Doxy or fluoroquinolone
Or adding fluoroquinolone if high severity

48
Q

What should happen if legionella pneumonia confirmed?

A

Refer to public health to look for source.
Send of sputum to get culture

49
Q

What abx should be given for legionella pneumonia?

A

Low-mod severity: oral fluoroquinolone or macrolide 7d

High severity: Fluoroquinolone +/- marolide (clari or azithromycin or rifampicin) 7-10 days- note risk of ECG abnormalities if quinolone-macrolide combo

Nb. Pontiac fever = non-pneumonic Legionella disease (headache, cough, fever) and doesn’t need treatment

50
Q

How should necrotising pneumonia be treated?

A

IV linezolid 600mg BD, Clindamycin 1.2g QDS, Rifampicin 600mg BD

51
Q

Necrotising pneumonia + skin abscesses. ?cause

A

PVL Staph aureus

52
Q

What bacteria can cause abscess in CAP?

A

S.aureus, gram +ve enteric bacilli, S.milleri, anaerobes

53
Q

How long should abx therapy be in empyema or abscess

A

6 weeks if not drained

54
Q

Who should have a pneumococcal vaccine?

A

> 65 or at risk pf pneumococcal disease admitted with CAP and who haven’t had already. Should get 23 valent vaccine

55
Q

When should smoking cessation advice be given in CAP?

A

All patients who smoke

56
Q

Jim has symptoms of CAP. He has no comorbidities and obs are normal. What micro tests should be done?

A

None

Low severity CURB 0-1 or CRB 0. <3% mortality
- no routine micro, may consider urine Ag or serology in outbreaks

Mod severity CURB 2. 9% mortality - blood culture, sputum if no prior abx, pneumococcal Ag, pleural fluid, PCR or serology if high viral/mycoplasma times, legionella Ag is suspected

High severity CURB 3-5. 15-40% mortality - blood & sputum cultures, pleural fluid, pneumococcal and legionella Ag, PCR for virus + atypicals

57
Q

What abx do you use for S.pneumonia?

A

Amox 500-1g tds PO or benpen 1.2g qds IV
Alt: Clari 500mg bd or cefuroxime 0.75-1.5g tds IV or cefotaxime 1-2g tds IV or ceftriaxone 2g od IV

58
Q

What abx do you use for M or C pneumonia?

A

Clari 500mg bd PO or IV
Alt: Doxy 200 then 100mg od PO or fluoroquinolone PO/IV

59
Q

What abx do you use for C.psittaci or C.burnetti?

A

Doxy 200mg then 100mg od
Alt. Clari PO or IV

60
Q

What abx do you use for Legionella?

A

Fluoroquinolone PO/IV
Alt: Clari PO/IV (or Azithromcyin)

61
Q

What abx do you use for H.influenza?

A

Non beta lactamase producing: amox PO/IV
Beta lactamase: co-amox PO/IV
Alt: cefuroxime 0.75-1.5g tds IV or cefotaxime 1-2g tds IV or ceftriaxone 2g od IV or fluoroquinolone PO/IV

62
Q

What abx do you use for gram negative enteric bacilli? E.coli, proteus, klebsiellla, Enterobacter, Serratia, Citrobacter

A

cefuroxime 0.75-1.5g tds IV or cefotaxime 1-2g tds IV or ceftriaxone 2g od IV
Alt: fluoroquinolone IV or imipenem 500mg qds IV or meropennem 0.5-1g tds IV

63
Q

What abx do you use to treat pseudomonas?

A

Ceftazidine 2g tds IV + gen or tobramycin
Alt: ciprofloxacin 400mg bd IV or Tazocin 4g tds IV plus gent or tobra

64
Q

What abx do you use to treat S.aureus?

A

Non-MRSA: flucloxacillin 1-2g QDS IV +/- rifampicin 600mg od/bd PO/IV
MRSA: vancomycin 1g bd IV or linezolide 600mg bd IV or teicoplanin 400mg bd IV +/- rifampicin 600mg od/bd PO/IV

65
Q

What abx do you use for aspiration pneumonia?

A

Co-Amox

66
Q

What AMTS score counts as confusion for CURB score?

A

<=8

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