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Respiratory YR3 > Case 3 - Pneumonia, TB and Covid > Flashcards

Case 3 - Pneumonia, TB and Covid Flashcards

1
Q

Common organisms causing CAP

A

Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis

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2
Q

Atypical organisms causing CAP

A

Legionella pneumophilia
Chlamydia pneumoniae
Mycoplasma pnuemoniae

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3
Q

Causes of HAP

A

Escherichia coli
MRSA
Pseudomonas aeruginosa

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4
Q

What is key to assessment of pneumonia?

A

Prompt assessment
CXR on admission - consolidation seen

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5
Q

Differentials for CXR consolidation

A
  • Pneumonia
  • TB - upper lobes consolidation
  • Lung cancer
  • Lobar collapse - blockage of bronchi
  • Haemorrhage
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6
Q

What scoring system is used to manage and predict mortality rate of pts with pneumonia?

A

CURB 65 - use local prescribing guides according to this
Also A-E

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7
Q

Management of pneumonia

A
  • Depends on CURB 65 score
  • Do not delay abx (or IV fluids if indicated)
  • +/- Paracetamol
  • FBC, U&Es, CRP and sputum culture
  • ABG if low sats
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8
Q

Management of high CURB 65 score

A

ITU referral
Atypical pneumonia screen - serology and urine legionella test

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9
Q

CURB 65 score

A
  • Confusion, MMT 2 or worse
  • Urea >7mmol
  • RR 30 or more
  • BP 90 systolic or less OR 60 systolic or less
  • Age 65 or above
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10
Q

What is legionaires disease?

A
  • Form of pneumonia
  • Usually caused by legionella pneumophilia
  • Associated with infected water in showers or hot tubs
  • ASK pt recent travel or stay in a hotel?
  • Associated with higher CURB 65 scores
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11
Q

Pneumonia follow up

A
  • HIV Test
  • Immunoglobulins
  • Pneumococcal IgG serotypes
  • Haemophilus influezae b IgG
  • F/u in clinic 6 weeks for rpt CXR to ensure resolution
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12
Q

Causes of non-resolving pneumonia

A

Complication - empyema, lung abscess
Host - immunocompromised
Antibiotic - inadequate dose, poor oral absorption
Organism - resistant or unexpected organism not covered by emperical abx
Second diagnosis - PE, cancer, organising pneumonia (swirls of inflammatory tissue)

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13
Q

Range of effects of Covid 19

A
  • common cold –> SARS-Cov
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14
Q

What is SARS-Cov-2?

A

Severe acute respiratory syndrome related coronavirus 2 - name of virus, not the disease that results from it

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15
Q

Patients who require hospital admission with Covid 19:

A
  • Hypoxic
  • Lymphopaenia - low WCC
  • Bilateral, lower zone changes on CXR
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16
Q

Management for pts in hospital with Covid 19?

A
  • O2 supplementation, some onto CPAP or invasive ventilation
  • Evidence based Dexamethasone (and consider Tocilizumab +/- Remdesivir)
  • Abx may be needed if supsected superadded bacterial infection
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17
Q

Cliniical features of TB

A
  • Fever and nocturnal sweats - drenching
  • Weight loss - weeks/months
  • Malaise
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18
Q

Features of respiratory TB specifically

A
  • Cough +/- purulent sputum
  • Haemoptysis
  • Pleural effusion presentation?
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19
Q

Features of non-respiratory TB

A
  • Erythema nodosum (tender red lumps on shins)
  • Lymphadenopathy
  • Meningitis
  • Disseminated miliary TB?
  • Cardiac - pericardial effusion?
  • Abdominal symptoms
  • Bone and joint symptoms
20
Q

Differentials for haemoptysis

A

Infection:
* Pneumonia
* TB
* Bronchiectasis or cystic fibrosis
* Cavitating lung lesion (fungal?)

Malignancy:
* Lung cancer
* Mets

Haemorrhage:
* Bronchial artery erosion
* Vasculitis
* Coagulopathy

Other:
* PE

21
Q

TB risk factors

A
  • History of TB
  • Known TB contact
  • Born in country with high TB incidence
  • Foreign travel to country with high incidence
  • Immunosupression - IV drug use, HIV, solid organ transplant recipients, renal failure/dialysis, malnutrition/low BMI, DM, alcoholism
22
Q

Management principles (investigations) of TB

A
  • A-E and culture where possible
  • Side room and infection control (masks, negative pressure room)
  • If productive cough - 3x sputum samples for AAFB (Zeihl Neelsen) and TB culture
  • If non productive - consider bronchoscopy
  • Routine bloods - esp LFTs and include HIV test, Vit D levels
  • CT chest if TB suspected but clinical feattures/CXR not typical
23
Q

Management (drugs principles) of TB

A
  • If diagnosis between pneumonia and TB unclear - start abx for pnuemonia as per CURB 65 guideline while investigating TB
  • If critically unwell and high chance of TB (no time to wait for AAFB) then start anti TB medication AFTER sputum samples sent
24
Q

Who to notify with TB diagnosis?

A
  • TB nurse specialists - support patient in investigation, during treatment, public health issues and initiate contact tracing
  • Public health
25
Q

How long does TB culture take?

A
  • 6-8 weeks - so treatment often started before culture confirms sensitivity etc
  • Gene Xpert - novel PCR test is available in some centres which can give immediate info re sensitivity and resistance
26
Q

Regime and drugs for TB

A
  • 4 abx for 2 months, then 2 for a further 4 months = 6 months total minumum
  • Rifampicin - 6 months
    Isoniazid - 6 months
    Pyrazinamide - 2 months
    Ethambutol - 2 months
27
Q

What is important to measure for dose of anti-TB meds?

A

Weight - doses are weight dependent

28
Q

What to monitor/get a baseline of before anti-TB drugs commence?

A
  • Baseline LFTs and monitor - multiple TB drugs can cause hepatitis as side effect
  • Baseline visual acuity - Ethambutol can cause retrobulbar neuritis
29
Q

How do we help compliance with anti-TB drugs?

A
  • Compliance is crucial with anti-TB drugs
  • Direct observed therapy sometimes
  • Leaflets to show common side effects
  • Can detain if necessary under Public Health
30
Q

What is given alongside anti-TB treatment and why?

A

Pyridoxine - Vit B6 while on Isoniazid
Prophylaxis for peripheral neuropathy

31
Q

What to do if suspect CNS TB?

A
  • MRI brain scan - more likely to identify tubercles than CT
32
Q

Major side effects of Rifampicin

A

Rifampicin:
* Hepatitis
* Rashes
* Febrile reaction
* Orange/red secretions (inc contact lenses)
* Drug interactions eg warfarin, OCPs

33
Q

Major side effects of Isoniazid

A

Isoniazid:
* Hepatitis
* Rashes
* Peripheral neuropathy
* Psychosis

34
Q

Major side effects of pyrazinamide

A

Pyrazinamide:
* Hepatitis
* Rashes
* Vomitting
* Arthralgia

35
Q

Major side effects of ethambutol

A

Ethambutol:
* Retrobulbar neuritis

36
Q

Pneumonia care bundle

A
  • Controlled O2
  • Abx - depending on CURB 65 score
  • Prophylactic dalteparin
37
Q

Discharge criteria for pneumonia

A
  • Normal O2 sats
  • Normal Obs
  • Improved symptoms + CRP
  • F/u CXR in 6 weeks time arranged
38
Q

Management of anaphylactic reaction to drug

A
  • A-E assessment
  • Remove trigger
  • Maintain airway
  • IM adrenaline 0.5mg
  • Repeat every 5 mins
  • IV hydrocortisone 200mg
  • IV chlorphenamine 10mg (antihistamine)
  • Treat bronchospasm with Nebs salbutamol
  • Treat laryngeal oedema with Nebs adrenaline
39
Q

When do we treat latent TB?

A

Once active TB is excluded via CXR
* if close contact of active TB
* HIV/immunocompromised
* Any age and healthcare professional

May have anti-TB treatment fir 3 or 6 months and f/u CXR at 3 and 12 months to assess

40
Q

When can diagnosis of idiopathic cough be made?

A
  • Cough for more than 3 weeks
  • No clear cause of cough - normal ENT, CXR, CT, lung function tests, normal sputum culture etc
41
Q

Antibiotic treatment for CAP vs HAP

A

CAP - Amoxicillin
HAP - Co-amoxiclav

42
Q

CURB 65 score and management recommendation

A
  • A CURB-65 score of 0-1 requires home treatment
  • 2 requires consideration for hospital treatment
  • 3-5 would need hospital admission alongside consideration for ITU referral.
43
Q

Antibiotic choice for low severity pneumonia (CURB 65 of 0-1)

A
  • Amoxicillin
  • Doxycycline/clarithromycin/erythromycin if allergic to penicillin
44
Q

Gold standard for testing for Mycoplasma

A

Blood serology PCR

45
Q
A

Respiratory YR3 (14 decks)

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