community acquired pneumonia Flashcards
what is pneumonia ?
an acute infection characterized by clinical signs of consolidation along with radiological signs of consolidation
what are the different types of pneumonia ?
CAP - acquired in community
HAP - in hospital ( more than 48 hours of admission)
VAP - on mechanical ventilation for more than 48 hours on ventilator
what are the different routes of transmission associated with pneumonia ?
inhalation
aspiration
colonization
blood spread
associated with viruses and atypical bacteria
what are the causes of having an unprotected airway and what are thee associated organisms ?
cerebrovascular stroke
alcohol
hypnotics
which can all cause aspiration, associated with oral flora which is anaerobic bacteria
what are the reasons behind colonization in pneumonia and what are the associated organisms ?
pre-existing lung disease :
bronchieactsis
chronic bronchitis
cystic fibrosis
variable organisms
what are the causes of bacteremia what are the associated organisms ?
IV drug addiction
intravenous cannula
heamodialysis
staph aureus, gram negative bacteria
what are the stages of pneumonia ?
congestion
red hepatization
grey hepatization
resolution
what does incomplete resolution in pneumonia result in ?
permanent scaring
how long do the stages pf pneumonia take ?
7-10 days
what is the clinical picture of atypical pneumonia ?
extra-thoracic affection
otitis, pharyngitis
haemolytic anemia
GI symptoms
confusion
hyponatraemia
in terms of pathology what is different about atypical pneumonia ?
formation of hyaline tissue
superimposed infection
what are the microorganisms causing atypical pneumonia ?
legionella pneumonia
mycoplasma pneumonia
chalmydia pneumoniae
what routine investigations would be performed on a patient suspecting pneumonia ?
chest x-ray CT Chest CBC ABG BUN ( renal function) divide urea by 2
what would the findings be on auscultation ?
reduced breathing sounds
bronchial breathing
crackles
what are the radiological findings with atypical pneumonia vs bacterial pneumonia ?
ground glass opacities in atypical pneumonia
consolidations in bacterial pneumonia
what is required to make a diagnosis of severe pneumonia ?
IDS/ATS criteria
1 major or 3 minor
what are the major criteria for pneumonia ?
- septic shock with need for vasopressors
- respiratory failure in need of mechanical ventilation
- respiratory failure requiring mechanical ventilation
what are the minor criteria ?
respiratory rate less than 30 hypotension corrected by IV fluids hypothermia confusion leukopenia thrombocytopenia uremia PaO2/FiO2 ratio is less than 250 multi lobar infiltrates
what are the specific tests for a case of pneumonia ?
1- sputum gram stain
2- sputum culture and sensitivity
3- blood culture and sensitivity
4- urinary antigen for legionella and pneumococcal bacteria
molecular test (PCR)
5- procalcitonin levels
what are the specific situations where it is required to make those special tests ?
patients managed inn the hospital AND have severe pneumonia according to the IDSA/ATS criteria
or
have risk factors for specific/resistant bacteria
- patients who have risk factors for specific/resistant bacteria
what is the target sample to test with intubated patients ?
endotracheal aspirate
what are the risk factors for acquiring specific/resistant bacteria ?
- recent hospitalisation and receipt of recent IV antibiotics inn the last 90 days
- previous isolation of pseudomans aeruginosa or MRSA
- presence of comorbidities
when would it be necessary to carry out a urinary antigen test ?
legionella outbreak/recent travel
or
severe pneumonia
when would a PCR resting of influenza be required ?
in influenza outbreaks or in pandemics like COVID-19
what may help in the differentiation between bacterial or viral pneumonia ?
procalcitonin
a high level of procalcitonin may be an indication of bacterial infection
how do we decide the site of care for a pneumonia patient ?
CURB-65 score
what does the CURb-65 score measure ?
confusion BUN level ( below 20 ) Respiratory rate ( below 30 ) low blood pressure (90/60) and an age of 65 years old
what scores indicate what location with the CURB-65 ?
0-1 at home outpatient
2 - ward
3-5 then the ICU
what is the treatment for a patient who scored 0-1 on the CURB-65 ?
depends on comorbidities and no risk of MRSA
no comorbidities :amoxycillin OR doxycilline OR macrolide
with comorbidities : we give a combination therapy of
amoxicillin/clauvanate + macrolide
OR
fluoroquinolone ( mono therapy)
if the patient is an inpatient ( score of 2 in the CURB-65), what treatments are required ?
IF NON SEVERE: give a combination of b lactam and macrolide OR fluoroquinolone IF SEVERE : give a combination of b lactam and macrolide OR B lactam and fluoroquinolone
what must the patient take if there is a risk of acquiring resistant/MRSA/p.aeruginosa ?
Anti-MRSA or
Anti-P.aeruginosa
what are examples of macrolides ?
azithromycin
clarithomycin
what are examples of fluroquinolones ?
levofloxacin
moxifloxacin
what are the antibiotics effective against MRSA?
vancomycin
linezolid
what is aspiration pneumonia caused by ?
anaerobic bacteria
when do you add anti-anerobic antibiotics in aspiration pneumonia ?
only when the patient develops complications including lung abscess or empyema ( clindamycin)
when should corticosteroids be used ?
only in CAP patients who are in septic shock that are not responsive to resuscitation and vasopressor support
when do you follow up on the patient when managing pneumonia ?
after 3 days - 72 hours
when do we diagnose non-responding pneumonia ?
if there is deterioration or no clinical improvement in antibiotic therapy that has lasted 5-7 days
what are the causes of non responsive pneumonia ?
doctor related
organism related
patient related
what can be done to prevent pneumonia ?
vaccination against influenza
vaccination against pneumococcal polysacchride vaccine
what are the types of influenza vaccine ?
inactivated influenza vaccine
recombinant influenza vaccine
live attenuated influenza vaccine
when is the live attenuated vaccine contraindicated ?
pregnant women
immunosuppression
adults older than 65
history of allergic reaction
in order to make a diagnosis of severe pneumonia using the IDSA/ATS criteria how many of each do wee need ?
1 major
or
3 minor
what is the treatment for P.areguinosa ?
levofloxacin or meropenem
what is the presentation of legionella pneumonia ?
associated with legionnaires disease
look for hyponatraemia and deranged LFTs
how is legionella pneumonia spread ?
through aerosolized water particles - bad air conditioning
what is the synonym for klebsiella pneumonia ?
friedlanderrs pneumonia
which type of patients are at a higher risk of developing klebsiella ?
diabetics and alcoholics
what is seen on chest x ray of a patient with klebsiella ?
fissure bulging sign ( due to massive enlargement of the right upper lobe )
what is distinctive about the appearance off the sputum of klebeisella ?
red currant sputum
