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Unit 13 > Community Acquired Pneumonia UK Lecture > Flashcards

Community Acquired Pneumonia UK Lecture Flashcards

1
Q

What are some differential types of respiratory tract infections?

A

Tracheitis
Acute bronchitis
Infective exacerbation COPD
Infective exacerbation bronchiectasis
Pneumonia
Lung abscess
Empyema

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2
Q

What is the definition of pneumonia?

A

Inflammation of the lung parenchyma leading to consolidation
Does not always need to be infectious (cryptogenic organising pneumonia) .
Is most commonly bacteria

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3
Q

What is the clinical definition of pneumonia?

A

Infection of the air-space lung
Symptoms of LRTI with CXR changes (usually consolidation)
Usually related to bacterial infection

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4
Q

Define community acquired pneumonia

A

Pneumonia acquired outside hospital or health care facilities

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5
Q

Define hospital acquired pneumonia.

A

Pneumonia acquired at least 48hrs into hospital admission that wasn’t incubating on admission.
Recently hospitalised patients can be treated as CAP unless additional risk factors for MDRs/HAP such as recent Ab use.

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6
Q

What is the key epidemiology of pneumonia?

A

Affects 1 in 10 adults every year
Almost 80% of cases are treated in primary care
Disproportionatly effects older population, doubling incidence in over 65yrs, then against in over 85yrs.
Disproportionaly affects people from socioeconomic deprivared backgrounds, with 70% higher incidence in NE versus london.

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7
Q

How does pneuomia affect health care stats?

A

More hospital admissions and bed days than any other lung disease
3rd most common cause of death from lung disease
Most common cause of sepsis presenting in ED.
Most common admission diagnosis to ICU, with a 30% mortality
Most common cause of ARDS.
Survivors have increased mortality rates at 1,5 and 7yrs.

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8
Q

What bacteria are the most common causes of typical pneumonia?

A

Streptococcus pneumonia
Haemophilius influenza
Moraxella catarrhalis
Staphylococcus aureus

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9
Q

What bacteria are the most common causes of atypical pneumonia?

A

Mycoplasm pneumoniae
Chlamydophila pneumoniae
Chlamydia psittaci
Legionella pneumonia

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10
Q

What is the difference between typical and atypical pneumonia?

A

Atypical pneumonia - current pathogen are hard to detect through common bacterial testing methods
Cases tend to have slightly different symptoms, slightly different appearance of chest x-ray, respond slightly different to empirical antibiotics used to CAP. Typically do not respond to B-lactam penicillins.

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11
Q

What bacteria can cause CAP? (not typical or atypical)

A

Pseudomonas aeruginose
Enterobacteriaceae
Group A streptococcus.

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12
Q

What viral pathogens commonly cause CAP?

A

Influenza A
Influenza B
Parainfluenza
Rhinovirus
Metapneumovirus
Respiratory syncytial virus
Corona virus

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13
Q

What pathogens cause hospital acquired pneumonia?

A

Aerobic gram negative bacilli
Specific: Pseudomonas aeruginose, escheria coli, Klebsiella pneumonia
Also Acinetobacter MRSA.

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14
Q

What are the different ways you can become infected with a pathogen leading to pneumonia?

A

Inhaled - air droplets
Aspiration from oropharynx - more common in compromised swallow (stroke) or during dental disease
Direct spread - saliva in kissing etc
Haemotogenous spread - Mycotis emboli

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15
Q

What patient history indicates most likley pneumonia?

A

Detect symptoms consistent with CAP (fever, cough, sputum)
Defects of immunity
Risk of exposure to specific pathogens

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16
Q

What are the key symptoms of pneumonia?

A

Cough - often with sputum production
Pleuritic chest pain
Chills, rigors, fever
Breathlessness
Haemoptysis
Malaise
Arthralgia
Myalgia.
Note in elderly and immunocompromised these tend to be more subtle

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17
Q

What symptoms in pneumonia can indicate legionellla as a cause?

A

Confusion
GI upset
Hyponatraemia (inappropraite ADH secretion)
Transaminitis (elevated transanimases - liver enzymes)
Lymphopaenia - reduce wcc

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18
Q

What symptoms in pneumonia indicate that mycoplasm as a cause?

A

Tend to be younger patients
Myringitis (Ear infection)
Uveitis (inflammation of middle eye)
Iritis (inflammation of iris)
Encephalitis (inflammation of the brain)
Myocarditis

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19
Q

What are some social/psychological risk factors for pneumonia?

A

Residence in a healthcare setting
Cigarette smoke exposure
Alcohol abuse
Contact with children

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20
Q

What are some biological risk factors from pneumonia?

A

Age - above 65yrs
COPD
HIV infection
Poor oral hygiene
Pharmaceuticals - PPI, inhlaed corticosteroids, antipyschotics, antidaibetic drugs, opioids
Diabetes mellitus
Chronic liver disease
Chronic kidney disease
Sickle cell disease
Splenectomy

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21
Q

What are some common differential diagnosis for pneumonia?

A

Left ventricular failure
Pulmonary embolus
Infective exacerbation COPD
Infective exacerbation bronchiectasis
Acute asthma
TB
Empyema
Lung neoplasm (primary or secondary)
Oesophageal rupture (gastric content into mediastinum - chest pain)

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22
Q

What is a patients history should indicate that an atypical pathogen is more likely?

A

Foreign travel
Prior antibiotics or hyponatraemia (mycoplasm)
Air conditioning exposure
Diarrhoea
Abnormal LFTs
Neurological symptoms
Prior Abs against legionella
Headache - chlamydophilia pneumoniae
Sub-acute presentation - weight loss, exposure ot pst history of TB
NH resident, swallowing issues, history of LoC with vomiting e.g alcohol, sexiures (aspiration pneumonia gram -ves and anaerboes)

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23
Q

On examination what should you look for in a pneumonia suspected patient?

A

Fever
Cyanosis, tachypnoea, dyspnoea
Tachycardia, hypotension - indicate sepsis/septic shock
Localising signs - dullness to percussion, bronchial breathing and crackles
AVPU

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24
Q

What is the purpose of a CXR in pneumonia diagnosis?

A

Needed to confirm diagnosis - before CXR is only suspected CAP/HAP
Result - consolidation with air bronchogram accompanied with symptoms of a LRTI
Severe CXR with little clinical signs can indicate legionella/mycoplasm
UZ changes - indicate M.Tb

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25
Q

What are the BTS standard regarding CXR use in diagnosing pneumonia?

A

CXR and CAP confirmed must be had within 4 hours of admission.

26
Q

What is the use of a CURB-65 score in diagnosing pneumonia?

A

Confusion - ABMT score of less than or equal to 8
Urea - above 7 mmol/L
RR - equal to or above 30bpm
BP - SBP <90 or DPB</=60 mmHg
Age - >/=65 years old
Score should always be recorded in notes
Measures risk of mortality in 30 days of patient to give appropriate level treatment and monitoring (IP or OP)
Only applicable for immunocompetent CAP patients.
Each of the above scores 1 point.

27
Q

How should CURB65 score be interpreted?

A

30 day mortality risk based on score
Low severity: 0 to 1 score: <3% mortality
Moderate severity: 2 : 9% mortality
Higher severity: 3 to 5: 15-40% mortality.

28
Q

What is required to diagnose a patients with severe CAP by ATS/IDSA criteria?

A

1 major or 3 minor criteria from checklists.

29
Q

What is a major indicator for severe CAP by ATS/IDSA?

A

Respiratory failure requiring mechanical ventilation
Septic shock with need for vasopressors.

30
Q

What is a minor indicator for severe CAP by ATS/IDSA?

A

RR >/= 30 bpm
PaO2 equal to or less than 33.33 kPa
Multilobar infiltrates
Confusion/disorientation
Urea >/= 7.14 mmol/L
Leukopenia due to infection alone = WBC , 4x10^9
Thrombocytopenia <100x10^9
Hypothermia temp <36
Aggressive fluid resuscitation

31
Q

What is the pneumonia severity index?

A

Considers patient factors such as demographics, co-morbidities, physical signs/vital signs and laboratory/imgaging to calculate a risk score
Risk score aligns with a risk class with an associated mortality % and recommended appropriate location of care.

32
Q

What do the different values of the PSI (pneumonia severity index) indicate?

A
33
Q

How factors are used to calculate the PSI (pneumonia severity index) score?

A

Demographics
Age (1p per year, -10 for females)
NH resident +10

Co-morbidities
Neoplasia +30
Liver disease +20
CHF, cerebrovascular disease, renal disease +10

Physical signs
Mental confusion, RR, SBP +20
Temperature +15
Tachycardia +15

Laboratory/imaging
Arterial pH +30
BUN, sodium +20
Glucose, Hematocrtic, pleural effusion, oxygenation +10

34
Q

What routine blood should be ordered for a patient with suspected pneumonia?

A

FBC
U&Es
LFTs
CRP and Procalcitonin
ABGs, look for T2RF and SpO2

35
Q

What additional tests should be ordered for a patient with medium to high severity CAP?

A

Blood cultures and antibodies
Sputum cultures and sample
Pneumococcal/legionella urinary antigen testing
Paired serology is not responding to treatment.

36
Q

What other unique investigations should be done in specialist cases of pneumonia patients?

A

HIV testing in younger patients or if known risk factors present
AFB cases and isolated if risk factors or clinical concern if TB.

37
Q

How does the location of patient management vary in pneumonia?

A

Is CURB 1 or below consider treatment from home is stable co-morbidities and social circumstances allow
Is CURB 2 or greater treat from hospital
May also treat from hospital if CURB is lower but with unstable co-morbidities and unsafe social circumstances
CURB greater than 3, requires critical care review or decide if WBCOC is best.

38
Q

What are some reasons why a pneumonia patient may be contraindicated for outpatient therapy?

A

Inability to maintain oral intake
History of substance abuse
Severe comorbid illnesses
Cognitive impairment
Impaired functional status
Availability of support at home.

39
Q

How might ultrasound be used to image pneumonia?

A

Is quick, simple, cheap, relaible and assess pleural collection
Sometimes misdiagnosed as interstitial pneumonia or diffuse disease
Lung will appear hepatisied, may also have signs of pleural effusion.

40
Q

How might chest CT be used to image pneumonia?

A

Provides the most information
Access ionzing raditaion
5% admissions CXR non-diagnostic
CT confirms these diagnoses
Can see areas of consolidation and air bronchograms.

41
Q

What management is offered to all pneumonia inpatients?

A

Oxygen to keep SpO2 between 94-98%, or 88-92% is T2RF
Intravenous fluid is hypotensive of AKI
VTE prophylaxis (low dose LMWH)
Nutritional support if prolonged illness
Sitting out for at least 20mins on 1st day, increasing thereafter
Chest physio review if has sputum and difficult expectorating or pre-existing lung condition.

42
Q

What are the key components of the British Thoracic Society Community Acquired Pneumonia Care Bundle?

A

1) Perform CXR within 4 hrs of admission
2) Assess oxygen saturation and prescribe oxygen according to appropriate target range
3) Calculate CURB 65 in all patients where CXR demonstrates pneumonia
4) Adminster antibiotics within 4hrs of diagnosis appropriate to CURB 65 score

43
Q

What is the aim of the BTS Community Acquired Pneumonia Care Bundle?

A

Sets out guidelines for treatment and assessment of pneumonia
Aims to reduce the length of stay and mortality from pneumonia

44
Q

What is the role of a microbiologist in CAP treatment?

A

Antimicrobial stewardship
infection control
Monitoring of organism prevalence
Antibiotic sensitivity testing
Antimicrobial advice
A sounding board

45
Q

What antibiotics tend to be used for mild CAP with CURB 0 when patient is discharged?

A

CUB 0 = 1st line Amoxicillin 500mg TDS PO for 5/7
Alternatives - clarithromycin 500mg BD 5/7 or doxycycline 200mg then 100mg OD for 5/7 days

Do not routinely offer fluoroquinolone or dual antibiotic therapy

46
Q

What antibiotics tend to be used for CURB 1 when patient is discharged?

A

1st line Amoxicillin 500Mg TDS PO for 7-10/7
Alternatives - clarithromycin 500mg BD PO for 7-10/7 or doxyclcyine 200mg stat then 100mg OD for 7-10/7.

Do not routinely offer fluoroquinolone or dual antibiotic therapy.

47
Q

What microorganisms is amoxicillin effective against?

A

Streptococci
Pneumococci
Enterococci
Haemophilius influenza
Escheria coli
H.pylori
Shigella
Chalymidae trachomatis
Neissteria menigitidis and other.

48
Q

What adverse effects of amoxicillin should doctors be aware of?

A

Penicllin argery - adverse effects due to fatal anaphylaxis
Amoxicillin rash - indicate infectious mononucleosis and develops in 80-90% of patients with EBV infection.

49
Q

What is the basic mechanism of action of doxycycline?

A

Is a broad spectrum tetracycline class.
Bacteriostatis
Inhibits bacteria protein synthesis - binds 30s ribosomal subunit, prevents the binding of transfer RNA to messenger RNA at the ribosomal subunit - amino acids cannont be added to polypeptide chains - no new proteins.

50
Q

What microorganisms in doxyxycline used against?

A

Haemophyllus
Klebsiella
Lyme disease
Chlamydia
Moraxella
Myocplasm
Ecoli
Malaria (and prophylaxis)
Staph aureus
Anthrax
And others

51
Q

What side effects of doxycycline should doctors be aware fo?

A

Diarrhea
Nausea
Vomitting
Increased risk of sunburn
Contraindicated in pregnancy and up to 8yrs age to to potential to disrupt bone and tooth development.

52
Q

What antibiotics are used for CURB 0-2 when the patient is admitted?

A

1st line amoxicilllin 1g tds PO or IV
Alternative clarithromycin 500mg bd PO or IV (norm PO unless NBM as bioavialability the same and can irriate veins)

53
Q

What antibiotics tend to be given for severe CAP with CURB-65 above or equal to 3 when patient is admitted?

A

First line co-amoxiclav 1.2g tds IV
(may consider adding clarithromycin 500mg bd PO as well)
Alternative cefuroxime 1.5g tds IV

54
Q

How should treatment be altered is consider atypical pneumonia?

A

Guidelines as normal then add clarithromycin 500mg bd regardless of CURB-65 score

55
Q

How should treatment be altered in aspirational CAP pneumonia is suspected?

A

Abs not indicated for chemical pneumonitis.
Is reasonable concern for secondary infection then Co-amoxical 1.2g tds IV
Contact micro if pen allergy.

56
Q

When might a patient require a smaller dosage of an antibiotic?

A

Renal impairement
Hepatic impairement
Very small body habitus.

57
Q

What criteria is required for the patient to be safety discharged from hospital?

A

Unless ‘abnormal’ criteria normal for patient should be
Temp less then 37.8
HR less than 100bpm
RR less than 24 min
SBP less than 90 mmHg
SpO2 more than 90%
Ability to maintain oral intake
Normal mental status.

58
Q

What follow up should be arranged for pneumonia patients after discharge?

A

CXR at 6/52 post discharge, this should to organised by the hospital or request for GP to do on discharge summary.
Purpose is to rule out cancer (4% CAP being 1st presentation lung cancer )
Safeguard to return to GP in 3/7 if symptoms do not improve after starting antibiotics or ED is worsens
Give pneumonia Patient information leaflet.

59
Q

What differential diagnosis should be considered if the patient does not start to get better from pneumonia?

A
  1. Empyema - pus in pleural cavity, new effusion, spking temp, less susceptible to Abs, reapt CXR, may need chest drain and USS/tap.
  2. Lung abcess - (has a clear air/fluid level on x-ray, may also CT chest, spiking temp)
  3. Lung cancer - mass like appearance on CXR, staging CT chest/abdo should be requested.
60
Q

What alternative treatments should be considered if a patient with pneumonia is not getting better?

A

Risk of altenative organism or AMR - reculture and sensitivity testing should be discussed with microbiology
offer bronchoscopy with lavage esp if immunocompromised.
Consider potential TB diagnosis - may order CT.

61
Q

What are the expected recovery times with pneumonia?

A

After one week - fever gone
4w - less phlegm and better chest
6w - not coughing and easier breathing
3m - nearly back to norm, tired
6m - back to normal.

Unit 13 (22 decks)

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