Pneumonia

Question 1

What is the CURB-65 score used to assess?

Answer 1

1. Risk stratification - CURB-65 estimates the 30-day mortality of CAP (community acquired pneumonia) to help determine treatment plan

Question 2

What are the CURB-65 criteria?

Answer 2

• C = Confusion
• U = Urea > 7mmol/L
• R = Resp rate >30
• B = Blood Pressure
  
  • Systolic <90
  • Diastolic < 60
• 65 age +

Question 3

In which patient groups is CURB-65 not as useful?

Answer 3

1. Patients younger than 65 with pneumonia
   
   • Younger patients also don’t compensate to the same extent so RR may not be > 30 and BP may not full < 90 mmHg
2. Chronic renal impairment
   
   • Patients may score on urea > 7, which may be baseline for their condition

Question 4

A CURB-65 score of 0-1 would get you what management?

Answer 4

Sent home with 5 day course of oral antibiotics e.g. amoxicillin

Question 5

A CURB-65 score of 2 would get you what management?

Answer 5

Admitted to hospital with a 7-10 day course of antibiotics, dual therapy

e.g. amoxicillin + macrolide (clarithromycin etc.)

Question 6

A CURB-65 score of 3 + would get you what management?

Answer 6

1. Admission to hospital (consider ICU)
2. 7-10 day course of dual therapy Abx with;
   
   1. Beta‑lactamase stable beta‑lactam Abx (e.g. co-amoxiclav, Tazocin)
   2. and a Macrolide (e.g. clarithromycin)

Question 7

CAPs are commonly caused by which bacteria?

Answer 7

1. Streptococcus pneumoniae
2. Haemophilus influenzae
3. Atypicals e.g. mycoplasma pneumoniae, legionella pneumophila

Question 8

HAPs are commonly caused by which bacteria?

Answer 8

1. Staphylococcus aureus *inluding MRSA*
2. Anaerobes e.g. fusobacterium, peptostreptococcus, clostridium
3. Coliforms e.g. enterobacter, e-coli, klebsiella
4. Psuedomonas

Question 9

Name the 4 main symptoms of pneumonia.

Answer 9

1. Cough
   
   • Dry
   • Productive - green, rust coloured (pneumococcal), or haemoptasis
2. SoB (Orthopnoea - patient unable to lie down)
   
   • ↓ O2 sats
   • ↓ Breath sounds, crackles, bronchial breathing
   • ↑ Vocal resonance (over affected area)
3. Fever
4. Chest pain (often pleuritic, worse when coughing/laughing/breathing)

Question 10

What are some less common symptoms Pneumonia can present with?

Answer 10

• Abdominal pain (if pneumonia is in lower zones)
• ↑ HR (tachy)
• Fever
• Diarrhoea
• Vomiting
• Loss of appetite
• Myalgia / Arthralgia - common with legionella or mycoplasma
• Pleural effusions - ‘stony dull’ percussion
• Sepsis
• Empyema - pus in pleural cavity
  
  • Needs draining as antimicrobial penetration into pus is poor
  • Klebsiella pneumoniae is part of normal gut flora and can cause pneumonia (typically following aspiration, more common in alcoholics) and empyema / abscess

Question 11

Define “ß-lactam” antibiotics and give some examples.

Answer 11

Definition: antibiotics which target the peptidoglycans in bacterial cell walls using a ß-lactam ring. The peptidoglycan layer is important for cell wall structural integrity, especially in Gram-positive organisms.

Examples:

• Penicillins (amoxycillin, flucloxacillin, piperacillin)
• Cephlasporins (cefuroxime, cefotaxime, ceftriaxone)
• Carbapenems (e.g. meropenem)
• Glycopeptides (vancomycin, teicoplanin)

Question 12

Give 2 examples of combination ß-lactams.

Answer 12

1. Co-amoxiclav (amoxicillin + clavulanic acid)
2. Tazocin (piperacillin + Tazobactam)

Question 13

What classes of antibiotic target protein synthesis?

Answer 13

1. Aminoglycosides - (e.g. gentamycin)
2. Tetracyclins - (e.g. doxycycline)
3. Lincosamides - (e.g. clindamycin)
4. Macrolides - (e.g. erthromycin, clarithromycin, azithromycin)

Question 14

What clases of antibiotic target DNA?

Answer 14

1. Fluroquinolones - (e.g. ciprofloxacin)
2. Miscs - (e.g. trimethoprim, nitrofurantoin (UTIs), metronidazole)

Question 15

What are 3 common indications for use of Macrolide Abx e.g. Clarithromycin?

Answer 15

1. Respiratory and skin and soft tissue infections - as penicillin alternative (when contraindicated by allergy)
2. Severe pneumonia (CURB-65 of 2 or higher) - it is added to a penicillin to cover ‘atypical’ organsisms e.g. Legionella and mycoplasma
3. H. Pylori eradication (e.g. peptic ulcer) in combination with PPI + (amoxicillin or metronidazole) - so called ‘triple therapy)

Question 16

What % of exacerbations of COPD are bacterial?

In a bacterial exacerbation of COPD, which 3 pathogens are most common?

Answer 16

50-70% bacterial exacerbations

1. Haemophilus influenzae
2. Streptococcus pneumoniae

Moraxella catarrhalis

N.B. Most common bacteria in Bronchiectasis also include; Haemophilus influenzae and Streptococcus pneumoniae (Like COPD) but Pseudomonas aeruginosa instead of Moraxella [in clinic the prescription of long-term amoxicillin was common]

Question 17

What are some common risk factors for Pneumonia?

Answer 17

1. Age >65 yrs
2. Hx of COPD
3. Hx of Bronchiectasis
4. Smoking
5. Alcohol abuse
6. Recent hospitalisation
7. Dysphagia - ↑ risk of aspiration pneumonia
8. Use of acid-reducing drugs e.g. PPI

Question 18

What blood tests might you want to do, and why, in suspected Pneumonia?

Answer 18

1. FBC:
   
   • ↑ WBC - can indicate infection (↑ neutrophils = likely bacterial)
   • Hb - concurrent anaemia can complicate pneumonia
   • Platelets - ↑ or ↓ platelets can be consistent with inflammation
2. CRP:
   
   • Acute phase inflammatory marker
   • ↑ = inflammation or other cause, ↑↑ (>100) = can indicate infection
3. Lactate:
   
   • ↑ in sepsis
4. U+Es:
   
   • Urea - for CURB-65
   • Urea:Creatinine ratio - ↑ in dehydration
5. LFTs:
   
   • If deranges can indicate ↓ perfussion associated with sepsis
6. Blood culture:
   
   • Not commonly done in CAP (as treatment is straightforward), more common in HAP
7. ABG:
   
   • If pts O2 sats are ↓ do ABG to determine respiratory failure
8. HIV:
   
   • If pt is <60 as pneumonia is a common presentation of HIV in undiagnised individuals

Question 19

Why might you want to take a beside urine sample in suspected Pneumonia?

Answer 19

Urinary antigen tests for pneumococcus and legionella are highly sensitive and specific, and results become available often in a few hours

Question 20

What is the difference between a ‘Typical’ and ‘Atypical’ organism?

Answer 20

• Typical:
  
  • Can be cultured in a lab from blood/sputum cultures etc
  • Can be treated with Abx affecting bacterial cell wall e.g. penicillins and cephalosporins etc.
• Atypical:
  
  • Are intracellular pathogens and cannot be cultured using standard methods - alternative methods needed e.g. PCR and serology
  • Do not have a cell wall –> need to be treated with Abx that enter intracellular space e.g. macrolides

Question 21

What are the most common causes of Viral Pneumonia?

Answer 21

1. Influenza A and B
2. Respiratory Syncytial virus
3. Adenovirus

Question 22

What is the most common Fungal cause of Pneumonia?

Answer 22

Pneumocystis jirovecii

• Mainly seen in immunodeficient patients e.g. HIV, transplant immunosuppression, corticosteroid treatment
• Also occurs in pts with underlying pathology e.g. COPD or CF

Question 23

How is HAP (hospital acquired pneumonia) defined?

Answer 23

Define HAP:

• new onset of symptoms and
• Compatible x-ray features
• Developing >48 hrs after admission to hospital OR in < 1 month from discharge

Question 24

When should patients with pneumonia be followed up after discharge from hospital and what should be included in the follow up?

Answer 24

• Follow up after 6 weeks
• In follow up:
  
  • CXR - check opacity has cleared
  • Smoking cessation advice if not already given at discharge

Question 25

How long does it take for a patient to feel ‘back to normal’ after pneumonia?

Answer 25

~ 6 weeks

(for the following to resolve; fever. chest pain, sputum, cough, SoB)

• Can take 3-6 months to feel fully back to normal

Question 26

In which part of the lungs is Aspiration Pneumonia most likely to manifest?

Answer 26

Right lower lobe

• This is because the right main bronchus is 1) straighter 2) broader –> so aspirated oropharyngeal or gastric contents are more likely to go into the right lung (the lower lobe is the natural continutation of the right main bronchus)

Question 27

Comment on this CXR

Answer 27

Right upper lobe collapse

1. Loss of lung volume and the ribs are pulled together on the right
2. Lobar collapse appears as ↑ opacity on CXR as there is no air so tissue collapses and thus is more dense
3. Trachea is shifted to the right
4. Compensatory hyper-inflation of the left lung
   
   • Notice flattened left diaphragm + costophrenic ‘blunting’ i.e. loss/reduction of normally sharp costophrenic angle

Question 28

Describe this CXR

Answer 28

Right middle zone pneumonia

1. We can confidently say this is consolidation due to the presence of well defined bronchograms (air filled, dark, bronchi - made visible by surrounding opacity of alveoli)
2. It is likely middle lobe as the right diaphragm border is well defined –> to confirm a lateral CXR would be required as these differentiate the lobes well

Question 29

How would you differentiate between an effusion and consolidation radiologically?

Answer 29

1. Margins of Opacification:
   
   1. ​Consolidation = not clear margins
   2. Effusion = clear margins
2. Density of Opacification:
   
   1. Consolidation = not dense due to air bronchograms
   2. Effusions = dense + no markings visible in the lung field
3. The diaphragm / costo-phrenic and cardio-phrenic angles:
   
   1. Consolidation = may still be visible (depends on affected area of lung)
   2. Effusions = not visible

Question 30

Patient is 67 years old and was admitted to hospital 3 months ago with biliary colic from which he has recovered. He takes no medications and is well otherwise. He presents to GP practice with an acute cough (<21 days) likely due to infection, do you give Abx?

Answer 30

No

• For patients > 65yrs they should be given antibiotics if they have 2 or more of the of the following co-existing conditions:
  
  1. Diabetes type 1 or 2
  2. Hx of heart failure
  3. Hospitalisation in the previous year
  4. Are being treated with oral corticosteroids

Question 31

A 35 year old man who looks unwell and has a high fever. He been unable go to work and has spent most of the weekend in bed with fevers, generalised aches and a cough productive of a small amount of green sputum. He is managing fluids, even though he has lost his appetite, and is usually very fit and well. He has some crackles on left when you auscultate his lungs with your stethoscope. His blood pressure is normal and his respiratory rate is not raised.

Do you give Abx?

Answer 31

Yes

• He has symptoms / signs consistent with pneumonia
• He is young, has a normal BP and RR and is not confused –> could be treated at home with oral Abx

Question 32

Legionnaire’s disease is a cause of atypical pneumonia (True or False)?

Answer 32

True

• It can occur when you breath in water vapours infested with L. Pneumophilia. This bacteria is often found in water supplies of buildings or cooling towers

Question 33

A person who has had persistent cough greater than 3 weeks with continuing night sweats, anorexia and weight loss and fatigue may have pulmonary TB (True or False)?

Answer 33

True

• TB should be suspected in anyone with;
  
  • Persisting signs of LRTI
  • Especially with prominent weight loss + night sweats
  • Haemoptysis can also occur

Question 34

NICE have discharge criteria for pneumonia in which they state a patient shouldn’t be discharged if in the past 24 hrs they have had 2 or more of a list of 7 things - what are they?

Answer 34

1. Temperature > 37.5°C
2. RR 24 or more
3. HR > 100 BPM
4. SystolicBP 90 mmHg or less
5. O2 sats
6. Abnormal mental status
7. Inability to eat without assistance

Question 35

What 3 differentials are commonly considered alongside suspected pneumonia?

Answer 35

1. Pulmonary embolism - pt isn’t usually systemically unwell and onset is more sudden
2. TB - can be systemically unwell and show CXR changes
3. Pulmonary oedema - produces coughing, haemoptysis, ↑ RR, ↑ HR, often secondary to cardiac pathology