Pneumonia Flashcards
What is pneumonia ?
Inflammation of the lung parenchyma with the normal air-filled lungs becoming filled with infective liquid (known as consolidation)
What is CAP ?
community-acquired pneumonia: caught outside of hospital
When is a diagnosis of HAP made?
a pneumoniacontracted > 48 hrs after hospital admission that was not incubating at the time of admission.
What is Ventilated acquired pneumonia ?
48 hours post intubation
Aspiration pneumonia what is it?
caused by theinhalation of oropharyngeal or gastric contents
This brings bacteria found in these environments into the lungs
Aspiration pneumonia- in what patients is it seen ?
associated with patients who are unable to adequately protect their airway, it may be seen in patients with:
- Reduced conscious level
- Neuromuscular disorders
- Oesophageal conditions
- Mechanical interventions such as endotracheal tubes.
- neurological dysphagias- stroke, epilepsy, alcoholics, drowning
- At risk- nursing home residents and drug overdose
Typical CAP organisms
Streptococcus pneumoniae (most common)
Haemophilus influenzae
Moraxella catarrahalis
Less:
Staphylococcus aureus and MRSA
Pseudomonas aeruginosa
Klebsiella pneumonia
Group A strep pyogenes
anaerobes
Haemophilus influenzae- common in ….
COPD patients
Moraxella catarrahalis seen in ……
immunocompromised patients or those with chronic pulmonary disease
Pseudomonas aeruginosa in patients with …..
cystic fibrosis or bronchiectasis
Klebsiella pneumonia seen in …
alcoholics
Atypical organisms causing CAP
- Legionella pneumophilia
- Mycoplasma pneumoniae
-Chlamydia pneumoniae - Coxiella burnetii (Q fever)
- Psittacosis- chlamidophila psittaci
What does atypical organism mean?
organism that cannot becultured in the normal way or detected using agram stain must use serology to identify
They don’t respond to penicillins and can be treated withmacrolides (e.g. clarithomycin),fluoroquinolones
(e.g. levofloxacin) ortetracyclines (e.g. doxycycline)
Mycoplasma pneumoniae: signs ?
- Dry cough
- Atypical chest signs/x-ray
- Erythema multiforme seen-> varying sized “target lesions” formed bypink rings withpale centres
- neurological symptoms in young patient in the exams.
Legionella pneumophilia: typical history, where caught from?
water sources, travel, infected air conditioning units
Legionella pneumophilia: what can it present with? (think electrolyte imbalance, WBC)
Commonly present with:
Hyponatraemia
SIADH
lymphopenia
HAP common organisms
- Staphylococcus aureus or MRSA
- Gram negative bacili
- Pseudomonas aeruginosa
- Escherichia coli
- Klebsiella pneumoniae
- Strep pneumoniae
What are viral causes of pneumonia?
- Cytomegalovirus- in immunocompromised eg. bone marrow recipients
- Influenza
- Adenovirus
- RSV (Respiratory syncytial virus)
- Rhinovirus
What are fungal causes of pneumonia?
Pneumocystis jiroveci (PCP)- HIV patients
Aspergillus spp- in prolonged neutropenia
Idiopathic interstitial pneumonia caused by
non infective causes-
cryptogenic organizing pneumonia
complication of rheumatoid arthritis or amiodarone therapy
Aspiration pneumonia organisms
Mixed infections- Viridans streptococcus and anaerobes
Differentials of cough
Heart failure w/ pul oedema
PE
Lung cancer
Acute exacerbation of bronchiectasis
Interstitial lung disease
URTI
Pneumothorax
TB
Differentials of consolidation on CXR
- Pneumonia
- TB
- Lung cancer
- Lobar collapse
- Haemorrhage
What would help differentiate TB from CAP
- Subacute presentation
- Night sweats, loss of appetite and weight loss, fatigue
- Born in country with high incidence TB- non-uk born
- HIV, immunocompromised, drug use, homelessness
Symptoms ?
- cough- productive- green/yellow sputum
- Dyspnoea
- Fever
-Malaise - Haemoptysis
- Pleuritic chest pain
- Delirium
- sepsis
Signs of pneumonia
- Fever
- Tachycardia
- Tachypneoa
- reduced oxygen sats
- Hypotension (shock)
- Confusion
- Cyanosis
Chest signs
- Reduced breath sounds
- Bronchial breath sounds
- Focal coarse crackles (bibasal)
- Dullness to percussion
- Increased vocal fremitus
Most important Investigations for pneumonia? if febrile? if high curb-65? low O2 stats?
- CXR
- FBC, U&Es, CRP
- Sputum culture
- Consider blood cultures if febrile
- If high CURB-65 score need Atypical pneumonia
screen – serology and urine legionella test - ABG if low sats
CURB-65 stand for
C- confusion
U- urea >7mmol/l
R- Resp rate >= 30
B- BP Sys <90 or dia <60
65- >65 yrs old
What do you do if CURB-65 =0
Low risk
NICE recommend thattreatment at homeshould be considered (alongside clinical judgement)
What do you do if CURB-65 = 1 or 2
intermediate risk
NICE recommend that hospital assessment should be considered
What do you do if CURB-65 = 3 or 4
high risk
NICE recommend urgent admission to hospital
What do you do if CURB-65 = 4 or 5
(>15% mortality)
should be managed in HDU or ITU
Non-invasive ventilatory support should always be offered here
CRP can guide antibiotic management. What are the parameters?
- CRP < 20 mg/L - do not routinely offer antibiotic therapy
- CRP 20 - 100 mg/L - consider a delayed antibiotic prescription
- CRP > 100 mg/L - offer antibiotic therapy
(usually over 100 in pneumonia)
Management of pneumonia
A-E- Check for indications of sepsis
Oxygen titrated to saturations
IV fluids
Appropriate analgesia- Paracetamol/ NSAIDs
Antibiotics
Low severity: Mild CAP- antibiotics ?
-Amoxicillin
- Tetracycline (doxycycline) or macrolide (clarithromycin) if penicillin allergic
5-7 days
Intermediate severity: Moderate CAP antibiotics ?
Dual therapywith a beta-lactam (e.g. amoxicillin) and a macrolide (e.g. clarithromycin)
- Tetracycline (doxycycline) if penicillin allergic
7-10 days
High severity: Severe CAP antibiotics ?
IV beta-lactamase stable beta-lactam(e.g co-amoxiclav) and a macrolide (e.g. clarithromycin)
- Tetracycline (doxycycline) if penicillin allergic
- 7-10 days may be extended to 14 or 21 days depending on clinical circumstance
HAP antibiotic treatment ?
- Should follow local guidelines based upon local microbial knowledge.
First line - Co-amoxiclav
Second line- Severe -Tazocin (piperacillin/tazobactam) or meropenem
If MRSA risk- which antibiotics?
Vancomycin and Linezolid
PCP- which antibiotics?
trimethoprim/sulfamethoxazole known as co-trimoxazole
Flu then has pneumonia, already had abx but still deteriorating - give …
co-amoxiclav
Follow up arrangements for pneumonia
Follow up in clinic in 6 weeks with a repeat CXR to ensure resolution
- HIV test
- Immunoglobulins
- Pneumococcal IgG serotypes
- haemophilus influenzae b IgG
Non-resolving pneumonia causes
CHAOS mnemonic
- Complication- empyema, abscess
- Host- immunocompromised
- Antibiotic- inadequate dose, poor oral absorption
- Organism- resistant or unexpected organism not covered by empirical antibiotics
- Second diagnosis- PE, Cancer, organising pneumonia
