Pneumonia

Question 1

Red flags indicating hospital admission for CAP

Answer 1

RR >= 22brpm
HR > 100bpm
SBP < 90mmHg
Acute-onset confusion
O2Sats <92 %RA
Lactate > 2 mmol/L

Question 2

What is a SMART-COP Grading Tool

Answer 2

• Acronym Grading tool to assess likelihood of patient with CAP will require Intensive care and provides risk of 30-day mortality
• Calculated based upon findings on clinical assessment.
• Systolic BP, Multilobar Pneumonia on CXR, Albumin < 35, RR >= 25 brp if Age <= 50 or RR >= 30 brpm if Age > 50, Tachycardia HR >= 125 bpm, Acute Confusion, O2 Sats low, Arterial pH < 7.35
• Grading of low, moderate, high, very high.

Question 3

Risk factors for CAP

Answer 3

Age > 65yo
Underlying Chronic lung disease
Underlying condition increasing risk of aspiration
- Dysphagia, dentures, Any alteration of consciousness (stroke, seizure, anaesthesia, drug or alcohol intoxication)
Immunocompromising conditions
- DM, HIV, Stem cell transplant, Immunosuppressive medication,
Malnutrition
Lifestyle factors - Smoking, EtOH, Homeless, Overcrowding
Instrumentation of respiratory tract
Viral Resp infection

Question 4

Organisms causing CAP

Answer 4

Causes of typical CAP
- Step Pneumoniae
- Haemophilus Influenzae
Causes of atypical CAP
- Mycoplasma Pneumoniae
- Coxiella burnetti
- Chlamydophila psittaci
- Chlamydophila pneumonia
- Legionella pneumophila
- Legionella longbeachae
Others
- Klebsiella pneumoniae
- Pseudomonas Aeruginosa
- Staphylococcis Aureus
Viral
- Respiratory Syncitial Virus
- Human Metapneumovirus
- Influenza
- Parainfluenza
- Adenovirus

Question 5

Empirical Therapy of CAP in Adults

Answer 5

Low severity and follow up in 48 hours possible
- Amoxicillin 1g PO TDS
Remote
- Procaine benzylpenicillin 1.5g IM OD
- Hypersensitive or likely atypical
- Doxycycline 100mg PO BD
- Clarithromycin 500mg PO BD
No Improvement in 48 hours? Combination therapy
- Add Doxycycline 100mg PO BD
Combination therapy but sensitive to peniciliin
-Non-severe - Cefuroxime 500mg PO BD + Doxycycline 100mg PO BD
- Severe - Moxifloxacin 400mg PO OD

Question 6

Duration of treatment with Abx for CAP

Answer 6

Significant improvement in 2-3 days? Treat for 5 days total.
Slow response? Treat for 7 days.
No response on monotherapy after 48hours -> combination.

Question 7

Empirical Therapy for CAP in Children

Answer 7

• Amoxicillin 25mg/kg (Max 1g) PO TDS x 3 days
• Immediate Non-severe or delayed nonsevere penicillin allergy?
  
  • Cefuroxime 15mg/kg (Max 500mg) PO BD x 3 days
• Severe penicillin reaction?
  
  • Azithromycin 10mg/kg (Max 500mg) PO OD x 3 days
  • Clarithromycin 7.5mg/kg (Max 500mg) PO BD x 3 days
  • Doxycycline PO BD x 3 days
    (Age 8+ for doxy for fear of theoretical tooth discoloration / enamel hypoplasia possibility)