Pneumonia

Question 1

Definition of general pneumonia

Answer 1

Inflammation of the substance of the lungs, usually caused by bacteria but also viruses and fungi, which results in abnormalities on the CXR + fever and signs in the chest

Question 2

Epidemiology of general pneumonia

Answer 2

5-11/1000
Increase in young and old
Mortality around 21% in hospital

Question 3

Types of pneumonia

Answer 3

Community
Hospital
Immunocompromised
Aspiration

Question 4

CAP epidemiology

Answer 4

Occurs across all ages but more common in extremes of age
Most common causative agent is S. Pneumonia
1-3/1000
25% cases require admission
M=F

Question 5

Clinical features of CAP

Answer 5

Cough - initially non productive
Breathlessness due to alveoli being filled with puss and debris
Fever
Generally unwell
Pleuritic chest pain
Abnormal auscultation inc increased fremitus, asymemetric breath sounds and pleural rub
Dullness to percussion
Cyanosis

Question 6

Characteristic colour of sputum in pneumococcal infection

Answer 6

Brown

Question 7

What is the CURB65 score?

Answer 7

Tool used to measure severity of pneumonia

C - Confusion present
U - Urea level > 7mmol/L
R - RR > 30
B - BP <90/<60
65 - Age

Question 8

Investigative methods in pneumonia

Answer 8

CXR
FBC showing a leukocytosis
Sputum tests

Question 9

What are the blood tests you would order to diagnose pneumonia?

Answer 9

WBC - leucocytosis 
ESR - may be normal
CRP = >100mg/L indicated likely pneumonia
FBC - leucosytosis
U+E - usually normal 
ABG - Assess saturations
LFT

Question 10

How is CAP managed?

Answer 10

O2 (if sats are low)
IV fluids ( if hypotensive)
Abx - loading dose within 4 hours of presentation
- PO once temp is controlled
- Seek micro help if unresponsive
Thromboprophylaxis if admitted for >12hrs
Analgesia for pain control

Question 11

Management of CAP in a previously healthy, non MDR pt

Answer 11

Macrolide or tetracycline therapy

Macrolides: azithromycin, clarithromycin, erythromycin all 500mg LD

Tetracyline: Doxycycline

Question 12

Treatment of severe CAP

Answer 12

IV co-amoxiclav*^ + macrolide (clarithromycin)

*Co-amoxiclav can be replaced with ampicillin or amoxicillin if not severe

^It’s a broad spectrum penicillin

Question 13

When is flucloxacillin added to treatment?

Answer 13

If staph is suspected

Question 14

Which drug is added to treatment if MRSA is present?

Answer 14

Vancomycin

Question 15

Definition of HAP

Answer 15

New onset of cough with purulent sputum along with a compatible CXR demonstrating consolidation in patients who are beyond 2 days of their initial admission to hospital

Question 16

Definition of Aspiration pneumonia

Answer 16

Defined as acute aspiration of gastric contents into the lungs which can produce an extremely severe and sometimes fatal illness

Question 17

Treatment of HAP

Answer 17

Broad spectrum abx which covers gram -ve organisms which are resistant to abx used in CAP:

CEPHALOSPORINS or
CARBAPENEMS or
ANTIPSEUDOMONAL PENICILLIN

Question 18

Treatment of Aspiration pneumonia

Answer 18

Cephalosporin IV + metronidazole IV

Question 19

Features of immunocompromised pneumonia

Answer 19

Commonest opportunistic pathogen - pneumocystitis

Presents w/ rapid desaturation on exertion and increased temp + dry cough + breathlessness

Question 20

Treatment of immunocompromised pneumonia

Answer 20

Aminoglycoside IV + antipseudomonal penicillin IV

Question 21

Complications of pneumonia

Answer 21

SLAP HER

Sepsis
Lung Abscess
AF
Pericarditis
Hypotension
Empyema
Resp failure T1

Question 22

CAP key risk factors

Answer 22

Smoking
COPD
Age >65
Poor oral hygiene
Alcohol abuse
Immunosuppressed
Resident in a healthcare setting

Question 23

DDx CAP

Answer 23

Acute bronchitis - no breathlessness and there would be no consolidation on the CXR

Asthma exacerbation - Signs of bronchospasm + no consolidation on CXR

Bronchiectasis exacerbation - Increasing cough, worsening dyspnoea + no consolidation on CXR

TB - long history with aspect of travel + cavitation on CXR w/ enlarged lymph nodes

Lung Cancer - red flag symptoms in history + multiple consolidation + pleural effusion

Question 24

RFs for HAP

Answer 24

Extremes of age
Hospitalised
Increased aspiration risk
Invasive procedures in the hospital setting
Immunocompromised

Question 25

Presentation of HAP

Answer 25

Cough - initially non productive
Breathlessness due to alveoli being filled with puss and debris
Fever
Generally unwell
Pleuritic chest pain
Abnormal auscultation inc increased fremitus, asymemetric breath sounds and pleural rub
Dullness to percussion

Question 26

RFs for Aspiration pneumonia

Answer 26

Swallow ability
Being old
Mental status
GI disease
Invasive procedure i.e. NG tube

Question 27

Causative agents of pneumonia in previously fit adults (6)

Answer 27

Pneumococcus
Mycoplasma
H. influenzae
Viruses
Staphylococcus
Legionella

Question 28

Causative agents of pneumonia in elderly patients with previous resp, illness?

Answer 28

Pneumococcus
H. influenzae
Staphylococcus
Klebsiella
Gram -ve organisms

Question 29

If a pt does not respond to standard abx treatment, which conditions should be investigated further?

Answer 29

TB
Mycoplasma
Legionella
Carcinoma

Question 30

Causative agents in HAP

Answer 30

1. P. aurigenosa
2. Gram negative enterobacillae
3. S. aureus

Question 31

Which microorganism commonly causes exacerbations in patient with COPD?

Answer 31

H. Influenzae

Question 32

Which pneumonia microorganism causes skin changes (Stevens-Johnson syndrome or erythema multiforme)?

Answer 32

Mycoplasma

Question 33

Which microorganism is usually only seen in patient with CF or bronchiectasis causing pneumonia?

Answer 33

Pseudomonas

Question 34

Which pneumonia microorganism commonly causes pneumonia in immunocompromised patients (HIV)?

Answer 34

Pneumocystitis

Question 35

What types of pneumonia microorganism causes a cavitating abscess?

Answer 35

Klebsiella

Staphylococcal