Pneumonia

Question 1

Describe the clinical features of community-acquired pneumonia

Answer 1

Cough: may be dry or productive, may be haemoptysis Purulent sputum Breathlessness: coarse crackles, bronchial breathing Fever: swinging indicated empyema Chest pain: pleuritic if pleura involved Confusion or atypical non-specific symptoms in elderly Extrapulmonary: depends on infection Consolidation of the lung on CXR

Question 2

Name 3 factors associated with increased mortality in community-acquired pneumonia

Answer 2

Comorbidites: Diabetes mellitus, congestive heart failure, COPD, CKD Bilateral or multilobar involvement PaO2 <8kPa or SaO2 <92%

Question 3

How is pneumonia classified?

Answer 3

Community-acquired pneumonia Hospital-acquired pneumonia Pneumonia in immunocompromised patients

Question 4

Name 5 risk factors for community-acquired pneumonia

Answer 4

Age: <16 or >65 Co-morbidities: HIV, diabetes, CKD, malnutrition, recent viral respiratory infection Other resp conditions: Cystic fibrosis, bronchiectasis, COPD, obstructing lesion (lung cancer, foreign body) Lifestyle: Smoking*, excess alcohol, IVDU Iatrogenic: Immunosuppressant therapy

Question 5

Name 5 causative agents of community-acquired pneumonia

Answer 5

Strep pneumoniae* “pneumococcus” Haemophilus influenzae Mycoplasma pneumoniae Staph aureus Legionella: recent foreign travel, flu-like symptoms, hyponatraemia, pleural effusion Moraxella catarrhalis Chlamydia pneumoniae

Question 6

List 3 extrapulmonary features of community-acquired pneumonia

Answer 6

Myalgia, arthralgia, malaise (common) Myocarditis and pericarditis: Mycoplasma pneumonia Headache: Legionella pneumonia Abdominal pain, DaV (common) Labial herpes simplex: Pneumococcal pneumonia Erythema multiforme, erythema nodosum: Mycoplasma Stevens-Johnson syndrome (rare)

Question 7

Define community-acquired pneumonia

Answer 7

Pneumonia that is acquired outside hospital, including nursing homes.

Question 8

How is severity of community-acquired pneumonia assessed?

Answer 8

CURB-65 score

• Confusion (abbreviated mental test <8/10) - 1
• Urea >7.0mmol/L - 1
• Respiratory rate >30 - 1
• Blood pressure SBP <90 or DBP <60 - 1 65yr or more - 1

0-1 (low risk): consider outpatient-based care

2 (intermediate risk): consider hospital-based care

3-5 (high risk): consider ICU assessment

Question 9

Upon admission to hospital/ICU, what investigations should be done in suspected pneumonia?

Answer 9

CXR*: do not delay treatment if awaiting report FBC, U&Es, LFTs, CRP Blood and sputum culture* Consider pneumococcal and legionella urinary antigen Consider serology Pulse oximetry and ABG if SaO2 <94%

Question 10

Outline the management of community-acquired pneumonia

Answer 10

ABC assessment Oxygen if hypoxic Treat any features of sepsis Otherwise treat with antibiotics as per local guidelines Empirical antibiotics: 0-1 (low risk): Amoxicillin or Clarithromycin or Doxycycline for 5 days 2 (medium risk): Amoxicillin plus either Clarithromycin or Doxycycline for 7-10 days 3-5 (high risk): Co-amoxiclav plus either Clarithromycin or Doxcycline for 7-10 days Ceftriaxone if co-amoxiclav contraindicated Ciprofloxacin if clarithromycin contraindicated Fluoroquinolone if Legionnaire’s suspected

Question 11

Name 3 causes of slow-resolving pneumonia

Answer 11

Complication: empyema, lung abscess, effusion Host: immunocompromised, aged, co-morbidities, smoking, malnutrition Antibiotics: inadequate dose/duration, poor absorption Organism: resistant, atypical, not covered by empirical Second diagnosis: PE, cancer*, organising pneumonia

Question 12

Name 3 complications of pneumonia

Answer 12

Type 1 respiratory failure Sepsis Parapneumonic effusion Empyema: swinging fever Lung abscess Atrial fibrillation: reversible Pericarditis and myocarditis

Question 13

What is cryptogenic organising pneumonia?

Answer 13

Rare non-infectious lung disease of unknown cause, featuring inflammation that blocks the alveoli and bronchioles.

Question 14

What follow-up arrangement should be made after discharge with a diagnosis of pneumonia?

Answer 14

Follow-up in 6 weeks with repeat CXR*: if CXR is unresolved, CT for atypical organisms and second diagnoses. Offer HIV test: pneumonia is a common initial presentation of previously undiagnosed HIV Immunoglobulins: especially in younger patients, looking for primary immunodeficiencies e.g. CVID Pneumococcal and H. influenzae b IgG: offer vaccines for at-risk groups Smoking cessation advice: independent risk factor

Question 15

Define hospital-acquired pneumonia

Answer 15

Pneumonia that develops 48 hours or more after hospital admission, and that was not incubating at hospital admission.

Question 16

Outline the management of hospital-acquired pneumonia

Answer 16

ABC assessment Oxygen if hypoxic Treat any features of sepsis Antibiotic therapy asap, certainly within 4h: Co-amoxiclav, tazocin, or meropenem for 5-10d

Question 17

Name 3 causative organisms of hospital-acquired pneumonia

Answer 17

Gram -ve bacteria*: Pseudomonas, E. coli, Klebseilla Staph aureus and MRSA: commoner in DM and ICU Enterobacter spp.

Question 18

Define Mendelson syndrome

Answer 18

Aspiration pneumonia caused by aspiration during anaesthesia, especially during pregnancy. Commonest cause of maternal anaesthetic death.

Question 19

Name 2 at-risk groups for aspiration pneumonia

Answer 19

Stroke Myasthenia gravis Bulbar palsies Reduced GCS Oesophageal disease

Question 20

What is the commonest cause of pneumonia in immunocompromised patients?

Answer 20

Pneumocystis jiroveci pneumoniae

Question 21

Describe the clinical features of Pneumocystis jiroveci pneumoniae

Answer 21

High fever Breathlessness Dry cough Rapid desaturation on exercise or exertion*

Question 22

What is the treatment of Pneumocystis jiroveci pneumoniae?

Answer 22

High-dose co-trimoxazole

Question 23

Name 3 groups affected by Pneumocystis jiroveci pneumoniae

Answer 23

Immunosuppressant therapy: -Long-term corticosteroids -Mono-clonal antibody therapy -Methotrexate -Anti-rejection medication post-transplant HIV: esp if CD4 <200 (AIDS)