Pneumonia Flashcards
How can pneumonias be sub-classified?
Community acquired
Hospital acquired
What is the definition of pneumonia in community practice?
Symptoms of a lower respiratory tract infection (cough and one other), new focal signs on examination, and signs of systemic illness, pyrexia, sweating, rigors
+ No other more likely cause
(Signs and symptoms suggestive of pneumonia with no other more likely cause)
Note- Unlike in a hospital setting radiological evidence is not required to diagnose pneumonia in the community
What is the definition of pneumonia in hospital practice?
Signs and symptoms suggestive of pneumonia
Radiological evidence of pneumonia on a CXR- radiographic shadowing for which there is no other explanation
What is the definition of a hospital acquired pneumonia?
Acquired more than 48 hours after hospital admission. Includes ventilator and healthcare acquired pneumonia
What is the most common causative organism of CAP and HAP?
Streptococcus pneumoniae
What are the two most common causes of pneumonia in ITU?
Streptococcus pneumoniae
Legionella
What are the symptoms of pneumonia?
Cough Sputum production Fever, Fatigue, Malaise Pleuritic chest pain Dyspnoea Rigors
What are the clinical signs of pneumonia? (includes signs seen on examination)
Tachycardia Tachypnoea Reduced chest wall expansion Dullness to percussion Crepitations on auscultation Reduced oxygen saturations Sputum pot Bronchial breathing Pyrexia Confusion, Drowsiness, Coma
What respiratory failure might be seen in pneumonia?
Type 1 due to V/Q mismatch
Results in hypoxia without carbon dioxide retention but this may be seen later on or in patients with pre-existing COPD
What immediate investigations should be done if presenting at hospital?
Oxygen saturations
CXR
What blood tests should be done for someone presenting with pneumonia to hospital?
FBC U+Es LFTs CRP ESR Culture HIV screen?
ABG if SPO2 less than 92%
When should an ABG be carried out for someone presenting with pneumonia?
If suspecting respiratory failure and SPO2 less than 92%
Should a sputum culture be done for all patients with pnuemonia?
Community- Not routinely, if not responding to ABx therapy consider
Hospital- Do for all hospital admissions for pneumonia or HAP. MC&S and AFB/ZN staining if considering TB
Should a sputum culture be done for patients in the community presenting with pneumonia?
Sputum culture should not be done routinely for all patients presenting with pneumonia in the community.
Should be considered if not responding to ABx treatment
If moderate or severe (CRB-65 of 2 or more) will require admission to hospital and a sputum culture should be done there
What might test might be done on the urine of a patient with severe CAP?
Legionella antigen
Common causative organism of ITU pneumonias
For a patient presenting at hospital with a CAP what investigations should be done?
CXR
Oxygen saturations
ABG if O2 Sats less than 92%
Bloods- FBC, U&E, ESR, CRP, LFT, Culture
Sputum culture- MC&S, Consider AFB/ZN Staining
Urine testing for legionella antigen (if severe)
How can CRP be used to guide ABX prescribing in the community?
CRP can be used to guide ABx prescribing for LRTI
0-20= No ABx
20-100= Delayed ABX
>100= Immediate ABx
What are the criteria for CURB-65?
Confusion= 1 point Urea> 7 = 1 Point Respiratory Rate> 30 = 1 Point Blood Pressure- DBP <60 or SBP<90 = 1 Point Aged 65 or more= 1 point
In the community what CRB-65 score indicates admission to hospital?
2 or more
But use clinical judgement
In the hospital what does the CURB-65 scores indicate?
0-1 = Low Risk 2= Moderate Risk 3-5= High Risk
(Of death)
If 4 or 5 refer to critical care team
Describe the supportive, definitive and preventative management for patients presenting with pneumonia at hospital
Supportive- IV Fluids, Oxygen Therapy, Monitoring
Definitive- ABx
Preventative- LMWH for VTE prophylaxis if appropriate
How soon should investigations and treatment be carried out for a CAP at hospital?
All within 4 hours
Offer ABx as soon as possible after diagnosis
How should a low severity CAP be treated? CRB- less than 2
What should you advise patients?
Oral ABx mono-therapy
Amoxicillin 500mg TDS 5 day course
Or doxycycline or clarithromycin if penicillin allergic
If no improvement or worsened symptoms after 3 days seek further medical help.
How should a moderate severity CAP be treated? CURB- 65 of 2-3
Oral ABx- Dual Therapy
Amoxicillin with a macrolide (clarithromycin or erythromycin)
7-10 days worth
Use IV prep if CI
How should a severe CAP be treated? CURB-65 of 3 or more
Parenteral dual antibiotic therapy with a beta-lactamase stable beta lactam ABx and a macrolide
Piperacillin and Tazobactam- Tazocin
Amoxicillin and clavulanic acid- Co-Amoxiclav
When is it safe to stop IV ABx therapy and switch to oral?
Patient afebrile for more than 24 hours
Oral treatment not CI- e.g. vomiting
If deemed severe in primary care, before admission, what should the GP give?
IV/IM Penicillin G/ Benzylpenicillin
PO Amoxicillin 1g
What ABx should be given for a hospital acquired pneumonia?
Follow trust guidelines/policy
Give within 4 hours
5-10 days course
What features would indicate that it is not safe to discharge someone?
Temperature higher than 37.5 RR of 24 or more HR>100 Systolic BP of 90 or less Oxygen Sats less than 90% of air Abnormal mental status Inability to eat without assistance
2 or more of the above don’t discharge (unless already present at baseline- e.g. altered mental status and dementia)
When should a follow-up appointment be done after pneumonia?
6/52
When would you consider doing a repeat CXR for patients with pneumonia at follow up?
If there is a higher risk of malignancy that may have been a pre-disposing risk of developing the pneumonia (due to reduced ventilation)
Outline that progress that should be made by patients after ABx treatment for pneumonia
1 week- Fever should’ve resolved
4 weeks- Chest pain and sputum production should have substantially reduced
6 Weeks- Cough and breathlessness should have substantially reduced
3 months- Most symptoms should have resolved but fatigue may still be present
6 Months- Most people will feel back to normal
What type of pneumonia is common in the immunosuppressed?
What is seen on a CXR?
Pneumocystitis jirovecii pneumonia (PJP) is a causative organism in the immunosuppressed (e.g. HIV)
Presents with a dry cough, exertional dyspnoea, low PaO2, fever, bilateral crepitations
CXR may be normal or show bilateral peri-hilar interstitial shadowing
How do you diagnose PJP? (common pneumonia in immunosuppressed)
Visualisation of the organism on induced sputum (nebulised salbutamol)
Bronchoalveolar Lavage
Lung biopsy
What is the treatment for PJP?
High dose co-trimoxazole or pentamidine by slow IVI for 2-3 weeks
Steroids beneficial if sever hypoxaemia
What is the most common cause of viral pneumonia?
Influenza virus
What are some complications of pneumonia?
Respiratory Failure (Type 1 Most Common)
Hypotension- Infective process, give fluid challenge of 250ml over 15 minutes if SBP <90
Pleural Effusion
Empyema- Pus in pleural space, suspect is fever remains after pneumonia resolved
Lun abscess
Septicaemia
When draining a pleural effusion what features indicate it is an empyema?
Empyema= pus in the pleural space Yellow fluid pH<7.2 Low glucose High amylase
What are some causes of lung abscess?
Inadequately treated pneumonia
Aspiration- alcoholism, oesophageal obstruction, bulbar palsy, MS, GBS
Bronchial obstruction- tumour, foreign body
Pulmonary infarction
Septic Emboli- septicaemia, right heart endocarditis, IVDU
Sub-phenic or hepatic abscess
What does a lung abscess look like on a CXR?
Cavitating lesion with an air fluid level
What are some symptoms of a pulmonary abscess?
Swinging fever Cough Foul smelling sputum Pleuritic chest pain Malaise Weight loss Empyema develops in 20-30%
What is the treatment for lung abscess?
Antibiotics for 4-6 weeks
Aspiration
Antibiotic instillation
Surgical excision
