Pneumonia Flashcards

1
Q

What is pneumonia? What are the 4 types?

A

Acute lower respiratory tract infection causing inflammation of lung alveoli .

  1. CAP - primary or secondary to underlying disease
  2. HAP - hospital acquired pneumonia - >48hr after admission
  3. Aspiration - happens to people with stroke, myasthenia, bulbar palsies, reduced consciousness, oesophageal disease, or poor dental hygiene.
  4. Immunocompromised patient

Histologically there is bronchopneumonia and lobar pneumonia.

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2
Q

How do you confirm and diagose a pneumonia?

A

X Ray - must have consolidation

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3
Q

List the typical and atypical organisms causing community acquired pneumonia.

A

Typical (85%): streptococcus pneumoniae, haemophilus influenzae

Atypical(15%): legionella, mycoplasma, coxiella, chlamydia.

Viruses account for up to 15%. Flu may be complicated by community-acquired MRSA pneumonia.

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4
Q

What are the causes of hospital acquired pneumonia?

A

Most commonly gram -ve enterobacteria or staph. aureus. Also pseudomonas, klebsiella, bacteroides, and clostridia.

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5
Q

Which microbes most commonly cause pneumonia in immunocompromised patients?

A
  • Strep. pneumoniae
  • H. influenzae
  • Staph. aureus
  • M. catarrhalis
  • M. pneumoniae
  • Gram -ve bacilli and pneumocystis jirovecii (formerly named P carinii)
  • Other fungi, viruses (CMV, HSV) and mycobacteria
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6
Q

What are the symptoms of pneumonia?

A
  • Fever
  • Rigors (sudden cold feeling)
  • Malaise
  • Anorexia
  • Dyspnoea
  • Cough
  • Purulent sputum
  • Heamoptysis
  • Pleuritic pain
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7
Q

What are the signs associated with pneumonia?

A
  • Pyrexia
  • Cyanosis
  • Confusion (can be the only sign in the elderly, may be hypothermic)
  • Tachyponea
  • Tachycardia
  • Hypotension
  • Signs of consolidation (reduced expansion, dull percussion, increased tactile vocal fremitus, bronchial breathing)
  • Pleural rub
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8
Q

What tests would you do if you suspect pneumonia?

A
  1. Assess oxygenation: oxygen saturation, ABGs, and BP.
  2. Blood tests: FBC, U&E, LFT, CRP (GPs should consider a point of care CRP to guide antibiotic prescription where LRTI is suspected, NICE 2014)
  3. CXR: lobar or muultilobar infiltrates, cavitation, or pleural effusion
  4. Sputum: for microscopy and culture
  5. Urine: check for legionella and pneumococcal urinary antigens
  6. Pleural fluid: aspirate for culture
  7. Bronchoscopy and bronchoalveolar lavage: if the patient is immunocompromised or on ITU
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9
Q

How do you assess the severity of pneumonia?

A
  • BUT this system may underscore the young so use clinical judgement. Other factors increasing risk of death: comorbidity, bilateral/multilobar. PaO2 <8kPa*
  • In GP setting urea not used and a score of 2-3 definitely needs consideration of admission.*
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10
Q

How do you manage pneumonia?

A
  • Antibiotics - broad spectrum initially then according to culture results
  • Oxygen to keep PaO2>8kPa and/or saturation >94%
  • IV fluids (anorexia, dehydration, shock)
  • VTE prophylaxis
  • Analgesia if pleurisy
  • Follow up at 6 weeks for a CXR
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11
Q

What are the complications of pneumonia?

A
  • Pleural effusion
  • Empyema
  • Lung abscess
  • Respiratory failure
  • Septicaemia
  • Others: Brain abscess, pericarditis, myocarditis, cholestatic jaundice, repeat CRP and CXR in patients not improving to look for progression/complications.
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12
Q

Which antibiotics would you give for mild-mod CAP?

A

Consult the local guidelines

Amoxicillin 0.5-1g PO TDS 5 days

[penicillin allergic: clarithromycin 500mg PO BD 5 days]

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13
Q

Which antibiotics would you give for severe CAP?

A
  1. Co-amoxiclav 1.2g IV TDS AND
  2. clarithromycin 500mg PO/IV BD

Switch to oral when afebrile for 48hrs and continue for 5 days

[levofloxacin 500mg PO/IV BD 5 days]

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14
Q

Which antibiotics for non-severe vs severe HAP?

A

Non-severe:

  1. Doxycycline 200mg PO stat then 100mg BD 5 days
  2. [co-trimoxazole 1.44g PO/IV BD if allergy]

Severe:

  1. Co-trimoxazole 1.44g PO/IV BD 5 days OR (co-amox 1.2g IV TDS + gentamicin IV)
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15
Q

Which antibiotics to treat aspiration pneumonia?

A

Co-trimoxazole 1.44g PO/IV BD

AND metronidazole IV 500mg or 400mg PO TDS

for 7 days

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16
Q

Which at-risk groups should get the pneumococcal vaccine?

A
  • All adults over 65
  • Chronic heart/liver/kidney/lung conditions
  • Diabetes mellitus or not well controlled diabetes
  • Immunosuppressed e.g. low spleen function/AIDs/on chemotherapy or prednisolone >20mg/d

CI - pregnant/lactating/anaphylaxis to previous vaccine

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17
Q

Describe the type of respiratory failure you can get in pneumonia.

A

Type 1 - PaO2 <8kPa

Treat with high flow oxygen (60%) and transfer to ITU if it does not improve.

If rising PaCO2/worsening acidosis then consider elective ventilation

Aim to keep saturations at 94-98% and PaO2 at >8kPa

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18
Q

What are the causes of lung abscess ?

A
  • Inadequately treated pneumonia
  • Aspiration (e.g. alcoholism, oesophageal obstruction, bulbar pasly)
  • Bronchial obstruction (tumour, foreign body)
  • Pulmonary infarction
  • Septic emboli (septicaeamia, right heart endocarditis, IV drug use)
  • Subphrenic or hepatic abscess
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19
Q

What clinical features are associated with lung abscesses?

A
  • Swinging fever
  • Cough
  • Purulent, foul smelling sputum
  • Pleuritic chest pain
  • Haemoptysis
  • Malaise
  • Weight loss

Look for finger clubbing, anaemia, crepitations, empyema (can develop in 20-30%)

20
Q

What are the tests and treatments for lung abscesses?

A

BLOODS (FBC, ESR, CRP, blood cultures)

SPUTUM microscopy, culture, cytology

CXR: walled cavity, often with fluid level.

Consider bronchoscopy.

Treatment: ANTIBIOTICS (until healed at about 4-6wks), POSTURAL DRAINAGE, repeated ASPIRATION, ANTIBIOTIC instillation, SURGICAL excision.

21
Q

Name some common viral pneumonias.

A
  • Influenza
  • Swine flu (H1N1)
  • CMV
  • Varicella zoster
  • Measles
22
Q

Which bacteria associated with pneumonia colonises water tanks kept t <60oC?

A

Legionella pneumophilia - e.g. in hotel air conditioning and hot water systems so causes outbreaks

Flu-like symptoms precede a dry cough and dyspnoea.

CXR will show BI-basal consolidation

23
Q

What is the commonest chalmydial infection?

A
  • Chlamydophilia pneumoniae causing pneumonia
  • Person to person spread and BIPHASIC illness

Symptoms: pharyngitis, hoarseness, otitis, then pneumonia.

24
Q

Which type of pneumonia can be acquired from parrots?

A

Chlamydophilia psittaci which causes psittacosis, headache, fever, dry cough, lethargy, arthralgia, anorexia, and D&V.

CXR will show patchy consolidation.

25
Q

Which pneumonial bacteria occurs in epidemics about every 4 years?

A

Mycoplasma pneumoniae

26
Q

Which pnemonial bacteria is a common causes of pneumonia in those after surgery or with CF?

A

Pseudomonas - common in bronchiectasis and CF, also causes HAP, particularly in ITU or after surgery.

27
Q

Which rare bacteria causes a cavitating pneumonia particularly in the upper lobes and is drug resistant?

A

Klebsiella pneumonia

Occurs in elderly, diabetics and alcoholics.

28
Q

Name two strains of avian influenza.

A

H5N1

H7N9

Responsible for most of human illnesses worldwide

29
Q

What is the microbiological difference between typical and atypical?

A

Typical - have a cell wall –> treated with BETA LACTAMS (affect the cell wall PBP penicillin binding protein)

Atypical - no cell wall –> treated with MACROLIDE (affect the ribosomal RNA P site)

30
Q

What is the difference between bronchopneumonia and lobar pneumonia?

A

Broncho - low virulence organisms in elderly, patchy consolidation

Lobar - mostly strep pneumo, affects the whole lobe

31
Q

What are the stages of lobar pneumonia?

A
  1. Congestion
  2. Red hepatisation
  3. Grey hepatisation
  4. Resolution
32
Q

Treatment for PCP?

A

Co-trimoxazole 960BD

2nd line: clindamycin + primiquine, IV methylpred

33
Q

What is the most likely pneumonia cause in a 18yo female presenting with fever and low sats?

A

Streptococcus pneumoniae

34
Q

What is shown?

A
  • CXR - double heart border (‘Sail’ sign)
  • Collapsed lower lobe
35
Q

What % of CAP is caused by S pneumoniae?

A

30-50%

36
Q

What are some signs of Streptococcus pneumoniae?

A
  • Acute onset
    • Severe pneumonia
    • Fever and rigors
    • Lobar consolidation
    • Rusty coloured sputum is characteristic of S. pnuemoniae
37
Q

Why is no identification of CAP organisms usually made?

A
  1. Difficulty obtaining a good sample
  2. Early treatment with antibiotics is commenced
38
Q

What are the causes of CAP at different ages?

A
  • 0-1 months –> E. coli, GBS, Listeria monocytogenes
  • 1-6 months –>Chlamydia trachomatis, Staphylococcus aureus, RSV
  • 6 months - 5 years –> Mycoplasma pneumoniae, Influenza
  • 16-30 years –> Mycoplasma pneumoniae, Streptococcus pneumoniae
39
Q

What % of CAP is caused by H. influenzae?

A

15-35% of CAP

40
Q

What organisms are responsible for cavitation?

A
  • Staph aureus
  • Klebsiella
  • Haemophilus
  • TB

NB: squamous cell carcinomas of the lung commonly cavitate.

41
Q

What is the most likely cause of cavitation on CXR in a man with LLL pneumonia and haemoptysis?

A

Haemophilus influenzae is most likely

42
Q

When is haemophilus influenzae pneumonia more common?

A

In pre-existing lung disease

43
Q

What are the clinical features of legionella pneumophilia?

A
  • Confusion
  • Abdo pain
  • Diarrhoea
  • Lymphopaenia
  • Hyponatraemia
44
Q

What are the main causes of HAP?

A
  1. Enterobacteriaciae (e.g. E. coli, K. pneumoniae) – 31%
  2. Staphylococcus aureus – 19%
  3. Pseudomonas spp – 17%
  4. Haemophilus influenzae – 5%
  5. Acinetobacter baumanii – 4%
  6. Fungi (Candida spp) – 7%
45
Q

What XR appearance does PCP cause?

A

Bilateral ground glass shadowing in a bat wing appearance

46
Q

22yr old man on chemo for leukaemia with prolonged neutropenia and has tried several antibiotics without luck. What is the diagnosis?

A

Aspergillus fumigatus