Pneumonia Flashcards
What is Pneumonia?
inflammation of the lungs with consolidation or interstitial infiltrates
In the majority this is secondary to bacterial infection
How can pneumonia be categorised?
Community or hospital
Typical or atypical (Mycoplasma, Chlamydia, Legionella)
Aspiration or Immunocompromised
What is the most common cause of pneumonia? What is it particularly associated with?
Streptococcus pneumoniae
(pneumococcus)
high fever, rapid onset, herpes labialis reactivation
In which patients is haemophilus influenzae pneumonia common?
COPD
Which organism is a classic cause of pneumonia in alcoholics?
Klebsiella pneumoniae
In which patients is pneumocystis jiroveci pneumonia typically seen? How does this present?
HIV
Dry cough, exercise-induced desaturations + absence of chest signs
What is idiopathic interstitial pneumonia?
Group of non-infective causes of pneumonia e.g.
Cryptogenic organising pneumonia
What is hospital acquired pneumonia?
Pneumonia occurring >,48h after admission
Which infections may cause HAP?
Gram-negative aerobes: Pseudomonas, Klebsiella, Escherichia coli
Anaerobes (due to aspiration pneumonia)
What is ventilator associated pneumonia?
A type of HAP that develops in intubated patients on mechanical ventilation for >48h
What is atypical pneumonia caused by?
Organisms undetectable on Gram stain + can’t be cultured with standard methods
List 3 organisms causing atypical pneumonia
Mycoplasma pneumoniae
Legionella pneumophila
Chlamydia pneumoniae
List 6 risk factors for CAP
Age >,65
Residence in nursing home
Contact with children
Pre-existing lung disease (e.g. COPD)
Smoking
Alcohol
List 4 common symptoms of CAP
Cough with increasing sputum
Dyspnoea
Pleuritic chest pain
Fever/ Rigors
What do elderly patients with CAP often present with?
Confusion
List 4 signs of CAP
Signs of systemic infection: fever, tachycardia
Reduced O2 sats + tachypnoea
Auscultation: reduced breath sounds, crackles, wheeze
Dullness to percussion
What should be used in primary care to assess CAP?
CRB65 criteria
Confusion: AMTS <8
RR >30
BP: SBO <90 or DBP <60
>65y
What is the mortality risk based on CRB65 scores? How should this be acted upon?
0: low risk <1%
1-2: intermediate risk 1-10%
3-4: high risk >10%
Home based care (abx) if score 0
Hospital assessment for all others
If a point of care CRP test is available, how does this guide antibiotic therapy?
CRP <20: do not routinely offer abx
CRP 20-100: consider delayed prescription
CRP >100: offer abx
What criteria is used to assess patients presenting to hospital with pneumonia?
CURB-65
Confusion: AMTS <8
Urea >7
RR >30
BP: SBP <90 +/or DBP <60
>65
How do CURB65 score influence management?
0-1: low risk <3%. Home based care
>,2: intermediate risk 3-15%. Admit.
>,3: high risk >15%. ICU assessment
What bloods are performed for CAP?
FBC: raised WCC
U+Es: urea for CURB65
CRP: raised, used to monitor response to Tx
LFTs: for baseline
How does CRP change differ from that of WCC? Why is this? When may this be seen?
CRP can lag in decreasing in comparison to WCC
CRP is an acute phase reactant
1. At start of infection, CRP can be inappropriately low/ normal
2. When infection is resolving, CRP can be unexpectedly high given the clinical picture.
What additional investigations are indicated for moderate-high severity CAP?
Blood culture
Sputum culture
Legionella + Pneumococcal urinary antigen test
CRP monitoring for admitted
What investigation allows definitive diagnosis of CAP? What does this show?
CXR
Consolidation
What pathogens can be detected with urine antigen testing? When should this be ordered?
Legionella + Pneumococcus
Mod-high severity CAP
Those with specific RFs
Describe management of low-severity CAP
Amoxicillin 5 days
(If pen allergic: Macrolide (Clarithromycin) or Tetracycline)
Describe the management of moderate severity CAP
Amoxicillin + Clarithromycin
PO or IV
Describe the management of high severity CAP
Co-amoxiclav + Clarithromycin IV
(if pen allergic: Ceftriaxone + Clarithromycin)
A patient with CAP should not be discharged if in the past 24h they have had 2 or more of what 7 findings?
Temp >37.5
RR >,24
HR >100
SBP ,<90
O2 sats <90% on RA
Abnormal mental status
Inability to eat without assistance
Describe the timeline of how symptoms should have resolved from CAP
1w: fever resolved
4w: chest pain + sputum production substantially reduced
6w: cough + breathlessness substantially reduced
3 mo: most Sx resolved, fatigue may still be present
6 mo: most feel back to normal
What follow up should be performed in all cases of pneumonia?
CXR 6w after clinical resolution to ensure consolidation has cleared + no underlying secondary abnormalities
List 4 symptoms of atypical pneumonia
Headache
Flu-like Sx + low grade fever
Cough
Myalgia
Give 5 signs of legionella pneumophila pneumonia
Hyponatraemia
Deranged LFTs
Lymphopenia
Relative bradycardia
Pleural effusion (30%)
Give 3 features of mycoplasma pneumoniae
Prolonged + gradual onset
Flu-like Sx precede dry cough
Bilateral consolidation on CXR
Give 2 haematological complications caused by cold agglutinins (IgM) of mycoplasma pneumoniae
Haemolytic anaemia
Thrombocytopenia
Give 2 dermatological complications of mycoplasma pneumoniae
Erythema multiform
Erythema nodosum
Give 2 neurological complications of mycoplasma pneumoniae
Meningoencephalitis
Guillain Barre Syndrome
What is a renal complication of mycoplasma pneumoniae?
Acute glomerulonephritis
What is an ENT complication of mycoplasma pneumoniae?
Bullous myringitis
Painful vesicles on the TM
What are the cardiac complications of mycoplasma pneumoniae?
Pericarditis
Myocarditis
What are the GI complications of mycoplasma pneumoniae?
Hepatitis
Pancreatitis
What are the investigations for mycoplasma pneumoniae?
Mycoplasma serology
+ve cold agglutination test
In which age group is atypical pneumonia more common?
<50s
What investigations should be performed for atypical pneumonia?
FBC: minor raise in WCC, mycoplasma can cause anaemia
LFTs: raised (mycoplasma + legionella)
Urinary antigen test + Sputum culture (Legionella)
CXR
Describe management of atypical pneumonia
Macrolide: Clarithromycin/ Erythromycin
or
Doxycycline
What environmental condition is legionella pneumophila associated with?
Air conditioning units
When in bronchoscopy performed in pneumonia cases?
if Pneumocystitis carinii is suspected
If Pneumonia fails to resolve
When would you add metronidazole to the baseline antibiotics being used to treat a pneumonia?
Aspiration
Lung abscess
Empyema
Describe management of severe HAP/ for patients at higher risk of resistance
Piperacillin/ Tazobactam IV
or Ceftriaxone IV
If MRSA suspected/ confirmed: + Vancomycin IV
Describe management of mild-moderate HAP/ patients not at high risk of resistance
Co-amoxiclav PO
(if pen allergic Doxycycline)
What supportive treatment may be necessary in treating pneumonia?
Oxygen
IV fluids
CPAP, BiPAP or ITU care for respiratory failure
Surgical drainage for lung abscesses + empyema
What would you consider in a non-resolving pneumonia?
Other causes: PE PH RHF Drug toxicity Unusual pathogens Alveolar haemorrhage
List 2 approaches to prevention of pneumonia
Pneumococcal vaccine
Haemophilus influenzae type B vaccine
Only usually given to high risk groups (e.g. >65, splenectomy)
List 5 complications of pneumonia
Pleural effusion Empyema Abscess Septic shock ARDS
Give 2 characteristics of klebsiella pneumoniae
Gram -ve rod
Part of human gut flora
Who does klebsiella pneumonia more commonly effect? When?
Alcoholics
Diabetics
May occur following aspiration
Give 2 features of klebsiella pneumonia
Red-currant jelly sputum
Often affects upper lobes
What is the prognosis of Klebsiella pneumonia?
Commonly causes lung abscesses + empyema
Mortality 30-50%
How is Chlamydia psittaci transmitted?
Via birds/ bird secretions
How do patients with psittacosis usually present?
Flu like Sx: fever, headache + myalgia
Resp Sx: dyspnoea, dry cough + chest pain
What signs may be found in the chest in psittacosis?
Unilateral crepitations + vesicular breathing
Evidence of pleural effusion (uncommon)
What 2 signs may psittacosis rarely present with in the abdomen?
Hepatomegaly
Splenomegaly
List 5 risk factors for aspiration pneumonia
Poor dental hygiene
Swallowing difficulties
Prolonged hospitalisation/ surgical procedures
Impaired consciousness
Impaired mucociliary clearance
Which lobes are most commonly affected by aspiration pneumonia?
Right middle + lower lobes
Due to larger calibre + more vertical orientation of R main bronchus
List 5 aerobic bacteria that may cause aspiration pneumonia
Strep pneumoniae
Staph aureus
Haemophilus influenzae
Pseudomonas aeruginosa
Klebsiella
List 4 anaerobic bacteria that may cause aspiration pneumonia
Bacteroides
Prevotella
Fusobacterium
Peptostreptococcus
