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Year 3 - CR > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

Why is pneumonia important

A
  • common disease with high rates of hospitalisation
  • it kills
  • expensive to treat
  • treatable

Presents to all specialities

  • GP
  • A and E
  • acute/general medicine
  • respiratory medicine
  • ITU
  • surgeons
  • Oncology
  • HIV
  • Radiology
  • Paediatrics
  • care the elderly
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2
Q

describe the epidemiology of pneumonia

A

• Incidence 5-11 cases/1000 adults
– 5-12% of respiratory infections presenting to GP’s
• Highest incidence in very young and very old
– BTS Audit – Mean age 71 (16-105) – 25% ≥85
• 22-42% require hospital admission in UK
• 5-7% need intensive care = 5% of ITU admissions – 50% Mortality
• 18.3% 30 day mortality
– 20% in first 24 hours – Median 5 days
• HAP affects 0.5-1% of inpatients

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3
Q

What is pneumonia

A

Symptoms and signs consistent with an acute lower respiratory tract infection associated with new radiographic shadowing for which there is no other explanation

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4
Q

What are the symptoms of pneumonia

A

Localised

  • Cough and at least one other from:
  • pleural pain
  • dyspnoea
  • tachypnoea

Systemic

  • sweating, fevers, shivers, aches and pains and/or
  • fever greater than 38 degrees
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5
Q

What are the signs of pneumonia

A
  • new and focal chest signs

- new radiographic shadowing with no other explanation

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6
Q

How can you classify pneumonia

A
  • aetiology
  • patient factors
  • clinical features
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7
Q

how do you classify pneumonia according to the aetiology

A

Organism

Source of infection

  • community acquired
  • health care associated - hospital acquired, ventilator associated, nursing home
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8
Q

How do you classify pneumonia according to patient factors

A
  • underlying disease

- immunocompromise states

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9
Q

how do you classify pneumonia according to clinical features

A
  • severity

- symptoms and signs

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10
Q

What organisms causes the most pneumonia

A

Strep Pneumoniae - greater than 50% of all cases

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11
Q

in approximately 50% of pneumonia cases there is…

A

no pathogen identified

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12
Q

what other factors can be used to help predict the organism that is causing the pneumonia

A
  • Source of infection
  • patient factors
  • clinical features
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13
Q

How do you define hospital acquired pneumonia

A
  • defined as someone who has developed pneumonia who has been in hospital for more than 48 hours or 10 days post discharge
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14
Q

What pathogens can cause hospital acquired pneumonia

A

Increased risk of

  • aspiration
  • H.influenzae
  • Gram negative
  • Staph aureus
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15
Q

What patient factors can help predict the most likely pathogen causing pneumonia

A
  • Elderly are less likely to have M.pneumoniae and Legionella
  • Diabetes - increase in bacteraemic pneumococcal pneumonia
  • COPD - increase in H.influenzae and M. Catarrhalis
  • Alcoholism - more likely to have all organisms - consider aspiration as more likely to aspirate and more likely to be infected with anaerobic bacteria
  • Immunodeficiency - still the most common cause but more likely to be due to legionella, neutropenic sepsis and TB, PCP etc
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16
Q

clinical features cannot …

A

predict the likely pathogen

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17
Q

what pathogens do you need to cover in hospital acquired pneumonia

A
  • Most commonly gram negative enterobacteria or staph Aureus
  • pseudomonas
  • Klebsiella
  • bactericides
  • clostridia
    – Cover Gram Negatives
    – No need to cover Legionella
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18
Q

what are the lung defence mechanisms

A

designed to treat a decrease in particle size as you go down the respiratory tract

  • filtration/deposition in upper airways
  • cough reflex
  • mucociliary clearance
  • alveolar macrophages
  • humeral and cellular immunity
  • oxidative metabolism of neutrophils
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19
Q

what can cause defects in the airway host defences

A
  • filtration/deposition in upper airways = anatomical abnormalities
  • cough reflex = aspiration e.g. post stroke
  • mucociliary clearance = cystic fibrosis, bronchiectasis
  • alveolar macrophages = alcoholism
  • humeral and cellular immunity = HIV
  • oxidative metabolism of neutrophils = chemotherapy
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20
Q

What has to happen in order for pneumonia to infect the body

A

Immune defence

  • defect in host defence
  • virulent organism
  • overwhelming inoculum such as aspiration
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21
Q

What investigations are needed in pneumonia

  • aid and confirm diagnosis
  • stratify severity/risk
  • target therapy
A

Aid/confirm diagnosis

  • chest radiograph - within 4 hours
  • FBC (WCC usually >15x109/l)/CRP (usually >100mg/l)

Stratify severity/Risk

  • urea and electrolytes
  • FBC/CRP/(LFT)
  • Oxygen saturations
  • ABG

Target therapy
- blood and sputum cultures – Pneumococcal urinary antigen
– Legionella urinary antigen +sputum culture
– Mycoplasma PCR (Sputum/Throat swab)
– Chlamydophilia PCR/Complement fixation
– Viral PCR(Nose/Throat swab)

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22
Q

What is the aim of microbiology

A

– Identify Pathogenic Bacteria
• Microscopy

– Test Sensitivity to Antibiotics
• Culture and Sensitivities

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23
Q

what cultures can be used to assess the microbiology of the pneumonia

A
  • Blood and/or Sputum Cultures
  • urinary antigens - only for pneumococcus and legionella
  • PCR - nose or throat swab for viruses
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24
Q

what is urinary antigen test supposed to be for

A
  • Pneumococcoal

- legionella – Only tests for Serogroup 1 (90% of European cases)

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25
Q

Describe urinary antigen tests

A

– Highly Sensitive (>80%) and Specific (>95%) – Rapid Result
– Remain Positive on Treatment
– No information on Antibiotic Sensitivities
– If positive → Specific sputum culture

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26
Q

When does staph aureus usually cause pneumonia

A
  • winter
  • 39% influenza symptoms
  • 39% influenza virus - 50% of those admitted to ITU
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27
Q

What radiographic changes might you see in pneumonia

A
  • Consolidation
  • air bronchograms - highly suggestive on pneumonia
  • shadowing
  • collapse
  • pleural effusion
  • lymphadenopathy
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28
Q

What are air bronchograms

A
  • dark lines going through a white area of lung

- air bronchi surrounded by the pus in the alveoli

29
Q

How long does it take for pneumonia changes on a radiograph

A
  • 73% at 6 weeks, slower in the elderly or multi lobar
30
Q

When would you use CT scanning in pneumonia

A
  • diagnostic doubt

- underlying cause such as cancer

31
Q

How can you guide your treatment of pneumonia

A

CURB65

32
Q

what is CURB65 made out of

A
  • C - new confusion (AMTS less than or equal to 8)
  • U - urea greater than 7mmol/l
  • R - respiratory rate greater than 30/min
  • B - blood pressure hypotensive
  • 65 age over 65
33
Q

What is the downside of CURB65

A
  • requires a blood test result as you need to know the urea
  • has binary cut offs
  • young people blood pressure doesn’t decrease until they are severely ill
34
Q

as CURB65 score increases….

A

mortality increases

35
Q

How do you treat pneumonia according to the CURB65 score

A 
– 0-1 – Treat at home
• >50% of cost related to admission
• ↓Mortality
• ↓RiskofVTE
• ↓ Risk of Hospital Acquired Infection

– 2 – Short admission, oral antibiotics

– 3+ – Admit + urgent senior review

– 4-5 – Admit + Critical Care (ITU/HDU) Review

36
Q

What else should be used in the treatment of pneumonia

A
  • Oxygen – Aim for target saturations
  • i.v. Fluids, analgaesia & DVT prophylaxis
  • Chest Physio/sitting out + Nutritional support
  • Smoking cessation
37
Q

What antibiotics are used in pneumonia

A
  • Beta lactam in mild pneumonia with a macrolide added in moderate to severe pneumonia
38
Q

What organisms are resistant to penicillin that can cause pneumonia

A

– Legionella & Mycoplasma

- but these are usually susceptible to macrolide

39
Q

What is there route of antibiotics that should be given

A

Oral – Unless:
• CURB65 ≥3
• Unable to swallow

40
Q

How long should the antibiotics be given for pneumonia

A
  • Mild 5/7
  • Moderate-Severe 7-10/7
  • Atypicals 14-21/7
41
Q

What can cause a failure to improve

A

Worried 3-4 days if not improving or getting worse
- repeat CXR/CRP at 3-4 days

Think about
– Incorrect diagnosis or complicating condition – Unexpected/resistant pathogen
– Impaired local or systemic immunity
– Local or distant complications of CAP

42
Q

What should you consider if the CXR does not improve at 6 weeks

A
  • consider bronchoscopy

- CT

43
Q

Why do you not give everyone broad spectrum antibiotics

A

Individual
- adverse consequences of antibiotics - MRSA and clostridium difficile

Society
- antibiotic resistance

44
Q

what are strategies for antibiotic stewardship

A
  • Ensure diagnosis secure
  • Discontinue if not appropriate
  • Narrow spectrum if specific pathogen identified
  • i.v. → oral switch
  • Stop dates on drug charts
45
Q

Who is give the influenza vaccine

A
  • all greater than 65 years + 2-4

greater than 6 months in an at risk group:

  • asthma
  • COPD
  • chronic respiratory, heart, kidney, liver or neurological disease
  • diabetes
  • immunosuppression
  • pregnant women
  • healthcare workers
46
Q

What are the benefits of the influenza vaccine

A

51-67% protection
– ↓Bronchopneumonia
– ↓Hospital Admissions
– ↓Mortality

47
Q

Who is given the pneumococcal vaccination

A
  • all over 65s

Greater than 2 years in an at risk group:

  • same as influenza
  • asplenia/splenic dysfunction - give 4-6/52 prior to splenectomy if possible
  • cochlear implants
  • CSF leaks

Revaccinate every 5 years

  • Asplenia/splenic dysfunction
  • CKD
48
Q

Who should you revaccinate with pneumococcoal vaccination

A
  • Asplenia/splenic dysfunction

- CKD

49
Q

describe what the pneumococcal vaccination does

A
  • poorly protective

- reduces septicaemia

50
Q

define atypical pneumonia

A

The term ‘atypical pneumonia’ has outgrown its historical usefulness and we do not recommend its continued use as it implies (incorrectly) a distinctive clinical pattern

51
Q

what is atypical pathogens used to define

A

• “The term ‘atypical pathogens‘ is used to define infections caused by:
– Mycoplasma pneumoniae – Chlamidophila pneumoniae – Chlamidophila psittaci
– Coxiella burnetii

52
Q

What do atypical pathogens all share

A

•Difficult to diagnose early in illness
• Resistant to β-lactams
• Replicate intracellularly
• Mixed reports regarding specific symptoms:
– Mycoplasma:
• ?Younger & less systemic features.
• Epidemics
– C.pneumoniae – ?Headaches, longer prodrome & older
– C.psittaci – Acquired from birds but only 20% have bird contact
– C.burnetii – Younger males, dry cough & high fever

53
Q

What is legionella caused by

A

Inhalation of aerosol from infected water source e.g. air conditioning

54
Q

How do you differentiate clinically legionella

A

– Men
– Healthy younger patients
– Smokers
– Neurological or GI symptoms – Less respiratory symptoms

55
Q

Who do you need to inform in legionella outbreak

A

Inform HPU to perform source investigation

56
Q

When do you do the follow up for pneumonia

A
  • follow up is at 6 weeks
57
Q

How do you treat low severity pneumonia CURB65=0-1

A 
Home 
- amoxicillin 500mg tis orally 
or 
- Doxycycline 200mg loading dose then 100mg orally
or 
- clarithromycin 500mg bd orally
58
Q

How do you treat moderate severity pneumonia = CURB65=2

A

Hospital

  • amoxicillin 500mg-1g tis orally plus clarithromycin 500mg bd orally
  • if oral administration not possible amoxicillin 500mg tds IV or benzylpenicillin 1-2g QDS IV plus clarithromycin 500mg bd IV

or

  • doxycycline 200mg daoding dose then 100mg orally
    or
    levofloxacin 500mg od orally or moxiflocaxin 400mg od orally
59
Q

How do you treat high severity pneumonia CURB65=3-5

A

Hospital (consider critical care)

  • antibiotics given as soon as possible
  • Co-amoxiclav 1.2g tis IV plus clarithromycin 500mg bd IV
  • if legionella strongly suspected consider adding levofloxacin

or

  • benzylpencillin 1.2g qds IV plus either levofloxacin 500mg bd IV or ciprofloxacin 400mg bd IV
    or
  • cefuroxime 1.5g tds IV or cefotaxime 1g tds IV or ceftriaxone 2g od IV, plus clarithromycin 500mg bd IV
60
Q

What are the clinical signs in consolidation

A
  • expansion is decreased on affected side
  • percussion is dull
  • tactile vocal remits is increased over the affected area
  • breath sounds are bronchial over the affected area
  • vocal resonance is increased over the affected area
61
Q

What are the clinical signs of lung collapse

A
  • mediastinum is shifters toward the abnormal side
  • expansion is decreased on the affected side
  • percussion is dull over the affected area
  • breath sounds are reduced
62
Q

What are the clinical signs of pleural effusion

A
  • the mediastinum is shifted away from the abnormal side
  • expansion is decreased on the affected side
  • percussion is dull
  • tactile vocal remits is decreased over the effect side
  • breath sounds are reduced over the affected area
  • vocal resonance is decreased over the affected area
63
Q

What is the difference between low pitched and high pitched sounds in pleural effusion

A
  • Low pitched sounds have poorer transmission through a pleural effusion than a normal lung
  • high pitched sounds appear to have slightly higher auscultatory transmission through a pleural effusion than a normal lung
64
Q

describe the clinical signs for a pneumothorax

A
  • expansion is decreased on affected side
  • percussion is resonant over the affected area
  • tactile vocal fremitus is decreased over affected area
  • breath sounds are reduced over the affected area
  • vocal resonance is decreased over the affected area
65
Q

What antibiotics are used against pneumococcal pneumonia

A
  • Amoxicillin
  • benzylpenicillin
  • cephalosporin
66
Q

What antibiotics is used against staphylococcal pneumonia

A
  • flucloxacillin and rifampicin
67
Q

What antibiotics is used against klebsillea pneumonia

A
  • cefotaxime

- imipenem

68
Q

What does the healing process of pneumonia look like

A
  • 1 week – fever should have resolved
  • 4 weeks – chest pain and sputum production should have reduced
  • 6 weeks – cough and breathlessness should have reduced
  • 3 months – most symptoms should have resolved but fatigue may still be present
  • 6 months – people will feel back to normal

Year 3 - CR (44 decks)

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