Pneumonia

Question 1

Definition

Answer 1

Infection of the distal lung parenchyma. Categorised in several ways:

• Community, hospital or nosocomial infection
• Typical or atypical (Mycoplasma, Chlamydia, Legionella)
• Aspiration or Immunocompromised

Question 2

Aetiology (community acquired infection)

Answer 2

Strep Pneumoniae 70%, 
H. Influenza, 
Moraxella catharris (COPD), 
Chlamydia (birds) 
Mycoplasma (epidemics) 
Legionella (AC) 
Staph areous (viral infection of IVDU) 
TB (presents as pneumonia)

Question 3

Aetiology (hospital acquired infection)

Answer 3

Klebsiella,

Pseudomonas

Question 4

Risk factors

Answer 4

age, 
hospital , 
immunocompromised, 
pre existing disease,
smoking
alcohol.

Question 5

Epidemiology

Answer 5

5-11 in 1000, 30 in 1000 in elderly

60k deaths py in the UK

Question 6

Presenting symptoms

Answer 6

Fever, rigors, sweating, pleuritic chest pain, shortness of breath, cough, yellow sputum (green, or rusty in S pneum).

Confusion in elderly (Legionella)

Atypical pneumonia: headache, myalgia, diaohrrea

Question 7

Signs on physical examination

Answer 7

Pyrexia, tachypnea, cold extremities, tachycardia, respiratory distress.

Decreased chest expansion, dullness, increased vocal fremitus, bronchial breathing (Insp=Exp), coarse crepitaitons on affected side,

Chronic suppurative disease ie. Abscess can present with clubbing

Question 8

Investigations

Answer 8

Blood: FBC (WCC) LFT, UE (Na), blood cultures, RBC (Mycoplasma agglutinates)

CX: Lobar patchy shadowing. Klebsiella upper lobes. May detect abscesses.

Sputum: microscopy, culture, sensitivity.

Urine: Pneumococcus or Legionella antigens.

Bronchoscopy: if Pneumocystitis carinii is suspected / Pneumonia fails to resolve in 2 weeks

Question 9

Management plan (antibiotics)

Answer 9

Assess severity and treat according to BTS guidelines.

Antibiotic course:

• Oral amoxicillin (0 markers)
• IV amoxicillin / erythromycin (1 marker)
• IV cefutroxime / coamoxiclav / cefotaxime and erythromycin (>1 marker)
• Add metronidazole if abscess / aspiration / empyma suspected
• Switch to appropriate antibiotic when sensitivity comes back.

Question 10

Management plan (supportive treatment)

Answer 10

• Oxygen (maintain pO2 > 8kPa but beware of hypercapnia in COPD).
• Parenteral fluids
• CPAP / BiPAP and ITU care for respiratory failure
• Surgical drainage may be needed for abscess

Question 11

Management plan (other)

Answer 11

Discharge planning:
Two of more features of clinical instability present (temperature, HR, RR, decrease BP and oxygen saturation preduct higher chance of readmission, take
into account

Non resolving pneumonia: think of other causes ie. PE, PH, RHF, drug toxicity, unusual pathogens, alveolar haemorrage etc.

Prevention: H influenza type B vaccine in the high risk groups ie. Immunocompromised etc.

Question 12

Possible complications

Answer 12

Pleural effusion, respiratory failrure, abscess, empyma (pus in pleural cavity), septic shock, ARDS, death

Pneumoniae: erythema multiforme, Guillame Barre, myocarditis, haemolytic
anaemia, meningoencephalitis, transverse myelitis

Question 13

Prognosis

Answer 13

Must resolve with max. 3 weeks of treatment. High mortality for those with sevre pneumonia (10% community, 30% hospital acquired, 50% itu).

Markers of prognosis CURB65 score:

• Confusion
• Urea>7mmol/l
• RR > 30/min
• BP 90/60
• Age 65+