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Respiratory > Pneumonia - CAP and HAP > Flashcards

Pneumonia - CAP and HAP Flashcards

1
Q

What is pneumonia?

A

Acute lower respiratory tract infection

Associated with fever, symptoms and signs in the chest + abnormalities on CXR

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2
Q

What is the incidence of pneumonia?

A

5-11/1000

Increases in extremes of age (30% are under 65yrs)

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3
Q

What is the mortality rate of pneumonia in hospital?

A

21%

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4
Q

What are the different classifications of pneumonia?

A

Community acquired - may be primary or secondary to underlying disease

Hospital acquired - defined as > 48 h after hospital admission

Aspiration

Immunocompromised patient

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5
Q

What are the typical causative organisms of CAP?

A

Streptococcus pneumoniae (commonest)

Haemophilus influenzae

Moraxella cartarrhalis

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6
Q

What are the atypical causative organisms of CAP?

A

Mycoplasma pneumoniae

Staphylococcus aureus

Legionella species

Chlamydia

Gram -ve bacilli (rarer) = Coxiella burnetti and anaerobes

MNEMONIC = Legions of Staph MCQ

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7
Q

What % of CAP are caused by viruses?

A

15%

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8
Q

What are the causative organisms of HAP?

A

Most commonly Gram -ve enterobacteria or Staph. aureus

Also:
- Pseudomonas
- Klebsiella
- Bacterioides
- Clostridia

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9
Q

What can flu be complicated by?

A

Flu many be complicated by community acquired MRSA pneumonia

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10
Q

Which group of patients are at increased risk of aspiration pneumonia?

A

Those with:
- stroke
- bulbar palsies
- myasthenia
- reduced consciousness (e.g., post ictal or intoxicated)
- oesophageal disease (e.g., achalasia, reflux)
- poor dental hygiene

Risk aspirating oropharyngeal anaerobes

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11
Q

What are the causative organisms of pneumonia in immunocompromised patients?

A

Strep. pneumoniae

H. influenzae

Staph. aureus

M. catarrhalis

M. pneumoniae

Gram -ve bacilli

Pneumocystis jirovecii

Other fungi, virus (CMV, HSV) and mycobacteria (e.g., M. tuberculosis)

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12
Q

What are common symptoms of pneumonia?

A

Fever

Rigors

Pleuritic chest pain (i.e., pain on inspiration)

Purulent sputum

Haemoptysis

Dyspnoea

Malaise

Anorexia

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13
Q

What are signs of pneumonia?

A

Pyrexia

Cyanosis

Confusion (can be the only sign in the elderly - may also be hypothermic)

Tachypnoea

Tachycardia

Hypotension

Signs of consolidation (reduced expansion, dull percussion, increased tactile vocal fremitus/vocal resonances, bronchial breathing)

Pleural rub

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14
Q

What investigations would you do?

A

O2 sats

ABGs (if SaO2 < 92% or severe pneumonia)

Bloods - FBC, U&E, LFT, CRP

Sputum - for MC+S

Urine - check for Legionella/Pneumococcal urinary antigens

Atypical organism/viral serology (PCR sputum/BAL, complement fixation tests acutely, paired serology)

Could aspirate pleural fluid for culture

Imaging
CXR - lobar or multilobar infiltrates, cavitation, or pleural effusion

Resp doctors may consider bronchoscopy and bronchoalveolar lavage if patient is immunocompromised or on ITU

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15
Q

What scoring system is used for pneumonia? What are its components and how are each scored?

A

CURB-65 - 1 point for each:

Confusion (AMTS ≤ 8)
Urea > 7mmol/L
RR ≥ 30/min
BP < 90 systolic and/or 60 diastolic
Age ≥ 65

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16
Q

A patient’s CURB-65 score is 0-1. How would you manage them?

A

PO Abx/home Tx

17
Q

A patient’s CURB-65 score is 2. How would you manage them?

A

Hospital therapy

18
Q

A patient’s CURB-65 score is ≥3. How would you manage them?

A

Severe pneumonia

Mortality = 15-40%

Consider ITU

19
Q

What other features increase the risk of death from pneumonia?

A

Other co-morbidities

Bilateral/multilobar

PaO2 < 8kPa

20
Q

What is the Tx for CAP with a CRB65 score 0 or CURB score of 0-1?

A

1st line
Amoxicillin PO 500mg TDS for 5 days (higher doses can be used - see BNF)

2nd line (in penicillin allergy or if amoxicillin unsuitable)
- Doxycycline 200mg on 1st day then 100mg PO OD for 4 days (5-day course in total)
- Clarithromycin 500mg PO BD for 5 days

21
Q

What is the Tx for CAP with a CURB score of 0-1 in pregnancy?

A

Erythromycin PO 500mg QDS for 5 days

22
Q

What is the Tx for CAP with a CRB65 score 1-2 or CURB score of 2?

A

1st line
Amoxicillin PO 500mg TDS for 5 days (higher doses can be used - see BNF)
AND (if atypical pathogens suspected)
Clarithromycin PO 500mg BD for 5 days OR Erythromycin (in pregnancy) PO 500mg QDS

2nd line (in penicillin allergy)
- Doxycycline PO 200mg on 1st day then 100mg PO OD for 4 days (5-day course in total)
- Clarithromycin 500mg PO BD for 5 days

23
Q

What is the Tx for CAP with a CRB65 score 3-4 or CURB score of 3-5?

A

1st line
Co-amoxiclav PO 500/125mg TDS or 1.2g TDS IV for 5 days
AND
Clarithromycin 500mg BD PO or IV for 5 days OR Erythromycin (in pregnancy) 500mg QDS PO for 5 days

2nd line (in penicillin allergy)
Levofloxacin (consider safety issues) 500mg BD PO or IV for 5 days

Also need urgent admission to the hospital (as a they have a score of 3 or more)

24
Q

What is the 1st choice oral Abx for HAP if non-severe symptoms or signs, and not at higher risk of resistance?

A

Co-amoxiclav 500/125mg PO TDS for 5 days then review

25
Q

What are the alternative Abx for HAP if non-severe symptoms or signs, and not at higher risk of resistance, but patient has penicillin allergy or if co-amoxiclav is unsuitable?

A

Doxycycline 200 mg on 1st day, then 100mg OD for 4 days (5 days in total)

OR

Cefalexin (caution in penicillin allergy as it is a cephalosporin) 500mg BD/TDS for 5 days then review
- can be increased to 1g to 1.5g TDS/QDS

Co-trimoxazole (off-label use) 960mg BD for 5 days then review

Levofloxacin (only if switching from IV levofloxacin with specialist advice; off label use; consider safety issues): 500mg OD/BD for 5 days then review

26
Q

What are the 1st choice IV Abx for HAP if severe symptoms or signs (e.g., sepsis), or at higher risk of resistance?

A

Piperacillin with tazobactam 4.5g TDS (increased to 4.5g QDS if severe infection)

Ceftazidime 2g TDS

Ceftriaxone 2g OD

Cefuroxime 750mg TDS (increased to 750mg QDS or 1.5g TDS/QDS if severe infection)

Meropenem 0.5g to 1g TDS

Ceftazidime with avibactam 2/0.5g TDS

Levofloxacin (off-label use, consider safety issues) 500mg OD/BD (use higher dosage if severe infection)

27
Q

Which Abx should be added if suspected or confirmed MRSA (i.e., dual therapy with a first-choice intravenous antibiotic)?

A

Vancomycin
- 15mg/kg to 20mg/kg BD/TDS, adjusted according to serum [vancomycin]
- a loading dose of 25mg/kg to 30mg/kg can be used in seriously ill people
- max 2g per dose

Teicoplanin
- initially 6mg/kg every 12 hours for 3 doses, then 6mg/kg OD IV

Linezolid (if vancomycin cannot be used; specialist advice only)
- 600mg BD PO/IV

28
Q

What is the Tx for aspiration pneumonia?

A

Cephalosporin IV + metronidazole IV

29
Q

What is the Tx of pneumonia in neutropenic patients?

A

For gram +ve cocci and -ve bacilli
- Aminoglycoside IV + antipseudomonal penicillin IV or 3rd generation cephalosporin IV

Fungi
- consider antifungals after 48 h

30
Q

Which at risk groups should be encouraged to get the pneumococcal vaccine?

A

All adults ≥ 65yrs old

Chronic heart, liver, renal or lung conditions

DM not controlled by diet

Immunosuppression e.g., reduced spleen functions, AIDS, or on chemo or prednisolone > 20mg/day, cochlear implant, occupation risk (e.g., welders), CSF fluid leaks

Vaccinate every 5 years

31
Q

What are the contraindications to the pneumococcal vaccine?

A

Pregnancy

Lactation

Increased T° (temperature)

Previous anaphylaxis to vaccine or one of its components

32
Q

What are the complications of pneumonia?

A

Respiratory failure - esp. T1

Hypotension

AF

Pleural effusion - fluid exudate into pleural space

Empyema - pus in pleural space

Lung abscess

Septicaemia

Pericarditis and myocarditis - these could also complicate pneumonia

Jaundice - usually cholestatic and may be due to sepsis or secondary to Abx therapy (esp. flucloxacillin and co-amoxiclav)

33
Q

Which mnemonic can help you remember the atypical causes of pneumonia

A

Legions of psittaci MCQs
- Legionella
- Psittaci
- Mycoplasma pneumoniae
- Chlamydophillia pneumoniae
- Q fever = Coxiella burnetti

34
Q

Sources

A

Oxford Handbook of Clinical Medicine ed.10 pg 166-171

https://www.nice.org.uk/guidance/ng138/chapter/Recommendations

https://www.nice.org.uk/guidance/ng139/chapter/Recommendations

Respiratory (10 decks)

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