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CR3 > Pneumonia & Chest Infections > Flashcards

Pneumonia & Chest Infections Flashcards

1
Q

Define pneumonia

A
  • symptoms and signs consistent with an acute LRTI
  • associated with new radiographic shadowing
  • no other explanation
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2
Q

Local symptoms

A 
- cough
AND 1 of
- pleural pain
- tachypnoea
- dyspnoea
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3
Q

Systemic symptoms

A
  • sweating
  • fevers
  • shivers
  • aches
  • pains
    AND/OR
  • fever>38
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4
Q

Signs

A

New and focal chest signs

- new radiographic shadowing with no other explanation

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5
Q

Types

A

CAP
HAP
VAP (ventilator acquired)

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6
Q

What common organism causing it?

A

S. pneumoniae

Just under 50% of all

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7
Q

Other organisms causing it

A 
H. influenzae
Leigonella spp
Staphylococcus
M. catarrhalis
M. pneumoniae
Chlamydophilia spp
Viruses
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8
Q

Most common causes for HAP

A
  • H. influenzae
  • Gram negative
  • Staph aureus
  • low legionella
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9
Q

RF

A
  • elderly
  • chronic illness
  • alcoholism
  • immunodeficiency
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10
Q

Common organisms causing pneumonia in elderly

A

M. pneumoniae
Legionella
Presentation less classical

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11
Q

Common chronic illnesses causing it

A

diabetes

COPD

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12
Q

Cause of pneumonia with steroid use

A

Legionella

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13
Q

Cause of pneumonia if on chemo

A

Fungal

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14
Q

Cause of pneumonia if have HIV/AIDs

A

TB

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15
Q

Lung defence mechanisms

A 
Filtration/deposition in upper airways
Cough reflex
Mucociliary clearance
Alveolar macrophages
Humoral and cellular immunity
Oxidative metabolism of neutrophils
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16
Q

How are lung defence mechanisms defected?

A
  • anatomical abnormalities
  • aspiration
  • CF/bronchiectasis
  • alcoholism
  • HIV
  • chemo
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17
Q

How are defence mechanisms overcome?

A
  • defected in host defence
  • virulent organism
  • overwhelming inoculum = aspiration
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18
Q

Ix for diagnosis

A
  • CXR

- FBC

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19
Q

FBC Results

A

WCC >15 x10^9/l

CRP >100mg/l

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20
Q

Ix for risk assessing

A

U&E
FBC/CRP/LFTs
Ox sats
ABG

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21
Q

Ix to assess targeted therapy need

A
  • blood culture
  • sputum culture
  • pneumococcal urinary antigen
  • legionella urinary antigen
  • mycoplasma ACT
  • chamydophilia PCR
  • viral PCR
22
Q

Ix in hospitalised

A 
CXR
FBC
U&E
CRP
Ox sats
23
Q

MC&S

A
  • microbiology
  • to identify pathogenic bacteria
  • test sensitivity to antibiotics
  • send quickly
24
Q

Urinary Antigens

A
  • highly sensitive and specific
  • rapid result
  • remain positive when treat
  • no info. on AB sensitivity
  • only for pneumococcal and legionella
  • if positive = specific sputum culture
25
Q

Influenza Ix

A

Nose/throat swab PCR

26
Q

Radiological Ix

A
  • consolidation
  • shadowing
  • air bronchograms!!!
  • pleural effusion
  • lymphadenopathy
  • 6w mostly resolved
  • if diagnostic doubt or to check if underlying cause = cancer
27
Q

Procedure for predicted prognosis

A
  • decision to admit
  • microbiological Ix
  • treatment
  • refer to ICU
28
Q

Factors for poor prognosis

A 
Old age
Pre-existing comorbidities
High RR
Confusion
Low BP
RF/hypoxaemia
WCC>20 or <4
Bilateral progressive CXR changes
Positive blood cultures
Biochemical markers = CRP, lactate, troponin
29
Q

CURB 65 measurements

A 
C = confusion (AMTS  ≤ )
U = urea >7
RR ≥ 30
BP <90 and/or <60
≥ 65
30
Q

CURB 65 criteria

A

0-1 treat at home
2 = short admission, oral AB
3 = admit and urgent senior review
4-5 = admit and critical care (ITU/HDU) review

31
Q

CURB 65 0-1 Risks

A
  • low risk of VTE, HAP

Mortality low

32
Q

management of pneumonia

A

Oxygen = aim for 88-92%
IV fluids, analgesia, DVT prophylaxis
Chest physio/sitting out and nutritional support
Smoking cessation

33
Q

AB Used

A

Beta lactam (+macrolide if moderate-severe)
e.g amoxicillin 500mg
Immediately after diagnosis by CXR
Oral unless CURB 65≥3 or unable

34
Q

Which organisms are resistant?

A

Legionella and mycoplasma penicillin resistant but not macrolide
S. penumoniae most sensitive to pen and macrolides

35
Q

How long is the AB course?

A 
Mild = 5 days
Mod-severe = 7-10 days
Atypical = 14-21 days
36
Q

Alternative treatment to amoxicillin

A

doxycycline 200mg loading then 100mg orally
OR
clarithromycin 500mg bd orally

37
Q

Moderate severity AB treatment

A
  • amoxicillin 500mg -1g tds orally
    PLUS
  • clarithromycin 500mg bd orally
38
Q

Moderative severity AB treatment if oral not possible

A
  • amox 500mg tds IV
    OR
  • benzypenicillin 1.2g qds IV plus clarithromycin 500mg bd IV
39
Q

High severity AB treatment

A

co-amoxiclav 1.2g tds IV
PLUS
Clarithromycin 500mg bd IV
If legionella strongly suspected = consider adding levofloxacin

40
Q

AB for gram negative bacilli

A

Cefuroxime 1.5g tds or cefotaxime 1-2g tds IV or ceftriaxone 1-2g bd IV

41
Q

S. aureus with MRSA AB

A 
vancromycin 1g bd IV
OR
linezolid 600mg bd IV
OR
teicoplanin 400mg bd IV
OR
Rifampicin 600mg OD or bd orally/IV
42
Q

What to check on follow up?

A
  • CXR
  • CRP
  • at 3-4 days
43
Q

What if failure to improve on follow up?

A
  • incorrect diagnosis
  • atypical/mixed/resistant pathogens
  • impaired immunity
  • complications = effusion, empyema
  • CXR lags behind clinical picture
  • slower in elderly and if multilobar
  • repeat at 6w if no improvement
  • consider CT/bronchoscopy
  • up to 50 days full return
44
Q

Adverse consequences of AB

A
  • C difficile
  • MRSA
  • society AB resistance
45
Q

Who is influenza vaccine offered to?

A
  • > 65
  • 2-4 yrs
  • asthma
  • COPD
  • chronic resp/heart/kidney/liver/neuro disease
  • diabetes
  • immunosuppressed
  • pregnant
  • healthcare workers
46
Q

Who is pneumococcal vaccine offered to?

A 
>65
>2 yrs and at risk of
- splenic dysfunction
- cochlear implants
- CSF leaks
- revacc every 5 yrs if asplenia or CKD otherwise once
47
Q

Atypical pathogens e.g.

A

M. penumoniae = young, less systmic
Chlamidophilia penumoniae = old, headache
Chlamidophila Psittaci
Coxiella burnetiid = young male, fever, dry cough

48
Q

Properties of atypical pathogens

A
  • difficult to diagnose
  • resistant to beta lactams
  • replicate IC
49
Q

Legionella who?

A
  • men
  • healthy young
  • smokers
  • neurological or GI
  • less respiratory symptoms
50
Q

HAP define

A

In patient >48 hours
OR
<10 days since discharge

CR3 (30 decks)

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