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
2
Q
Local symptoms
A
- cough AND 1 of - pleural pain - tachypnoea - dyspnoea
3
Q
Systemic symptoms
A
- sweating
- fevers
- shivers
- aches
- pains
AND/OR - fever>38
4
Q
Signs
A
New and focal chest signs
- new radiographic shadowing with no other explanation
5
Q
Types
A
CAP
HAP
VAP (ventilator acquired)
6
Q
What common organism causing it?
A
S. pneumoniae
Just under 50% of all
7
Q
Other organisms causing it
A
H. influenzae Leigonella spp Staphylococcus M. catarrhalis M. pneumoniae Chlamydophilia spp Viruses
8
Q
Most common causes for HAP
A
- H. influenzae
- Gram negative
- Staph aureus
- low legionella
9
Q
RF
A
- elderly
- chronic illness
- alcoholism
- immunodeficiency
10
Q
Common organisms causing pneumonia in elderly
A
M. pneumoniae
Legionella
Presentation less classical
11
Q
Common chronic illnesses causing it
A
diabetes
COPD
12
Q
Cause of pneumonia with steroid use
A
Legionella
13
Q
Cause of pneumonia if on chemo
A
Fungal
14
Q
Cause of pneumonia if have HIV/AIDs
A
TB
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
16
Q
How are lung defence mechanisms defected?
A
- anatomical abnormalities
- aspiration
- CF/bronchiectasis
- alcoholism
- HIV
- chemo
17
Q
How are defence mechanisms overcome?
A
- defected in host defence
- virulent organism
- overwhelming inoculum = aspiration
18
Q
Ix for diagnosis
A
- CXR
- FBC
19
Q
FBC Results
A
WCC >15 x10^9/l
CRP >100mg/l
20
Q
Ix for risk assessing
A
U&E
FBC/CRP/LFTs
Ox sats
ABG
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
Influenza Ix
Nose/throat swab PCR
26
Radiological Ix
- consolidation
- shadowing
- air bronchograms!!!
- pleural effusion
- lymphadenopathy
- 6w mostly resolved
- if diagnostic doubt or to check if underlying cause = cancer
27
Procedure for predicted prognosis
- decision to admit
- microbiological Ix
- treatment
- refer to ICU
28
Factors for poor prognosis
```
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
CURB 65 measurements
```
C = confusion (AMTS ≤ )
U = urea >7
RR ≥ 30
BP <90 and/or <60
≥ 65
```
30
CURB 65 criteria
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
CURB 65 0-1 Risks
- low risk of VTE, HAP
| Mortality low
32
management of pneumonia
Oxygen = aim for 88-92%
IV fluids, analgesia, DVT prophylaxis
Chest physio/sitting out and nutritional support
Smoking cessation
33
AB Used
Beta lactam (+macrolide if moderate-severe)
e.g amoxicillin 500mg
Immediately after diagnosis by CXR
Oral unless CURB 65≥3 or unable
34
Which organisms are resistant?
Legionella and mycoplasma penicillin resistant but not macrolide
S. penumoniae most sensitive to pen and macrolides
35
How long is the AB course?
```
Mild = 5 days
Mod-severe = 7-10 days
Atypical = 14-21 days
```
36
Alternative treatment to amoxicillin
doxycycline 200mg loading then 100mg orally
OR
clarithromycin 500mg bd orally
37
Moderate severity AB treatment
- amoxicillin 500mg -1g tds orally
PLUS
- clarithromycin 500mg bd orally
38
Moderative severity AB treatment if oral not possible
- amox 500mg tds IV
OR
- benzypenicillin 1.2g qds IV plus clarithromycin 500mg bd IV
39
High severity AB treatment
co-amoxiclav 1.2g tds IV
PLUS
Clarithromycin 500mg bd IV
If legionella strongly suspected = consider adding levofloxacin
40
AB for gram negative bacilli
Cefuroxime 1.5g tds or cefotaxime 1-2g tds IV or ceftriaxone 1-2g bd IV
41
S. aureus with MRSA AB
```
vancromycin 1g bd IV
OR
linezolid 600mg bd IV
OR
teicoplanin 400mg bd IV
OR
Rifampicin 600mg OD or bd orally/IV
```
42
What to check on follow up?
- CXR
- CRP
- at 3-4 days
43
What if failure to improve on follow up?
- 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
Adverse consequences of AB
- C difficile
- MRSA
- society AB resistance
45
Who is influenza vaccine offered to?
- >65
- 2-4 yrs
- asthma
- COPD
- chronic resp/heart/kidney/liver/neuro disease
- diabetes
- immunosuppressed
- pregnant
- healthcare workers
46
Who is pneumococcal vaccine offered to?
```
>65
>2 yrs and at risk of
- splenic dysfunction
- cochlear implants
- CSF leaks
- revacc every 5 yrs if asplenia or CKD otherwise once
```
47
Atypical pathogens e.g.
M. penumoniae = young, less systmic
Chlamidophilia penumoniae = old, headache
Chlamidophila Psittaci
Coxiella burnetiid = young male, fever, dry cough
48
Properties of atypical pathogens
- difficult to diagnose
- resistant to beta lactams
- replicate IC
49
Legionella who?
- men
- healthy young
- smokers
- neurological or GI
- less respiratory symptoms
50
HAP define
In patient >48 hours
OR
<10 days since discharge
