pneumonia/infection

Question 1

How many patients are diagnosed with CAP by GP/year?

Answer 1

5-12% of all abx prescribed

Question 2

How many patients admitted with CAP/year?

Answer 2

22-42%

Question 3

Mortality of hospitalised CAP?

Answer 3

5.7-14%
Long term mortality at 5 yrs is 35-39%

Question 4

Mortality of CAP on ITU?

Answer 4

> 30%

Question 5

Most common pathogens in community/hospital/ITU for CAP?

Answer 5

Community: S pneumoniae, H. influenzae and FLU

Hospital: S. Pneumoniae, Mycoplasma/chlamydiae, flu

ITU: S. Pneumoniae, Legionella, FLU/S. aureus

Question 5

which orgnism is involved with CAP in bird workers?

Answer 5

C psittaci

Question 5

which orgnism is involved with CAP in sheep workers and calving season?

Answer 5

Coxiella burnetii

Question 6

S aureus CAP can cause cavitation which is associated with…?

Answer 6

Panton-Valentine
Leucocidin toxin

Question 7

Strep CAP is associated with what features?

Answer 7

increasing age, comorbidity,
acute onset, high fever and pleuritic chest pain

Bacteraemia: F, no cough or a non-productive cough,
history of excess alcohol, diabetes mellitus or COPD.

Question 8

legionella CAP is associated with what features?

Answer 8

M, smokers, young, diarrhoea

Question 9

coxiella burnetii CAP is associated with what features?

Answer 9

males, dry cough, high fever

Question 10

Klebsiella CAP is associated with what features?

Answer 10

alcoholic males

Question 11

strep viridans CAP is associated with what features?

Answer 11

aspiration

Question 12

acinotobacter CAP is associated with what features?

Answer 12

alcoholics, high mortality

Question 13

radiographic resolution in elderly?

Answer 13

35%, 60% and 84% at 3, 6
and 12 weeks

Question 14

what % resolve after 6 weeks of CXR?

Answer 14

73%

Question 15

when should you repeat the CXR?

Answer 15

persistence of
symptoms or physical signs or who are at higher risk
of underlying malignancy (especially smokers and those aged 50 years)
whether or not they have been admitted to hospital

Question 16

What is the gold standard to test for mycoplasma?

Answer 16

complement fixation test- although it lacks sens and spec

Question 17

What treatment do you give a low severity CAP that is an IP?

Answer 17

amox- still tend to be Strep so should be sensitive, clari if allergy

Question 18

What treatment do you give a moderate severity CAP that is an IP?

Answer 18

need to cover for legionella as they can fit in this bracket so need to include a macrolide/B lactam added to amox

Question 19

What treatment do you give a high severity CAP that is an IP?

Answer 19

even though gram neg and Staph are rarer causes, they carry high mort.
Why you need broad spectrum B lactams

Question 20

Is Legionella notifiable?

Answer 20

Yes!!. But reporting the the health protection unit can:
- investigations recent travel and activities within 2 weeks before illness onset (the usual
incubation period is 2–10 days) from the patient or their
relatives to assist epidemiological investigation

Question 21

What is the other name for PVL CAP? What is the treatment?

Answer 21

necrotising pneumonia
IV linezolid 600 mg bd, IV clindamycin 1.2g qds and IV rifampicin 600mg bd

Question 22

What are the factors involved with failing to improve?

Answer 22

multilobar involvement
cavitating pneumonia
pleural effusion
liver disease
cancer or neurological disease
aspiration pneumonia
legionella
Gram-neg pneumonia
leucopenia
high disease severity
inappropriate antibiotics

Question 23

what are the main differences between NICE an BTS CAP guidelines?

Answer 23

CONSIDER testing for legionella in high severity CAP (NICE) test (BTS)
review after 3 days (NICE) 2 days (BTS)
5 days Abx for low severity and 7-10 for others (NICE) not 7days (BTS)

ON THE WHOLE FOLLOW NICE

Question 24

What organisms are implicated in tropical pulmonary eosinophilia?

Answer 24

Wuchereria bancrofti, brugia malayi

different from loefflers as Hx tends to be more insidious

Question 25

a 21F has a cough and feels breathless- they have spent the last week in Mississippi kayaking and swimming. A course of amox didn’t help. They have bilateral infiltrates on CXR. Which organism is likely?

Answer 25

blastomycosis

assoicated with outdoor activities near waterways

Question 26

a 21F army officer has a cough, feels fatigued and breathless- they have spent the last month on desert training. A course of amox didn’t help. They have lobar consolidation on CXR. Which organism is likely?

Answer 26

coccidiomycosis

eosinophilia

southwest desert areas following sand storms, constuction, military exercises and dry periods after rainy season

Question 27

a 21F has a cough and with joint pain- they have spent the last few weeks in Ohio taking photos of abandoned buildings by the river. A course of amox didn’t help. They have bilateral cavitatory infiltrates on CXR. Which organism is likely?

Answer 27

histoplasmosis

areas around ohio river- associated with bat or rodent droppings

Question 28

a 21F has had a bone marrow transplant and presents with fever, cough and chest pain. A course of amox didn’t help. They have a cavitatory lesion on CXR. Which organism is likely?

A. histoplasmosis
B Mucormycosis
C Paracoccidiomycosis
D Coccidiomycosis
E Blastomycosis

Answer 28

B Mucormycosis

only in immunocompromised
usually a solitary nodule, or cavitatory lesion. but can be disseminated

Question 29

a 21F has fevers, weight loss and new hepatospenomegaly- they have spent the last month travelling in south america. A course of amox didn’t help. They have nodular changes on CXR. Which organism is likely?

Answer 29

Paracoccidiomycosis

endemic to SA

Question 30

What treatment do you give HAP?

Answer 30

early HAP (<5 days)
penicillin with beta lactamase or ceph or quinolone

late HAP (>5 days)
anti-pseud plus flouroquinolone