PNEUMONIA - make new oxford Flashcards
defintion of CAP ?
pneumonia symptoms which is LESS THAN 48 HOURS OF HOSPITAL ADMISSION
etiology of CAP ?
typical :s pneumonia (lobar and bronchopneumonia )
h influenza (bronchopenumonia) - most common in copd
sometimes - s areus (bronchopneumonia) klebseilla (bronchopneumonia) - most common alcohol = CURRENT JELLY SPUTUM !
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atypicall - MOSTLY INTERSTITIAL PNEUMONIA
mycoplasma pneumonia , chlamidophylia pneumonia (these two are more common in children and adolescent)
legionella (lobar)
viruses - adenovirus , RSV
definition of NOSOCOMICAL pneumonia ?
any pneumonia that occurs that occurs after 48 hours in the hopsital
etiology of NOSOCOMICAL pneumonia ?
Gram negative pathogens
P aeruginosa.
enterobacteriaceae
Staphylococcus aureus, including methicillin-susceptible S aureus (MSSA) and methicillin-resistant S aureus (MRSA)
strep pneumoniae = lobar pneumonia
risk factors of pneumonia ?
Old age and immobility of any cause
Chronic diseases :
Preexisting cardiopulmonary conditions (e.g., bronchial asthma, COPD, heart failure)
Immunosuppression : HIV infection Diabetes mellitus Cytostatic and immunosuppressive therapy Alcoholism Malnutrition
Impaired airway protection
Alteration in consciousness (e.g., due to stroke, seizure, anesthesia, drugs, alcohol)
Dysphagia
Smoking
Environmental factors :
Crowded living conditions (e.g., prisons, homeless shelters)
Toxins (e.g., solvents, gasoline)
clinical features of typical pneumonia?
Typical pneumonia is characterized by a sudden onset of symptoms caused by lobar infiltration.
tacycardia
hypotension
Severe malaise
High fever and chills
Productive cough with purulent sputum (yellow-greenish)
Tachypnea and dyspnea (nasal flaring, thoracic retractions)
Pleuritic chest pain when breathing, often accompanying pleural effusion
confusion
what are the physical findings in pneumonia ?
Crackles and bronchial breath sounds on auscultation
Decreased breath sounds
Enhanced bronchophony, egophony, and tactile fremitus
Dullness on percussion
diminished expansion
increased tactile vocal fremitus/vocal resonance,
pleural rub
Atypical pneumonia clinical manifestation?
slow onset - unlike typical = acute onset
Nonproductive, dry cough
Dyspnea
Auscultation often unremarkable
Common extrapulmonary features include fatigue, headaches, sore throat, myalgias, and malaise.
diagnosis of pneumonia ?
chest x ray
lobar - opacity of one or more pulmonary lobes
presence of air bronchograms
bronchopneumonia - patchy infiltrates scattered through out the lungs with presence of air bronchograms
atypical - reticular opacities
cbc - crp , ESR, leukocytosis
serum prolactonin
blood culture - mainly for s pneumonia
sputum culture and gram staining
pneumococcal urinary antigen test
legionella pneumophilia irunary antigen test
chest CT
advanced diagnostics - bronchoscopy
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any admitted patients - MRSA nares swab (PCR and/or culture)
Severe CAP HAP VAP \: Blood cultures (2 sets) Sputum culture and gram stain Pneumococcal urinary antigen Legionella pneumophila urinary antigen Consider Chlamydia pneumoniae respiratory PCR.
what is the management of pneumonia ?
A-E
treat hypoxia with oxygen,
start at 24–28% if history COPD/hypercapnia
Treat hypotension/shock/ dehydration = IV fluid support
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start investigations - X ray
pulseoximetry and abg
FBC, UE, LFT , CRP , prolactin
blood culture, urinary pneumoccocal antigen , pleural fluid an be aspirated FOR CULTURE CURB 65 is 2 or more
sputum culture of curb 65 3 or more or 2 or more with no antibiotics et
legionella antigen is CURB65 3 or more
consider viral throat swabs
and mycoplasma PCR and serology
IF IMMUNOCOMPROMISED - bronchoscopy or brochoalveolar lavage
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give empirical antibiotics - according to local guidelines
If pneumonia not severe and not vomiting (CURB-65 1–2)
give PO antibiotic;
severe (CURB-65 >2) give IV
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analgesia for pleuritic chest pain - paracetamol 1g /6h or NSAIDS
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if still hypoxic consider CPAP to recruiit lung parenchyma ad improove ocygenation
but if HYPERCAPNIC require non inavsive ir invasive ventilation and ITU support
how is severity checked in pneumonia
CURB -65
C - confusion
AMT test less than or equal to 8
U - urea >7mmol/L
R - respiratory rate > or equal to 30/min
B - blood pressure <90 systolic
age = 65 or more
what is the interpretation of CURB-65 ?
0–1, PO antibiotic/home treatment;
2, hospital therapy;
≥3, severe pneumonia indicates
mortality 15–40%—consider ITU
what are the emperical treatments for CAP
community acquired
strep pneumonia
haemophilus
and CURB 0-1
oral amoxicillin 500mg-1g every 8hr /
clarithromycin = 500mg/12h
/ doxycycline
5 days of therapy is usually sufficient for CAP that is treated in the outpatient setting
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CAP
pathoetioligy as above with mycoplasma
CURB 2
oral amoxicillin (she dose as above) + clarithromycon same dose as above (or doxycyclin )
if IV required amoxicillin and clarithromycin (7 day)
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CAP
pathoetiology as above
CURB 3 or more
IV co -amoxiclav / 2nd gen cephalosporin cefuroxime
+
clarithromycin
7 days
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is staph susupected
ADD flucloxacillin +- rifampicin
if MRSA suspected = vancomycin or teicoplanin and treat for 10d
PANTON VALENTINE LEUKOCIDIN PRODUCING STAPH AUREUS - SEEKURGENT HELOP - CONSIDER iv LINEZOLID , clindamycin and rifampicin
WHAT ARE THE emperical treatment option for atypical organisms ?
legionella pneumophilia
fluroquinilone (levofloxacin and ciprofloxacin) combined with clarithromyhcin / rifampicin
chlamydia
tetracylin
what are the typical local guideline treatment for HAP ?
gram negatgive bacilli - pseudomonas / anaerobes
aminoglycoside IV (gentamicin , streptomycin) \+ antipseudomoinal anti pneumococal b lactum penicillin IV such as piperacillin tazopbactum / IV 3rd gen cephalopsorin - ceftriaxone
