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Year 3 > Pneumonia (RESP) > Flashcards

Pneumonia (RESP) Flashcards

1
Q

Define pneumonia.

A

Respiratory infection characterised by inflammation of the alveolar space (with consolidation/interstitial lung infiltrates)

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2
Q

What are the different types of causative organisms for pneumonia? (3)

A
  • bacterial pneumonia (most common, Streptococcus pneumoniae most common pathogen)
  • viral pneumonia
  • fungal pneumonia (e.g. Pneumocystis jiroveci)
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3
Q

What are some different types of pneumonia?

A
  • community-acquired pneumonia (CAP)
  • hospital-acquired pneumonia (HAP)
  • viral pneumonia
  • aspiration pneumonia
  • atypical pneumonia
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4
Q

Define community-acquired pneumonia.

A

CAP is defined as pneumonia acquired outside hospital or healthcare facilities (majority of patients)

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5
Q

What are the two types of community-acquired pneumonia?

A
  • typical
    • Streptococcus pneumoniae
    • Haemophilus influenzae
    • Staphylococcus aureus
    • Klebsiella pneumoniae
  • atypical
    • Mycoplasma pneumoniae
    • Legionella pneumophilia
    • Chlamydia psittaci
    • Pneumocystis jirovecii
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6
Q

What organisms can cause typical CAP?

A
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Staphylococcus aureus
  • Klebsiella pneumoniae
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7
Q

What are the clinical features of Streptococcus pneumoniae typical CAP? (3)

A
  • gram +ve encapsulated lancet shaped coccobacilli
  • rusty sputum
  • can reactivate HSV and cause cold sores
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8
Q

What are the features of Haemophilus influenzae typical CAP? (2)

A
  • gram -ve coccobacilli
  • especially in COPD patients (most common cause of exacerbation)
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9
Q

What are the features of Staphylococcus aureus typical CAP? (4)

A
  • gram +ve cocci found in clusters
  • common in IVDU
  • also occurs after influenza
  • causes cavitating (gas-filled) lesions on CXR
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10
Q

What are the features of Klebsiella pneumoniae typical CAP? (6)

A
  • gram -ve non-motile encapsulated bacillus
  • alcoholics and diabetics
  • causes cavitating (gas-filled) lesions on CXR, typically upper lobe
  • blood-stained sputum (red-currant jelly)
  • commonly due to aspiration
  • causes lung abscess formation and empyema (pus collection in lungs)
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11
Q

How is typical CAP treated?

A

Amoxicillin or Co-amoxiclav

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12
Q

What organisms can cause atypical CAP? (4)

A
  • Mycoplasma pneumoniae
  • Legionella pneumophilia
  • Chlamydia psittaci
  • Pneumocystis jirovecii
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13
Q

Which diseases is Mycoplasma pneumoniae associated with? (2)

A
  • erythema multiforme (ring-shaped rash)
  • autoimmune haemolytic anaemia (cold agglutins, IgM) –> RBC accumulation on blood smear
  • diagnosed with serology and positive cold agglutination test
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14
Q

What can Legionella pneumophilia be caused by? (2)

A
  • faulty air conditioning
  • recent return from holiday
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15
Q

What are the clinical features of Legionella pneumophilia atypical CAP? (3)

A

Legionella = Low sodium, Liver derangement, Leukopenia

  • hyponatraemia
  • abnormal LFTs
  • leukopenia

Diagnosed with urinary antigen

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16
Q

What is a risk factor for Chlamydia psittaci atypical CAP?

A

Associated with pet birds

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17
Q

Who does Pneumocystis jirovecii atypical CAP affect and how do we treat it?

A

HIV / immunocompromised individuals and causes desaturation on exercise –> treated with co-trimoxazole (trimethoprim + sulfamethoxazole)

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18
Q

How are atypical CAP treated?

A

Clarithromycin

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19
Q

What is idiopathic interstitial pneumonia?

A
  • group of non-infective causes of pneumonia
  • e.g. cryptogenic organising pneumonia –> a form of bronchiolitis that may develop as a complication of RA or amiodarone therapy
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20
Q

Define hospital-acquired pneumonia (HAP).

A

Pneumonia which has developed within hospitals occurring 48 hours or more after hospital admission and is not incubating at the time of admission

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21
Q

What organisms can cause hospital-acquired pneumonia? (2)

A
  • gram -ve enterobacteria:
    • Pseudomonas aeruginosa
    • Klebsiella pneumoniae
    • E. coli
    • Acinetobacter spp
  • Staphylococcus aureus
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22
Q

What does Pseudomonas aeruginosa cause in HAP? (2)

A
  • CF
  • bronchiectasis
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23
Q

What does S. aureus cause in HAP?

A

Cavitating (gas-filled) lesions on CXR

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24
Q

How is HAP treated?

A

Tazocin (piperacillin + tazobactam)

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25
Q

How is MRSA treated?

A

Vancomycin

26
Q

What organisms can cause viral pneumonia? (3)

A
  • influenza
  • RSV
  • parainfluenza
27
Q

What is aspiration pneumonia?

A
  • results from inhalation of oropharyngeal contents into lower airways –> chemical pneumonitis, lung injury, and resultant bacterial infection
  • usually seen in patients with dysfunctional or unsafe swallow
  • e.g. stroke, myasthenia gravis, bulbar palsies, alcoholics, reduced consciousness, oesophageal disease, neurological injury (–> aspiration of stomach contents)
28
Q

What procedure puts patients at risk of aspiration pneumonia?

A

Intubation

29
Q

Which lung is more commonly affected in aspiration pneumonia?

A

Right - since right bronchus is wider and more vertical than left

CXR = consolidation at right lung base

30
Q

How do we treat aspiration pneumonia?

A

Amoxicillin and metronidazole

31
Q

What are the features of a lung abscess? (5)

A
  • chest pain
  • subacute productive cough
  • foul-smelling breath
  • night sweats
  • fever
32
Q

How do we manage a lung asbcess?

A

IV Abx (rarely need to drain)

33
Q

What are the symptoms of typical pneumonia? (8)

A
  • productive cough with purulent sputum (yellow-green)
  • dyspnoea (SOB) / tachypnoea
  • pleuritic chest pain
  • rigors or night sweats
  • fever (and chills)
  • confusion
  • malaise
  • red currant-jelly (bloody) sputum (Klebsiella pneumoniae)
34
Q

What are the symptoms of atypical pneumonia? (7)

A
  • slower onset
  • non-productive cough
  • headache
  • low-grade fever
  • myalgia and malaise
  • diarrhoea
  • SOB

Constitutional symptoms often predominate over respiratory findings, and there may be extrapulmonary manifestations

35
Q

What is seen on examination in pneumonia? (7)

A
  • crackles on auscultation (bronchial breathing)
  • decreased breath sounds
  • dullness on percussion
  • increased tactile vocal fremitus
  • coarse crepitations
  • cyanosis
  • chronic suppurative lung disease (empyema, abscess) –> clubbing
36
Q

What are the extra clinical features of aspiration pneumonia? (6)

A
  • Hx of vomiting
  • foul-smelling breath
  • frothy/purulent sputum
  • delirium
  • reduced appetite
  • reduced mobility
37
Q

What are the risk factors for pneumonia? (5)

A
  • age <2 or >65
  • smoking
  • pre-existing chronic disease (COPD, bronchiectasis, HF)
  • immunosuppression e.g. HIV
  • crowded living conditions
38
Q

What are the first-line investigations for pneumonia? (4)

A
  • CXR
  • pulse oximetry
  • ABG
  • U&Es
39
Q

What do we see on CXR in pneumonia? (6)

A
  • alveolar opacification
  • air bronchograms
  • consolidation
  • lobar/multilobar shadowing (patchy)
  • pleural effusion/cavitation (gas-filled)
  • complications e.g. lung abscess
40
Q

When do we redo CXR in pneumonia?

A

At 6 weeks after clinical resolution to rule out underlying malignancies that were hidden by original pneumonia consolidation

41
Q

What might an pulse oximetry & ABG show in pneumonia?

A

Low arterial oxygen saturation (assess pulmonary function, can also find pre-existing respiratory disease e.g. COPD)

42
Q

What might U&Es show in pneumonia?

A
  • usually normal, elevated in patients with severe CAP
  • urea>7mmol/L counts for 1 point in CURB-65 score to assess severity
43
Q

What do we see on bloods in pneumonia? (4)

A
  • FBC - neutrophilia in bacterial infection
  • CRP - raised
  • U&Es - dehydration (high urea)
  • procalcitonin - increased in LRTIs
44
Q

When do we do urinary antigen test for pneumonia? (2)

A

Rapid bedside test for diagnosis of:
- Legionella (atypical pneumonia)
- Streptococcus pneumoniae

45
Q

What special investigation can we do for pneumonia?

A

Sputum MC&S

46
Q

What lobes does Klebsiella pneumoniae tend to affect?

A

Upper lobes

47
Q

What are some differential diagnoses for pneumonia? (12)

A
  • COVID-19
  • acute bronchitis
  • congestive heart failure
  • COPD exacerbation
  • asthma exacerbation
  • bronchiectasis exacerbation
  • TB
  • lung cancer/metastases
  • empyema
  • pulmonary embolism
  • pneumothorax
  • hypersensitivity pneumonitis
48
Q

What are some differential diagnoses WITHIN pneumonia? (9)

A
  • CAP
  • HAP (>48h after admission; P. aeruginosa, S. aureus, Enterobacteria)
  • aspiration pneumonia (unsafe swallow, right lung more common)
  • Staphylococcal pneumonia (bilateral cavitating bronchopneumonia, IVDU, elderly, influenza)
  • Klebsiella pneumonia (upper lobes, cavitating, red-currant sputum, complications e.g. empyema/abscess/pleural adhesions, weakened immune systems)
  • Mycoplasma pneumonia (flu-like symptoms, younger patients, AIHA, erythema multiforme, complications e.g. SJS-TEN, GBS, meningoencephalitis)
  • Legionella pneumonia (fever, myalgia, malaise –> dyspnoea, dry cough; poor hotel AC; hyponatraemia, deranged LFTs, leukopenia; antigen in urine)
  • Chalmydophila psittaci (infected birds, lethargy, arthralgia, headache, anorexia and systemic symptoms)
  • Pneumocystis pneumonia (immunosuppressed/HIV +ve)
49
Q

What system do we use to assess severity of pneumonia?

A

CURB-65 (or CRB-65 in primary care):

  • Confusion (abbreviated mental test <=8/10)
  • Urea >7mmol/L
  • Respiratory rate >/=30
  • Blood pressure <90 systolic/<60 diastolic
  • Age >/=65 years
50
Q

What is the scoring for CURB-65 and CRB-65 for pneumonia?

A

CURB-65:

  • 0-1 (low): outpatient - treat with amoxicillin
  • 2 (moderate): hospitalisation - treat with amoxicillin and clarithromycin 7-10d
  • 3-5 (high): ICU level of care - treat with IV co-amoxiclav and clarithromycin 7-10d

CRB-65 in primary care:

  • 0 (low severity): treatment at home with oral amoxicillin 1st line
  • 1/2 (moderate severity): hospital referral
  • 3/4 (high severity): urgent hospital admission
51
Q

What Abx do we give for CAP? (4)

A
  • amoxicillin - typical
  • clarithromycin - atypical/penicillin allergy
    • erythromycin - pregnancy
  • doxycycline - penicillin/macrolide allergy
52
Q

When do we avoid clarithromycin?

A

Avoid in patients with long QT syndrome

53
Q

What Abx do we give for HAP? (3)

A
  • co-amoxiclav if within 5 days of admission
    • side effect: cholestasis = high BR and ALP
  • tazocin (piperacillin/tazobactam) if after 5 days of admission
  • if severe: piperacillin/tazobactam, ceftriaxone, cefuroxime, levofloxacin
54
Q

How do we manage pneumonia according to CURB-65 score?

A
  • 0-1 (low severity): outpatient - empirical oral Abx –> amoxicillin
  • 2 (moderate severity): hospitalisation - empirical oral/IV Abx –> amoxicillin + clarithromycin 7-10d (doxycycline if penicillin/macrolide allergy)
  • 3-5 (high): ICU - broad spectrum IV Abx –> IV co-amoxiclav + clarithromycin 7-10d
    • if penicillin-allergic, use cephalosporin (cefuroxime / cetriaxone) + macrolide
55
Q

What Abx can we use in atypical pneumonia?

A
  • Legionella: fluoroquinolone (levofloxacin) + rifampicin
  • Chlamydophilia: tetracycline
  • Pneumocystis jiroveci: high-dose co-trimoxazole
56
Q

What supportive care can we give to patients with pneumonia? (5)

A
  • oxygen - if hypoxemic (<94% / <88% at risk of hypercapnia)
  • IV fluids - if hypotensive/signs of dehydration
  • VTE prophylaxis with LMWH in immobile patients
  • airway clearance
  • analgesia (e.g. for pleuritic pain)
57
Q

What do we prescribe on top of Abx for pneumonia patients with COPD?

A

Prednisolone, even if no sign of COPD exacerbation

58
Q

How can we prevent pneumonia in high-risk groups? (2)

A
  • Pneumococcal vaccine
  • Haemophilus influenzae type B vaccine
59
Q

What are some complications of pneumonia? (11)

A
  • pleural effusion
  • septic shock
  • ARDS
  • Abx-associated C. difficile colitis
  • heart failure
  • empyema
  • lung abscess (swinging fever, persistent pneumonia, foul-smelling sputum, Klebsiella/S. aureus)
  • ACS
  • cardiac arrhythmias
  • necrotising pneumonia
  • pneumothorax
60
Q

What are some specific complications of Mycoplasma pneumonia? (3)

A
  • erythema multiforme
  • autoimmune haemolytic anaemia
  • myocarditis
61
Q

Describe the prognosis of pneumonia.

A
  • mortality increases with age and increasing CURB-65 score
  • mortality of HAP>CAP

Year 3 (145 decks)

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