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Respiratory > Pneumonia symposium - pneumonia and lower resp tract infections > Flashcards

Pneumonia symposium - pneumonia and lower resp tract infections Flashcards

1
Q

Give some clinical features of pneumonia

A 
runny nose 
cough
chest apin
joint pain
myalgia - muscle ache 
fever 
increased HR 
SOB
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2
Q

What are the possible differential diagnoses of pneumonia?

A 
heart failure 
PE
cancer 
TB
interstitial lung disease
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3
Q

How does pneumoia appear on CXR?

A

consolidation

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4
Q

Which individuals are particularly at risk of pneumonia?

A

Infants and the elderly
COPD and certain other chronic lung diseases
Immunocompromised
Nursing home residents
Impaired swallow (neurological conditions etc.)
Diabetes
Congestive heart disease (as causes breathing problems)
Alcoholics and intravenous drug users

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5
Q

What is pneumonia?

A

inflammation of the lung parenchyma (portion of the lung involved in gas transfer - the alveoli, alveolar ducts and respiratory bronchioles) usually caused by infection

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6
Q

Explain the pathogenesis of pneumonia

A
  1. pathogens enter the alveoli
  2. macrophages try to phagocytose the bacteria but they get overwhelmed
  3. the macrophages signal for neutrophils to come and help via cytokines
  4. this causes collateral damage to the structures of the lung ie an inflammatory response
  5. neutrophils and inflammatory exudate fill the alveolar space
  6. T cells also come to the site of infection, the most important being Th17, which is a pro-inflammatory T cell and helps the neutrophils
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7
Q

Why is consolidation seen on CXR with pneumonia?

A

the alveoli are full of pus, dead cells and bacteria and immune cells which absorbs X-rays

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8
Q

What is heard on auscultation of a pt chest with pneumonia?

A

will hear less air going in and out of the lungs

crackles - as the alveoli are trying to open but are full of fluid

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9
Q

what will be heard on percussion of the chest of a pt with pneumonia?

A

will sound dull

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10
Q

What happens if the resolution phase is not reached in pneumonia?

A

so much damage to the lung parenchyma is caused, that there is communication with the blood vessels and therefore get an invasive disease

gas exchange may be so poor that respiratory support is needed

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11
Q

what is the resolution phase of pneumonia?

A

when the bacteria are cleared
inflammatory cells are removed by apoptosis
resolution phase leads on to complete recovery

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12
Q

what are the symptoms of pneumonia?

A

fever, sweats, rigors
cough
sputum - classically rusty sputum with S. pneumoniae but there may be none with other organisms
SOB
pleuritic chest pain - worse on deep breathing
weakness
malaise
extrapulmonary features - neurological or gastrointestinal with legionella and rash with mycoplasma

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13
Q

What are signs of pneumonia?

A 
Abnormal vital signs:
raised HR
raised resp rate 
low BP
fever 
dehydration 
signs of lung consolidation on percussion and auscultation:
dull to percussion
decreased air entry
bronchial breath sounds 
crackles 
may be wheeze 
increased vocal resonance 
hypoxia and signs of resp failure may be present if chronic lung disease or severe pneumonia
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14
Q

What does it tell you if a pt has more signs present?

A

that the pneumonia is more severe

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15
Q

What investigations are done for pneumonia?

A 
CXR
FBC
biochemistry
CRP
pulse oximetry
microbiological tests
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16
Q

What are you looking for partciularly in the FBC?

A

neutrophilia/WCC as a marker of severity

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17
Q

Why do we check biochem?

A

we check the urea and electrolytes and LFTs as the kidneys and liver can fail if sb is very dehydrated

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18
Q

Why is pulse oximetry done?

A

gives indication of gas exchange ability and so can assess severity

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19
Q

What microbiological tests are done for pneumonia?

A

sputum culture and sensitivities
gram staining of bacteria from sputum
blood culture
serology eg Abs - we do acute and convalescent
(can do legionella urinary antigen and viral throat swab)
PCR

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20
Q

what features can be seen on CXR for sb with pneumonia?

A

air bronchogram - air filled bronchi made visible by the consolidation of the alveoli
multilobar suggestive of particular pathogens
multiple abscesses in the lung due to S. aureus
upper lobar cavities may represent K. pneumoniae
Interstitial or diffuse shadowing more suggestive of viral or Pneumocystis pneumonia (PCP) in HIV or immunocompromised
pleural collections may be present

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21
Q

What are the empirical antibiotics is used for community acquired pneumonia?

A

depends on the CURB65 score:
= 0 - oral amoxicillin, or oral clarythromycin or oral doxycycline
= 1-2 - oral amoxicillin (oral doxycycline if penicillin allergy) PLUS oral clarythromycin
= 3-5 IV co-amoxiclav (IV ceftriaxone given if penicillin allergy) PLUS IV clarythromycin

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22
Q

What re the features of sepsis?

A

pro-inflammatory cytokines
vasodilation
impaired cardiac contractility due to inflammation
reduced BP due to the vasodilation and the impaired cardiac contractility
impaired organ perfusion
tissue hypoxaemia

confusion/delerium as there is reduced perfusion of the brain
renal impairment as there is reduced perfusion of the kidneys, urine output reduced and rise in urea
increased oxygen demand causes a high resp rate
lactic acid production

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23
Q

what factors may mean you are more susceptible to sepsis?

A

age

comorbidity

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24
Q

How do we assess the severity of community acquired pneumonia?

A

CURB65 - the higher the score the more severe it is and the greater the risk of mortality, so is used to find out whether a pt should be admitted to hospital and how much close monitoring they need

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25
Q

What does CURB65 stand for?

A 
Confusion
Urea ≥7mmol/L
Respiratory rate≥ 30/min 
Blood pressure; low systolic < 90mm/Hg or diastolic ≤60mm/Hg
Age ≥ 65
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26
Q

What are the disadvantages of broad spec antibiotics?

A

expensive
adverse effects
IV - so harder to give
promotes resistance

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27
Q

What is the most common community acquired pneumonia pathogen?

A

Strep. pneumoniae

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28
Q

What are the causative pathogens for pneumonia and what are the relative percentages?

A 
S. pneumoniae 40%
Mycoplasma  11%
Chlamydophila pneumoniae 13%
Legionella  sp. 4% 
H. influenzae 5%
Klebsiella pneumoniae (rare; homeless and in hospital)
Staphylococcus aureus (low % in community but increased after influenza and in hospital especially)
Viruses 13%
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29
Q

Which community acquired pathogens are most likely to take people to ITU?

A

S. pneumoniae (as it is most common)
S. aureus
Legionella sp.

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30
Q

What are the atypical pathogens that cause pneumonia?

A 
Mycoplasma pneumoniae (~10% peaks in epidemic seasons)
Chlamydophila pneumoniae (~10%)
Legionella pneumophila and other spp.(<5%)
(also Chlamydophila psittaci and Coxiella burnetti ‘Q fever’)
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31
Q

What would S. pneumoniae look like under the microscope with gram stain?

A

Gram positive cocci

so purpule cocci

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32
Q

What type of haemolysis does S. pneumoniae result in on blood agar?

A

alpha haemolysis

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33
Q

Is S. pneumoniae optochin sensitive or resisitant?

A

optochin sensitive

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34
Q

What antibiotics would you use for S. pneumoniae infection?

A

amoxicillin
or Cefuroxime/cefotaxime (both cephalosporins and good to use if the pt is allergic to penicillin)

an alternative is a macrolide eg Clarithromycin

35
Q

What does H. influenza look like under the microscope?

A

Gram negative cocobacillus

36
Q

Which pathogens tend to follow influenza to cause pneumonia?

A

H. influenzae (hence the name)

S. aureus

37
Q

Which pathogen may cause pneumonia associated with ventilation?

A

S. aureus

38
Q

What is Klebsiella pneumoniae?

A

Gram negative bacillus

one of the Enterobacteriaceae

39
Q

What antibiotics would be used to treat H. influenzae?

A

Co-amoxiclav (amoxicillin + clavulanic)

Tetracyclines ie doxycycline

40
Q

What antibiotics would NOT be used for H. influenzae?

A

Macroclides eg clarythromycin

41
Q

What antibiotics would you use for S. aureus pneumonia?

A

beta lactams eg flucloxacillin or cefuroxime (cephalosporin)
if its MRSA - Vancomycin or Linezolid

42
Q

What antibiotics would you use for K. pneumoniae infection?

A

Beta lactams: co-amoxiclav or cephalosporins

43
Q

What are the characteristics of the atypical pathogens?

A

they won’t grow on blood agar, so need to make the diagnosis by other methods
eg serology - like looking for the legionella urinary antigen
need different antibiotics ie not the beta lactams

44
Q

Which antibiotics would you use for the atypical pathogens

A

Macrolides (erythromycin / clarithromycin) or fluorquinolones (ciprofloxacin) or tetracyclines (doxycycline)

45
Q

What are the extrapulmonary features of M. pneumoniae and what are they due to?

A 
haemolytic anaemia 
raynauds 
erythema multiforme
bullous myringitis (blisters on the tympanic membrane) 
encephalitis 
due to cold agglutinins
46
Q

What are cold agglutinins?

A

cross reactive antibodies (IgM) against red blood cells. These cross-reactive antibodies are specific (and diagnostic) for Mycoplasmas infection and some other diseases. antibodies form and coalesce in areas which are a bit colder like the skin. It is a form of autoimmune haemolytic anaemia, specifically one in which antibodies only bind red blood cells at low body temperatures

47
Q

What extrapulmonary features can Legionnaire’s cause?

A 
diarrhoea, 
abnormal liver function tests,
hyponatremia, 
myalgia, raised creatinine kinase, 
interstitial nephritis, 
encephailitis, confusion
48
Q

How are S. pneumoniae colonies described?

A

Draughtsman colonies

49
Q

What antibiotic do we use for mild pneumonia in the community?

A

PO Amoxicillin - if penicillin allergic use clarythromycin

50
Q

If the pt has moderate severity pneumonia which antibitoics would you use?

A

PO amxocillin + clarythromycin

51
Q

Why do we not just give clarythromycin to everyone?

A

as it promotes antibiotic associated diarrhoea and has the side effect of nausea

52
Q

What would we use to treat severe pneumonia?

A

IV co-amoxiclav AND claryhtromycin

alternatively if penicllin allergic would give IV cefuroxime and clarythromycin

53
Q

How long would we give antibiotic treatment for?

A

5 days if mild to moderate and more than 5 days if severe

14-21 days if S. aureus or G- bacteria or Legionella

54
Q

What is PVL?

A

= Panton–Valentine leukocidin (PVL) is a cytotoxin produced by some aggressive strains of S. aureus that cause a fulminant necrotising pneumonia

55
Q

How can we prevent pneumonia and who can we offer this preventative treatment to?

A

PPV - polysaccharide penumococcal vaccine given to >65’s, people with splenic dysfunction, the immunocompromised, people with chronic medical conditions eg heart, lung, kidney disease, diabetes

influenza vaccine
smoking cessation
PCV - pneumococcal conjugate vaccine in children

56
Q

What does the PPV vaccine protect against?

A

invasive pneumococcal disease but not pneumonia

57
Q

Name some complications of pneumonia

A

parapneumonic effusion - a type of pleural effusion that can be infected ie become an empyema- the infection would not be treatable with antibiotics so the pt gets worse despite antibiotics

58
Q

What are the clinical features of empyema?

A

failure of fever or markers of inflammation (WBC/CRP) to settle on antibiotics
pain on deep inspiration
signs of pleural collection (stony dull to percussion, reduced air entry)

59
Q

What investigation do you need to carry out is a pt has a parapneumonic effusion?

A

diagnostic thoracocentesis to identify bacteria, cloudy fluid, pus, low pH
will also find out whether it is a transudate or exudate so if pneumonia, we would be looking for an exudate ie high protein

60
Q

How would you manage an empyema?

A

needs draining by therapeutic thoracocentesis (chest tube) or cardiothroacic surgery and decortication
may not need to change antimicrobials but would need to give them for longer about 3 weeks eg Co-amoxiclav, meropenam or piperacillin-tazobactam

61
Q

What are Light’s criteria?

A

criteria that help to identify whether an effusion needs draining, ie will need draining if there is an infection in the fluid eg empyema

62
Q

Which organisms can cause lung abscesses?

A

s. aureus eg with an IVDU - comes from the skin
Strep. milleri from the mouth - dental work
anaerobes and Klebsiella pneumonia from aspiration of vomit and other gram -ve bacteria
Furosobacteria from Lemierre’s syndrome which is infectious thrombophelbitis of the IJV as a complication of sore throat infection - infection gets into RHS of the heart and causes infection in the lungs

63
Q

How may an IVDU with a DVT get an abscess in the lung and empyema of the pleural space?

A

There is an infected DVT in the leg and the embolus from the DVT goes to the lungs and causes an infection and PE in the lungs. The infection is invasive and erodes into the pleura

64
Q

How is a lung abscess managed?

A

prolonged antibiotics for 6 weeks
may need surgical drainage
[most are treated successfully with antibiotics even without drainage, drainage is second line]

65
Q

How is hospital acquired pneumonia defined?

A

development of pneumonia at least 48 hours after admission

66
Q

Who is most at risk of HAP?

A

the elderly
ventilated
post-operative

67
Q

How is HAP diagnosed?

A 
new fever 
purulent secretions 
New radiological infiltrates 
New leukocytosis / CRP increase
plus increasing O2 requirements
68
Q

How is HAP treated?

A

start broad and then focus with the antibiotics as the bacteria in hospital are more resistant

69
Q

Which antibiotics would you give to a pt who has got HAP within 5 days of being in hospital and why?

A

the organisms are likely to be similar to the ones acquired in the commnity, with anerobes being a possibility as well
so give Metronidazole OR beta lactam with a beta-lactamse inhibitor such as Co-amoxiclav or piperacilllin-tazobactam

70
Q

which antibiotics would you give to a pt who has developed pneumonia after 5 days of being in hospital and what organisms is the HAP likely to be caused by?

A

First line is Piperacillin-tazobactam IV

MRSA (vancomycin)
Pseudomonas aeruginosa (give piperacillin-tazobactam)
Acinetobacter baumanii
Klebsiella pneumoniae

71
Q

what drug would you use as a last resort for multi-drug resistant Gram-negatives (MDR)

A

IV colistin

72
Q

What is the antibiotic regimen for CAP for mild, moderate and severe according to the CURB65 score?

A

Mild: amoxicillin PO (clarythromycin if allergic)

moderate: amoxicillin PO (clarythromycin if allergic) if not responding to amoxicillin after 2 days give co-amoxiclav PO

severe: co-amoxiclav IV PLUS clarythrocmycin (PO/IV)
if allergic to penicillin give Cefuroxime IV PLUS Clarythromycin

73
Q

What bacteria, viruses and fungi can immunocompromised people additionally get infected by?

A

Bacterial
- Pseudomonas aeruginosa

Fungal

  • Pneumocystis pneumonia (PCP) due to the yeast-like fungus Pneumocystis jirovecii
  • Moulds e.g. Aspergillus spp.

Viruses

  • Cytomegalovirus (CMV)
  • Adenovirus
  • Respiratory syncytial virus (RSV)
74
Q

what are the causes of chronic pneumonia? (> 6weeks)

A 
bacteria 
fungi 
parasites 
malignancy
vasculitis
drugs
eosinophils
75
Q

what is bronchiolitis?

A

Infections due to Respiratory syncytial virus
Inflammation of bronchioles and mucus production cause airway obstruction
happens in young babies esp those born prematurely

76
Q

What signs may you find in a baby with bronchiolitis?

A

low O2 sats
respiratory retractions
widespread crackles and wheeze
severe resp distress

77
Q

What is SARS?

A

severe acute respiratory syndrome associated coronavirus

Severe respiratory illness with respiratory failure

78
Q

What is MERS?

A

Middle East Respiratory Syndrome novel Coronavirus

similar to SARS

79
Q

What is bronchitis?

A

self-limited inflammation of the epithelia of the bronchi due to upper airway infection

80
Q

What organisms cause bronchitis?

A

majority caused by viral infection but can rarely be caused by bacteria eg Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordatella pertussis so similar organisms to CAP

81
Q

What are the clinical features of bronchitis?

A 
cough either productive or not 
SOB
wheeze
no signs of focal consolidation 
fever and systemic features are unusual and suggest influenza or pneumonia
82
Q

What are the investigations that are done for bronchitis?

A
  • CXR to exclude pneumonia - so the CXR is normal
  • viral and bacterial throat swabs
  • serology for mycoplasma and chlamydia pneumoniae
83
Q

What is the treatment for bronchitis?

A

usually none if viral

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