Respiratory: Pneumonia II Flashcards
Describe the criteriaNICE recommends that patients should initially be assessed in primary care using [4]
Based of CRB65 scores, how do you determine where care occurs? [2]
NB CRB65 is primary care
Home-based care for patients with a CRB65 score of 0 (or 1)
Hospital assessment for all other patients, particularly those with a CRB65 score of 2 or more.
Alongside CURB65, describe which test is sometimes used to determine Abx therapy in the primary care setting [3]
NICE also mention point-of-care CRP test. This is currently not widely available but they make the following recommendation with reference to the use of antibiotic therapy:
CRP < 20 mg/L - do NOT routinely offer antibiotic therapy
CRP 20 - 100 mg/L - consider a DELAYED antibiotic prescription
CRP > 100 mg/L - OFFER antibiotic therapy
What CURB65 scores determine the level of care patients recieve? [3]
Home care: 0-1
Hospital care: 2+
Intensive care: 3+
Which investigations would you conduct for HAP? [5]
Chest x-ray
Hypoxia
Full blood count: Elevated WCC
Renal profile: urea level for the CURB-65 score and acute kidney injury
CRP
Culture of sputum
Describe the treatment algorithm for mild / low severity CAP? [2]
First line: 5 day course
- Amoxicillin
- If if penicillin allergic: clarithromycin (macrolide) OR doxycycline (tetracycline)
Second line:
- No respond to amoxicillin monotherapy, consider adding, or switching to, a macrolide (e.g., clarithromycin).
How quickly should you try and prescribe treatment for moderate severity pneumonia after hospital admission? [1]
This should be within 4 hours of presentation to hospital
Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | moderate-severity (CURB-65 = 2)?
7-10 day course is recommended
1st line:
- ORAL amoxicillin plus a macrolide: clarithomycin
- For patients who are allergic to penicillin in whom oral antibiotics are contraindicated: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone)
PLUS
clarithromycin, or intravenous levofloxacin monotherapy
2nd line:
- Change to doxycycline or a fluoroquinolone: ciprofloxacin AND pneumococcal cover: levofloxacin or moxifloxacin
d
What are NICE guidelines about route of administration about Abx? [1]
NICE guidelines on antimicrobial prescribing in adults recommend reviewing intravenous antibiotics by 48 hours, and considering switching to oral treatment if possible
Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | high-severity (CURB-65 = 3-5)?
DOUBLE CHECK
1st line:
- A broad-spectrum beta-lactamase-resistant penicillin: amoxicillin/clavulanate plus a macrolide: clarithromycin
- If allergic to penicillin: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) PLUS a macrolide (e.g., clarithromycin)
2nd line:
- Doxycycline OR
- Cefalexin OR
- Trimethoprim
3rd Line:
- levofloxacin
BMJ BP
In patients with suspected or confirmed Staphylococcus aureus MRSA infection, what are the two treatments? [2]
IV Vancomycin
OR
IV teicoplanin
with or without
Rifampicin (orally or intravenously)
In patients with suspected or confirmed Staphylococcus aureus non-MRSA infection, what are the two treatments? [2]
Flucloxacillin (intravenously)
with or without
Rifampicin (orally or intravenously)
State the treatments for these atypical pneumonias [5]
A: Clarithromycin (orally or intravenously)
B: Fluoroquinolone (ciprofloxacin) (orally or intravenously)
C: Amoxicillin (orally) or
D: benzylpenicillin
(intravenously)
E: Doxycycline (orally)
What is the treatment algorithm for mild to moderate symptoms/signs and not at higher risk of resistance for HAP? [2]
How long for? [1]
5 day prescription
ORAL:
- amoxicillin/clavulanate (aka Co-amoxiclax)
- If allergic: Doxycycline
Cefalexin (use caution in penicillin allergy)
Trimethoprim/sulfamethoxazole
NICE
What is the treatment algorithm for severe symptoms/signs and not at higher risk of resistance for HAP? [2]
How long for? [1]
1st line:
- piperacillin/tazobactam OR
- ceftazidime OR
- cefuroxime OR
- meropenem
2nd line:
- levofloxacin
In severe pneumonia, strong suspicion of what needs to be suspected? [1]
How do you manage this? [1]
Pneumonia is one of the main sources of sepsis
State 5 potential pulmonary complications of pneumonia [5]
- Pleural effusion
- Empyema
- Acute respiratory distress syndrome (ARDS)
- Lung abscess
- Pneumothorax
State 4 potential extra -pulmonary complications of pneumonia [5]
Bacteremia and sepsis
Acute kidney injury (AKI): esult from sepsis, hypovolemia, or drug-induced nephrotoxicity
Pericarditis: direct extension of pneumonia or hematogenous spread
NICE recommend that patients are not routinely discharged if in the past 24 hours they have had 2 or more of the following findings? [6]
- temperature higher than 37.5°C
- RR 24 breaths per minute or more
- HR over 100 beats per minute
- SBP 90 mmHg or less
- oxygen saturation under 90% on room air
- abnormal mental status
- inability to eat without assistance.
Label the progress expected post-pneumonia from 1 week - 6 months
1 week:
- Fever should have resolved
4 weeks:
- Chest pain and sputum production should have substantially reduced
6 weeks:
- Cough and breathlessness should have substantially reduced
3 months
- Most symptoms should have resolved but fatigue may still be present
6 months:
- Most people will feel back to normal.
What immunological cause makes alcoholics more likely to suffer from pneumonia? [1]
Alveolar macrophages are less effective in alcoholics
All patients admitted to hospital with pneumonia should have what investigations? [5]
(NICE & BTS)
CXR
FBC (WCC raised; CRP raised)
U&E
LFTS
Oxygen sats
All patients with moderate-severe pneumonia should have what investigations? [3]
(NICE & BTS)
All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats
Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum
All patients with severe + outbreaks of pneumonia should have what investigations? [3]
(NICE & BTS)
All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats
Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum
Severe+:
- Mycoplasma PCR
- Chlamydophilia PCR
- Viral PCR
