Signs and management of pneumonia

Question 1

What are the symptoms and signs of pneumonia

Answer 1

• Cough and purulent sputum
• Rigors and fever
• Dyspnoea
• Chest pain (pleuritic, sudden onset)
• Abdominal pain
• Confusion (elderly, multimorbid patient)
• Myalgia and arthralgia

Question 2

What are the typical clinical findings that indicate pneumonia?

Answer 2

• Temp 38.5-40 + °C
• Tachypnoea
• Tachycardia
• Stony dullness on percussion over area of consolidation
• chest expansion reduced on side of infection
• Bronchial breathing
• Focal crackles
• Mental confusion

Question 3

What is the CURB-65 score for pneumonia?

Answer 3

• C - confusion (new disorientation in person, place or time)
• U - urea >7
• R - respiratory rate ≥ 30
• B - BP < 90 systolic or ≤60 diastolic
• 65 ≥ age

Question 4

How does the CURB-65 score guide admission to hospital?

Answer 4

• Score 0/1 = consider treatment at home
• Score ≥2 = consider hospital admission
• Score ≥3 = consider intensive care assessment -> severe pneumonia

Question 5

When may CURB-65 not always be helpful?

Answer 5

• Patients <65yrs
  Younger patients tend to compensate
• CKD
  May have a high baseline urea

Question 6

How would you manage CAP with a CURB-65 score of 0?

Answer 6

Amoxicillin 500mg tid for 5 days

OR Doxycycline 200mg on first day, then 100mg o.d. for 4 days

OR Clarithromycin 500mg bd for 5 days

OR Erythromycin 500mg qid for 5 days

Question 7

Which antibiotic is safe in pregnancy?

Answer 7

Erythromycin

Question 8

How would you manage CAP with a CURB-65 score of 1/2?

Answer 8

Amoxicillin 500mg tid for 5 days AND
• Clarithromycin 500mg bd for 5 days
• OR erythromycin 500mg qid for 5 days

OR doxycycline 200mg on first day, then 100mg od for 4 days

OR clarithromycin 500mg tds for 5 days

Question 9

How would you manage CAP with a CURB-65 score of 3/4?

Answer 9

Co-amoxiclav 500mg/125mg and clarithromycin/erythromycin 500mg for 5/7 days

Question 10

What would you do if someone with pneumonia was deteriorating?

Answer 10

• IV antibiotics

- Change to broader spectrum antibiotics

Question 11

How do you follow up a person with CAP?

Answer 11

• Reassess if symptoms and signs do not improve
Could this be non-bacterial causes?
• CURB-65
• When results from microbiology are available, consider changing AB
• CXR after 6 weeks for adults:
With persistent symptoms and signs
Who are at high risk of underlying malignancy (smokers, >50yrs)
• Consider whether pneumococcal or influenza vaccine are necessary

Question 12

How would you manage someone with non-severe HAP?

Answer 12

Co-amoxiclav 500mg/125mg tid

Question 13

How would you manage someone with severe HAP?

Answer 13

Piperacillin with tazobactam 4.5g tid

Question 14

What would you do if someone with a severe HAP gets worse?

Answer 14

Increase peperacillin with tazobactam to 4.5g qid

Question 15

What are the complications of pneumonia?

Answer 15

• Parapneumonic effusion
• Lung abscess
• Sepsis
• VTE
• Worsening of comorbidities
  AF, HF, CKD, COPD

Question 16

What are parapneumonic effusions?

Answer 16

Pleural effusion that results due to pneumonia
Classified into:
- Uncomplicated
      Sterile effusion
- Complicated
      Infected effusion
- Empyema 
      Pus in the pleural space

Question 17

What is a lung abscess?

Answer 17

Pus in the lung parenchyma

Question 18

When would you give antibiotics for an acute cough (<21 days)?

Answer 18

• Patients taking immunosuppressant drugs
• Patients with significant heart, lung, renal, liver or neuromuscular disease
• >65yrs and have 2+ of co-existing conditions:
T1/T2DM
HF
Hospitalisation in the last year
o Taking oral corticosteroids
• Signs of pneumonia

Question 19

In order to write the prescription for Piperacillin with tazobactam which is the most appropriate monitoring information you need?

Answer 19

eGFR

- Both drugs are dosed according to renal function as they are renally excreted