13.2 Current diagnosis & management of CAP (Community Acquired Pneumonia) in UK Flashcards
(36 cards)
1
Q
What are common respiratory tract infections?
A
- Acute bronchitis
- Bronchiolitis
- Pneumonia
2
Q
What is the definition of pneumonia?
A
-
Inflammation of lung parenchyma leading to consolidation (Infection of the air-space of the lung)
- Doesn’t have to be infectious or bacterial (e.g. viruses, fungi)
- CXR changes (consolidation)
- Treated as bacterial infection
3
Q
What is the definition of community-acquired pneumonia (CAP)?
A
- Pneumonia acquired outside hospital or healthcare facilities
4
Q
What is the definition of hospital acquired pneumonia (HAP)?
A
- Pneumonia acquired ≥ 48 hrs. into hospital admission that wasn’t incubating on admission
5
Q
Who is at risk of getting pneumonia?
A
- OLD (co-morbidities - COPD, HIV, diabetes mellitus, chronic kidney disease, sickle cell disease, frailty, immunosenescence - gradual deterioration of the immune system)
-
DISADVANTAGED
- Socioeconomic deprivation
-
PHARMCEUTICALS
- PPI
- Inhaled corticosteroids
- Antipsychotics
- Opioids
- Alcohol abuse
- Poor oral hygiene
-
Contact with children
*
6
Q
What are the types of bacterial pathogens that cause pneumonia?
A
-
TYPICAL
- Streptococcus pneumoniae
- Staphylococcus aureus
- Haemophilius influenza
-
ATYPICAL - DO NOT respond to B-LACTAM PENICILLINS
-
Add clarithromycin in treatment regardless of CURB-65 score
- Mycoplasma pneumoniae
- Chlamydophilia pneumoniae
-
Add clarithromycin in treatment regardless of CURB-65 score
-
OTHERS
- Pseudomonas aeruginosa
- Enterobacteriaceae
7
Q
Give examples of viral pathogens causing pneumonia
A
- Influenza A
- Influenza B
- Rhinovirus
- Corona virus
- COVID-19
- SARS
- Metapneumovirus
8
Q
Explain the pathophysiology of pneumonia
A
- Inhaled
- Aspiration from oropharynx
- Direct spread
- Haematogenous spread (in blood)
9
Q
From one’s history how could you detect pneumonia?
A
- Detecting symptoms consistent with CAP
- Chills (Fever)
- Breathlessness (Dyspnoea)
- Cyanosis
- Cough
- Sputum production
- Pleuratic chest pain
- Haemoptysis
- Arthralgia (pain in joints)
- Myalgia (pain in muscles/group of muscles)
-
Dullness to percussion
- Crackles when breathing
-
Defects of immunity
- Elderly
- Immunocompromiseed
- Risk of exosure to specific pathogens
-
LEGIONELLA
- Confusion, GI upset, lymphopaenia (decreased lymphocytes in blood), hyponatraemia (low sodium in blood)
-
MYCOPLASMA
- Young, encephalitis (inflammation of the brain), myocarditis
-
LEGIONELLA
10
Q
What is the differential diagnosis of pneumonia?
A
- Left ventricular failure
- Pulmonary embolus
- Infective exacerbation COPD
- TB
- Acute asthma
- Oesophageal rupture
11
Q
At what point could you consider that the pneumonia is due to ‘atypical pathogens’?
A
- Foreign travel (all atypicals)
- Prior antibiotics, hyponatraemia (mycoplasma)
- Air conditioning exposure
- Diarrhoea
- Abnormal LFT’s
- Neurological symptoms
- Headache (Chlamydophila pneumoniae)
12
Q
What is the purpose and findings on a CXR for pneumonia?
A
- To confirm diagnosis of ‘suspected CAP/HAP’
- Consolidation will be seen
- If little clinical signs but severe = legionella/myoplasma
- Needs to be done within 4 hours of admission and CAP confirmed within this time
13
Q
What is a CURB-65?
A
- Confusion (AMTS (abbreviated mental test score) <=8/10)
- Urea (>7mmol/L)
- RR (>= 30breaths/min)
- BP (SBP <90mmHg, DBP <= 60mmHg)
- Age >65 years old
1 point awarded for each category if in zone (thus, out of 5 points)
No bloods needeed for CRB-65
Needs to be recorded in NOTES
14
Q
What to determine from CURB-65?
A
- Based on scoring = severity:
- LOW = 0-1 = <3% mortality risk
- MODERATE = 2 = 9% mortality risk
- HIGH = 3-5 = 15-40% mortality risk
- The HIGHER risk of death = treat MORE aggressively (& decides what kind of treatment needed)
15
Q
What is the ATS/IDSA criteria for severee CAP?
A
To have SEVERE CAP must be 1 major category or 3+ minor categories
-
Major criteria
- Respiratory failure requiring mechanical ventilation
- Septic shock with the need for vasopressors
-
Minor criteria
- Respiratory rate ≥30/minute
- Confusion/disorientation
- Urea ≥7.14 mmol/L
- Leukopenia due to infection alone WBC < 4 x 109
- Thrombocytopaenia < 100
- Hypothermia, temp < 36
16
Q
What is PSI (pneumonia severity index)?
A
- Is a tool used to put patients into risk classes (1-5):
- DEMOGRAPHICS (study of a population based on factors such as age, race, and sex)
- CO-MORBIDITIES
- PHYSICAL EXAM/VITAL SIGNS
- LABORATORY/IMAGING
- When risk class 4-5 recommended site of care = INPATIENT (other classes = outpatient care)
17
Q
What are routine bloods for someone with pneumonia?
A
- FBC
- U&E’s
- LFT’s
- CRP
- Procalcitonin
- ABG’s (SpO2 <94%)
18
Q
What tests to do if someone has medium - high severity CAP (CURB-65 >=2)?
A
- Sputum test
- Pneumococcal/legionella urinary antigen testing
- Paired serology (scientific study of serum and other body fluids) if not responding to treatment
19
Q
What tests would you do if someone is young and has pneumonia (mild)?
A
- HIV testing
- Test for TB (as may need isolating) (AFB - acid fast bacillus = shows active TB)
20
Q
Consider the different management options with severity of pneumonia
A
-
LOW severity = Consider home treatment (CURB-65 = 0-1) –> if no unstable co-morbidities
- 1st line: Amoxicillin
- Alternatives: Clarithromycin or Doxycycline
-
MODERATE severity = (CURB-65>=2) –> hospital treatment also if lower score but unstable co-morbidities
- 1st line: Amoxicillin
- Alternatives: Clarithromycin
-
SEVERE = (CURB-65 >= 3) –> consider CCU (critical care unit) treatment and transfer
- 1st line: Co-amoxiclav
- Alternative: Cefuroxime
ALL patients oxygen given to keep SpO2 94-98% (or if COPD 88-92%)
21
Q
What are the contraindications to outpatient therapy?
A
- Inability to maintain oral intake
- History of substance abuse
- Severe comorbid illnesses
- Cognitive impairment
- Impaired functional status
- Availability of support at home
22
Q
What are the advantages and disadvantages of using a lung ultrasound in pneumonia?
A
-
ADVANTAGES
- Quick
- Simple
- Cheap
- Reliable
- Assess pleural collections
-
DISADVANTAGES
- Miss diagnosis (interstitial pneumonias)
- Diffuse disease
23
Q
Explain the use of a chest CT in diagnosis of pneumonia
A
- Most information
- Access, ionizing radiation
- 5% admission CXR non-diagnostic,
- CT confirmation
24
Q
Step by step when patient comes in with suspected pneumonia
A
- Perform CXR within 4hrs of admission
- Assess Oxygen Saturation and prescrube oxygen according to appropriate target range
- Calculate CURB 65 in all patients where CXR demonstrates pneumonia
- Adminster antibiotics within 4hrs of diagnosis appropriate to CURB 65 score
25
Explain the mechanism of action of amoxicillin and an allergy to it
1. **Bacteriocydal** - Attaches cell wall of susceptible bacteria and kills
2. Inhibits cross-linkage between the linear peptidoglycan polymer chains that make up a major component of the bacterial cell wal
* Is a **derivative** of **penicillin** (is better absorbed orally)
* Penicillin allergy --\> taking amoxicillin can havee adverse side effects (can be fatal due to **anaphylaxis**)
26
Explain the mechanism of action of doxyxycline
* Is a **broad-spectrum**, tetracycline class
1. **Bacteriostatic** (Capable of inhibiting the growth or reproduction of bacteria) - _inhibits_ **bacterial proteins synthesis**
2. Binds 30S ribosomal subunit, prevents the binding of transfer RNA to messenger RNA at the ribosomal subunit
3. Amino acids _cannot_ be added to polypeptide chains
4. _No_ new proteins
27
What are the common side effects of doxyxycline?
* Diarrhea
* Nausea
* Vomiting
* Increased risk of sunburn
* Tetracycline antibiotics are contraindicated in pregnancy and up to eight years of age, due to the potential for disrupting bone and tooth development
28
What to prescribe if there is a reason to believe that there is a secondary infection with pneumonia?
* Prescribe **co-amoxiclav**
29
When would a patient require lower doses of antibiotics when they have pneumonia?
* Renal impairment
* Hepatic impairment
* Very small body habitus
30
At what point can a patient be discharged if they had pneumonia?
* When patient has:
* Temperature ≤ 37.8°C
* HR ≤ 100/min
* RR ≤ 24/min
* SBP ≥ 90 mm Hg
* SpO2 ≥ 90%
* Ability to maintain oral intake
* Normal mental status
31
What is the differential diagnosis if the patient _isn't_ getting better (suspected pneumonia)?
1. **_Empyema_** (It's a condition in which pus gathers in the area between the lungs and the inner surface of the chest wall - pleural space)
* Will have a **HIGH** temp
* Need new CXR
* May need **chest drain**
2. **_Lung abscess_** (is a bacterial infection that occurs in the lung tissue. The infection causes tissue to die, and pus collects in that space)
* **HIGH** temp
* Repeat CXR and CT chest
3. **_Lung cancer_**
1. Red flag!!!
2. Mass-like appearance on CXR
32
What condition is this?
Empyema
33
What condition is this?
Lung abscess
34
What condition is this?
Lung cancer
35
What to do if the patient isn't getting better and suspected pneumonia?
* Different organsim, **antimicrobial resistance**
* _Reculture_, discuss with **microbiology**
* **Bronchoscopy** with lavage esp. if immunocompromised TB could be
* Consider doing a CT
36
How soon will someone get better from pneumonia?
* Can take a **few months** to feeel better again
* Depends on how severe pneumonia was
* Start of recovery:
* **REST** and **build up**
* After **1 week**:
* Fever should be gone
* After **4 weeks**:
* Chest feel better & _less_ phlegm in chest
* After **6 weeks**
* _Not_ coughing as much & breathing easier****
* After **3 months**:
* Nearly back to normal but can feel _tired_
* After **6 months**:
* Back to NORMAL
