Case 12 - Pneumonia

Question 1

What is the CURB-65 scoring system?

Answer 1

Assessment of severity of CAP
C - Confusion 
U - Urea >7
R - Respiratory rate >30
B - BP <90/60
65 - Age >65

0-1 (low severity), 2 (moderate severity), 3-5 (high severity)

Question 2

How is pneumocystis jiroveci pneumonia treated?

Answer 2

Oral Co-trimoxazole

Question 3

What are the most common viral causes of community acquired pneumonia (CAP)?

Answer 3

Streptococcus pneumoniae (gram positive)
Haemophilus Influenzae (gram negative)
Mycoplasma pneumonia

Question 4

What are the most common causes of hospital acquired pneumonia (HAP)?

Answer 4

Gram negative enterobacteria (e.coli, klebsiella, enterobacter)
Staphylococcus aureus (gram positive)
Pseudomonas (gram negative)

Question 5

How is hospital acquired pneumonia defined?

Answer 5

Infection following 48 hours after hospital admission

Question 6

Which type of bacteria is associated with community acquired pneumonia in patients with alcohol excess?

Answer 6

Klebsiella pneumonia

Question 7

What is the clinical effectiveness of the influenza vaccine?

Answer 7

Overall efficacy is between 60-82%, being lower in elderly subjects

Question 8

What are the main symptoms of pneumonia?

Answer 8

Fever
Rigours
Malaise
Dyspnoea (difficulty breathing)
Cough - can be with purulent sputum or haemoptysis 
Plueretic chest pain

Question 9

What are the main signs of pneumonia?

Answer 9

Pyrexia 
Cyanosis 
Confusion 
Tachypnoea
Tachycardia
Dull percussion 
Bronchial breathing (higher pitched)

Question 10

Which patients with respiratory infection should be referred to hospital for treatment?

Answer 10

Patients with suspected pneumonia

E.g, with high fever/low blood pressure/high respiratory rate/ confusion

Question 11

How are mild, moderate and severe CAP treated?

Answer 11

Mild: oral amoxicillin or clarithromycin (5 day course)
Moderate: oral amoxicillin + clarithromycin (7-10 day course)
Severe: IV co amoxiclav and oral clarithromycin

Also remember IV fluids and VTE prophylaxis

Question 12

Where might the CURB65 not be useful?

Answer 12

Younger patients - unable to score >65, also they are likely to compensate so wouldn’t score as severe

Chronic renal patients - who have a higher baseline urea value

Question 13

What are the major complications of pneumonia?

Answer 13

Pleural effusion (complicates 50% of cases)
Empyema (collection of pus in pleural cavity)
Lung abscess (rare)
Respiratory failure
Septicaemia

Question 14

What is PipTaz (Tazocin) and when is it used

Answer 14

Piperacillin-Tazobactam is a broad spectrum antibiotic

Used to cover a broad spectrum of bacteria in clinical deterioration

Question 15

Why should you avoid using broad spectrum antibiotics once you know what the infective cause is sensitive to?

Answer 15

To decrease the risk of developing resistance

Question 16

In which bacterial infections are muscle and joint pain more common?

Answer 16

Legionella

Mycoplasma

Question 17

What blood tests would you take in suspected pneumonia and why?

Answer 17

FBC - check for WCC, neutrophils and platelets
U&E - looking at urea especially
LFTs - can be deranged in reduction of liver perfusion in sepsis
CRP - look for inflammation
Lactate - look for signs of sepsis

Question 18

What should be taken from any patient presenting with fever?

Answer 18

Blood cultures to help diagnose the infection

Taking the blood culture at the time of fever helps to increase the likelihood of ‘catching’ the bacteria in the blood stream

Question 19

What tests should be done in suspected pneumonia?

Answer 19

Blood tests: FBC, U&E, LFTs, CRP, lactate
Blood culture
Sputum culture
Urinary antigen test 
Chest X ray 
ABGs

Question 20

What additional test should be offered to patients presenting with pneumonia who are under the age of 60 and why?

Answer 20

HIV test

This is common presentation of HIV in an undiagnosed individual

Question 21

What is meant by typical and atypical pneumonia

Answer 21

Typical organisms can be cultured in the lab - treated with beta lactams
Atypical organisms are intracellular organisms that cannot be cultured used standard methods - atypical organisms need to be treated with antibiotics that get into intracellular spaces (macrolides)

Question 22

What is the most common type of pneumonia causing agent which is seen in immunocomprimised patients

Answer 22

Pneumocystis jirovecii

Question 23

What is ventilator acquired pneumonia?

Answer 23

A type of HAP occurring in patients on mechanical ventilation. Mortality rate can reach 50% or higher

Question 24

What are the risk factors for developing HAP?

Answer 24

ICU stay, mechanical ventilation
Prolonged hospital stay
Severe underlying illness, multiple co-morbities
Underlying respiratory disease e.g, COPD, asthma
Abdominal surgery, vomiting/aspiration

Question 25

In which lobe of the lungs does aspiration pneumonia usually occur and why?

Answer 25

Right lower lobe

The right main bronchus is straighter from the trachea compared to the left main bronchus

Question 26

How would you differentiate between an effusion and a consolidation radiologically?

Answer 26

Both produce opacification of the lung field

In consolidation - the margins of opacification are not as cleaner
In effusion - the opacification is dense and there are no visible markings in the lung field, whereas you can see air bronchograms in consolidation
In effusion - the costophrenic and cardiophrenic angles are not visable

Question 27

What are the main systemic symptoms of TB?

Answer 27

Weight loss
Night sweats
Fever

Question 28

What investigations are specific for TB?

Answer 28

Early morning urine - to detect Genito urinary tract TB

Tuberculin skin test - however this is unable to separate latent from active TB

Question 29

What signs are seen on an X-ray with TB?

Answer 29

Upper lobe consolidation 
Apical segment lower lobe
Consolidation, cavitation, fibrosis and calcification 
Pleural effusion 
Lymphadenopathy 
Miliary TB nodules

Question 30

How is TB treated?

Answer 30

Initial phase (8 weeks on 4 drugs): rifampcin, isoniazid, pyrazinamide, ethambutol 
Continuation phase (16 weeks on 2 drugs): rifampicin, isoniazid

Question 31

When should patients with pnemonia be followed up after discharge from hospital and what should be included in the follow up?

Answer 31

Should be followed up after 6 weeks

Chest X ray should be performed to make sure infection has cleared

Question 32

When should patients feel “back to normal” after having pneumonia

Answer 32

6 months

After 3 months symptoms will have resolved but fatigue may still be present

Question 33

What is the risk of death for the different scores on CURB-65?

Answer 33

0-1 low severity (<3% risk of death)
2 Moderate severity (3-15% risk of death)
3-5 high severity (>15% risk of death)