Infections - comm acq pneumonia - PD

Question 1

Inf markers - systemic?

Answer 1

Fever
Rigor
Chills
Myalgia
Malaise
Headache
Anorexia
Delirium

Question 2

Inf markers - local/peripheral

Answer 2

Erythema
Pain
Heat
Swelling
Pus

Question 3

Inf markers - vital signs

Answer 3

change in body temp
Tachycardia
Hypotension
Tachypnoea

Question 4

Inf markers - Haematology

Answer 4

Increase WBC count
Change to neutrophils (generally increase but low in neutropenic sepsis)
Increased platelets

Question 5

Inf markers - Biochemistry

Answer 5

• Increased C reactive protein
• Increased erythrocyte sedimentation rate
• Increased serum creatinine
• Increased liver function test
• Change to procalcitonin level

Question 6

inf markers - Microbiology tests

Answer 6

Presence of organism
Microscopy
Culture
Serology
Polymerase chain reaction

Question 7

inf markers - Urinalysis

Answer 7

Presence of leucocyte esterase
Presence of nitrates

Question 8

examples of respiratory infections

Answer 8

• Covid 19
• Infective exacerbation of COPD
• Tuberculosis (TB)
• Bronchiectasis
• Empyema
• Acute bronchitis
• Influenza
• Pleurisy
• Pneumonia (community acquired)

Question 9

What is pneumonia?

Answer 9

• ‘Inflammation of the lungs caused by a bacterial or viral infection, in which the air sacs fill with pus and can become solid’
  children under 5 and adults over 70 - highest mortality

Question 10

both lungs definition and single lung?

Answer 10

bilateral pneumonia
unilateral pneumonia

Question 11

3 categories

Answer 11

• CAP
• HAP (hospital)
• Aspiration pneumonia

Question 12

CAP - symptoms?

Answer 12

• Overgrowth of pathogenic bacteria in upper resp tract – leading to infection
• Bacteria responsible depends on local epidemiology
• Severity depends:
  Invading organism and response antimicrobial treatment
  Patients underlying co-morbidities
  Presence of risk factors

Question 13

CAP Risk factors

Answer 13

• Age >65
• PMHx of COPD
• Cigarette smoke
• Care homes
• Alcohol abuse
• Use of acid-reducing drugs – stomach acid decrease allows pathogens to colonise upper resp tract more easily (GIS ISU)

Question 14

Diagnosis and assessment?

Answer 14

• Thorough history from patient – including HxPC
• Blood tests (CRP+, WCC +)
• Patient observations
  1. BP
  2. HR
  3. Resp rate
  4. Temp
  5. O2 sat
• Chest X-ray – shows new signs of consolidation
  1. Within 4 hours of presentation
  2. Within 1 hour if suspecting sepsis

Question 15

Differential Diagnosis?

Answer 15

• Covid 19 associate CAP – treatment differ
• Acute bronchitis
• Infective exacerbation of COPD
• Tuberculosis
• Empyema
• Lung cancer
• Pulm Emb

Question 16

Treatment?

Answer 16

• Severity of patients condition can be calculated on scoring system but clin judgement also advised
• Patient gets 1 point if they have any of the following parameters

Question 17

CURB - 65 - hospital
CRB – 65 (primary care). (prediction of >18 years pneumonia mortality risk)

Answer 17

C – Confusion
U – Urea > 7.0mmol/L
R – Resp rate >30 / min
B – Blood pressure
1. Low systolic <90 mmHg
2. Low diastolic <60 mmHg
65 – Age > 65 years
CRB – 65 scoring
- 0 – low severity - <1% mortality
- 1-2 – Intermediate – 1-10% mortality
- 3-4 – High - >10% mortality
CURB – 65 scoring
- 0-1 – low severity - <3% mortality
- 2 – Intermediate – 3-15% mortality
- >3 – High - >15% mortality

Question 18

use of CRB - 65

Answer 18

• Use to help guide mortality risk, place of care and antibiotics.

Question 19

Confusion?

Answer 19

(abbreviated mental test score <8 – age, time, address for recall at end of test. Year, place, identification of 2 persons, DOB, year of WW1, present monarch, count backwards 20-1)

Question 20

Score 3-4?

Answer 20

urgent hopsital admission
- Clinically assess need for dual therapy to cover atypical infections if high CRB65 score. However, mycoplasma infection is rare in over 65s.
- Give safety net advice and likely duration of different symptoms, such as cough 6 weeks
- If recent influenza infection, consider need for anti-staphylococcal cover e.g doxycycline monotherapy or addition of flucloxacillin to standard treatment
- If failure of first-line agents, patients should be reassessed for on-going signs of infections before further treatment is prescribed
- British HIV association recommend testing for HIV in adult patients presenting with CAP

Question 21

If CRB is 0?

Answer 21

Treat at home
First line –
- Amoxicillin
- 500mg TDS
Second line (failure 1st line treatment/penicillin allergy/atypical pathogen suspected)
- Doxycycline
- 200mg stat then 100mg OD
- Clarithromycin
- 500mg BD
Third line (prev treatment failure)
- Co – trimoxazole
- 960mg BD
Treatment duration for all is 5 days. Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course length is needed or the person is not clinically stable.

Question 22

Amoxicillin?

Answer 22

Class: Penicillin
Side effects:
- Common
- GI issues: n+v, diarrhoea, abdominal pain
- Rash
- Yeast infections: oral thrush, vaginal candidiasis

• Uncommon (but severe)
• Anaphylaxis: severe allergic reaction
• Liver enzyme abnormalities
• Severe diarrhoea
  Contraindication:
• Allergy to penicillin or cephalosporins
• History of severe allergic reactions
• Mononucleosis – risk of skin rash
  Cautions
• Renal impairment
• Pregnancy – gen safe
• Breastfeeding – gen sfe – caution advised
• GI diseases – caution with history like colitis, antiobiotics can exacerbate issues
• Mononucleosis – more prone to developing rash

Question 23

Doxycycline

Answer 23

Class: Tetracycline antibiotic
Side effects:
- Common
- GI: n+v, diar, abdominal discomfort
- Photosensitivity
- Oesophageal irritation- can cause irritation or ulceration in the oesophagus if not taken with enough water
- Skin rash
- Dizziness or vertigo

• Less common
• Anaphylaxis
• Liver toxicity
• Tooth discolouration
• Intracranial hypertension
• Superinfection
  Contraindications
• Pregnancy (esp 2nd and 3rd trimester): c/I due to potential to cause harm to foetus. Category D
• Children under 8
• Hypersensitivity to tetracyclines – if allergic reaction to similar don’t use
• Severe liver disease
  Cautions
• Renal impairment
• Pregnancy
• Breastfeeding
• Photosensitivty
• GI conditions
• Superinfection risk

Question 24

Clarithromycin?

Answer 24

Class: Macrolide antibiotic
Side effects:
- Common
- GI issues + dyspepsia
- Taste disturbances
- Headache
- Rash

• Uncommon
• Hepatoxicity
• QT interval prolongation
• Severe allergic reaction
• Clostridium difficile-ass diarrhoea – disrupt normal gut flora
• Pancreatitis
  Contraindications
• Hypersensitivity to macrolides
• Severe hepatic impairment
• Concurrent use with certain meds – (ergotamine, pimozide, fentanyl, terfenadine)
  Cautions
• Renal impairment
• Liver disease
• Pregnancy – category C
• Breastfeeding – gen sfe – caution advised
• Cardiac arrythmias – monitor closely
• Drug interaction – CYP3A4 inhibitor and can increased plasma conc of certain drugs (statins, benzos, CCBs)

Question 25

Cotrimoxazole?

Answer 25

Class: Combination antibiotic Side effects: - Common - GI - Rash - Headache - Fatigue - Less common but severe - Hypersensitivity reactions (Stevens-Johnson syndrome) - Haematological reactions: leukopenia, thrombocytopenia, and agranulocytosis, aplastic anaemia - Liver toxicity - Renal impairment - Hyperkalaemia - Pneumonitis - Blood dyscrasias Contraindications: - Hypersensitivity to sulfonamides or trimethoprim – contra ind in severe allergic reactions (anaphylaxis or S-J syndrome) - Severe renal or hepatic impairment - Folate deficiency - Pregnancy (esp in the first trimester) – foetal harm - Breastfeeding – gen not recommended esp in infants under 2 months - Infants under 2 months of age – due to risk of kernicterus Cautions - Renal impairment - Liver disease - Elderly - Glucose 6 phosphate dehydrogenase - Pregnancy (2nd and 3rd) - Alcohol consumption - Drug interactions (warfarin, methotrexate, phenytoin) Indications - UTI - Resp tract infections – pneumonia - GI infections - Ear - Skin - Prophylaxis

Question 26

CRB – 65 score – 1 and at home?

Answer 26

First line – - Amoxicillin - 500mg TDS - PLUS - Clarithromycin - 500mg BD Second line (failure 1st line treatment/penicillin allergy/atypical pathogen suspected) - Doxycycline - 200mg stat then 100mg OD Third line (prev treatment failure) - Co – trimoxazole - 960mg BD Treatment duration for all is 5 days. Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course length is needed or the person is not clinically stable.

Question 27

CURB-65 score ? >3

Answer 27

- Non-pen allergic - Co-amoxiclav - PO – 625mg TDS (5 days) - IV – 1.2g TDS (5 days) - Clarithromycin - PO/IV – 500mg BD - Pen allergic - Levofloxacin - PO/IV – 500mg BD (all 5 days treatment)

Question 28

Co-amoxiclav?

Answer 28

Class: Penicillin Side effects: - As per amoxicillin - Hepatic disorders Contra indications - Hx of jaundice due to co-amoxiclav administration Monitoring - Liver function Notes - Allergy potential Unlikely you will see co-amox for CAP in hospital setting, unless advised by microbiology consultant or for very specific indications Why? - High risk of clostridium difficile – infective diarrhoea often associated with the excess use of broad spectrum antibiotics - High resistance rates beginning to develop

Question 29

Within SBUHB and HDUHB – 1st line for CAP, CURB-3 -

Answer 29

Amoxacillin 1g TDS plus - Clarithromycin (PO/IV) 500mg BD

Question 30

Levofloxacin?

Answer 30

Class: Quinolone Side effects: - GI upset - QT prolongation - Affect glucose control - Photosensitivity reactions - Eye disorders - Headache - Convulsions - Tendon damage - Serious musclo-skeletal and nervous system disorders Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate Levofloxacin – MHRA warnings 1. Can induce cnvulsions 2. Tendon damage - C/I in patients with Hx of quinolone induced tendon damage - Patients >60 at an increased risk - Risk increased when used with corticosteroids - Stop immediately is tendonitis suspected 3. Increased Risk of aortic aneurysm/dissection 4. Increased risk of disabling, long lasting or irreversible adverse reactions affecting the musclo-skeletal and nervous system - Patients should be provided with MHRA advice sheet outlining s/e to lookout for Levofloxacin Cautions - Patients with QT prolongation risk factors - Use in children - Patients >60 - +s/e risk - Disorders that pre-dispose patient to seizures: (epilepsy, alcohol dependence) - Contra-indications – Hx of quinolone induced tendon damage - Counselling: provide MHRA advice leaflet, look out for signs - Monitoring: signs of s/e – discuss with the patient, renal function

Question 31

Summary

Answer 31

0-1 (low severity) Non-pen allergic Amoxicillin (PO) – 500mg TDS Pen allergic Doxycycline (PO) – 200mg STAT, 100mg OD OR Clarithromycin (PO) – 500mg BD 2 (moderate severity) Non-pen allergic Amoxicillin (PO) - 500mg – 1000mg TDS PLUS Clarithromycin (PO) – 500mg BD Pen allergic Doxycycline (PO) – 200mg STAT, 100mg OD OR Clarithromycin (PO) – 500mg BD >3 (highest severity) Non-pen allergic Co-amoxiclav (IV) – 1.2g TDS PLUS Clarithromycin (PO/IV) – 500mg BD Pen allergic: Levofloxacin (PO/IV) – 500mg BD

Question 32

Counselling

Answer 32

- Patient expectation in terms of symptom resolution should be addressed - Symptoms resolution timeline - 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