Pneumonia

Question 1

What is pneumonia ?

Answer 1

Inflammation of the lung parenchyma with the normal air-filled lungs becoming filled with infective liquid (known as consolidation)

Question 2

What is CAP ?

Answer 2

community-acquired pneumonia: caught outside of hospital

Question 3

When is a diagnosis of HAP made?

Answer 3

a pneumoniacontracted > 48 hrs after hospital admission that was not incubating at the time of admission.

Question 4

What is Ventilated acquired pneumonia ?

Answer 4

48 hours post intubation

Question 5

Aspiration pneumonia what is it?

Answer 5

caused by theinhalation of oropharyngeal or gastric contents
This brings bacteria found in these environments into the lungs

Question 6

Aspiration pneumonia- in what patients is it seen ?

Answer 6

associated with patients who are unable to adequately protect their airway, it may be seen in patients with:

• Reduced conscious level
• Neuromuscular disorders
• Oesophageal conditions
• Mechanical interventions such as endotracheal tubes.
• neurological dysphagias- stroke, epilepsy, alcoholics, drowning
• At risk- nursing home residents and drug overdose

Question 7

Typical CAP organisms

Answer 7

Streptococcus pneumoniae (most common)
Haemophilus influenzae
Moraxella catarrahalis

Less:
Staphylococcus aureus and MRSA
Pseudomonas aeruginosa
Klebsiella pneumonia
Group A strep pyogenes
anaerobes

Question 8

Haemophilus influenzae- common in ….

Answer 8

COPD patients

Question 9

Moraxella catarrahalis seen in ……

Answer 9

immunocompromised patients or those with chronic pulmonary disease

Question 10

Pseudomonas aeruginosa in patients with …..

Answer 10

cystic fibrosis or bronchiectasis

Question 11

Klebsiella pneumonia seen in …

Answer 11

alcoholics

Question 12

Atypical organisms causing CAP

Answer 12

• Legionella pneumophilia
• Mycoplasma pneumoniae
  -Chlamydia pneumoniae
• Coxiella burnetii (Q fever)
• Psittacosis- chlamidophila psittaci

Question 13

What does atypical organism mean?

Answer 13

organism that cannot becultured in the normal way or detected using agram stain must use serology to identify
They don’t respond to penicillins and can be treated withmacrolides (e.g. clarithomycin),fluoroquinolones
(e.g. levofloxacin) ortetracyclines (e.g. doxycycline)

Question 14

Mycoplasma pneumoniae: signs ?

Answer 14

• Dry cough
• Atypical chest signs/x-ray
• Erythema multiforme seen-> varying sized “target lesions” formed bypink rings withpale centres
• neurological symptoms in young patient in the exams.

Question 15

Legionella pneumophilia: typical history, where caught from?

Answer 15

water sources, travel, infected air conditioning units

Question 16

Legionella pneumophilia: what can it present with? (think electrolyte imbalance, WBC)

Answer 16

Commonly present with:
Hyponatraemia
SIADH
lymphopenia

Question 17

HAP common organisms

Answer 17

• Staphylococcus aureus or MRSA
• Gram negative bacili
  
  • Pseudomonas aeruginosa
  • Escherichia coli
  • Klebsiella pneumoniae
• Strep pneumoniae

Question 18

What are viral causes of pneumonia?

Answer 18

• Cytomegalovirus- in immunocompromised eg. bone marrow recipients
• Influenza
• Adenovirus
• RSV (Respiratory syncytial virus)
• Rhinovirus

Question 19

What are fungal causes of pneumonia?

Answer 19

Pneumocystis jiroveci (PCP)- HIV patients
Aspergillus spp- in prolonged neutropenia

Question 20

Idiopathic interstitial pneumonia caused by

Answer 20

non infective causes-
cryptogenic organizing pneumonia
complication of rheumatoid arthritis or amiodarone therapy

Question 21

Aspiration pneumonia organisms

Answer 21

Mixed infections- Viridans streptococcus and anaerobes

Question 22

Differentials of cough

Answer 22

Heart failure w/ pul oedema
PE
Lung cancer
Acute exacerbation of bronchiectasis
Interstitial lung disease
URTI
Pneumothorax
TB

Question 23

Differentials of consolidation on CXR

Answer 23

• Pneumonia
• TB
• Lung cancer
• Lobar collapse
• Haemorrhage

Question 24

What would help differentiate TB from CAP

Answer 24

• Subacute presentation
• Night sweats, loss of appetite and weight loss, fatigue
• Born in country with high incidence TB- non-uk born
• HIV, immunocompromised, drug use, homelessness

Question 25

Symptoms ?

Answer 25

- cough- productive- green/yellow sputum - Dyspnoea - Fever -Malaise - Haemoptysis - Pleuritic chest pain - Delirium - sepsis

Question 26

Signs of pneumonia

Answer 26

- Fever - Tachycardia - Tachypneoa - reduced oxygen sats - Hypotension (shock) - Confusion - Cyanosis Chest signs - Reduced breath sounds - Bronchial breath sounds - Focal coarse crackles (bibasal) - Dullness to percussion - Increased vocal fremitus

Question 27

Most important Investigations for pneumonia? if febrile? if high curb-65? low O2 stats?

Answer 27

- CXR - FBC, U&Es, CRP - Sputum culture - Consider blood cultures if febrile - If high CURB-65 score need Atypical pneumonia screen – serology and urine legionella test - ABG if low sats

Question 28

CURB-65 stand for

Answer 28

C- confusion U- urea >7mmol/l R- Resp rate >= 30 B- BP Sys <90 or dia <60 65- >65 yrs old

Question 29

What do you do if CURB-65 =0

Answer 29

Low risk NICE recommend that treatment at home should be considered (alongside clinical judgement)

Question 30

What do you do if CURB-65 = 1 or 2

Answer 30

intermediate risk NICE recommend that hospital assessment should be considered

Question 31

What do you do if CURB-65 = 3 or 4

Answer 31

high risk NICE recommend urgent admission to hospital

Question 32

What do you do if CURB-65 = 4 or 5

Answer 32

(>15% mortality) should be managed in HDU or ITU Non-invasive ventilatory support should always be offered here

Question 33

CRP can guide antibiotic management. What are the parameters?

Answer 33

- 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 (usually over 100 in pneumonia)

Question 34

Management of pneumonia

Answer 34

A-E- Check for indications of sepsis Oxygen titrated to saturations IV fluids Appropriate analgesia- Paracetamol/ NSAIDs Antibiotics

Question 35

Low severity: Mild CAP- antibiotics ?

Answer 35

-Amoxicillin - Tetracycline (doxycycline) or macrolide (clarithromycin) if penicillin allergic 5-7 days

Question 36

Intermediate severity: Moderate CAP antibiotics ?

Answer 36

Dual therapy with a beta-lactam (e.g. amoxicillin) and a macrolide (e.g. clarithromycin) - Tetracycline (doxycycline) if penicillin allergic 7-10 days

Question 37

High severity: Severe CAP antibiotics ?

Answer 37

IV beta-lactamase stable beta-lactam (e.g co-amoxiclav) and a macrolide (e.g. clarithromycin) - Tetracycline (doxycycline) if penicillin allergic - 7-10 days may be extended to 14 or 21 days depending on clinical circumstance

Question 38

HAP antibiotic treatment ?

Answer 38

- Should follow local guidelines based upon local microbial knowledge. First line - Co-amoxiclav Second line- Severe -Tazocin (piperacillin/tazobactam) or meropenem

Question 39

If MRSA risk- which antibiotics?

Answer 39

Vancomycin and Linezolid

Question 40

PCP- which antibiotics?

Answer 40

trimethoprim/sulfamethoxazole known as co-trimoxazole

Question 41

Flu then has pneumonia, already had abx but still deteriorating - give ...

Answer 41

co-amoxiclav

Question 42

Follow up arrangements for pneumonia

Answer 42

Follow up in clinic in 6 weeks with a repeat CXR to ensure resolution - HIV test - Immunoglobulins - Pneumococcal IgG serotypes - haemophilus influenzae b IgG

Question 43

Non-resolving pneumonia causes

Answer 43

CHAOS mnemonic - Complication- empyema, abscess - Host- immunocompromised - Antibiotic- inadequate dose, poor oral absorption - Organism- resistant or unexpected organism not covered by empirical antibiotics - Second diagnosis- PE, Cancer, organising pneumonia