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PNEUMONIA Flashcards

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1
Q

What is pneumonia?

A

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

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2
Q

Whats the most common microorganism type to cause pneumonia?

A

Bacteria

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3
Q

How can bacteria reach the lungs to cause pneumonia?

A

Inhalation
Aspiration
Rare - Haematogenous e.g. staph aureus with IV drug users

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4
Q

Whats the most common causative pathogen of CAP?

A

Streptococcus pneumoniae (80% of cases)

Others - H.influenza, staph aureus, atypical pneumonias and viruses

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5
Q

What atypical bacteria cause CAP?

A

Chlamydia pneumoniae
Chlamydia psittaci (parrots!)
Legionella pneumophila
Mycoplasma pneumoniae
Coxiella Burnetti (Q fever)

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6
Q

What viruses cause CAP?

A

Influenza A and B
RSV
Adenovirus
Some coronaviruses

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7
Q

What are the 2 presentations of CAP?

A

Typical - classic symptoms
Atypical - insidious onset, subacute onset, pulmonary and extra pulmonary symptoms

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8
Q

What is HAP?

A

efined by NICE as a pneumonia contracted > 48 hrs after hospital admission that was not incubating at the time of admission.

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9
Q

What organisms are most likely to cause HAP?

A

Gram-negative bacilli (e.g. Pseudomonas aeruginosa)
Staphylococcus aureus
Legionella pneumophila

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10
Q

Which groups of pt are at risk of aspiration pneumonia?

A

Reduced conscious level
Neuromuscular disorders
Oesophageal conditions
Mechanical interventions such as endotracheal tubes.
Hospitalised pt on PPI

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11
Q

What organisms are most common with aspiration pneumonia?

A

Bacteria that usually reside in the oral cavity
Aerobic e.g. streptococcus pneumonia, staph aureus, H.influenza, pseudomonas aeruginosa, klebsiella (klebsiella - mostly in alcoholics)
Anaerobic - bactericides, prevotella, fusobacterium, peptostreptococcus

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12
Q

What is Mendelson’s syndrome?

A

a chemical pneumonitis caused by aspiration of acidic gastric contents

Most commonly associated with anaesthesia

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13
Q

What are likely causative organisms in immunocompromised patients?

A

Bacteria: Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella pneumoniae, Pseudomonas aeruginosa, Legionella pneumophila, and Staphylococcus aureus.

Viruses: RSV, influenza virus, CMV, HSV, VZV.

Fungi: Candida albicans, Aspergillus fumigatus, Pneumocystis jirovecii, and Cryptococcus neoformans.

Parasites: Toxoplasma gondii and Strongyloides stercoralis.

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14
Q

What type of CAP does streptococcus typically cause?

A

Lobar pneumonia

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15
Q

What is idiopathic interstitial pneumonia?

A

a group of non-infective causes of pneumonia e.g. bronchiolitis that develops as a complication of RA

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16
Q

What is atypical pneumonia?

A

pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain. They don’t respond to penicillins

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17
Q

What are the significant features of strep pneumoniae?

A

Associated with high fever, rapid onset and reactivation of herpes labialis (cold sores)
Rust coloured sputum
Frequently causes significant leukocytosis and raised CRP

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18
Q

Who is pneumonia caused by haemophilus influenza most common in?

A

Pt with COPD

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19
Q

What are the significant features of staph aureus-caused pneumonia?

A

Often occurs in patient following influenza infection

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20
Q

What are the important features of pneumonia caused by mycoplasma pneumoniae?

A

It tends to affect a younger demographic and occurs in cyclical epidemics i.e. every 4 years.

It causes an atypical pneumonia with a prolonged, insidious onset and often presents with a dry cough. It may exhibit extrapulmonary features.

Extrapulmonary features include:
Erythema multiforme (target lesions)
Autoimmune haemolytic anaemia
Arthralgia
Neurological symptoms in young patients
Myocarditis, pericarditis

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21
Q

What are the important features of pneumonia caused by legionella pneumophilia?

A

Atypical pneumonia. Chest symptoms may be preceded by several days of myalgia, headache and fever
Hyponatraemia secondary to SIADH and lymphophenia are common. Can also cause hypophosphataemia and raised serum ferritin.
Classically seen secondary to infected air conditioning units, humidifiers and showers

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22
Q

Who typically gets pneumonia caused by klebsiella pneumoniae?

A

Alcoholics

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23
Q

Which microorganism causes a pneumonia with a sputum with red-current jelly appearance?

A

Klebsiella pneumoniae

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24
Q

What are the important features of pneumonia caused by pneumocystis jiroveci?

Study These Flashcards
A

Typically seen in patients with HIV
Presents with a dry cough, exercise-induced desaturations and the absence of chest signs
Hypoxia and a raised LDH are also common findings.
It does not respond to antifungals and is instead treated with co-trimoxazole (trimethoprim-sulfamethoxazole).

25
What are symptoms of pneumonia?
Cough Sputum Dyspnoea Chest pain which may be pleuritic Fever Delirium Sepsis
26
What are signs of pneumonia?
Ssystemic - fever, tachycardia, hypotension Reduced ox sats Reduced breathe sounds and bronchial breathing, focal coarse crackles on auscultation Dullness to percussion
27
How do we determine the severity of CAP?
CRB-65
28
How do we determine the severity of HAP?
CURB65
29
Outline the CURB65 scoring scale?
C – Confusion (new disorientation in person, place or time) U – Urea > 7 R – Respiratory rate ≥ 30 B – Blood pressure < 90 systolic or ≤ 60 diastolic. 65 – Age ≥ 65
30
How do you interpret CURB65 score?
0-1 - consider home-based care- low risk (less than 5% 30 day mortality risk) 2 - consider hospital-based care - intermediate risk (less than 10% 30 day mortality risk) 3 or more - consider intensive care assessment - high risk (4 points 40% mortality risk)
31
What is the most common cause of pneumonia in cystic fibrosis?
Pseudomonas aeruginosa
32
What can you treat atypical pneumonia with?
Macrolides - first line Fluoroquinolone Tetracyclines
33
Pt recently went on a cheap hotel holiday and returned with cough, SOB and hyponatraemia. Whats the causative organism?
Legionella pneumophila (they may have legionnaires disease)
34
What is Q fever?
Bacterial infection caused by coxiella burnetii. Zoonotic disease - cattle, sheep, goats most common Can cause mild flu-like symptoms or pneumonia, hepatitis and endocarditis Vaccines are available for high risk people e.g. those who work in the livestock industry
35
What is psittacosis?
A respiratory tract infection caused by chlamydia psittaci Usually spread through contact with infected birds and their droppings (parrots, cockatiels, budgerigars) Symptoms are fever, chills, headache, muscle aches, cough, SOB and in severe cases, pneumonia
36
What are some of the main differences between the presentations of the different types of microorganisms that cause pneumonia?
Bacterial - develops quickly causes high fever, cough with sputum, SOB and chest pain. It can lead to sepsis Viral - develops more slowly than bacterial and causes milder symptoms e.g. dry cough, fever, fatigue. In severe cases it can cause acute respiratory distress syndrome Fungal - develops slowly with fever, night sweats, dry cough and SOB. More common in immunocompromised Parasitic - fever, cough, SOB and more common in people who travel to regions with high rates of parasitic infections
37
How are pt with low CD4 counts protected against pneumocystis jiroveci?
Prophylactic oral co-trimoxazole
38
How do you investigate pneumonia?
Bedside - obs, sputum sample for culture, urinary sample (pneumococcal and legionella urinary antigen test), ECG Bloods - FBC, U&E, CRP, blood culture Imaging - CXR,
39
How do you interpret CRB65 score?
0: low risk (less than 1% mortality risk) NICE recommend that treatment at home should be considered (alongside clinical judgement) 1 or 2: intermediate risk (1-10% mortality risk) NICE recommend that ' hospital assessment should be considered (particularly for people with a score of 2)' 3 or 4: high risk (more than 10% mortality risk) NICE recommend urgent admission to hospital
40
What are CXR findings for pneumonia?
Consiolidation (initially may be patchy but becomes confluent as infection develops) Air bronchograms May also show complications e.g. parapneumonic effusion, pleural collections, abscess or cavitation
41
How do you manage CAP in the community?
Low severity - amoxicillin 5 days Moderate severity - dual antibiotic therapy with amoxicillin and a macrolide for 7-10 days ( High severity - beta-lactamase stable penicillin (e.g. co-amoxiclav) + macrolide for 7-10 days
42
Outline the typical speed of improvement in CAP?
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 might still be present. 6 months — symptoms should have fully resolved
43
How should you follow up a pt with CAP in primary care?
Reassess people with community-acquired pneumonia if symptoms and signs do not improve as expected or worsen rapidly or significantly. Review choice of antibiotics according to microbiological testing results Arrange a CXR after 6 weeks if symptoms/signs persist or if at higher risk of underlying maliganncy Advise smoking cessation Consider whether pneumococcal or influenza immunization is necessary after the person has recovered from the acute illness
44
How should you manage pneumonia in hopsital?
Oxygen if needed IV fluids Analgesia High severity CAP - IV beta-lactamase stable beta-lactam e.g. co-amoxiclav and a macrolide HAP - mild - co-amoxiclav 625mg orally TDS HAP - severe - Tazocin 4.5g IV TDS
45
What are complications of pneumonia?
Sepsis Pleural effusion Empyema Lung abscess Death
46
Who should have a follow up CXR following pneumonia and when?
6-8 weeks post-event Anyone over 50 yo check for underlying lung cancers and to check consolidation has resolved (11% of smokers over 50 who have pneumonia have lung cancer)
47
What factors suggest you should delay discharge for a pt with pneumonia?
temperature >37.5°C RR 24 BPM or more HR >100 bpm systolic bp 90 mmHg or less ox sats <90% on room air abnormal mental status inability to eat without assistance.
48
What are the stages of lobar pneumonia?
Congestion - 1-2 days - blood vessels and alveoli start filling with excess fluid Red hepatization - 3-4 days - exudate, neutrophils and fibrin start filling airspaces and makes them more solid Grey hepatization - 5-7 days - lungs still firm but colour has changed as RBCs in exudate start breaking down Resolution - day 8 and continues for 3 weeks - the exudate gets digested by enzymes, ingested by macrophages, or coughed up.
49
What are the types of pneumonia?
Lobar pneumonia Bronchial pneumonia Interstitial pneumonia
50
What is lobar pneumonia?
pneumonia affecting one lobe of a lung Multilobar pneumonia refers to the involvement of multiple lobes in a single lung or both lungs. Panlobar pneumonia involves all the lobes of a single lung.
51
What is bronchial pneumonia?
pneumonia affecting the tissue around the bronchi and/or bronchioles Aka lobular pneumonia
52
What is interstitial pneumonia?
pneumonia affecting the tissue between the alveoli
53
How do you diagnose mycoplasma pneumoniae?
Serology
54
How do you diagnose legionella pneumophila?
Urinary antigen test
55
What can predispose you to staphylococcus aureus pneumonia?
Preceding influenza infection
56
Which sites of the lungs is aspiration pneumonia most likely to occur and why?
Right middle and lower lung lobes - larger calibre and more vertical orintetaion of the right main bronchus
57
Who should receive prophylaxis for pneumocystis jiroveci?
Patients with CD4 counts <200
58
Whats a common complication of pneumocystis jiroveci?
Pneumothorax

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