Pneumonia Flashcards by Apiraa J

Define Lower Respiratory Tract Infection / Pneumonia?

Refers to an infection causing inflammation of the alveoli and terminal bronchioles.

Leads to consolidation of bronchopulmonary segment or lobe.

This means that tissue is filled with inflammatory cells and oedema.

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Key signs to look out for in Lower Respiratory Tract Infection / Pneumonia?

Rapid onset of:
- high fever
- productive cough

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Risk factors for pneumonia?

Infants and elderly
Smoking
Alcohol excess
Recent viral infections
Bronchial obstruction: COPD
Bronchiectasis
Immunosuppression: AIDS, chemotherapy
Hospitalisation
Underlying predisposing disease: Diabetes, CVD

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Most common/common/uncommon causes of pneumonia?

Most common:
- strep pneumonia

Common:
- staph aureus
- mycoplasma pneumoniae
- haemophilus influenzae

Uncommon:
- klebsiella pneumonia
- strep pyogenes
- pseudomonas, aeruginosa
- Coxiella burnetti
- Chlamydia psittaci
- Actinomyces Israeli

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How is pneumonia classified?

Community acquired
Hospital acquired (nosocomial)
Pneumonia in immunocompromised individuals

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Presentation of pneumonia?

Fever
Malaise
Rigors
Cough
Purulent sputum
Pleuritic chest pain
Haemoptysis

Tachypnoea
Tachycardia
Hypotension
Cyanosis
Pyrexia
Dull percussion
Increased vocal resonance/ tactile vocal fremitus
Pleural rub

Bronchial breathing - this is a higher pitch and inspiration and expiration are equal. There is an audible pause between inspiration and expiration.

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How are bacterial causes of community acquired pneumonia (CAP) classified?

Typical
- classical rapid onset of symptoms, including high fever and productive cough.

Atypical
- more gradual onset of symptoms, which may be non-specific initially (fever, myalgia, dry cough).

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Typical bacterial causes for community acquired pneumonia (CAP)?

Streptococcus pneumoniae (gram +ve cocci found in pairs)

Staphylococcus aureus

Haemophilus influenzae (gram -ve rod, potent beta-lactamase producer)

Moraxella catarrhalis (gram -coccus, potent beta-lactamase producer)

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Atypical bacterial causes for community acquired pneumonia (CAP)?

Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella pneumophila
Coxiella burnettii
Chlamydia psittaci

Not detectable on gram stain.

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Who does atypical pneumonia commonly affect? Treatment for atypical pneumonia?

Atypical bacteria commonly affects healthier people.

Macrolides or doxycycline

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Viral causes for community acquired pneumonia (CAP)?

Influenza A
HSV
CMV
VZV

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Fungal causes for community acquired pneumonia (CAP)?

Candida - dimorphic yeast
Aspergillus - fungus with hyphae
Cryptococcus - encapsulated yeast

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Causes in COPD and community acquired pneumonia (CAP)?

Pneumococcus -MOST COMMON
Haemophilus influenzae
Morexella catarrhalis

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Causes in cystic fibrosis and community acquired pneumonia (CAP)?

Staph aureus
Pseudomonas aeruginosa
Burkholderia cepacia

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Causes in homeless/malnourished/alcohol or drug dependent/immunosuppressed patients with community acquired pneumonia (CAP)?

Mycobacterium tuberculosis

Aspiration pneumonia (consider in pt with an UNSAFE SWALLOW or DEPRESSED CONSCIOUSNESS)

Klebsiella pneumoniae (RED CURRENT JELLY sputum, causes lung abscess and empyema)

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Investigations for community acquired pneumonia (CAP)?

Bloods:
- FBC
- U&Es
- CRP
- LFTs
- WCC

Blood cultures
Sputum culture
ABG

PCR for mycoplasma pneumonia

Urinary antigen tests for Legionella and pneumococcus

CXR (identify lobar, multi-lobar, cavitation and signs of pleural effusion)

Pleural fluid aspiration (if pt has pleural effusion)

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Complications of Lower Respiratory Tract Infection / Pneumonia?

Pleural effusion
Empyema (suspect if persistent, swinging fever with leucocytosis found after abx therapy)
Abscess (can be caused by S. pneumoniae, Klebsiella, staph aureus; can develop pyopneumothorax)
Pneumothorax
Septicemia
AF
Post-infective bronchiectasis

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How does strep pneumonia/pneumococcal pneumonia present? Transmission? Affects which age groups? Treatment?

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Homogeneous consolidation on one or more lobes or segments.
Gram-positive paired cocci, lancet shaped, many polymorphonuclear.

Affects all ages, especially early and middle adult life.

Transmit via droplet spread.

Acute illness -cough, purulent sputum, fever, aches and pains, vomiting, anorexia, pleuritic chest pain, dyspnoea.

Penicillin or cephalosporin

Complications of strep pneumonia/pneumococcal pneumonia?

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Organisation of exudate
Pleural effusion
Lung abscess
Bacteraemia may result in
endocarditis, meningitis, arthritis,
otitis media

What is hospital acquired pneumonia (HAP)?

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Lower respiratory tract infection that develops more than 48 hours after admission to hospital.

Not present at time of admission.

Risk factors for hospital acquired pneumonia (HAP)?

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Poor hand hygiene and hospital infection control
Intubation and ventilation

Causes of hospital acquired pneumonia (HAP)?

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Pseudomonas aeruginosa
Staphylococcal aureus
Enterobacteriaceae (especially Klebsiella, E.coli and Enterobacter spp)

What does pseudomonas pneumonia cause? Diagnosis? Treatment?

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Causes:
- hospital acquired pneumonia (ITU, post surgery)
- cystic fibrosis
- bronchiectasis

Sputum culture

Tx:
- antipseudomonal penicillin (e.g. ticarcillin, piperacillin)
- ceftazadime
- meropenem
- ciprofloxacin

Treatment for hospital acquired pneumonia (HAP)?

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HAP within 5 days of admission
- Offer co-amoxicillin or cephalosporin (e.g. cefuroxime)

HAP >5 days of admission
- Offer tazocin or cephalosporin (e.g. ceftazidime) or quinolone

What is aspiration pneumonia?

Refers to a type of pneumonia caused by bacteria entering the lungs when we accidentally breathe in (inhale) food, fluid or saliva. This leads to severe infection. Food/fluid goes down the trachea instead of the oesophagus.

Risk factors for aspiration pneumonia?

Stroke Myasthenia gravis Bulbar palsy Alcoholism Achalasia

CXR findings in aspiration pneumonia?

Right lung is most commonly affected because RIGHT BRONCHUS is wider and more vertical than the left bronchus, hence more likely to facilitate the passage of aspirate.

In which pts is Staphylococcal pneumonia found in? Microscopy finding? Management?

IV drug users Elderly pts Influenza infection Gram-positive cocci found in clusters. Tx: flucloaxcillin, erythromycin

In which pts is Klebsiella pneumonia found in? Microscopy finding? Distinguishing factors?

Primarily affects upper lobes. Red currant sputum Gram-negative anaerobic rod. Weak immune system pts - e.g. diabetic, elderly, alcoholic, malignancy, COPD, long-term steroid use, renal failure.

What occurs in Klebsiella pneumonia more than others? What is it often associated with? Management?

Haemoptysis Alcoholism Diabetes COPD Elderly Cefuroxime

In which pts is Mycoplasma pneumonia found in? How does it present? Distinguishing factors?

Primarily affects younger pts -children and adults. Presents with flu-like symptoms. Auto-immune manifestation due to cold agglutinins causing an autoimmune haemolytic anaemia.

CXR findings and treatment for mycoplasma pneumonia?

CXR: - Homogeneous dense lobar consolidation - Patchy consolidation - Nodular opacity - Bilateral parahilar infiltration Tx: Erythromycin/clarithromycin, tetracycline

Complications of mycoplasma pneumonia?

- myocarditis - meningo-encephalitis - maculopapular rash - haemolytic anaemia

In which pts is Legionella pneumonia found in? What do blood tests show -distinguishing factors?

Pts exposed to poor air conditioning. Pts who were previously healthy. Blood tests: - hyponatraemia - deranged LFTs Legionella antigen present in urine.

Treatment for Legionella pneumonia? Mortality?

Erythromycin 14-21days, oxygen, IVx abx and fluid -depending how severely unwell Rifampicin BD oral or IV in pts not yet confirmed diagnosis. Mortality is 15%. Some pts may die despite abx due to respiratory failure.

How does Chlamydia pneumonia transmit and present?

Transmit via droplet spread, coughing, sneezing. Biphasic illness (starts viral then becomes pneumonia). Pharyngitis, hoarseness, otitis media followed by pneumonia. Additional features include: - hepatitis - splenomegaly - nephritis - infective endocarditis - meningoencephalitis - rash

Diagnosis and treatment of Chlamydia pneumonia?

Diagnosis: - Chlamydial PCR in nasopharyngeal swabs/aspirate, sputum or pleural fluid Treatment: - tetracycline/ macrolide/ fluoroquinolones - Azithromycin -1st line

Prevention of pneumonia?

Pneumococcal vaccine - routinely offered as three injections at the age of 2months, 4months, and 12-13months. Some patients within the at-risk group require a vaccination every 5 years. At-risk groups include chronic heart, liver or renal conditions, immunosuppressed, age 65 and above.

What is CURB65 score?

Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment. Score out of 5. Confusion (yes/no) Urea (>7mmol/l) RR (≥30/min) BP (SBP<90 DBP ≤60) Age ≥65 years * 0: low risk (<1% mortality risk) →outpatient tx * 1-2: intermediate →hospital admission (esp if score of 2) * 3-5: high (>15% mortality risk) →urgent admission

What causes pneumonia in the immunocompromised?

A fungal infection caused by Pneumocystis Jiroveci.

How does Pneumocystis Jiroveci present?

Dry cough Exertional dyspnoea & desaturation Fever Bilateral crepitations End-inspiratory crackles may be present

Diagnosis/IVx for Pneumocystis Jiroveci?

CXR: - normal OR bilateral bihilar interstitial infiltrates CT: - look for cysts and nodules Bronchoscopy with bronchoalveolar lavage -DIAGNOSTIC Sputum samples -less specific Grocott's silver stain -"Mexican hat" appearance. ABG -assess severity of disease -partial pressure of oxygen.

Management of Pneumocystis Jiroveci?

High dose co-trimoxazole (1ST LINE) Clindamycin-primaquine, dapsone, or IV pentamidine may be used (2ND LINE) Steroid -if hypoxaemia; REDUCES MORTALITY AND RISK OF RESP FAILURE Prophylaxis -if CD4 count <200 x 10^6L or after the 1st attack.

Pneumonia Flashcards

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