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1st Year Medicine > Pneumonia. > Flashcards

Pneumonia. Flashcards

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1
Q

What are the most common causative organisms of CAP in order of highest to lowest?

A 
Streptococcus pneumoniae 70%
Atypicals/viruses
Haemophilus influenza
Staphylococcus aureus.
Other bacteria.
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2
Q

What is streptococcus pneumoniae?

A

Gram positive cocci in pairs or short chains.
It is alpha haemolytic on culture.
Has a draughtsman appearance.

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3
Q

What is the treatment for streptococcus pneumoniae?

A

Penicillin sensitive e.g. Amoxicillin.

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4
Q

What antibiotic can we use for staph aureus?

A

Coamoxiclav but not amoxicillin.

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5
Q

What are some predisposing factors to nosocomial pneumonia?

A

Intubation, ICU, antibiotics, surgery and immunosuppression.

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6
Q

What organisms most commonly cause nosocomial pneumonia?

A

60% are gram negative organisms.

Includes: pseudomonas aeriginosa and coliforms such as E.coli and Klebsiella sp.

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7
Q

When do we admit people with pneumonia to the hospital?

A

Signs of sepsis, low sats or respiratory failure.

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8
Q

What does pneumonia mean?

A

Disease of the lungs.

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9
Q

What is the pathophysiology of pneumonia?

A

Infection involving the distal airspaces usually with inflammatory exudation. Fluid filled spaces lead to consolidation.

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10
Q

Are the lungs sterile under normal circumstances?

A

No they contain commensal bacteria.

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11
Q

How do we classify pneumonia?

A

By clinical setting, by organism and by morphology.

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12
Q

What viruses can commonly cause pneumonia?

A

Influenza, parainfluenza, measles, varicella-zoster, respiratory syncytial virus (RSV).

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13
Q

Who does CAP classically affect?

A

Otherwise healthy young adults in close proximity e.g. Barracks or dormitories.

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14
Q

What 4 general patterns does CAP manifest as?

A

Lobar, bronchopneumonia, interstitial pneumonia and miliary pneumonia.

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15
Q

What is lobar pneumonia and what normally causes it?

A

Confluent consolidation involving a complete lung lobe.
Usually caused by streptococcus pneumoniae (pneumococcus)

Can be other organisms e.g. Klebsiella and legionella.

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16
Q

What is the pathology of pneumonia?

A

Classic acute inflammatory response with exudate and immune system involvement.

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17
Q

What does the classical inflammatory response cause in pneumonia?
E.g. Exudate contents.

A

Exudation of fibrin rich fluid
Neutrophil infiltration
Macrophage infiltration
Resolution.

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18
Q

What are the complications of pneumonia?

A

Organisation with fibrous scarring.
Abcess.
Bronchiectasis
Empyema.

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19
Q

What is bronchopneumonia?

A

Infection starting in the airways and spreading to adjacent alveolar tissue . Most often seen in pre-existing disease.

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20
Q

What are some secondary causes of pneumonia?

A

COPD, CF, complications of viral infection and as a result of aspiration.

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21
Q

What organisms are usually seen in aspiration pneumonia?

A

Staph, anaerobes and coliforms.

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22
Q

What is the definition of CAP?

A

Infection of the alveoli, distal airways and interstitium of the lungs that occurs outwith the hospital setting.

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23
Q

What are parenchyma?

A

The functional parts of the organ of the body.

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24
Q

What is stroma?

A

Structural tissues e.g. Connective tissue.

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25
What is the annual incidence of CAP in the UK?
About 5-11 per thousand.
26
What causal agent of CAP are less frequent in the elderly?
Mycoplasma and legionella infections.
27
What are risk factors for CAP?
Winter months, being very young of very old. Chronic lung, heart, renal and liver disease. DM and immunosuppression.
28
How is CAP usually contracted? I.e what methods of transmission.
Acquired via inhalation into lung segment or lobe. Less commonly from secondary bacteraemia from a secondary source such as E.coli urinary tract infection. Can also be CAP from aspiration.
29
What is the only form of CAP involving multiple pathogens?
Aspiration CAP.
30
What are independent risk factors for CAP?
Alcoholism, asthma, immunosuppression, institutionalisation and age over 70.
31
How does alcohol use affect pneumonia? What is alcoholism an independent risk factor for in respiratory disease?
Higher incidence of gram neg bacterial pneumonia. Worse clinical symptoms. Require longer courses of antibiotics. Prolonged, fever, slower resolution and higher rates of empyema. Excessive alcohol use is an independent risk factor for the development of acute respiratory distress syndrome.
32
What is ALPS and what is its mortality rate?
Alcoholism Leukopenia. Pneumococcal sepsis Moratality rate of 80%
33
What do oral steroids do in relation to infection?
Increase infection risk as it knocks off the B cell numbers.
34
What specific organisms for CAP usually affects those that have been exposed to birds?
Chlamydia psittaci.
35
What specific organisms for CAP usually affects those that have been exposed to sheep, goats and parturient cats?
Coxiella burnetii.
36
What specific organisms for CAP usually affects those that have been exposed to soil?
L. Longbeachii - lives in compost.
37
What are the symptoms for CAP?
Breathlessness, cough usually productive of purulent sputum, occasional heamoptysis, pleuritic chest pain, fever.
38
What will we find on examination for CAP?
Fever, tachypnoea and tachycardia. Dullness to percussion, crackles, pleural rub. Bronchial breathing.
39
When do we get increased/decreased tactile fremitus?
Increased - reflects underlying consolidated lung. | Decreased - reflects pleural fluid.
40
When do we get aegophony?
When high pitched noises are transmitted more easily across the fluid in the lungs. The lower frequencies are filtered out by the fluid.
41
Why do we hear bronchial breathing?
Air moving in large bronchioles surrounded by consolidation.
42
What can elderly people display initially when they have CAP?
New onset or worsening confusion.
43
What tests should we do for CAP?
CXR, sputum culture prior to antibiotics, ABG, FBC, U & Es, liver transaminase, CRP, serology and legionella urinary antigen. Throat swab for viral PCR.
44
Why do we get CXR's for CAP?
To exclude conditions mimicking CAP. To differentiate between viral and bacterial infections. Viral - few or no infiltrates, but ones present are bilateral, peri hilar symmetric and interstitial. Bacterial - predominantly focal or lobar. Cavitating CAP usually staph aureus Legionnaires - rapidly progressive asymmetric infiltrates.
45
What might happen if we CXR a new onset case of CAP and what should we do?
If early in CAP may not show up and will have to repeat in 24 hours.
46
Will blood cultures pick up CAP?
Will often pick up S pneumoniae and H influenzae. Particularly if pyrexic.
47
What do we do ABGs for CAP?
Looks for signs of respiratory failure or acidosis from sepsis. Tells you how sick the patient is.
48
What do we do a FBC for CAP?
To look for WCC.
49
Why do we do U & Es for CAP?
Deranged renal function is an important indicator of severity.
50
Why do we do liver transaminases for CAP?
Rise may suggest legionella, psittacosis or Q fever.
51
Does serology always pick up CAP infections?
No they may be negative in the early stages of CAP.
52
If a patient is infected with legionella will the urinary antigen test be positive?
Not necessarily, it only checks for type 1, which accounts for 80% of infections. It also stays positive for a long time but may be negative in early infections.
53
What is the severity scoring system most commonly used in the UK for CAP and what do the results mean?
CURB65. Score 1 for each thing. Score of 3 or more have a 21 fold greater chance of death.
54
What does CURB65 stand for?
Confusion - new onset, can use the mental state questionnaire. Urea of over 7mmol/l Respiratory rate of 30 or higher. Blood pressure under 90 systolic and 60 diastolic 65 years or older.
55
What other things can indicate the severity of CAP?
Hypoxia on ABG or sats. | Bilateral or multilobar shadows on CXR.
56
What is the general management of CAP?
``` High flow O2 but monitor ABG's in COPD. IV fluids for severe pneumonia. Paracetamol for pleuritic pain. Nutritional supplements in prolonged illness. ICU if can't maintain sats. ```
57
What is the ideal time for the administration of antibiotics for CAP?
Within four hours of being admitted.
58
What antibiotics do we give for a CURB score of 0-1?
Oral amoxicillin or doxycycline if penicillin allergic.
59
What antibiotics do we give for a CURB score of 3-5?
IV Coamoxiclav plus IV clarithromycin.
60
When are CAP patients managed at home or as an out patient?
CURB65 score of 0 or 1 with no preexisting adverse conditions e.g. Age over 50 or coexisting illness. If patients do have these they can still be manged out of hospital if it is judged to be safe clinically.
61
When are patients managed in hospital as non severe cap?
They have a CURB score of 0-2. Additional existing conditions or are over 50 and they have saggy SATs and abnormal X-ray findings.
62
When are patients managed in hospital as severe CAP?
Definitely if have a CURB score of three or more. | Score of 1-2 if have other conditions and clinical judgments about SATS and CXR and ABGs etc. says they are ill.
63
When do we use IV antibiotics for CAP? When do we stop this?
If severe pneumonia, impaired consciousness, loss of swallowing reflexes and malabsorption. We need to step down therapy when no longer needed.
64
What patients get a CXR, 6 weeks after their initial presentation? Why?
Aged over 55 years and a smoker. | To make sure pneumonia has cleared and to check their in no underlying neoplasms.
65
How many patients with CAP get pleural effusions? | How should we test and treat them?
Around 40% of hospitalised patients. If greater than 1cm then we should aspirate. If the ph of the fluid is under 7.2, glucose level is under 2.2 and LDH content of over 1000. Also if positive on gram staining or culture it should be trained. Thoracotomy and decortication may be necessary All patient need consultation with a thoracic surgeon.
66
What should we do if we aspirate frank pus from a pleural effusion?
Insert a large bore chest tube.
67
What are the risk factors for lung abcesses in CAP?
``` Conditions casing impaired cough reflex or aspiration. Dental caries. Bronchiectasis Bronchial carcinoma Pulmonary infarction. ```
68
What is the most likely cause if a CAP recurrence affects the same area?
An obstructed bronchus due to a tumour or foreign body.
69
What is the most common cause of recurrent CAP?
COPD and recurrent macro aspiration.
70
What tests should we do for individuals with recurrent pneumonia that don't have COPD, no risk factors for aspiration and it is in a different place?
Test for immunodeficiency e.g. HIV test, immunoglobulin determination and a chest CT for anatomical defects e.g. Bronchiectasis.
71
What is the prognosis for CAP?
Very dependent on host co-morbidities. Young people fare better then old. Patients with impaired splenic function may develop overwhelming pneumococcal sepsis despite treatment and die within 12-24 hours. Delayed antibiotic treatment is associated with a pooper outcome.
72
Who should the flu jab not be given to?
People with a hypersensitivity to hens eggs.
73
What is PPV and who should it be given to?
Pneumococcal polysaccharide vaccine. Kids over 2 who have risk factors that mean pneumococcal infection will be worse. All over 65 on a one off basis.
74
When should PPV not be given?
During acute infection or pregnancy.
75
What virus can cause CAP in an adult smoker?
Chicken pox.
76
What may be absent in legionella? But what other symptoms are common?
Chest symptoms absent but often GI symptoms instead.
77
What antibiotics do mycoplasma, coxiella and chlamydophila respond to?
Tetracycline and macrolides e.g. Clarithromycin.
78
Who does mycoplasma commonly infect?
Common cause of CAP in older children and young adults. Spreads easily from person to person.
79
What diseases do coxiella burnetii cause and where do we catch it? What is a complication of it?
Pneumonia and pyrexia of unknown origin (Q fever) We get it from sheep and goats. Culture negative endocarditis is a complication.
80
What is psittacosis, where do we catch it and how does it present?
Respiratory disease caused by Chlamydophilia psittaci. It is caught from pet birds. Usually presents and pneumonia.
81
Where does haemophilus influenzae live?
Upper respiratory tract.
82
What is haemophilus influenzae? | How do they grow in culture?
Small gram neg bacillus. Bacillus are really short, some think they look like cocci. They make small translucent colonies on chocolate agar when cultured.
83
Why must we culture haemophilus influenzae on chocolate agar and not blood?
Chocolate is the heated version of blood agar that has made the blood lose and spill its contents. Therefore allowing the blood loving bacteria nutrients to grow.
84
Why do we use CURB 65 instead of just using clinical judgment?
To prevent the over usage of the big antibiotics to try and prevent resistance to them.

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