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Flashcards in Pneumonia Deck (29):
1

Common causes of CAP

S pneumonia
M pneumoniae
Chlamydia pneumoniae
Legionella
Burholderia pseudomallei (tropical Aus)

2

Risk factors

Strong

age over 65 years
HIV/immunocompromise
recent respiratory infection
exposure to respiratory infection
recent travel
high-risk occupation
recent antibiotic exposure
smoking
comorbid medical conditions

3

Clinical features

Fevers
Rigors
Malaise
Anorexia
Dyspnea
Cough
Purulent sputum
Hemoptysis
Pleuritic chest pain

4

Initial investigations and results

CXR: infiltration, consolidation, effusion, cavitation
FBC: leukocytosis
RFTs: usually normal
Glucose: usually normal
Oximetry of ABG: hypoxemia, respiratory acidosis
Blood culture: infecting organism
Sputum culture: infecting organism
Sputum gram staining: visualising infecting organism

5

Secondary investigations and findings

1. rapid urinary antigen tests:
positive for Legionella pneumophila, S pneumoniae, or M pneumoniae infection
2. pleurocentesis
exudate
3. serology:
rise in serum/convalescent titres, C pneumoniae, M pneumoniae, Legionella
4. PCR:
detection of C pneumoniae, M pneumoniae, Legionella organisms
5. M pneumoniae cold agglutinins:
elevated IgM titre if M pneumoniae infection
6. rapid viral diagnostic tests:
rapid detection of influenza A and B, parainfluenza, RSV
7. CT chest:
consolidation, cavitation, effusions, neoplasm
8. bronchoscopy:
may clarify causative organism or non-infectious aetiology

6

Red flags for pneumonia in adults (6)

Respiratory rate >30
BP

7

Assessing severity CURB-65

Confusion
Uremia
Respiratory rate >30
BP 65 yo

8

Criteria for severe CAP

Minor criteria:
1. Respiratory rate 30 breaths/minute or greater
2. PaO2/FiO2 ratio 250 or less
3. Multi-lobar infiltrates
4. Confusion/disorientation
5. Uraemia (urea ≥20 mg/dL)
6. Leukopenia (WCC

9

Management of pneumonia

ABC
Oxygen to maintain >92%
IV access
Investigations
Fluids
Analgesia (paracetamol) + antiemetic
Antibiotics
Admission if required
Monitor: symptoms, FBC, o2 saturation

10

Patient instructions

Adhere to medications
Call if not improved in 72 hours
+Water intake
Smoking cessation
Paracetamol or aspirin
Avoid cough suppressants
Fatigue is common, however more rest not required

11

Complications

Pleural effusion
Empyema
Sepsis
Abscess
Respiratory failure
Myocarditis
Pericarditis
Cholestasis
Atrial fibrillation

12

Empirical therapy in CAP if outpatient

Amoxycillin or doxycicline

13

Inpatient moderate disease empirical CAP

Benzylpenicillin + doxycycline PO

Tropical-->
1. Risk factors present= ceftriaxone IV + Gentamicin IV as initial. Consider adding doxycycline.

14

Risk factors to consider with empirical therapy in tropical area (B. pseudomallei and A baumanni)

Diabetes
Alcohol ++
CKD
Chronic lung disease
Immunosuppressive therapy

15

Inpatient severe disease empirical CAP

Ceftriaxone IV + azithromycin

Tropical-->
1. Wet season= meropenem IV + azithromycin
2. Dry season= piperacillin + tazobactam IV + azithromycin

16

Definition of hospital acquired pneumonia and likely organisms

Pneumonia >48 hours after admission
Enterobacteria
S aureus
Pseudomonas
Klebsiella
Bacteroides
Clostridia

17

Risk of MDR in HAP

Ward
Length

Treatment with antibiotics recently
Recurrent/prolonged admission
High level nursing
Immunosuppression

18

What are high risk wards

intensive care unit, high-dependency unit, or area with a high rate of MDR organisms

19

Length of stay in high risk ward which places person at high risk

When stay is >5 days

20

Treatment of HAP when lower risk of MDR organisms

Mild: amoxycillin + clavulanate PO
Moderate/severe: ceftriaxone IV
Severe: When no additional risk for MDR as above
If additional risks= treat as higher risk MDR organisms

21

Treatment of HAP when higher risk of MDR organisms

Piperacillin + tazobactam IV

+Vancomycin in severe sepsis/considering MRSA
+Gentamycin if severe sepsis/risk of pseudomonas/risk of gram negative

22

Managment following initial commencement of antibiotics in HAP

Review in 48-72 hours

Improving?
1. Culture +ve direct therapy
2. Culture -ve consider stopping/de-escalating

Not improving
1. Consider complications
2. Culture +ve direct therapy
3. Repeat Ix and adjust antibiotic therapy

23

In what groups is S pneumonia commoner (6), clinical features, CXR findings

Elderly
Alcoholics
Post-splenectomy
Diabetics
Immunosuppressant
CHD
Lung disease

Lobar consolidation
Herpes labilis, fever, pleurisy

24

When might you sees S aureus (5), CXR

Young, elderly, complicating influenza, underlying disease
Bilateral cavitating bronchopneumonia

25

When does Klebsiella occur (3), CXR

Elderly, alcoholics, diabetics
Cavitating pneumonia

26

Mycoplasma CXR, complications

Reticular nodular pattern
STS, EM, GBS

27

Legionella presentation, extra-pulmonary features (7), CXR, blood test findings, urinalysis

Fever, malaise, dry cough, myalgia, dyspnea
EPF: renal failure, DV, hepatitis, anorexia, confusion
Bi-basal consolidation
Lymphopenia, hyponatremia, deranged LFTs, hematuria

28

How is Chlamydia psittaci acquired

From birds

29

Assessing pneumonia severity

Systolic BP
Multi-lobar involvement
Albumin low
RR >25/>30
TachyC >125
Confusion (acute)
Oxygen