Describe the clinical features of community-acquired pneumonia
Cough: may be dry or productive, may be haemoptysis Purulent sputum Breathlessness: coarse crackles, bronchial breathing Fever: swinging indicated empyema Chest pain: pleuritic if pleura involved Confusion or atypical non-specific symptoms in elderly Extrapulmonary: depends on infection Consolidation of the lung on CXR
Name 3 factors associated with increased mortality in community-acquired pneumonia
Comorbidites: Diabetes mellitus, congestive heart failure, COPD, CKD Bilateral or multilobar involvement PaO2 <8kPa or SaO2 <92%
How is pneumonia classified?
Community-acquired pneumonia Hospital-acquired pneumonia Pneumonia in immunocompromised patients
Name 5 risk factors for community-acquired pneumonia
Age: <16 or >65 Co-morbidities: HIV, diabetes, CKD, malnutrition, recent viral respiratory infection Other resp conditions: Cystic fibrosis, bronchiectasis, COPD, obstructing lesion (lung cancer, foreign body) Lifestyle: Smoking*, excess alcohol, IVDU Iatrogenic: Immunosuppressant therapy
Name 5 causative agents of community-acquired pneumonia
Strep pneumoniae* "pneumococcus" Haemophilus influenzae Mycoplasma pneumoniae Staph aureus Legionella: recent foreign travel, flu-like symptoms, hyponatraemia, pleural effusion Moraxella catarrhalis Chlamydia pneumoniae
List 3 extrapulmonary features of community-acquired pneumonia
Myalgia, arthralgia, malaise (common) Myocarditis and pericarditis: Mycoplasma pneumonia Headache: Legionella pneumonia Abdominal pain, DaV (common) Labial herpes simplex: Pneumococcal pneumonia Erythema multiforme, erythema nodosum: Mycoplasma Stevens-Johnson syndrome (rare)
Define community-acquired pneumonia
Pneumonia that is acquired outside hospital, including nursing homes.
How is severity of community-acquired pneumonia assessed?
- Confusion (abbreviated mental test <8/10) - 1
- Urea >7.0mmol/L - 1
- Respiratory rate >30 - 1
- Blood pressure SBP <90 or DBP <60 - 1 65yr or more - 1
0-1 (low risk): consider outpatient-based care
2 (intermediate risk): consider hospital-based care
3-5 (high risk): consider ICU assessment
Upon admission to hospital/ICU, what investigations should be done in suspected pneumonia?
CXR*: do not delay treatment if awaiting report FBC, U&Es, LFTs, CRP Blood and sputum culture* Consider pneumococcal and legionella urinary antigen Consider serology Pulse oximetry and ABG if SaO2 <94%
Outline the management of community-acquired pneumonia
ABC assessment Oxygen if hypoxic Treat any features of sepsis Otherwise treat with antibiotics as per local guidelines Empirical antibiotics: 0-1 (low risk): Amoxicillin or Clarithromycin or Doxycycline for 5 days 2 (medium risk): Amoxicillin plus either Clarithromycin or Doxycycline for 7-10 days 3-5 (high risk): Co-amoxiclav plus either Clarithromycin or Doxcycline for 7-10 days Ceftriaxone if co-amoxiclav contraindicated Ciprofloxacin if clarithromycin contraindicated Fluoroquinolone if Legionnaire's suspected
Name 3 causes of slow-resolving pneumonia
Complication: empyema, lung abscess, effusion Host: immunocompromised, aged, co-morbidities, smoking, malnutrition Antibiotics: inadequate dose/duration, poor absorption Organism: resistant, atypical, not covered by empirical Second diagnosis: PE, cancer*, organising pneumonia
Name 3 complications of pneumonia
Type 1 respiratory failure Sepsis Parapneumonic effusion Empyema: swinging fever Lung abscess Atrial fibrillation: reversible Pericarditis and myocarditis
What is cryptogenic organising pneumonia?
Rare non-infectious lung disease of unknown cause, featuring inflammation that blocks the alveoli and bronchioles.
What follow-up arrangement should be made after discharge with a diagnosis of pneumonia?
Follow-up in 6 weeks with repeat CXR*: if CXR is unresolved, CT for atypical organisms and second diagnoses. Offer HIV test: pneumonia is a common initial presentation of previously undiagnosed HIV Immunoglobulins: especially in younger patients, looking for primary immunodeficiencies e.g. CVID Pneumococcal and H. influenzae b IgG: offer vaccines for at-risk groups Smoking cessation advice: independent risk factor
Define hospital-acquired pneumonia
Pneumonia that develops 48 hours or more after hospital admission, and that was not incubating at hospital admission.
Outline the management of hospital-acquired pneumonia
ABC assessment Oxygen if hypoxic Treat any features of sepsis Antibiotic therapy asap, certainly within 4h: Co-amoxiclav, tazocin, or meropenem for 5-10d
Name 3 causative organisms of hospital-acquired pneumonia
Gram -ve bacteria*: Pseudomonas, E. coli, Klebseilla Staph aureus and MRSA: commoner in DM and ICU Enterobacter spp.
Define Mendelson syndrome
Aspiration pneumonia caused by aspiration during anaesthesia, especially during pregnancy. Commonest cause of maternal anaesthetic death.
Name 2 at-risk groups for aspiration pneumonia
Stroke Myasthenia gravis Bulbar palsies Reduced GCS Oesophageal disease
What is the commonest cause of pneumonia in immunocompromised patients?
Pneumocystis jiroveci pneumoniae
Describe the clinical features of Pneumocystis jiroveci pneumoniae
High fever Breathlessness Dry cough Rapid desaturation on exercise or exertion*
What is the treatment of Pneumocystis jiroveci pneumoniae?
Name 3 groups affected by Pneumocystis jiroveci pneumoniae
Immunosuppressant therapy: -Long-term corticosteroids -Mono-clonal antibody therapy -Methotrexate -Anti-rejection medication post-transplant HIV: esp if CD4 <200 (AIDS)