Pneumonia

Question 1

COMMUNITY-ACQUIRED PNEUMONIA (CAP)

• commonly caused by?

Answer 1

streptococcus pneumoniae (commonest), Haemophilus influenzae.

Question 2

HOSPITAL ACQUIRED PNEUMONIA

• defined as?
• commonly caused by?

Answer 2

o Defined as >48hr admission in hospital.

o Most commonly gram –ve bacilli or staph aureus, then pseudomonas.

Question 3

ASPIRATION PNEUMONIA

• defined as?

Answer 3

o Most commonly streptococcus pneumonia.

Question 4

what tool is used to determine if someone should come into hospital?

what does the scoring system result in?

in hospital have CURB65 - What does U stand for?

admit if oxygen saturation is less than?

Answer 4

CRB-65

Confusion
Resp rate >30
BP <90 systolic or <60 diastolic
>65

Urea >7

3 or 4 = urgently admit to hsop
1 or 2 = refer/ consider for same day assessment w/ PO ABx
0 = treat at home

92%

Question 5

resp rate criteria is different in CRB 65 and Sepsis

Answer 5

Resp rate = >30

Sepsis = >20

Question 6

NICE also mention point-of-care CRP test. With the following recommendation with reference to the use of antibiotic therapy:

CRP <20 ?
CRP 20-100 ?
CRP >100 ?

Answer 6

• CRP < 20 mg/L - do not routinely offer antibiotic therapy
• CRP 20 - 100 mg/L - consider a delayed antibiotic prescription
• CRP > 100 mg/L - offer antibiotic therapy

Question 7

Complications of Pneumonia?

Answer 7

Respiratory failure (Type 1) – common
Hypotension (dehydration and vasodilation – give fluids)
AF – common in elderly, goes away with Tx of pneumonia or give digoxin or B-blocker if not.

Question 8

Those eligible for pneumococcal vaccine?

Answer 8

• All adults over the age of 65.
• Diabetes mellitus not controlled by diet.
• Chronic heart, renal or lung conditions.
• Immunocompromised.

Question 9

Abx Treatment for Pneumonia

empirical therapy for CAP ?

empirical therapy for HAP ?

Answer 9

CAP

amoxicillin +/- clarithromycin

HAP

co-amoxiclav +/- gentamycin OR tazocin

Question 10

Commonest bacterial pneumonia (80% of cases)?

Tx?

Answer 10

streptococcus pneumoniae

amoxicillin, or cephalosporin.

Question 11

Particularly common in COPD patients?

Answer 11

Haemophilus influenza

Question 12

Occur in young, elderly, IVDU or patients with underlying disease (leukaemia, lymphoma). ?

Tx?

Answer 12

Staphylococcal Pneumonia

Tx: flucloxacillin

Question 13

air conditioned rooms and hospitals?

Tx?

Answer 13

Legionella Pneumophila

Tx: fluroquinolone or clarithromycin.

Question 14

skin rashes and anaemia ?

Tx?

Answer 14

Mycoplasma Pneumomiae

Tx – erythromycin in children and amoxicillin in adults

Question 15

birds/parrots ?

Answer 15

Chlamyd’s psittaci

Question 16

commensal on skin ?

Answer 16

staph. aureus

Question 17

aspiration pneumonia?

Answer 17

mixed anaerobes

Question 18

what do you treat streps with ?

what do you treat staphs with?

Answer 18

streps: amoxicillin
staphs: flucoxacillin

Question 19

A 3-year-old girl presents to the emergency department with lethargy, cough and breathlessness for the last 2 weeks. The mother tells you that the cough has been getting worse, but it is not productive of sputum. Her observations show fever, tachycardia and tachypnoea. Based on her age and the worsening of the cough, you suspect that the infecting organism is Mycoplasma pneumonia. Chest x-ray shows right lower zone consolidation.

What is the most appropriate oral therapy?

amoxicillin 
co-amoxiclav 
benzylpenicillin 
erythromycin 
aciclovir

Answer 19

erythromycin

Question 20

Which of the following factors is least useful in assessing patients with a poor prognosis in community-acquired pneumonia?

AMTS 
Urea 
CRP 
Resp rate 
Age

Answer 20

CRP

Question 21

occurs in HIV positive patients with a low CD4 count.?

Tx?

Answer 21

pneumocystis jirovecii pneumonia (PCP)

treated with oral co-trimoxazole or IV pentamidine in severe cases.

Question 22

Management of low-severity community acquired pneumonia (CURB score of 1 or 2)

1st line ?
if penicillin allergic?

Answer 22

amoxicillin is first-line
if penicillin allergic then use a macrolide or tetracycline
NICE now recommend a 5 day course of antibiotics for patients with low severity community acquired pneumonia

Question 23

A 63-year-old gentleman presents to the Emergency Department with a productive cough and shortness of breath for the past five days. His basic observations are: heart rate 90/min, blood pressure 100/55 mmHg, respiratory rate 26/min. His abbreviated mental test score (AMTS) is 9/10. His respiratory examination reveals right-sided dullness to percussion and increased vocal resonance.

Urea = normal

A plain chest radiograph shows consolidation of the right middle lobe. Based on this information how should he be managed?

Admit to ITU

Admit to hosp for amoxicillin 500mg TDS

Discharge with no treatment

Discharge with amoxicillin 500mg TDS

Answer 23

Discharge with amoxicillin 500mg TDS

His CURB 65 score is 1, as only his diastolic blood pressure is below the threshold. However, he is symptomatic so he should be treated with antibiotics as an outpatient.

Question 24

A 74-year-old man presents with confusion and is found to have evidence of right lower lobe pneumonia on chest x-ray. On examination the respiratory rate is 36 breaths per minute, pulse rate is 90 per minute and the blood pressure is 106/48 mmHg. Initial bloods show a urea of 12 mmol/l.

His CURB 65 score is:

1
2
3
4
5

what does this score mean for management?

Answer 24

5

A score of 5 necessitates admission to hospital for treatment with IV antibiotics

Question 25

A 48-year-old salesman presents with a 5 day history of cough and pleuritic chest pain. He has no past medical history of note. On examination his temperature is 38.2ºC, blood pressure is 120/80 mmHg, respiratory rate 18/min and pulse 84/min. Auscultation of the chest reveals bronchial breathing in the left base and the same area is dull to percussion. What is the most suitable management? oral amoxicillin oral co-amoxiclav oral erythromycin admit

Answer 25

oral amoxicillin

Question 26

A 70-year old lady presented to the emergency department with a three day history of increasing shortness of breath and cough productive of green sputum. She had a previous medical history of hypertension and diverticular disease of the colon. Her medication comprised of amlodipine. She was a non-smoker. On examination, she was muddled with an abbreviated mental test score (AMTS) of 6/10. Her temperature was 37.4 degrees Celsius, her pulse was 115 beats per minute and regular, her blood pressure was 88/55 mmHg, her respiratory rate was 20 breaths per minute and her oxygen saturations were 92% on room air. There were coarse crackles at the right lung base. Urea 13 Chest radiograph: patchy shadowing at the right base What is the CURB-65 score? ``` 1 2 3 4 5 ```

Answer 26

4

Question 27

A 76-year-old man has recently been stepped-down from ITU following re-exploration surgery after partial right nephrectomy due to haemorrhage. On the ward, he has become very chesty and drowsy after eating a meal. His oxygen sats are 86% on air and respiratory rate is 34/min. He has an urgent portable chest X-ray which shows new patchy opacification in the right lower lobe and he is started on IV tazocin and IV fluids. Which of the following factors would predispose him the most to this deterioration? ``` hosp admission >48 hours COPD upright position Recent intubation on iTU Previous chest infection ```

Answer 27

recent intubation in ITU Recent intubation is a risk factor for aspiration pneumonia

Question 28

how do you treat Aspiration pneumonia?

Answer 28

IV cefuroxime + metronidazole