Pneumonia - CAP and HAP Flashcards by Tolu Daramola

What is pneumonia?

Acute lower respiratory tract infection

Associated with fever, symptoms and signs in the chest + abnormalities on CXR

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What is the incidence of pneumonia?

5-11/1000

Increases in extremes of age (30% are under 65yrs)

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What is the mortality rate of pneumonia in hospital?

21%

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What are the different classifications of pneumonia?

Community acquired - may be primary or secondary to underlying disease

Hospital acquired - defined as > 48 h after hospital admission

Aspiration

Immunocompromised patient

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What are the typical causative organisms of CAP?

Streptococcus pneumoniae (commonest)

Haemophilus influenzae

Moraxella cartarrhalis

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What are the atypical causative organisms of CAP?

Mycoplasma pneumoniae

Staphylococcus aureus

Legionella species

Chlamydia

Gram -ve bacilli (rarer) = Coxiella burnetti and anaerobes

MNEMONIC = Legions of Staph MCQ

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What % of CAP are caused by viruses?

15%

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What are the causative organisms of HAP?

Most commonly Gram -ve enterobacteria or Staph. aureus

Also:
- Pseudomonas
- Klebsiella
- Bacterioides
- Clostridia

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What can flu be complicated by?

Flu many be complicated by community acquired MRSA pneumonia

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Which group of patients are at increased risk of aspiration pneumonia?

Those with:
- stroke
- bulbar palsies
- myasthenia
- reduced consciousness (e.g., post ictal or intoxicated)
- oesophageal disease (e.g., achalasia, reflux)
- poor dental hygiene

Risk aspirating oropharyngeal anaerobes

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What are the causative organisms of pneumonia in immunocompromised patients?

Strep. pneumoniae

H. influenzae

Staph. aureus

M. catarrhalis

M. pneumoniae

Gram -ve bacilli

Pneumocystis jirovecii

Other fungi, virus (CMV, HSV) and mycobacteria (e.g., M. tuberculosis)

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What are common symptoms of pneumonia?

Fever

Rigors

Pleuritic chest pain (i.e., pain on inspiration)

Purulent sputum

Haemoptysis

Dyspnoea

Malaise

Anorexia

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What are signs of pneumonia?

Pyrexia

Cyanosis

Confusion (can be the only sign in the elderly - may also be hypothermic)

Tachypnoea

Tachycardia

Hypotension

Signs of consolidation (reduced expansion, dull percussion, increased tactile vocal fremitus/vocal resonances, bronchial breathing)

Pleural rub

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What investigations would you do?

O2 sats

ABGs (if SaO2 < 92% or severe pneumonia)

Bloods - FBC, U&E, LFT, CRP

Sputum - for MC+S

Urine - check for Legionella/Pneumococcal urinary antigens

Atypical organism/viral serology (PCR sputum/BAL, complement fixation tests acutely, paired serology)

Could aspirate pleural fluid for culture

Imaging
CXR - lobar or multilobar infiltrates, cavitation, or pleural effusion

Resp doctors may consider bronchoscopy and bronchoalveolar lavage if patient is immunocompromised or on ITU

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What scoring system is used for pneumonia? What are its components and how are each scored?

CURB-65 - 1 point for each:

Confusion (AMTS ≤ 8)
Urea > 7mmol/L
RR ≥ 30/min
BP < 90 systolic and/or 60 diastolic
Age ≥ 65

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A patient’s CURB-65 score is 0-1. How would you manage them?

PO Abx/home Tx

A patient’s CURB-65 score is 2. How would you manage them?

Hospital therapy

A patient’s CURB-65 score is ≥3. How would you manage them?

Severe pneumonia

Mortality = 15-40%

Consider ITU

What other features increase the risk of death from pneumonia?

Other co-morbidities

Bilateral/multilobar

PaO2 < 8kPa

What is the Tx for CAP with a CRB65 score 0 or CURB score of 0-1?

1st line
Amoxicillin PO 500mg TDS for 5 days (higher doses can be used - see BNF)

2nd line (in penicillin allergy or if amoxicillin unsuitable)
- Doxycycline 200mg on 1st day then 100mg PO OD for 4 days (5-day course in total)
- Clarithromycin 500mg PO BD for 5 days

What is the Tx for CAP with a CURB score of 0-1 in pregnancy?

Erythromycin PO 500mg QDS for 5 days

What is the Tx for CAP with a CRB65 score 1-2 or CURB score of 2?

1st line
Amoxicillin PO 500mg TDS for 5 days (higher doses can be used - see BNF)
AND (if atypical pathogens suspected)
Clarithromycin PO 500mg BD for 5 days OR Erythromycin (in pregnancy) PO 500mg QDS

2nd line (in penicillin allergy)
- Doxycycline PO 200mg on 1st day then 100mg PO OD for 4 days (5-day course in total)
- Clarithromycin 500mg PO BD for 5 days

What is the Tx for CAP with a CRB65 score 3-4 or CURB score of 3-5?

1st line
Co-amoxiclav PO 500/125mg TDS or 1.2g TDS IV for 5 days
AND
Clarithromycin 500mg BD PO or IV for 5 days OR Erythromycin (in pregnancy) 500mg QDS PO for 5 days

2nd line (in penicillin allergy)
Levofloxacin (consider safety issues) 500mg BD PO or IV for 5 days

Also need urgent admission to the hospital (as a they have a score of 3 or more)

What is the 1st choice oral Abx for HAP if non-severe symptoms or signs, and not at higher risk of resistance?

Co-amoxiclav 500/125mg PO TDS for 5 days then review

What are the alternative Abx for HAP if non-severe symptoms or signs, and not at higher risk of resistance, but patient has penicillin allergy or if co-amoxiclav is unsuitable?

Doxycycline 200 mg on 1st day, then 100mg OD for 4 days (5 days in total) OR Cefalexin (caution in penicillin allergy as it is a cephalosporin) 500mg BD/TDS for 5 days then review - can be increased to 1g to 1.5g TDS/QDS Co-trimoxazole (off-label use) 960mg BD for 5 days then review Levofloxacin (only if switching from IV levofloxacin with specialist advice; off label use; consider safety issues): 500mg OD/BD for 5 days then review

What are the 1st choice IV Abx for HAP if severe symptoms or signs (e.g., sepsis), or at higher risk of resistance?

Piperacillin with tazobactam 4.5g TDS (increased to 4.5g QDS if severe infection) Ceftazidime 2g TDS Ceftriaxone 2g OD Cefuroxime 750mg TDS (increased to 750mg QDS or 1.5g TDS/QDS if severe infection) Meropenem 0.5g to 1g TDS Ceftazidime with avibactam 2/0.5g TDS Levofloxacin (off-label use, consider safety issues) 500mg OD/BD (use higher dosage if severe infection)

Which Abx should be added if suspected or confirmed MRSA (i.e., dual therapy with a first-choice intravenous antibiotic)?

Vancomycin - 15mg/kg to 20mg/kg BD/TDS, adjusted according to serum [vancomycin] - a loading dose of 25mg/kg to 30mg/kg can be used in seriously ill people - max 2g per dose Teicoplanin - initially 6mg/kg every 12 hours for 3 doses, then 6mg/kg OD IV Linezolid (if vancomycin cannot be used; specialist advice only) - 600mg BD PO/IV

What is the Tx for aspiration pneumonia?

Cephalosporin IV + metronidazole IV

What is the Tx of pneumonia in neutropenic patients?

For gram +ve cocci and -ve bacilli - Aminoglycoside IV + antipseudomonal penicillin IV or 3rd generation cephalosporin IV Fungi - consider antifungals after 48 h

Which at risk groups should be encouraged to get the pneumococcal vaccine?

All adults ≥ 65yrs old Chronic heart, liver, renal or lung conditions DM not controlled by diet Immunosuppression e.g., reduced spleen functions, AIDS, or on chemo or prednisolone > 20mg/day, cochlear implant, occupation risk (e.g., welders), CSF fluid leaks Vaccinate every 5 years

What are the contraindications to the pneumococcal vaccine?

Pregnancy Lactation Increased T° (temperature) Previous anaphylaxis to vaccine or one of its components

What are the complications of pneumonia?

Respiratory failure - esp. T1 Hypotension AF Pleural effusion - fluid exudate into pleural space Empyema - pus in pleural space Lung abscess Septicaemia Pericarditis and myocarditis - these could also complicate pneumonia Jaundice - usually cholestatic and may be due to sepsis or secondary to Abx therapy (esp. flucloxacillin and co-amoxiclav)

Which mnemonic can help you remember the atypical causes of pneumonia

Legions of psittaci MCQs - Legionella - Psittaci - Mycoplasma pneumoniae - Chlamydophillia pneumoniae - Q fever = Coxiella burnetti

Sources

Oxford Handbook of Clinical Medicine ed.10 pg 166-171 https://www.nice.org.uk/guidance/ng138/chapter/Recommendations https://www.nice.org.uk/guidance/ng139/chapter/Recommendations