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AIP: Shortness of breath > Pneumonia (CAP + HAP) > Flashcards

Pneumonia (CAP + HAP) Flashcards

1
Q

What is the definition of pneumonia?

A

describes any inflammatory condition affecting the alveoli of the lungs, but in the vast majority of patients this is secondary to a bacterial infection

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2
Q

What is the most common cause of pneumonia seen in clinical practice and what other causes are there?

A

bacterial

other infective causes include viral and fungal (e.g. Pneumocystis jiroveci)

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3
Q

What single species of organism is the commonest cause of pneumonia and what proportion of cases does it account for?

A

Streptococcus pneumoniae (80%)

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4
Q

What are 4 clinical features particularly associated with Streptococcus pneumoniae pneumonia?

A
  1. High fever
  2. Rapid onset
  3. Pleuritic chest pain
  4. Herpes labialis (cold sores)
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5
Q

What prophylactic treatment is available to protect some patient groups against Streptococcus pneumoniae pneumonia?

A

vaccine to pneumococcus

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6
Q

In which patient group is Haemophilus influenzae a particularly common cause of bacterial pneumonia?

A

patients with COPD

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7
Q

When is Staphylococcus aureus a more common cause of pneumonia?

A

following influenza infection

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8
Q

What are 5 examples of bacteria causing atypical pneumonia?

A
  1. Mycoplasma pneumoniae
  2. Chlamydia pneumoniae
  3. Legionella pneumoniae
  4. Coxiella burnettii
  5. Chlamydia psittaci
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9
Q

How does mycoplasma pneumonia commonly present?

A

dry cough, atypical chest signs/x-ray findings

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10
Q

What are 6 possible features associated with Mycoplasma pneumoniae?

A
  1. Autoimmune haemolytic anaemia - cold agglutinin production
  2. Erythema multiforme
  3. Erythema nodosum
  4. Guillain-Barre syndrome (possibly other neuro complications e.g. aseptic meningitis, cerebellar disease, transverse myelitis)
  5. Chlamydia pneumonia
  6. Bullous myringitis: painful vesicles on tympanic membrane
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11
Q

What are 3 common findings on blood tests in Legionella pneumophilia?

A
  1. Hyponatraemia
  2. Lymphopenia
  3. deranged LFTs
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12
Q

What is classically the cause of Legionella pneumophilia pneumonia?

A

secondary to infected air conditioning units

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13
Q

In which patient group is Klebsiella pneumoniae classically seen?

A

alcoholics

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14
Q

In which patient group is Pneumocstic jiroveci classically seen?

A

patients with HIV

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15
Q

What are 3 features classically seen in Pneumocystic jiroveci?

A
  1. Dry cough
  2. Exercise-induced desaturations
  3. Absence of chest signs
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16
Q

What is the name of the group of non-infective causes of pneumonia?

A

Idiopathic interstitial pneumonia

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17
Q

What is an example of an idiopathic interstitial pneumonia?

A

Cryptogenic organising pneumonia - form of bronchiolitis

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18
Q

What are 2 things that cryptogenic organising pneumonia may develop in response to?

A
  1. Rheumatoid arthritis
  2. Amiodarone therapy
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19
Q

Why is the distinction between community vs hospital acquired pneumonia important?

A

causative organisms very difference, hence first-line antibiotic guidelines different

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20
Q

What are 5 symptoms of pneumonia?

A
  1. Cough
  2. Sputum
  3. Dyspnoea
  4. Chest pain: may be pleuritic
  5. Fever
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21
Q

What are 3 clinical signs on examination of pneumonia?

A
  1. Signs fo systemic inflammatory response: fever, tachycardia
  2. Reduced oxygen saturations
  3. Auscultation: reduced breath sounds, bronchial breathing
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22
Q

What is the classical x-ray finding in pneumonia?

A

consolidation, e.g. in right upper lobe abutting horizontal fissure in the example

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23
Q

What is important to remember when identifying ‘consolidation’ on a chest x-ray in pneumonia?

A

the position of the opacity on the film doens’t necessarily correlate with the lobe affected e.g. middle of lung on film but could be upper lobe

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24
Q

As a side-note, based on lung anatomy, if an ETT is inserted too low which bronchus is it likely to go down and why?

A

right bronchus as this is more vertical than the left (and therefore only one lung will be ventilated)

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25
Q

What are 6 key investigations to perform in suspected pneumonia?

A
  1. Chest x-ray
  2. Bloods: FBC, U+Es, CRP
  3. Blood cultures if intermediate-high risk
  4. Sputum cultures if intermediate-high risk
  5. Pneumococcal and legionella urinary antigen tests
  6. ABG
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26
Q

What are 3 types of bloods that you would perform in suspected pneumonia and why for each?

A
  1. FBC: neutrophilia in bacterial infections
  2. U+Es: check for dehydration - U in CURB-65
  3. CRP: raised in infection
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27
Q

What are 2 reasons why you would perform an ABG in suspected pneumonia?

A
  1. Low oxygen saturations
  2. Pre-existing respiratory disease e.g. COPD
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28
Q

What are 2 key aspects to the management of pneumonia?

A
  1. Antibiotics
  2. Supportive care: oxygen, IV fluids
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29
Q

What is the name of the risk stratification system used in community-acquired pneumonia to determine management? What are the components?

A

CURB-65

  • C: confusion, 8 or less on AMTS
  • U: urea >7
  • R: respiratory rate >30
  • B: systolic BP <90, diastolic <60
  • 65: age over 65
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30
Q

Which type of pneumonia specifically can CURB-65 be applied to?

A

community-acquired pneumonia

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31
Q

How does the result of the CURB-65 score relate to the management of a patient with pneumonia?

A
  • if score 0: manage in community
  • score 1: measure oxygen saturations. if over 92%, manage in community and perform chest x-ray. if CXR showed bilateral/multilobar shadowing, hospital admission advised
  • score 2 or more: manage in hospital, = severe CAP
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32
Q

What CURB-65 score requires treatment in hospital?

A

2 or more

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33
Q

What is the management of pneumonia with a CURB-65 score of 1?

A
  • measure O2 sats, if >92% manage in community and perform CXR
  • also perform CXR, if shows bilateral/multilobar consolidation manage in hospital
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34
Q

What are 5 causes of community acquired pneumonia to be aware of?

A
  1. Streptococcus pneumoniae
  2. Haemophilus influenzae
  3. Staphylococcus aureus (after influenza infection)
  4. Atypical pneumonias (e.g. mycoplasma)
  5. Viruses
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35
Q

How does the scoring system to determine the management of pneumonia differ in primary vs secondary care settings?

A

no urea measurement in primary care

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36
Q

How does the CRB-65 score work in the community in terms of determining management?

A

home based care for score of 0

hospital assessment for all other patients, especially score 2 or more (i.e. send 1 or more to ED and they can do CURB-65)

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37
Q

How does the CRB-65 relate to mortality?

A
  • score of 0: <1% mortality risk
  • 1 or 2: 1-10% mortality risk
  • 3 or 4: >10% mortality risk
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38
Q

What role does the point-of-care CRP test in suspected pneumonia recommended by NICE play?

A

not widely available currently

  • CRP <20: do not routinely offer antibiotic therapy
  • 20-100: consider delayed antibiotic prescription
  • >100: offer antibiotics
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39
Q

At what CURB-65 score should intensive care assessment be considered?

A

3 or more

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40
Q

What can be used to monitor response of pneumonia to treatment?

A

serial CRP measurements

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41
Q

What is first-line management of low-severity community acquired pneumonia?

A

amoxicillin, 5 day course

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42
Q

What is the alternative to amoxicillin in penicillin allergic patients for low severity community acquired pneumonia?

A

macrolide or tetracycline

43
Q

What is the first-line management of moderate and high-severity community acquired pneumonia?

A

dual antibiotic therapy: amoxicillin and macrolide, 7-10 day course

or can given beta-lactamase stable penicillin + macrolide e.g. co-amoxiclav, ceftriaxone, tazocin + macrolide

44
Q

What are 7 things that, if a patient has had 2 or more of in the past 24 hours, mean that patients should not routinely be discharged?

A
  1. Temperature higher than 37.5oC
  2. RR 24 or more
  3. HR >100
  4. SBP <90
  5. sats <90 on RA
  6. abnormal mental status
  7. inability ot eat without assistance
45
Q

What is the recommendation about temperature and delaying discharge in pneumonia?

A

if temperature is >37.5, recommended to delay discharge

46
Q

What information should be given to patients about time frame of resolution of effects of pneumonia?

A
  • 1 week: fever should have resolved
  • 4 weeks: chest pain and sputum production substantially reduced
  • 6 weeks: cough and breathlessness shoudl have substantially reduced
  • 3 months: most symptoms should have resolved but fatigue may still be present
  • 6 months: most people will feel back to normal
47
Q

What is the pathophysiology of pneumonia?

A

infection and subsequent inflammation of the alveoli and terminal bronchioles occurs

this leads to entire bronchopulmonary segment or lobe becoming consolidated, which means tissue is filled with inflammatory cells and oedema

48
Q

What determines a ‘typical’ pneumonia?

A

these cause a classical rapid onset of symptoms, including high fever and productive cough

49
Q

What are 4 examples of ‘typical’ pneumonias?

A
  1. Streptococcus pneumoniae
  2. Staphylococcus aureus
  3. Haemophilus influenzae
  4. Moraxella catarrhalis
50
Q

What determines an atypical pneumonia?

A

more gradual onset of symptoms which may be non-specific initially (fever, myalgia, dry cough) and organisms are intracellular

51
Q

What is the most common viral cause of community-acquired pneumonia?

A

influenza A

52
Q

What are 4 viral causes of community-acquired pneumonia?

A
  1. influenza A
  2. CMV
  3. HSV
  4. VZV
53
Q

What can influenza A pneumonia predispose to?

A

superadded Staph aureus pneumonia

54
Q

What are 3 fungal/opportunistic Mycoses causing CAP?

A
  1. Candida - dimorphic yeast
  2. Aspergillus - fungus with hyphae
  3. Crytpococcus - encapsulated yeast
55
Q

What are 3 causes of CAP in COPD patients?

A
  1. Streptococcus pneumoniae still most common
  2. Haemophilus influenzae
  3. Moraxella catarrhalis
56
Q

What are 3 causes of CAP in cystic fibrosis?

A
  1. Staphylococcus aureus
  2. Pseudomonas aeruginosa
  3. Burkholderia cepacia
57
Q

What are 3 causes of CAP in homeless people (malnourished, alcohol or drug-dependent, immunosuppressed)?

A
  1. Mycobacterium tuberculosis
  2. Aspiration pneumonia
  3. Klebsiella pneumoniae
58
Q

What are 4 possible features of legionella pneumophila?

A
  1. Diarrhoea and vomiting
  2. Hepatorenal syndrome
  3. low sodium
  4. lymphopenia
59
Q

What are 4 possible rare complications of Legionella pneumophila?

A
  1. Pancreatitis
  2. Peritonitis
  3. Myocarditis, endocarditis, pericarditis
  4. Glomerulonephritis
60
Q

What are 2 examples of causes of CAP in abbatoir workers/famers/vets?

A
  1. Coxiella burnettii
  2. Brucella spp.
61
Q

In what patient group can Bacillus anthracis cause CAP?

A

animal hide importers/sorters

62
Q

What is the name of CAP specifically affected by cave-explorers exposed to bats/bat droppings?

A

Histoplasma capsulatum

63
Q

What causes CAP in exposure to birds?

A

chlamydia psittaci: causes psittacosis

64
Q

What are the 2 bacterial causes of pneumonia that can be tested for with a urinary antigen test?

A

legionella and pneumococcus

65
Q

What is the definition of hospital acquired pneumonia?

A

lower respiratory tract infection that develops more than 48 hours after admission to hospital

66
Q

When should patients with suspected pneumonia be screened for malignancy and how?

A

in patients >50 years olf ± smoker - repeat CXR at 6 weeks

67
Q

What are 5 key causative organisms for hospital acquired pneumonia?

A
  1. Pseudomonas aeruginosa
  2. E. coli
  3. Klebsiella pneumoniae
  4. Acinetobacter species
  5. Serratia species
68
Q

What are 2 options for antiobiotics for hospital acquired pneumonia within 5 days or admission?

A
  1. co-amoxiclav or
  2. cephalosporin e.g. cefuroxime
69
Q

What are 3 options for hospital acquired pneumonia antibiotics acquired >5 days after admission?

A
  1. tazocin
  2. cephalosporin e.g. ceftazidime
  3. quinolone
70
Q

What causes aspiration pneumonia?

A

any cause of depressed consciousness or impairment of the swallowing mechanism - develops as a result of foreign materials gaining entry to the bronchial tree

71
Q

What are the materials that can lead to aspiration pneumonia to develop?

A

usually oral or gastric contents such as food and saliva. infection caused by mixed aerobic and anaerobic mouth flora, can cause cavitatory pneumonia or empyema

72
Q

What can develop in addition to the aspiration pneumonia and why?

A

chemical pneumonitis: depending on acidity of aspirate

73
Q

What are 4 examples causes of aspiration pneumonia?

A
  1. Stroke
  2. Multiple sclerosis
  3. Intoxication
  4. Intubation
74
Q

What are 5 risk factors for the development of aspiration pneumonia?

A
  1. Poor dental hygiene
  2. Swallowing difficulties
  3. Prolonged hospitalisation or surgical procedures
  4. Imapired consciousness
  5. Impaired mucociliary clearance
75
Q

What are the most common sites affected by aspiration pneumonia and why?

A

right middle and lower lung lobes: due to large calibre and more vertical orientation of right main bronchus

76
Q

What are the 4 bacteria most commonly implicated in aspiration pneumonia?

A
  1. Streptococcus pneumoniae
  2. Staphylococcus aureus
  3. Haemophilus influenzae
  4. Pseudomonas aeruginosa
77
Q

How frequently do epidemics of Mycoplasma pneumoniae occur?

A

every 4 years

78
Q

Why is it so important to recognise atypical pneumonia such as mycoplasma pneumoniae?

A

they may not respond to penicillins or cephalosporins due to lacking a peptidoglycan cell wall

79
Q

What are 5 of the possible neurological associations of mycoplasma pneumoniae?

A
  1. Guillain Barre syndrome
  2. Aseptic meningitis
  3. Transverse myelitis
  4. Cerebellar disease
  5. Meningoencephalitis
80
Q

What is bullous myringitis (associated with mycoplasma pneumoniae)?

A

painful vesicles on the tympanic membrane

81
Q

How is diagnosis of Mycoplasma pneumoniae usually made? 2 things

A

Mycoplasma serology, positive cold agglutination test

82
Q

What are 2 options for Mycoplasma pneumoniae treatment?

A
  1. Doxycycline
  2. Macrolide e.g. erythromycin / clarithromycin
83
Q

What was Pneumocystis jiroveci previously referred to as?

A

Pneumocystis carinii

84
Q

What is Pneumocystis jiroveci?

A

unicellular eukaryote, generally classified as fungus, some authorities consider it a protozoa

85
Q

When in AIDS are patients given prophylaxis for Pneumocystic jiroveci?

A

CD4 count <200/mm3

most common opportunistic infection

86
Q

What is a common complication of pneumocystis jiroveci pneumonia?

A

pneumothorax

87
Q

How common are extrapulmonary manifestations of Pneumocystis jiroveci?

A

rare, 1-2% of cases

88
Q

What are 3 extrapulmonary manifestations of pneumocystis jiroveci pneumonia?

A
  1. Hepatosplenomegaly
  2. Lymphadenopathy
  3. Choroid lesions
89
Q

What are 3 investigations in pneumocystis jiroveci and what are they likely to show?

A
  1. CXR: bilateral interstitial pulmonary infiltrates but can also show lobar consolidation/be normal
  2. Exercise-induced desaturation
  3. Sputum: often fails to show PCP
  4. Bronchoalveolar lavage (BAL): often needed to demonstrate PCP; silver stain shows characteristic cysts
90
Q

What are 4 possible aspects of treatment of pneumocystis jiroveci pneumonia?

A
  1. co-trimoxazole
  2. IV pentamidine in severe cases
  3. aerosolized pentamidine alternative for PCP but less effective
  4. steroids if hypoxic
91
Q

What drug is used rather than co-trimoxazole for severe cases of PCP?

A

IV pentamidine

92
Q

What is a risk associated with aerosolized pentamidine for treating PCP?

A

pneumothorax

93
Q

When are steroids given to treat PCP and what is the benefit?

A

if hypoxic - reduce risk of respiratory failure by 50% and death by third

94
Q

What does the CT show?

A

large pneumothorax developing in patient with PCP

95
Q

What type of bacteria is Klebsiella?

A

Gram-negative rod, part of normal gut flora

96
Q

What are 3 classical clinical features of Klebsiella pneumonia?

A
  1. red currant jelly sputum
  2. lung abscess formation
  3. empyema
97
Q

Which part of the lung is typically affected by Klebsiella pneumonia?

A

upper lobes

98
Q

How is chlamydophila psittaci pneumonia acquired?

A

contact with infected animals such as parrots, cattle, horse and sheep

99
Q

What are 6 clinical features of Chlamydophila psittaci pneumonia?

A
  1. Lethargy
  2. Arthralgia
  3. Headache
  4. Anorexia
  5. Dry cough
  6. Fever
100
Q

What are the 2 types of pneumococcal vaccine which protects against Streptococcus pneumoniae?

A
  1. Conjugate
  2. Polysaccharide
101
Q

Which type of pneumococcal vaccine is more commonly given and why?

A

the polysaccharide vaccine -covers greater number of serotypes

102
Q

Which patients are offered the pneumococcal vaccine?

A
  • routinely offered at ages 2 months, 4 months, 12-13 months
  • people aged 65 years or older and those in at-risk groups
    • at risk groups =
      • chronic heart, liver or renal conditions
      • immunsuppressed
      • chronic lung conditions
103
Q

Which patients may require a pneumococcal vaccination every 5 years?

A

those with decreased splenic function and nephrotic syndrome

AIP: Shortness of breath (12 decks)

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