Respiratory: CAP

Question 1

In what percentage of cases is no causative organism found?

Answer 1

Over 50%

Question 2

Are viruses or bacteria the most common cause in young children?

Answer 2

Viruses

Question 3

Are viruses or bacteria the most common cause in older children?

Answer 3

Bacteria

Question 4

Mixed bacterial-viral infections are found in up to what fraction of cases?

Answer 4

1/3

Question 5

In clinical practice, is it difficult to distinguish from viral or bacterial cause?

Answer 5

Yes but organisms vary with age and some clinical features make either more likely

Question 6

What are the most common causative organisms in newborns?

Answer 6

Group B streptococcus
Gram negative enterococci and bacilli
(Organisms from mothers genital tract)

Question 7

What are the most common causative organisms in infants and young children?

Answer 7

Respiratory viruses - RSV most common
Bacterial: streptococcus pneumoniae, haemophilius influenzae
Also pertussis and chlamydia

Uncommon: staph aureus

Question 8

What are the most common causative organisms in children over 5?

Answer 8

Streptococcus pneumoniae
Mycoplasma pneumoniae
Chlamydia pneumoniae

Question 9

What causative organism should be considered at all ages?

Answer 9

Mycobacterium tuberculosis

Question 10

What causative organism has there been a marked reduction of since the introduction of a vaccine for it?

Answer 10

Haemophilius influenzae
Also there is a vaccine for 13 of the most common serotypes of streptococcus pneumoniae responsible for invasive disease (part of routine immunisation in UK)

Question 11

Viral pneumonia is most common below what age?

Answer 11

2 years old

Question 12

Describe the onset of viral pneumonia

Answer 12

Gradual over 24-48 hours 
Coryzal prodrome (runny nose, cough)

Question 13

What clinical findings are seen with viral pneumonia?

Answer 13

Myalgia, rash, mucous membrane signs
Temperature <38.5
Cough usually dry 
Bilateral, diffuse chest signs
Associated wheeze
No pleuritic pain

Question 14

In suspected viral pneumonia, will other family members be unwell?

Answer 14

Most likely - concurrent RTI, rash, conjunctivitis

Question 15

In bacterial pneumonia, what age is typically affected?

Answer 15

Over 2 years

Question 16

Describe the typical onset of bacterial pneumonia

Answer 16

Abrupt (often appearing toxic)

No prodrome, no runny nose

Question 17

What clinical findings are seen with bacterial pneumonia?

Answer 17

Appears toxic
Temperature > 38.5 
Cough can be wet and productive 
Pleuritic pain: chest, abdomen or neck
Unilateral clinical signs 
No wheeze on auscultation

Question 18

Will other members of the family be unwell (in suspected bacterial pneumonia)?

Answer 18

No usually not

Question 19

What clinical findings are there on chest examination?

Answer 19

Bronchial breathing (indicates patent airway surrounded by consolidated lung tissue)
Reduced expansion on inspiration 
Increased vocal fremitus 
Increased vocal resonance 
Diminished air entry 
Possible crackles 
Pleural rub 
Dullness to percuss

Question 20

What is the most sensitive clinical sign of pneumonia in children?

Answer 20

Increased RR - may be the only respiratory sign

Question 21

Can a child have no abnormal signs on auscultation and have pneumonia?

Answer 21

Yes

Question 22

What are the characteristics of mild CAP in infants?

Answer 22

RR <50/min
CRT <2 sec
Mild recessions
Taking full feeds

Question 23

What are the characteristics of mild CAP in older children?

Answer 23

RR<35/min
CRT <2 sec
Mild breathlessness
Taking full feeds

Question 24

What are the characteristics of moderate CAP in infants?

Answer 24

RR 50-70/min
CRT about 2 sec
Moderate recessions
Reduced feeds

Question 25

What are the characteristics of moderate CAP in older children?

Answer 25

RR 35-50 CRT about 2 sec Moderate recessions Reduced feeds

Question 26

What are the characteristics of severe CAP in infants?

Answer 26

``` RR>70/min CRT>2 sec Nasal flaring Intermittent apnoea Grunting Unable to feed ```

Question 27

What are the characteristics for severe CAP in older children?

Answer 27

``` RR>50 CRT>2 Unable to complete sentences Severe recessions Nasal flaring Signs of dehydration ```

Question 28

What indicates increased work of breathing?

Answer 28

Nasal flaring Expiratory grunting - increased PEEP Use of accessory muscles Retractions - suprasternal, SC and IC

Question 29

When deciding whether to treat child in the community or admit for hospital based care, what factors should be considered?

Answer 29

Assessment of severity Underlying risk factors Ability of carers to manage the illness in the community

Question 30

Can children with mild symptoms be managed in the community?

Answer 30

Yes As long as they are able to tolerate fluids and medications, do not need additional oxygen to maintain sats over 92%. Providing parents are adequately supported, reassured and informed

Question 31

Do children with moderate CAP need admission?

Answer 31

Yes will likely need admission | Can usually be managed on oral antibiotics

Question 32

Should children with severe CAP be admitted?

Answer 32

Yes - need IV antibiotics

Question 33

Are blood tests and CXRs routinely needed in children admitted with moderate CAP?

Answer 33

No

Question 34

When should CXR be done?

Answer 34

Diagnosis unclear Complicated pneumonia suspected Severe pneumonia

Question 35

What bloods should be done in children with severe CAP?

Answer 35

FBC, CRP, U&E Blood culture Mycoplasma serology Ideally before antibiotics commenced

Question 36

Children on IV fluids will need what done daily?

Answer 36

U&Es to check for evidence of hyponatraemia secondary to SIADH

Question 37

When should microbiology testing be done?

Answer 37

All children with severe pneumonia and those with complicated pneumonia Includes: Point of care testing for respiratory viruses during flu season Blood culture Nasopharyngeal secretions and/or nasal swabs - viral detection by PCR and bacterial culture Mycoplasma serology If present, pleural fluid sent

Question 38

Who should receive antibiotics?

Answer 38

All children with suspected bacterial CAP

Question 39

In Children less than 2 admitted with moderate features of CAP, wheeze, temp less than 38.5 a viral cause is more likely. Can registrar / consultant decide to withhold antibiotics?

Answer 39

Yes but child should be monitored closely for signs of deterioration

Question 40

What antibiotics should be given to children with moderate CAP?

Answer 40

Oral amoxicillin | If allergy to penicillin: clarithromycin

Question 41

What antibiotics should be given in severe CAP?

Answer 41

IV co-amoxiclav and clarithromycin | Allergy to penicillin: cefuroxime and clarithromycin

Question 42

Is there an advantage of giving IV rather than oral treatment in mild/moderate pneumonia?

Answer 42

No

Question 43

What antibiotic class should be used if mycoplasma or chlamydia suspected?

Answer 43

Macrolides e.g erythromycin

Question 44

Is sputum often produced by children?

Answer 44

No rarely produced as they swallow it - main exception is purulent lung disease e.g from CF