Week Two - Case Two

Question 1

what is pneumonia and what is it characterised by

Answer 1

a common lower respiratory tract infection and is characterised by inflammation of the lung tissue.

it is almost always an acute infection, and almost always is caused by bacteria.

Question 2

what is diagnosis of pneumonia usually confirmed by

Answer 2

chest x-ray

Question 3

what is the most fatal hospital acquired infection

Answer 3

pneumonia

Question 4

what percentage of pneumonia cases at pneumococcal in cause and what are the rest

Answer 4

75% of cases are pneumococcal in cause, and 20% atypical. The remaining 5% may be caused by aspiration of vomit, radiotherapy and allergic mechanisms.

Question 5

what is hospital acquired pneumonia defined as

Answer 5

pneumonia that develops 48hrs after admission

Question 6

what is the prognosis for hospital acquired pneumonia

Answer 6

generally poor, due to co-morbidities, older age range of patients, and resistance of organisms

Question 7

what are the common organisms in hospital acquired pneumonia

Answer 7

gram negative bacilli, staphylococcus aureus

drug resistant organisms are more common and are more dangerous

Question 8

what is the prognosis for community acquired pneumonia

Answer 8

generally good, especially for younger patients

S. pneumoniae and viral pneumonias are still fatal in older patients

Question 9

what are the common organisms in community acquired pneumonia

Answer 9

streptococcus pneumoniae, haemophilius influenzae

anaerobes are rare

Question 10

what does step pneumoniae infection often follow

Answer 10

often follows viral infection with influenza or parainfluenza

Question 11

what is hospital acquired infection often with

Answer 11

gram negative organisms

Question 12

what are the symptoms of pneumonia

Answer 12

Typically the same for hospital acquired / non-hopsital acquired cases

Shortness of breath

Cough
May be productive in adolescents and adults – Purulent sputum possible
Often dry in infants and the elderly

Fever

Rigors

Vomiting

Headache

Loss of appetite

Very occasionally – haemoptysis

Pleuritic chest pain – which may on occasion radiate to the shoulder (if diaphragm is involved) or the anterior abdominal wall
Pleuritic chest pain – a sharp shooting or stabbing pain, usually in the side, that is most painful on inspiration, but can also be felt on expiration, or even whilst talking.

Upper abdominal tenderness in some patients with lower lobe pneumonia

Signs of consolidation – both on examination and CXR

Dyspnoea

Tachypnoea

Tachycardia

Increased secretions – noticeable in ventilated patient in hospital acquired cases

Question 13

what are the signs seen in strep pneumoniae

Answer 13

rapid shallow breathing and pleural rub

Question 14

what may be the only sign in elderly patients

Answer 14

confusion

Question 15

what oxygen saturation is usually worrying

Answer 15

<92%

Question 16

what would a CXR look like

Answer 16

• evidence of infiltrate in the form of consolidation
• changes may not appear for up to 48hrs after symptoms, however, after effective treatment, consolidation may still be seen on CXR for up to 6 weeks

Question 17

what is not routine in community acquired infection of pneumonia

Answer 17

blood cultures to assess the identity of the causatory organism

Question 18

what would a FBC show

Answer 18

• elevated WCC
• elevated ESR (>100mm/h) and increased CRP
• possible anaemia (sign of abscess)
• blood cultures - check for septicaemia

Question 19

why would one take a urine sample in suspected pneumonia

Answer 19

in severe cases of pneumonia, where legionella is suspected, urine testing for legionella antigen may be indicated

Question 20

what is pleural fluid aspiration test used for

Answer 20

to assess for organisms.

Question 21

what is the CURB-65 score and what is it used for

Answer 21

used to assess the severity of community acquired pneumonia. it predicts the risk of mortality. (CURB score 0 = <1% risk, CURB score 5= 60% risk). Each factor of the score is worth 1 point

C – Confusion – use the abbreviated mental test (score ≤8)

U – Urea – >7mmol/L

Respiratory rate – ≥30/min

Blood Pressure <90 systolic, or <60 diastolic

65 – age >65 years
A score ≥3 is severe pneumonia. ≥2 requires hospitalisation

Question 22

what are the differentials for pneumonia

Answer 22

PE - patient is not usually scenically unwell. shortness of breath is more likely to be of a sudden onset

pulmonary/pleural TB

pulmonary oedema

Question 23

what is the treatment for pneumonia if not vomiting and CURB65 score is < or equal to 2

Answer 23

use oral antibiotics, if severe and/or vomiting IV antibiotics are required

Question 24

what should oxygen saturation be kept at

Answer 24

> 92%

Question 25

what is used to prevent dehydration and shock

Answer 25

fluids

Question 26

what is the most common complication of pneumonia

Answer 26

respiratory failure

Question 27

what is respiratory failure defined as

Answer 27

PaO2 <8kPa.

Question 28

what is respiratory failure treated with

Answer 28

60% oxygen (high flow)

Question 29

what should you aim to keep stats at when on oxygen

Answer 29

90-94%

Question 30

what may be given if atrial fibrillation occurs

Answer 30

this is the most common complication in the elderly. it usually resolves but digoxin may be given to reduce the HR as short term therapy

Question 31

what is empyema

Answer 31

the infection of the pleural fluid

Question 32

what is lobar collapse most commonly the result of

Answer 32

sputum retention

Question 33

what is a late complication of pneumonia

Answer 33

lung abscess - this is a cavitating lesion containing pus within the lung

Question 34

what can septicaemia result in

Answer 34

infective endocarditis and meningitis

Question 35

what is the most common type of pneumonia

Answer 35

strep-pneumonia

very commonly preceded by viral infection

Question 36

what happens in cases of strep pneumoniae

Answer 36

the patient will rapidly become febrile, with a temp of up to 39.5, pleuritic pain and dry cough

may be pleural rub and rust coloured sputum

Question 37

what strains are common in the young, but rare in the elderly

Answer 37

Mycoplasma pneumoniae, Chlamydia pneumoniae

Question 38

what stains are common in the elderly but not in young people

Answer 38

Haemophilus influenzae

Question 39

if someone smoked 5 cigarettes per day for 60 years what is their smoking history in pack years

Answer 39

5 cigarettes per day = 1/4 pack

60 x 1/4 = 15 pack years

Question 40

what is myalgia

Answer 40

muscle aches and pain

Question 41

what is anosmia

Answer 41

partial or full loss of smell

Question 42

what does a CURB65 score of greater than 3 mean

Answer 42

urgent admission to hospital

Question 43

what initial investigations should u order when querying pneumonia

Answer 43

• ABG
• blood cultures
• CRP
• CXR
• ECG
• FBC
• Lactate
• LFTs
• U+E

Question 44

what is the initial management of a patient with potential pneumonia

Answer 44

• start oxygen
• monitor urine output
• start antibiotics
• start IV fluids

Question 45

what is an elevated lactate level indicative of

Answer 45

sepsis

Question 46

what samples would you send to the microbiology labs if querying CAP

Answer 46

• sputum cultures
• blood cultures
• HIV test
• respiratory virus screen
• urine pneumococcal and legionella antigen

Question 46

what are the common clinical presentations of someone with pneumonia

Answer 46

cough: may be dry or productive. Sputum in pneumococcal pneumonia is characteristically rust coloured.

breathlessness: alveoli become filled with pus which impairs gas exchange, the patient will complain of feeling breathless, not able to lie down and reduction in oxygen saturations

fever: this can be up to 39.5 to 40 degrees

chest pains: commonly pleuritic in nature and worse when coughing

Question 47

what is a sign of effusion

Answer 47

Dullness on percussion

Question 48

what in particular do we want to look at in the FBC

Answer 48

white cell count

haemoglobin

platelets

Question 49

what is bacterial pneumonia characterised by

Answer 49

acute inflammation of the lung parenchyma

this is associated with neutrophil inflitration

Question 50

what test should patients presenting with pneumonia be offered

Answer 50

a HIV test

Question 51

what kind of bacteria is streptococcus pneumoniae

Answer 51

gram positive coccus

Question 52

what is the key information of streptococcus pneumoniae

Answer 52

Commonest cause of CAP, up to 80% of infections.

Can be detected from blood culture (in 30% of cases) or via urinary antigen.

Vaccine available for babies and >65 year olds, for immunosuppressed and asplenic patients and those with long term conditions.

Rates of infection have fallen due to immunisation.

Question 53

what type of bacteria is haemophilus influenzae

Answer 53

gram negative bacillus

Question 54

what is the key information about haemophilus influenzae

Answer 54

Rates of infection have fallen as children now immunised.

Note: vaccine does not cover for all serotypes and is not particularly efficient in adults

Around 20% of UK strains now resistant to penicillins.

Question 55

what type of bacteria is Klebsiella pneumoniae

Answer 55

gram negative bacteria

Question 56

what is the key information about Klebsiella pneumoniae

Answer 56

Commensal organism of the GI tract.

Elderly patients and people with comorbidities at increased risk, alcohol excess also risk factor

Clinically tends to affect upper lobes

Inherently resistant to penicillins, cephalosporins recommended, penicillin combined with a beta-lactamase inhibitor may be an option.

Question 57

what type of bacteria is staphylococcus aureus

Answer 57

gram positive coccus

Question 58

what is the key information about staphylococcus aureus

Answer 58

Chronic lung pathology also a risk factor, i.e., cystic fibrosis and bronchiectasis

Flucloxacillin mainstay of therapy but important to consider MRSA if not improving

Question 59

what are the atypical causes of pneumonia

Answer 59

mycoplasma pneumoniae

legionella pneumonophilia

chlamydia pneumoniae

Chlamydia psittaci

Question 60

what is the key information about mycoplasma pneumoniae

Answer 60

Can be associated with epidemics and tends to affect younger patients.

Dry cough Patchy consolidation on CXR

Cannot be cultured in routine laboratories, diagnosis by PCR or serology

Treat with macrolide

Question 61

what is the key information about legionella pneumophilia

Answer 61

Occasionally sporadic cases but often occur in outbreaks, associated with air conditioning systems.

Think of this in patients who have recently been on holiday.

Tends to affect males (2:1 ratio) and smokers.

Prodromal syndrome of high fevers before a dry cough develops

Can be diagnosed with urinary antigen testing.

Treat with macrolides.

5-10% of CAP.

Occurs in outbreaks in families and institutions

Question 62

what is the key information about chlamydia pneumoniae

Answer 62

Young adults and extremes of age vulnerable

Diagnosis made on acute and convalescent serology or PCR Treat with macrolide or doxycycline.

Around 3% of CAP

Question 63

what is the key information about Chlamydia psittaci

Answer 63

Classically associated with contact with birds esp. parrots and pigeons

Can occasionally cause hepatosplenomegaly

Diagnosis made on acute and convalescent serology or PCR Treat with macrolide or doxycycline.

Question 64

what is meant by typical and atypical pneumonia

Answer 64

Pneumonia is classically divided into typical and atypical organisms based on historical laboratory techniques: typical organisms can be cultured in the laboratory whereas atypical organisms are intracellular pathogens and cannot be cultured using standard methods and alternative diagnostic tools are needed. This division is clinically relevant as atypical organisms need to be treated with antibiotics which get into intracellular space (e.g. macrolides). Also, atypical organisms do not possess a cell wall on which penicillins or cephalosporins can act.

Question 65

what is common in pneumonia and complicates around 50% of cases

Answer 65

pleural effusion

Question 66

what is empyema

Answer 66

collection of pus in the pleural space

Question 67

what antibiotics should be started for case patients pneumonia

Answer 67

Co-amoxiclav 500/125mg tds clarithromycin 500mg bd for 5/7

As per CURB65 guidelines, this prescription offers broad spectrum cover of potential microbial causes of pneumonia.

Question 68

why do we prescribe clarithromycin

Answer 68

In severe pneumonia, we add additional antibiotic treatment (typically with clarithromycin) to broaden antibiotic spectrum and cover atypical bacterial causes of pneumonia.

Question 69

what should happen to all pneumonia patients after 6 weeks

Answer 69

have a follow up CXR in 6 weeks because

chest radiograph should be arranged after about 6 weeks for patients who have persistence of symptoms or physical signs or who are at higher risk of underlying malignancy (especially smokers and those aged >50 years. The vast majority of patients (98%) who are diagnosed with CAP have a significant risk factor for underlying malignancy. Follow-up CXR screens for malignancy after the acute infiltrate has cleared.