Pneumonia

• What is empyema?


  Infected effusion
• What is shown in the image?

  R lower zone consolidation

  
• What Abx are used in pneumonia?


  Amoxicillin

  Doxycycline (if penicillin allergy)
• What is pneumonia?


  Infection of lung parenchyma
• What is community-acquired pneumonia?


  Pneumonia acquired in the community
• What is hospital-acquired pneumonia?


  Pneumonia that occurs ≥ 48 hours after hospital admission
• What is ventilation-acquired pneumonia?


  Pneumonia that develops ≥ 48 hours after endotracheal intubation
• What are some features of atypical pneumonia?


  Symptoms may be subacute or less severe → 'walking pneumonia'

  Absence of lobar consolidation on CXR

  Not detectable on Gram stain

  Lack of response to penicillin antibiotics
• Give 4 examples of atypical pneumonias.


  Legionella pneumonia

  Mycoplasma pneumonia

  Q fever secondary to Coxiella brunetii

  psittacosis secondary to Chlamydophila psittaci
• Pneumonia pathophys


  Pathogen inhalation → bound by mucous → move towards pharynx (mucociliary escalator)

  Pathogens evade structural barriers & reach alveoli → phagocytosis by alveolar macrophages → when inoculum size is sufficient or impaired host immune defences → pathogens overwhelm resp tract’s defence mechanisms → replicate & produce virulence factors → damage host tissues → inflam response → accumulation of PMNs (polymorphonuclear leukocytes), fibrin & cellular debris → fill infected alveoli w/ purulent exudates → lung tissue consolidation → impairs gas exchange → hypoxaemia
• What are the signs & symptoms of pneumonia?


  Cough (productive/non-productive)

  Purulent sputum (bacterial)

  Fever

  Fatigue

  SOB

  Pleuritic chest pain

  Wheeze

  Haemoptysis

  Tachypnoea

  Tachycardia

  Hypoxia

  Coarse crackles

  Reduced air entry

  Pleural rub
• What are the RFs of pneumonia?


  Extremes of ages (< 5 or > 65)

  Smoking

  Recent viral resp tract infection

  Chronic resp distress (cystic fibrosis & COPD)

  Immunosuppression (cytotoxic drug therapy & HIV)

  Pts at risk of aspiration (PD or those with oesophageal obstruction)

  IV drug users

  Other non-respiratory co-morbidities (diabetes & CVD)
• What are the Inx of pneumonia?


  Obs

  Full Hx & examination

  Bloods (FBC, U&Es, LFTs, CRP, ABG, cultures (immunocompromised pts))

  CXR

  Sputum culture

  Pleural fluid analysis

  Urinary antigens for pneumococcal antigen and legionella antigen (Depending on CURB score)

  Bronchoscopy (when diagnosis remains unclear)
• What are the DDx of pneumonia?


  Bronchitis

  TB

  Lung cancer
• What are the possible complications of pnuemonia?

  Pleural effusion

  Empyema

  Lung abscess

  ARDS

  PTX

  Sepsis

  Pericarditis
• What tool can be used to decide what level of treatment pts should receive for pneumonia?

  CURB-65
• CURB-65


  Confusion

  Urea > 7 mmol

  Resp rate > 30 breaths/min

  BP (systolic < 90 mmHg, diastolic < 60 mmHg)

  over 65

  Each part scores 1 point

  Results

  • 0-1: Low risk (home-based care)
  • 2-3: Intermediate risk (consider hospital-based care)
  • 3 or more: High risk (consider intensive care)
• What is the treatment for low risk pneumonia?

  Amoxicillin (1st line), 5 day course

  If allergic to penicillin -> macrolide or tetracycline
• What is the treatment for intermediate or high risk pneumonia?


  Dual Abx therapy, 7-10 days -> amoxicillin + macrolide

  NICE recommend considering a beta-lactamase stable penicillin (co-amoxiclav, ceftriaxone, piperacillin) with tazobactam and a macrolide in high-severity community acquired pneumonia
• What are the signs of Legionella pneumonia?

  Lymphopenia

  Hyponatraemia

  Deranged LFTs