Definition?
Pneumonia acquired outside of hospital and healthcare facilities.
RF?
• >65 • Residence • COPD • Exposure to cigarette smoke • Alcohol abuse • Poor oral hygiene • Acid-reducing drugs children
Ddx?
- COVID-19-dry cough, fever, loss of taste or smell
- Acute Bronchitis-no dyspnoea, no crackles
- CHF-oedema, cardiomegaly, hypotension
- COPD/Asthma/bronchiectasis exacerbation
- TB-night sweats, cough, weight loss, lethargy
- Lung cancer-night sweats, weight loss, lethargy
- Empyema-as above
- PE-dyspnoea, pleuritic chest pain, DVT
- Pneumothorax-acute onset
- Hypersensitivity pneumonitis-lasts a few days
Epidemiology?
Age:>65
Sex:
Ethnicity:
Aetiology?
• Strep pneumoniae
Haemophilus influenzae,Staphylococcus aureus(including MRSA), group A streptococci, andMoxarella catarrhalis.
• Atypical bacteria-Mycoplasma pneumoniae,Chlamydophila pneumoniae, andLegionella pneumophila
• Influenza virus A/B, respiratory syncytial virus, adenovirus, rhinovirus, and parainfluenza virus
Pneumocystis jirovecii, aspergillus, candida, staph aureus, strep pneumoniae, Hib, cytomegalovirus, HSV
CP?
• Cough with sputum • Dyspnoea • Pleuritic chest pain • Rigors • Fever • crackles, decreased breath sounds, dullness to percussion, and wheeze • Confusion • RFs • CURB-65 Atypical - onset was less acute and are more likely during known community outbreaks.
CURB 65?
confusion uremia resp rate BP age
Pathophysiology?
• Protection via coughing mucociliary escalator or macrophages
• Microbes colonises bronchioles or alveoli and invades lung tissue
• Inflammatory response of white blood cells, proteins, fluid, RBC
• Bronchopneumonia-throughout lung
• Lobar-consolidation of whole lobe-caused by s.pneumoniae
Blood vessels and alveoli fill with fluid , exudate fill airspace and have liver-like appearance, rbcs breakdown and cleared by immune system.
Investigation first line?
- CXR-consolidation, cavitation, pleural effusions
- Pulse oximetry-less than 94% indicates oxygen therapy
- ABG-low arterial saturation
- U and E-elevated/urea
- FBC-leukocytosis, bacterial causes
- CRP-baseline for infection diagnosis
- LFT-baseline for liver disease
Investigation-Second line?
- Blood culture
- Sputum culture
- Urinary antigen testing for legionella and pneumococcous
- PCR
- CT chest
- Chest US
- Pleural fluid culture
- bronchoscopy
M-suspected?
• IV antibiotics if Life-threatening Illness
• CXR
• Oxygen-
• 94% to 96%in acutely ill patients who arenot at risk of hypercapnia
• 88% to 92%in patientsat risk of hypercapnia.
• Fluid resuscitation
• Vasopressors
Analgesia
M-community suspected?
• Low-oral Abs and assess after 5 days
• Mod-if stable and can take oral Abs
High-Hospital and IV benzylpenicillin or oral amoxicillin or clarithromycin
M-confirmed?
• IV antibiotics-oral amoxicillin and/or clarithromycin
• Fluoroquinolone-if not responsive to above or if legionella
• Oxygen-
• 94% to 96%in acutely ill patients who arenot at risk of hypercapnia
• 88% to 92%in patientsat risk of hypercapnia.
• Fluid resuscitation
• Vasopressors
• Analgesia
Pathogen-specific AB therapy
AB for mycoplasma pneumoniae/chlamydophila?
clarithromycin
legionella
fluroquinolone
strep pneu?
amoxicillin
chlam psittaci/coxiella?
doxycycline
hib?
amoxicillin
G- enteric bacilli?
cefotaxime/ceftriaxone
pseudomonas aeruginosa?
ceftazidime
staphyloccous aureus
flucloxacillin
MRSA?
vancomycin
Prognosis?
- 5-15% but increases to 20%-50 if in ICU
- Depends on RFs
- Exacerbation of co-morbidities lead to readmission
Complications?
- Sepsis
- ARDS
- C.diff colitis
- HF
- ACS
- Arrhythmias
- Necrotising pneumonia
- Pleural effusion
- Lung abcess
- pneumothorax
