1. Pneumonia SAHD Senior Academic Half Day Matt Rogers & James Clayton
Consultant Microbiologists
June 2010

2. Learning objectives Recognise the Clinical features of pneumonia
Demonstrate appropriate use of CURB-65 severity scoring index
Know the main causes of Community acquired pneumonia
Interpret laboratory results and apply to Clinical decisions
Understand the key principles of antibiotic prescribing

3. Are you feeling Excited about the session
Apprehensive about the session
Apathetic about the session
Go away and leave me alone of 5

4. Are you
Male
Female of 5

6. What is your favourite speciality?
Medicine
Surgery
Pathology GP
Other…and offended! of 5

7. How well do you think you could deal with a patient in ED with a Chest Infection?
Superbly
Well
Adequately
Poorly
Rather not say of 5

8. Presentation of pneumonia
Fever/chills/sweats/rigors
Cough
Productive of sputum – clear/purulent/blood stained etc.
Dyspnoea
Pleuritic chest pain
Malaise
Anorexia and vomiting
Headache
Myalgia
Diarrhoea

9. Chest examination Anatomic Landmarks The Extrathoracic Examination
Chest Inspection, Palpation, Percussion
Chest Auscultation

10. Clinical signs of pneumonia
Pyrexia
Tachypnoea
Cyanosis – rare
Altered mental state
Consolidation
Dull percussion note
Inspiratory crepitations
Bronchial breathing
Increased vocal resonance and tactile vocal fremitus (voice vibration felt with the hand greater over areas of consolidation)
Whispering pectoriloquy (increased loudness of voice over area of consolidation when auscultating)

11. Infective exacerbation of COPD
Please exclude a diagnosis of Infective exacerbation of COPD before treating for Community Acquired Pneumonia (CAP)
Infective Exacerbation of COPD – past history of COPD
↑ dyspnoea
↑ sputum volume
increased sputum purulence

12. Classification of pneumonias
Typical vs Atypical ??IS THIS VALID??
Community acquired (CAP) vs hospital acquired (HAP)
Lobar vs Bronchopneumonia
Aspiration pneumonia
Immunocompromised host pneumonia
There is often difficulty in placing a pneumonia into one category or another

13. Management of pneumonia
Depends on severity and co-morbidity (particularly CAP)
Formally assess severity CURB-65
Supportive treatment essential
IV fluids
Oxygen
Analgesia
need for ventilation?
Investigations
Antibiotic therapy

14. Complications of pneumonia
Bacteraemia/Septicaemia……death
Lung abscess
Parapneumonic effusion/empyema

15. Which criteria are included in CURB-65 severity scoring
Cyanosis
Urea
Respiratory rate
Base excess
65% O2 required of 5

16. Severity: CURB-65 Confusion: new confusion AMT <8 Urea >7mmol/l
Respiratory rate: >=30/min
Blood pressure: sys <90 or dias <60
>65 years old
Hypoxia Arterial pO2 <8Kpa
Multilobar disease

17. CURB-65

18. Implications of CURB-65 Severe pneumonia is CURB-65 >3
Score of 3 = mortality 17%,
Score of 4 = mortality 41.5%,
Score of 5 = mortality 57%
Need admission and IV antibiotics
Non-severe pneumonia CURB-65 0 or 1
Score of 1 = Mortality 3.2%
O/p treatment with oral antibiotics
CURB 2 – Needs clinical judgement in hospital
Mortality 13%

19. MAU Audit Zoe Campbell F2 SHO
Only those with Severe pneumonia according to CURB criteria should receive IV antibiotics
18 out of 25 patients received IV antibiotics
18 patients were classified mild/mod (? Oral antibiotics)
7 patients were classified severe (? IV antibiotics)
I.V.
Oral
Mild/
Moderate
Severe

20. Investigations of Pneumonia
CXR
O2 saturation +/- gases
Microbiology…
Biochemistry
Urea
LFT
CRP
Haematology
FBC: WBC, plts, ?clotting

21. What microbiology samples would you send on a patient with severe CAP?
Sputum
Nose swab
Urinary Antigen
Serology
Blood Culture of 5

22. Send appropriate samples

23. Sputum: microscopy Sputum appearance?
Mucoid/Salivary/Blood stained/Green/Yellow etc
Gram stain??: Sputum/BAL etc.
Special stains: TB/PCP etc.

24. Sputum: culture and sensitivity

25. Blood culture
Blood cultures should be taken from anyone with severe pneumonia
Sterile technique vital
Inoculate into blood culture bottles, aerobic and anaerobic
Automated blood culture machine for 5 days
Please take before pt on antibiotics!!!

26. Others BAL/Pleural fluid more of a reliable sample than sputum
Serology-Acute and convalescent phase (0 and 14 days). A useful test for Mycoplasma, Chlamydia, Legionella, Coxiella, Influenza etc.
Antigen detection: Immunoflourescence (eg RSV from NPAs)
Urine for legionella/pneumococcal antigen

27. BTS guidelines All patients admitted with severe CAP should have
Blood cultures
Sputum culture
Legionella antigen
All patients admitted with non-severe CAP need
Sputum cultures (unless have had recent course of antibiotics)

28. Which bacteria are common causes of CAP
Escherichia coli
Streptococcus pneumoniae
Haemophilus influenzae
Coagulase negative staphylococci
Moraxella catarrhalis of 5

29. Organisms causing Pneumonia
Viruses – Influenza, parainfluenza
Community acquired pneumonia
Streptococcus pneumoniae Mycoplasma pneumoniae
Haemophilus influenzae Legionella pneumophila
Moraxella catarhalis Chlamydia psittaci
Staphylococcus aureus Coxiella burnetti
Hospital acquired Pneumonia
Escherichia coli, Klebsiella pneumoniae,
Acinetobacter baumanii etc

30. CAP causative organisms

31. Streptococcus pneumoniae
Gram positive streptococcus, commensal flora. Need to distinguish infection from colonisation
Acute pyogenic infection
Rapidly progressing infection often associated with bacteraemia
Often fatal in elderly/immunocompromised. Capsule is the most important virulence factor
Capsular based vaccines available for at risk groups

32. Hospital acquired pneumonia
Often after courses of antibiotics
At risk patients
Possibly ventilated
Enteric gram negative bacilli –E.coli, K.pneumoniae etc
Pseudomonas aeruginosa
MRSA

33. Chest Infection Possible choices Amoxicillin
Augmentin Cefuroxime Ciprofloxacin
Ceftazidime Tazocin Meropenem
+/- erythromycin/clarithromycin (Atypical cover)

34. And Atypicals!

40. Coventry and Warwickshire Treatment Guidelines (Hospital)

41. Community acquired pneumonia
Strep. pneumoniae ~ %
Haemophilus influenzae ~ %
Staph. aureus ~ %
Severity of infection (CURB-65 score)
Determines need for IV or oral treatment
Determines need for broad vs narrow cover

42. Don’t forget atypicals in CAP!
Legionella pneumophila ~ 1 - 5%
Mycoplasma pneumoniae ~ %
Chlamydophila pneumoniae < 10% ?
Chlamydia psittaci, Coxiella < 2%
Viruses including Influenza < 15%
Addition of
Macrolide e.g. erythromycin or clarithromycin
Tetracycline e.g. doxycycline
(Ciprofloxacin)

43. Chest Infection Recommendation

44. Chest Infection recommendation

45. Mid session interval
You have 5 minutes, the attendance book will be available for signing on your return

46. Which of the following do you do when prescribing antibiotics
Review pts previous microbiology results
Document indication and duration/review date in the patients notes
Write indication on drug chart
Write review or stop date on drug chart
Review antibiotic at 48hrs and change to oral if appropriate of 5

47. How well do you think you could deal with a patient in ED with a Chest Infection?
Superbly
Well
Adequately
Poorly
Rather not say of 5