QuestionSBA
QuestionChoice
CURB-65 is made up of five components, all scoring either 0 or 1: confusion, urea >7mmol/L, respiratory rate ≥ 30, systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg , and age ≥ 65. This patient scores for all sections except respiratory rate, therefore she scores 4, putting her in the highest risk group with 27.8 30-day mortality
33184
b
1
QuestionChoice
CURB-65 is made up of five components, all scoring either 0 or 1: confusion, urea >7mmol/L, respiratory rate ≥ 30, systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg , and age ≥ 65. It's purpose is to estimate mortality for community-acquired pneumonia to help determine whether they should be managed as an inpatient or outpatient i.e. whether to admit them. CURB-65 score 0-1 assigns them to a low risk group with 2.7% 30-day mortality where they can likely be managed as an outpatient. Score 2 assigns them to moderate risk group with 6.8% 30-day mortality where they should either be managed as an inpatient or as an outpatient with close follow-up. Score 3 assigns them to severe risk group with 14.0% 30-day mortality where they should be admitted with possible intensive care admission. Score 4-5 puts them in the highest risk group with 27.8% 30-day mortality where they should be admitted with possible intensive care admission. This patient scores for all sections except respiratory rate, therefore she scores 4, putting her in the highest risk group
33183
a
4
QuestionChoice
CURB-65 is made up of five components, all scoring either 0 or 1: confusion, urea >7mmol/L, respiratory rate ≥ 30, systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg , and age ≥ 65. This patient scores for all sections except respiratory rate, therefore she scores 4, putting her in the highest risk group with 27.8 30-day mortality
33185
c
2
QuestionChoice
CURB-65 is made up of five components, all scoring either 0 or 1: confusion, urea >7mmol/L, respiratory rate ≥ 30, systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg , and age ≥ 65. This patient scores for all sections except respiratory rate, therefore she scores 4, putting her in the highest risk group with 27.8 30-day mortality
33186
d
3
QuestionChoice
CURB-65 is made up of five components, all scoring either 0 or 1: confusion, urea >7mmol/L, respiratory rate ≥ 30, systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg , and age ≥ 65. This patient scores for all sections except respiratory rate, therefore she scores 4, putting her in the highest risk group with 27.8 30-day mortality
33187
e
5
Concept
Chapter
# Summary 
 
Pneumonia is a radiological diagnosis, often due to a lower respiratory tract infection causing inflammation of the alveoli and terminal bronchioles, leading to consolidation of bronchopulmonary segment or lobe. Key signs and symptoms include rapid onset of high fever and productive cough for typical bacterial causes. Key investigations include blood tests, sputum culture, urinary antigen tests, and chest x-ray. Management strategies involve use of antibiotics, assessment of severity using CURB-65 score and inpatient treatment for severe cases.
 
 
# Definition
 
- Lower Respiratory Tract Infection/ Pneumonia is caused by infection and subsequent inflammation of the alveoli and terminal bronchioles.
- This leads to an entire bronchopulmonary segment or lobe becoming consolidated, which means that tissue is filled with inflammatory cells and oedema.
 
 
# Community Acquired Pneumonia (CAP)
 
 
## Bacterial Causes
 
 
- Typicals - so called because of the classical rapid onset of symptoms, including high fever and productive cough;
- Streptococcus pneumoniae (gram +ve cocci found in pairs, also known as 'Pneumococcus')
- Staphylococcus aureus
- Haemophilus influenzae (gram -ve rod, potent beta-lactamase producer)
- Moraxella catarrhalis (gram -coccus, potent beta-lactamase producer)
- Atypicals: so called because of the more gradual onset of symptoms, which may be non-specific initially (fever, myalgia, dry cough). The organisms are also intracellular;
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
- Legionella pneumophila
- Coxiella burnettii
- Chlamydia psittaci
 
 
## Viral Causes 
 
- Most commonly Influenza A, which can predispose to superadded Staph aureus (or strep pneumoniae) pneumonia.
- Others: CMV, HSV, VZV
 
## Fungal Causes
 
Can be seen after silver staining and microscopy:
 
- Candida - dimorphic yeast
- Aspergillus - fungus with hyphae
- Cryptococcus - encapsulated yeast
 
 
## Specific Causes 
 
COPD: 
 
- Pneumococcus still most common
- Haemophilus influenzae
- Morexella catarrhalis
 
Cystic Fibrosis:
 
 
- Staph aureus
- Pseudomonas aeruginosa
- Burkholderia cepacia
 
Causes in Homeless people: malnourished, alcohol or drug dependent, immunosuppressed:
 
 
- Mycobacterium tuberculosis
- Aspiration pneumonia (infection with normal flora of mouth and anaerobes, also consider in any patient with an unsafe swallow or with depressed consciousness)
- Klebsiella pneumoniae (causes 'red-current jelly' sputum, and commonly causes lung abscess formation and empyema)
 
 
Occupational/travel situations:
 
- Aerosols from humidifiers and airconditioning (e.g. at holiday resorts) - Legionella pneumophila.
- Patients can present with diarrhoea and vomiting, develop hepatorenal syndrome and have a low sodium. Severe pneumonia develops, with other rare complications such as:
- Pancreatitis
- Peritonitis
- Myocarditis, endocarditis, pericarditis
- Glomerulonephritis
 
 
Closed populations e.g. schools, offices
 
- Mycoplasma pneumoniae
- Extra respiratory symptoms:
- Erythema multiforme, erythema nodosum
- Guillain-Barre Syndrome (and rarely other neurological complications e.g. aseptic meningitis, cerebellar disease, transverse myelitis).
- Cold agglutinin production with haemolytic anaemia
- Chlamydia pneumoniae
 
 
Zoonotic Causes: 
 
- In Abattoir worker, farmer, vets
- Coxiella burnettii
- Brucella spp.
 
- Animal hide importers/sorters
- Bacillus anthracis
- Coxiella burnettii
 
 
- Following exposure to birds
- Chlamydia psittaci (causes psittacosis)
- Exposure to bats/bat droppings
- Histoplasma capsulatum (a fungus, classically affects cave-explorers)
 
 
## Investigations
 
 
- Bloods: including FBC, U+Es, CRP, WCC and blood cultures
- Sputum culture
- Urinary antigen tests for Legionella and pneumococcus
- Chest X-Ray
- Could assess pleural fluid aspirate in patients with pleural effusion
 
 
## CURB-65 
 
 
- Use the CURB-65 score to aid in deciding the severity of pneumonia and further management based on this
- Components (1 point for each if present):
- Confusion +/-
- Urea >7
- Respiratory Rate >30
- Blood pressure: systolic < 90 or diastolic <60
- More than 65 years old
 
 
CURB-65 mortality by score:
 
- 0 or 1 - 1.5%
- 2 - about 10%
- 3 or more - 10% or more 
 
 
 
 
## Management
 
If a patient is very unwell, adopt an A-E approach, initiate the sepsis six and seek early senior input.
 
- Management based on CURB-65 score:
- 0/1: home-based care, give oral amoxicillin for 5 days (macrolide e.g. clarithromycin, doxycycline or tetracycline if penicillin allergic).
- 2: hospital-based care, 7-10 day course of dual antibiotic therapy with amoxicillin (IV or oral) and a macrolide
- 3: Hospital/ITU-based care, 7-10 day course of dual antibiotic therapy with IV co-amoxiclav/ceftriaxone/tazocin and a macrolide.
 
 
- Atypical and typical community-acquired pneumonia are both managed in the same way initially.
- Liaise with microbiology to guide targeted antibiotics following culture results e.g. flucloxacillin for staph aureus pneumonia.
- A repeat chest x-ray is required after 6 weeks to assess for underlying pathology.
 
 
## Complications
 
 
- Pleural effusion
- Empyema (suspect if persistent, swinging fever with leucocytosis found after antibiotic therapy)
- Abscess (can be caused by S. pneumoniae, Klebsiella, staph aureus). Can develop pyopneumothorax.
- Pneumothorax
- Septicemia
- Atrial fibrillation
- Post-infective bronchiectasis
 
 
 
 
# Hospital Acquired Pneumonia
 
 
## Definition
 
 
Lower respiratory tract infection that develops more than 48 hours after admission to hospital
 
 
## Risk Factors
 
 
- Poor hand hygiene and hospital infection control
- Intubation and ventilation
 
 
## Causative Organisms
 
 
- Pseudomonas aeruginosa
- E. coli
- Klebsiella pneumoniae
- Acinetobacter species (can acquire high potency beta-lactamases, known as ESBLs)
- Serratia species (can acquire high potency beta-lactamases, known as ESBLs)
 
 
## Investigations
 
May include:
 
- Bloods: including FBC, U+Es, CRP, WCC and blood cultures
- Sputum culture
- Urinary antigen tests for Legionella and pneumococcus
- Chest X-Ray
- Could assess pleural fluid aspirate in patients with pleural effusion
 
 
## Management 
 
If a patient is very unwell, adopt an A-E approach, initiate the sepsis six and seek early senior input and discussion with microbiology. Empirical antibiotics are guided by severity and likelihood of resistant organisms:
 
- HAP within 5 days of admission: co-amoxiclav is usually first line for non-severe symptoms
- HAP more than 5 days after admission (associated with higher risk of resistance) or severe symptoms: tazocin or cephalosporin (e.g. ceftazidime) or quinolone first-line.
- If MRSA is suspected, add vancomycin
 
 
# Aspiration Pneumonia 
 
 
- Caused by any cause of depressed consciousness or impairment of the swallowing mechanism
- Infection caused by mixed aerobic and anaerobic mouth flora, which can cause cavitary pneumonia or empyema
- Same empirical therapy as for non-aspiration pneumonia, but later antibiotic choice made by pathogen and sensitivities. Metronidazole often added in to cover for anaerobic organisms. Local guidance should be sought.
 
 
# NICE Guidelines
 
 
[Click here for NICE CKS on chest infections](https://cks.nice.org.uk/topics/chest-infections-adult/)
 
[Click here for NICE guidance on antimicrobial prescribing in hospital-acqui
271
2650
Pneumonia
Topic
20
Respiratory Physiology
4
6637
A 72-year-old woman with advanced motor neurone disease presents to A&E with a 3-day history of worsening breathlessness, fever, and acute confusion.
On examination her respiratory rate is 28, peripheral oxygen saturations 95% on 2L nasal cannula, heart rate 107, blood pressure 104/58, temperature 38.2°C

Auscultation reveals reduced air entry at both bases and coarse inspiratory crepitations in the left lower zone. GCS: 13 (E4V3M6).  

Chest X-ray reveals bibasal atelectasis and left lower zone patchy consolidation

Bloods reveal the following

||||
|--------------|:-------:|---------------|
|Haemoglobin|118  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|17.1x10<sup>9</sup>/L|3.0 - 10.0|
|Urea|11.1 mmol/L|2.5 - 7.8|
|Creatinine|170 µmol/L|60 - 120|
|C Reactive Protein|135 mg/L|< 5|


What of the following is the patient's calculated CURB-65 score?
a