1. Pneumonia and Tuberculosis
Ben Ryan Final Year Medical Student

2. Contents Pneumonia Tuberculosis (TB) Definition Classification
Causative Organisms
Assessment
Management
Tuberculosis (TB)
Latent TB
Active TB

3. Pneumonia - Definition
Acute Lower Respiratory Tract Infection of the lung parenchyma
Associated with:
Fever, sweats, myalgia
Chest symptoms (Cough, Shortness of Breath, Sputum production, Pleuritic Chest Pain)
Chest signs (Reduced breath sounds, increased work of breathing)
May cause consolidation or pleural effusion
Pneumonia is one type of chest Infection
Other chest infections include acute bronchitis, infective exacerbations of COPD, and infective exacerbations of asthma

4. Classification Community-Acquired Pneumonia (CAP)
Patient has had no recent admission to hospital
Hospital-Acquired Pneumonia (HAP)
Contracted in hospital, at least hours after being admitted to hospital. Often associated with ventilation/intubation.
Aspiration Pneumonia
Results from inhalation of stomach contents. Risk factors: Stroke, myasthenia gravis, cranial nerve palsies, reduced consciousness, oesophageal disease, general anaesthetic, drug or alcohol abuse, misplaced NG tubes

5. Causative Organisms - CAP
Streptococcus pneumonia is the commonest cause.
Also referred to as ‘pneumococcus’
Gram-positive diplococci
Vaccination exists – on NHS, for those over 65, those with long-term health conditions including COPD and heart failure, and babies
Haemophillus influenza
Second commonest cause.
Most common cause of infective exacerbations of COPD.
Mycoplasma pneumoniae, viruses.
Staph. aureus can be complicated by flu.
Legionella – have they been abroad? Have they got hyponatraemia? Do a urinary legionella antigen test

6. Assessment – CURB-65 score
CURB-65 score – used to determine whether patients with CAP are low/medium/high risk
This is used in hospital. There is a similar CRB-65 score for patients in GP.
1 point for each of the following:
C - Confusion
U - Raised blood urea (more than 7 mmol/litre)
R – Respiratory rate over 30/minute
B – Low blood pressure (systolic less than 90, diastolic less than 60)
65 – aged over 65
Consider home-based care for scores of 0-1
Consider hospital-based care for scores of 2 or more
Consider ICU assessment for scores of 3 or more

7. Assessment Basic Observations (BP, RR, HR, temperature, oxygen sats)
CXR – may show signs of consolidation or pleural effusion
Oxygen Sats
Blood tests – FBC, U&C, Bone Profile, CRP
Sputum microscopy and culture
?Blood cultures – identify pathogen and sensitivities
?ABGs
If pleural effusion – aspirate fluid under ultrasound guidance

8. Antibiotic Therapy for CAP
Each area and trust has their own guidelines
Low risk – amoxicillin for 5 days (if allergic, think about doxycycline or clarithromycin)
Moderate/high risk – Consider 7-10 day course. Consider combining amoxicillin with another agent. Commonly, co-amoxiclav is given (amoxicillin and clavulanic acid, which inhibits B-lactamase)
If admitted, wait till systemically well for 24 hours before discharging

9. Patient information - recovery
Some symptoms may last
After 1 week, fever should have resolved
4 weeks, chest pain and sputum production should have reduced
6 weeks, cough and breathlessness should have reduced

10. Causative Organisms - HAP
Often caused by gram-negative bacteria (52%)
Klebsiella, Legionella, E. coli, Enterobacter
19% from Staph aureus (think about MRSA)
Viruses
Appears to vary depending on area

11. Treatment of HAP
Depends on area – follow local guidelines. Some you may hear of being used:
Tazocin (piperacillin and tazobactam)
Meropenem
Ceftriaxone
Guided by sensitivities (sputum culture/blood culture)

12. Assessment - SEPSIS
In any suspected infection, be sure the patient doesn’t have sepsis!
Life-threatening response to infection – can lead to tissue damage, organ failure and death
Many different diagnostic approaches to SEPSIS, but look for: High or low temperature Raised heart rate High Respiratory Rate High or low neutrophil count Low Oxygen Sats Altered mental state low BP (or drastically reduced BP) high lactate Evidence of Organ Damage
Some diagnostic approaches: SIRS criteria, Q-SOFA and SOFA criteria
Always think sepsis!

13. Management of SEPSIS SEPSIS 6: BUFALO B – Blood cultures
U – measure Urine output (think about catheterisation)
F – Fluid challenge (500mL of 0.9% Sodium Chloride)
A – broad-spectrum Antibiotics
L – Lactate (measure lactate)
O – give high-flow Oxygen

14. Tuberculosis

15. TB - definition
Infectious disease caused by the bacterium ‘Mycobacterium tuberculosis’
Most commonly affects the lungs, but can affect other areas (extrapulmonary):
Pleura
CNS – meningitis
Lymphatic system
Genitourinary system
Bones and joints (Pott disease, if affects the spine)
Miliary TB – wide dissemination of TB infection throughout body

16. Quick Overview
Can have ‘latent TB’ – have infection, with no symptoms, and not contagious
10% of latent TB become active TB – symptomatic and contagious
Risk factors for latent TB becoming active – mainly if immunosuppressed
Antibiotic resistance growing in TB ‘MDR-TB’ (Multi-drug Resistance TB)
More common in Asia (especially India?) and Africa
TB requires long-term antibiotics (even in most latent cases)

17. Latent TB - Assessment No symptoms
Assess for latent TB if risk factors e.g. close contact with active TB, new NHS employees
Mantoux test – tuberculin sensitivity test intradermally, checked 2-3 days afterwards.
Positive if reaction bigger than 5mm. (BCG vaccination, but not that big)
Interferon gamma release assay can be done after Mantoux to confirm diagnosis of latent TB.
Rule out active TB

18. Latent TB - Management
3 months of isoniazid (with pyridoxine) and rifampicin or 6 months of isoniazid (with pyridoxine)
Pyridoxine is just vitamin B6, reduces risk of peripheral nerve damage from isoniazid
Rifampicin causes many bodily fluids to turn orange-red.
Both isoniazid and rifampicin can cause hepatotoxicity – this should be kept in mind when offering treatment.
Offer HIV testing.

19. Active Pulmonary TB
Clinical features: Features of lung disease or constitutional symptoms lasting longer than 2 weeks Chest pain, prolonged cough causing sputum fever, chills, night sweats, loss of appetite, weight loss and fatigue Nail clubbing CXR – patchy shadowing with possible cavitation. Mainly affects upper lobe.
Risk factors of contracting TB, and risk factors of getting active TB (immunosuppression)

20. Diagnosis of Active TB
Depends on location! We’re just focusing on pulmonary
Microscopy and culture of respiratory samples (typically sputum samples). Sometimes described as ‘Acid-Fast Bacilli Smear’. Nucleic Acid Amplification Test can help, especially in immunocompromised.
Can consider Chest X-ray, and CT thorax
Can start treatment before diagnosis confirmed if needed.

21. Management of Active TB
MDT approach – many different professionals involved. TB clinics exist.
Typically: 2 months of isoniazid (with vitamin b6), rifampicin, pyrazinamide and ethambutol and a further 4 months of isoniazid (with vitamin b6) and rifampicin
Longer if they have TB affecting their CNS

22. Managing Active TB Steroids can also be used in TB affecting the CNS
Some role for surgery in particular kinds of TB
Regular follow-up checking adherence
Infection control! If in hospital:
Side room
Not on a ward with immunocompromised patients
Wearing a mask if they leave their side room

23. Latent to Active TB Most latent TB does not become active (90%)
Some groups at more risk:
HIV positive
Younger than 5 years
Excessive alcohol
Injective Drug Users
Solid organ transplants
Haematological malignancy
Chemotherapy
Diabetes
Chronic Kidney Disease

24. MCQ - 1
A 61 Year Old female presents to GP with 4 day history of worsening cough, producing green sputum. She also has a fever, and mild chest pain on her right side, worse on breathing in. She has no other symptoms. She has had no recent hospital admissions, and has nil past medical history of note. On auscultation of the chest, air entry is reduced in the lower zone of the right lung with crackles heard on inspiration. Respiratory rate is 20/minute. Blood pressure is 130/85. What is the most likely causative organism?
A – Haemophillus influenza B – Staphylococcus aureus C – Adenovirus D – Streptococcus pneumoniae E – Legionella

25. MCQ - 1
A 61 Year Old female presents to GP with 4 day history of worsening cough, producing green sputum. She also has a fever, and mild chest pain on her right side, worse on breathing in. She has no other symptoms. She has had no recent hospital admissions, and has nil past medical history of note. On auscultation of the chest, air entry is reduced in the lower zone of the right lung with crackles heard on inspiration. Respiratory rate is 20/minute. Blood pressure is 130/85. What is the most likely causative organism?
A – Haemophillus influenza B – Staphylococcus aureus C – Adenovirus D – Streptococcus pneumoniae E – Legionella

26. MCQ – 2
A 63 Year Old male presents to GP with 4 day history of worsening cough, producing green sputum. He also has a fever, a mild wheeze on inspiration, and worsening of shortness of breath. He has no other symptoms. He has a history of COPD, and a 60-pack year smoking history. On auscultation of the chest, air entry is reduced throughout both lungs, with a polyphonic wheeze audible. What is the most likely causative organism of this episode?
A – Haemophillus influenza B – Staphylococcus aureus C – Adenovirus D – Streptococcus pneumoniae E – Influenza

27. MCQ – 2
A 63 Year Old male presents to GP with 4 day history of worsening cough, producing green sputum. He also has a fever, a mild wheeze on inspiration, and worsening of shortness of breath. He has no other symptoms. He has a history of COPD, and a 60-pack year smoking history. On auscultation of the chest, air entry is reduced throughout both lungs, with a polyphonic wheeze audible. What is the most likely causative organism of this episode?
A – Haemophillus influenza B – Staphylococcus aureus C – Adenovirus D – Streptococcus pneumoniae E – Influenza

28. MCQ - 3
A 46 year old female presents to A&E with a 3 day history of worsening cough, with green sputum production. She recently returned from Spain, where she stayed in cheap accommodation. She also has a fever. Her blood tests show the following: Na: 130 (low) K: 4.0 Urea: 6.0 Creatinine: 60
What is the likely causative organism?
A – Haemophillus influenza B – Staphylococcus aureus C – Adenovirus D – Streptococcus pneumoniae E – Legionella

29. MCQ - 3
A 46 year old female presents to A&E with a 3 day history of worsening cough, with green sputum production. She recently returned from Spain, where she stayed in cheap accommodation. She also has a fever. Her blood tests show the following: Na: 130 (low) K: 4.0 Urea: 6.0 Creatinine: 60
What is the likely causative organism?
A – Haemophillus influenza B – Staphylococcus aureus C – Adenovirus D – Streptococcus pneumoniae E – Legionella

30. MCQ – 4
A 61 Year Old female presents to ED with 4 day history of worsening cough, producing green sputum. She also has a fever, and mild chest pain on her right side, worse on breathing in. Her partner reports she has became increasingly confused over the past today. She has had no recent hospital admissions, and has nil past medical history of note. On auscultation of the chest, air entry is reduced in the lower zone of the right lung with crackles heard on inspiration. Respiratory rate is 32/minute. Blood pressure is 90/55. Which of the following would be part of your initial management plan? (more than one correct answer)
A – 500mL of 0.9% Sodium Chloride B – Prescribe 500mg Amoxicillin TDS C – Arrange an urgent CT head D – Arrange high-flow Oxygen E – Inform your senior F – Inform the Critical Care Outreach Test G – Arrange an out-patient Chest X-Ray H – Place a Chest Drain in the 5th ICS mid-axillary line I – Perform a Mantoux Test

31. MCQ – 4
A 61 Year Old female presents to ED with 4 day history of worsening cough, producing green sputum. She also has a fever, and mild chest pain on her right side, worse on breathing in. Her partner reports she has became increasingly confused over the past today. She has had no recent hospital admissions, and has nil past medical history of note. On auscultation of the chest, air entry is reduced in the lower zone of the right lung with crackles heard on inspiration. Respiratory rate is 32/minute. Blood pressure is 90/55. Which of the following would be part of your initial management plan? (more than one correct answer)
A – 500mL of 0.9% Sodium Chloride B – Prescribe 500mg Amoxicillin TDS C – Arrange an urgent CT head D – Arrange High-Flow Oxygen E – Inform your senior F – Inform the Critical Care Outreach Test G – Arrange an out-patient Chest X-Ray H – Place a Chest Drain in the 5th ICS mid-axillary line I – Perform a Mantoux Test

32. Sepsis 6 BUFALO (sometimes give 3, take 3) Blood cultures Urine output
Fluid challenge (500mL of sodium chloride 0.9%)
Antibiotics (broad spectrum)
Lactate (do a lactate blood test)
Oxygen (high flow)
It’s also important to tell your senior, and the critical care outreach team like to have high-risk patients on their radar.

33. References
NICE CKS
NICE Guidelines
Oxford Handbook
wikipedia