History

Fact Explanation
Productive cough This usually follows an influenza like prodrome. The causative organism is staphylococcus aureus.The cough is due to irritation caused by inflammatory mediators.The sputum consists of secretions and cell debris.
Haemoptysis Necrotizing pneumonia is caused by Panton-Valentine leukocidin-positive Staphylococcus aureus [3]
Dyspnoea This due to respiratory stimulation following hypoxia and hypercarbia. This can also be an early feature of sepsis.[1]
High fever This is due to the cytokines acting on hypothalamic thermoregulatory center.
Pleuritic type chest pain This is due to the inflammation of pain sensitive pleura that get stretched in respiration.
Recent history of respiratory infection It is due to bronchial surface getting infected with secondary bacterial infection, such as S. aureus[2]
Recent skin and other infections Previously healthy individuals can acquire pneumonia due to skin infections (impetigo, abscess, cellulitis, furunculosis ) or other infections such as septic abortion, in the form of hematogenous dissemination of the infection[2]
Recent Hospitalization S. aureus is relevant in patients who require hospitalization.The elderly with chronic diseases such as COPD, cardiovascular diseases, diabetes mellitus, hemodialysis are affected.[2]
Altered consciousness This is a complication of sepsis, which indicates cerebral involvement.[1]
Reduced urine output Acute kidney injury is manifested as oliguria.This is due to the renal hypo perfusion caused by vasodilation and hypotension,as a result of sepsis.[1]
Reduced bowel opening and abdominal distention Paralytic ileus is a complication of systemic sepsis.[1]
Bleeding manifestations (Gum bleeding, Echemotic patches) Thrombocytopenia, and disseminated intravascular coagulation can be a result of systemic sepsis.[1]
Collapse This is due to hypotension caused by peripheral vasodilation.[1]
Risk factors for acquiring MRSA infections Following groups have high risk of acquiring MRSA infections: athletes, IV drug users, military personnel, prison Inmates, veterinarians and pig farmers. [4]
References
  1. ANGUS DC, VAN DER POLL T. Severe sepsis and septic shock. N Engl J Med [online] 2013 Nov 21, 369(21):2063 [viewed 11 June 2014] Available from: doi:10.1056/NEJMc1312359
  2. SANTOS JW, NASCIMENTO DZ, GUERRA VA, RIGO VDA S, MICHEL GT, DALCIN TC. Community-acquired staphylococcal pneumonia. J Bras Pneumol [online] 2008 Sep, 34(9):683-9 [viewed 11 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18982205
  3. KHANAFER NAGHAM, SICOT NICOLAS, VANHEMS PHILIPPE, DUMITRESCU OANA, MEYSSONIER VANINA, TRISTAN ANNE, BèS MICHèLE, LINA GéRARD, VANDENESCH FRANçOIS, GILLET YVES, ETIENNE JéRôME. Severe leukopenia in Staphylococcus aureus-necrotizing, community-acquired pneumonia: risk factors and impact on survival. Array [online] 2013 December [viewed 11 June 2014] Available from: doi:10.1186/1471-2334-13-359
  4. DEFRES S, MARWICK C, NATHWANI D. MRSA as a cause of lung infection including airway infection, community-acquired pneumonia and hospital-acquired pneumonia. Eur Respir J [online] 2009 Dec, 34(6):1470-6 [viewed 12 June 2014] Available from: doi:10.1183/09031936.00122309

Examination

Fact Explanation
Fever This is typically a high fever 38C<[2].This is due to mediators released by the bacteria as well as the host defense system.
Tachycardia This is a common finding in Staphylococcal pneumonia. Hyperpyrexia and catecholamines released can also increase the heart rate.
Tachypnoea This due to respiratory stimulation following hypoxia and hypercarbia. This can also be an early feature of sepsis.[1]
Warm peripheries This is due to peripheral vasodilation.
Hypotension This is due to peripheral vasodilation.[1]This sign indicates the onset of septic shock,which is a complication.[1]
Dull percussion note This can be the result of: multi lobar consolidation, [2] lobar collapse, pleural effusion[2]
Reduced air entry This can be the result of: multi lobar consolidation, [2] lobar collapse, pleural effusion[2]
Broncial breating This is due to air flow in patent bronchioles while there is surrounding consolidation.
Coarse crackles This occurs due to opening of collapsed airways.[2]
Signs of infective focus: Pustular lesions, tender erythematous, localized swellings and wounds with pus discharge Skin infections (impetigo, abscess, cellulitis, furunculosis ) can be associated with staph pneumonia[1]
Gum bleeding and ecchymosis. Thrombocytopenia, and disseminated intravascular coagulation can be a result of systemic sepsis.[1]
Abdominal distention Paralytic ileus is a complication of systemic sepsis.[1]
Reduced GCS This is a complication of sepsis, which indicates cerebral involvement.[1]
References
  1. ANGUS DC, VAN DER POLL T. Severe sepsis and septic shock. N Engl J Med [online] 2013 Nov 21, 369(21):2063 [viewed 11 June 2014] Available from: doi:10.1056/NEJMc1312359
  2. KREIENBUEHL L, CHARBONNEY E, EGGIMANN P. Community-acquired necrotizing pneumonia due to methicillin-sensitive Staphylococcus aureus secreting Panton-Valentine leukocidin: a review of case reports Ann Intensive Care [online] :52 [viewed 12 June 2014] Available from: doi:10.1186/2110-5820-1-52

Differential Diagnoses

Fact Explanation
Streptococcus pneumoniae Acute onset, flu-like symptoms followed by cough and rust coloured sputum. Pleuritic pain is common.[1][2]
Mycoplasma pneumoniae This is common in young patients and it is mild. extrapulmonary symptoms (headache, malaise, myalgia) are prominent. complications: haemolytic anaemia, erythema multiforme, meningoencephalitis, hepatitis. [1][2]
Legionella pneumophila This is acquired by inhaling droplets from air conditioning symptoms which is a colonizing site for legionella. There is GI involvement such as diarrhea, liver involvement (altered enzymes) .[1][2]
Chlamydophila pneumoniae It causes mild disease and prolonged prodrome.[1] There can be cutaneous, GI and neurological symptoms. [2]
Haemophilus influenzae This is commoner in patients with lung disease such as cystic fibrosis, bronchiectasis and COPD or in the elderly.[1]
Coxiella burnetti (Q fever) Occurs more commonly in young men. There is dry cough and high fever. Endocarditis is a known complication.[1][2]
Klebsiella pneumonia More common in alcoholics, poor dental hygiene and diabetes mellitus. Systemic symptoms are common. [1]
Pseudomonas aeruginosa This is a hospital acquired condition. Cavitation and abscess formation is seen. There is high incidence in patients with lung pathology (cystic fibrosis,bronchiectasis, COPD) or immune suppression.[1]
All respiratory viruses Common in the elderly with subsequent staphylococcal pneumonia. This is a mild disease.[1][2]
Fungal infections Occurs in immunocompromised patients and in those with an underlying lung pathology.
References
  1. KUMAR, Parveen. CLARK, Michael.Kumar & Clark’s Clinical Medicine.8th Edition.London.Elsevier.2012.pp.833-839
  2. BRITISH THORACIC SOCIETY STANDARDS OF CARE COMMITTEE. BTS Guidelines for the Management of Community Acquired Pneumonia in Adults. Thorax [online] 2001 Dec:IV1-64 [viewed 12 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11713364

Investigations - for Diagnosis

Fact Explanation
Full blood count and differential count. There can be leucocytosis or leucopenia because of the effect of staphylococcal toxins. [1]
C-reactive protein This is a acute phase protein and it is often elevated very high.[1]
Blood culture,Gram staining and antibiogram This identifies bacteremia, [2] on the culture,there will be golden colored colonies.The gram staining will show the classical gram positive, bunch of grapes appearance. Antibiogram will indicate inhibitions of growth according to the sensitivity to the drug.
Sputum or broncho-alveolar lavarge culture,Gram staining and antibiatogram Helps to identify the pathogen. On the culture,there will be golden colored colonies.The gram staining will show the classical gram positive bunch of grapes appearance. Antibiogram will indicate inhibitions of growth according to the sensitivity to the drug..[2][3]
Chest X-Ray It shows multilobular cavitating alveolar infiltrates[1]
CT thorax Cavitations, pleural effusions, pneumatoceles and pneumothoraces can be confirmed by a computed tomography scan [3]
Microarrays to identify PVL and other staphylococcal toxins superantigens Helps in identifying MRSA. [3]
References
  1. RUBINSTEIN E, KOLLEF MH, NATHWANI D. Pneumonia caused by methicillin-resistant Staphylococcus aureus. Clin Infect Dis [online] 2008 Jun 1:S378-85 [viewed 12 June 2014] Available from: doi:10.1086/533594
  2. KUMAR, Parveen. CLARK, Michael.Kumar & Clark’s Clinical Medicine.8th Edition.London.Elsevier.2012.pp.833-839
  3. DEFRES S, MARWICK C, NATHWANI D. MRSA as a cause of lung infection including airway infection, community-acquired pneumonia and hospital-acquired pneumonia. Eur Respir J [online] 2009 Dec, 34(6):1470-6 [viewed 12 June 2014] Available from: doi:10.1183/09031936.00122309

Investigations - Fitness for Management

Fact Explanation
Pulse oxymetry This Indicates the level of oxygen saturation.The lover level of adequate saturation is 94%[1] and when the saturation is decreasing below 90% while on oxygen supplementation, intubation and ventilation may have to be considered. Precise control arterial oxygenation is needed because there is a risk of ischemia. (eg- global cerebral ischemia)
Arterial Blood Gas Analysis This can additionally indicate the pH level (it can be reduced and indicate respiratory acidosis) This is usually done when oxygen saturation drops less than 94%[1]
Plasma urea level This is used to calculate CURB 65 score.[1]
Albumin level This is an indicator of severity (less than<35 g/L) [1]
Coagulation screen: PT,APTT,Platelet count There is coagulopathy [2] DIC can be identified.
References
  1. KUMAR, Parveen. CLARK, Michael.Kumar & Clark’s Clinical Medicine.8th Edition.London.Elsevier.2012.pp.833-839
  2. KREIENBUEHL L, CHARBONNEY E, EGGIMANN P. Community-acquired necrotizing pneumonia due to methicillin-sensitive Staphylococcus aureus secreting Panton-Valentine leukocidin: a review of case reports Ann Intensive Care [online] :52 [viewed 12 June 2014] Available from: doi:10.1186/2110-5820-1-52

Investigations - Followup

Fact Explanation
Chest X Ray Indicates the level of resolution of pneumonia, [1] should be performed after 6 weeks.
References
  1. BRITISH THORACIC SOCIETY STANDARDS OF CARE COMMITTEE. BTS Guidelines for the Management of Community Acquired Pneumonia in Adults. Thorax [online] 2001 Dec:IV1-64 [viewed 12 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11713364

Management - General Measures

Fact Explanation
Oxygen The saturation should maintain between 94% and 98%.The levels should be between 88%-92% in a COPD.[1]
Intravenous fluids Required in hypotensive patients with volume depletion[1]
Physiotherapy. Chest physiotherapy is needed in sputum retention[1]
Analgesia. (paracetamol or non-steroidal anti-inflammatory Drugs) It minimizes pleuritic pain, and minimize sputum retention, atelectasis or secondary infection.[1]
Nutritional supplementation This is considered in severe disease, (by a dietician.)[1]
Thromboprophylaxis If admitted for >12 hours subcutaneous LMW heparin should be given (unless contraindicated )exist and TED stockings[1]
Admission to hospital If staph pneumonia is suspecting(specially MRSA)[2], CURB 65 score is 2[1]hospitalization is needed.
ICU admission If complicated (Septic shock,DIC), CURB 65 score more than 3[1], patient should be admitted to an ICU.
Precautions taken in MRSA management. 1.Hand hygiene 2.Patient isolation 3.Contact precautions(Patient placement,Glows,Droplet precautions-Masks)[2]
References
  1. KUMAR, Parveen. CLARK, Michael.Kumar & Clark’s Clinical Medicine.8th Edition.London.Elsevier.2012.pp.833-839
  2. Guidelines for the Control of Methicillin-resistant Staphylococcus aureus in New Zealand.Ministry of Health,New Zealand.2002.http://www.moh.govt.nz/cd/mrsa

Management - Specific Treatments

Fact Explanation
Regeim For community acquired patients Amoxycillin PLUS clarithromycin (IV if oral not possible) • Penicillin allergy: levofloxacin [1] For patients of CURB 65 score more than 3 • Co-amoxiclav intravenously PLUS clarithromycin intravenously • Penicillin allergy: IV cephalosporin PLUS clarithromycin • Benzylpenicillin a fluoroquinolone (levofloxacin )[1] Amoxycillin, co-amoxiclav and cephalosporin are broad spectrum antibiotics. They are bactericidal in action.[4] Clarithromycin has more gram positive action and it is bacteriostatic[4] Levofloxacin is has more gram negative action and it is bactericidal[4]
Regeim For Hospital acquired patients The rout is intravenous . A fluoroquinolone (levofloxacin ) PLUS amoxicillin/clavulanate or a second- or third-generation cephalosporin PLUS azithromycin /Clarythromycin[2] Amoxycillin, co-amoxiclav and cephalosporin are broad spectrum antibiotics. They are bactericidal in action.[4] Clarithromycin has more gram positive action and it is bacteriostatic[4] Levofloxacin is has more gram negative action and it is bactericidal[4]
For HA-MRSA or CA-MRSA pneumonia IV vancomycin or clindamycin [2],[3],[5] Vancomycin is bactericidal in action and has good gram positive cover[4] Clindamycin has good gram positive cover and bacteriostatic in action[4].
Management of lung abcesses CT-guided percutaneous drainage is the initial treatment of choice for patients with failed medical treatment with prolonged antibiotic treatment.[6]
Management of pleural effusion The treatment options include therapeutic 1.thoracentesis, 2.drainage catheter placement, 3.fibrinolytic therapy, 4.pleurodesis,[6]
Topical Management of MRSA To eradicate nasal and skin colonization by MRSA [Note: these practices depend on the condition of the individual patient} 1.application of mupirocin ) to the anterior nares 2.use antiseptic washes of skin ( chlorhexidine 4%, triclosan 1%, and povidine iodine 7.5% in detergent solution) 3. apply fusidic acid intranasally and on wounds[7]
References
  1. KUMAR, Parveen. CLARK, Michael.Kumar & Clark’s Clinical Medicine.8th Edition.London.Elsevier.2012.pp.833-839
  2. MILLS K, GRAHAM AC, WINSLOW BT, SPRINGER KL. Treatment of nursing home-acquired pneumonia. Am Fam Physician [online] 2009 Jun 1, 79(11):976-82 [viewed 12 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19514695
  3. LIU C, BAYER A, COSGROVE SE, DAUM RS, FRIDKIN SK, GORWITZ RJ, KAPLAN SL, KARCHMER AW, LEVINE DP, MURRAY BE, J RYBAK M, TALAN DA, CHAMBERS HF, INFECTIOUS DISEASES SOCIETY OF AMERICA. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis [online] 2011 Feb 1, 52(3):e18-55 [viewed 12 June 2014] Available from: doi:10.1093/cid/ciq146
  4. BENNETT,Peter N.BROWN,Morris J ed.CLINICAL PHARMACOLOGY.10 th ed.London:CHURCHILL LIVINGSTONE ELSEVIER.2008 .pp.188-207
  5. RUBINSTEIN E, KOLLEF MH, NATHWANI D. Pneumonia caused by methicillin-resistant Staphylococcus aureus. Clin Infect Dis [online] 2008 Jun 1:S378-85 [viewed 12 June 2014] Available from: doi:10.1086/533594
  6. YU H. Management of Pleural Effusion, Empyema, and Lung Abscess Semin Intervent Radiol [online] 2011 Mar, 28(1):75-86 [viewed 12 June 2014] Available from: doi:10.1055/s-0031-1273942
  7. Guidelines for the Control of Methicillin-resistant Staphylococcus aureus in New Zealand.Ministry of Health,New Zealand.2002.http://www.moh.govt.nz/cd/mrsa