Pneumonia due to staphylococcus

Pulmonology

Clinicals - 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. 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 Haemoptysis
Necrotizing pneumonia is caused by Panton-Valentine leukocidin-positive Staphylococcus aureus
Dyspnoea This due to respiratory stimulation following hypoxia and hypercarbia.
This can also be an early feature of sepsis.
Dyspnoea
This due to respiratory stimulation following hypoxia and hypercarbia.
This can also be an early feature of sepsis.
High fever This is due to the cytokines acting on hypothalamic thermoregulatory center. 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. 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 Recent history of respiratory infection
It is due to bronchial surface getting infected with secondary bacterial infection, such as S. aureus
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 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
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. 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.
Altered consciousness This is a complication of sepsis, which indicates cerebral involvement. Altered consciousness
This is a complication of sepsis, which indicates cerebral involvement.
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. 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.
Reduced bowel opening and abdominal distention Paralytic ileus is a complication of systemic sepsis. Reduced bowel opening and abdominal distention
Paralytic ileus is a complication of systemic sepsis.
Bleeding manifestations (Gum bleeding, Echemotic patches) Thrombocytopenia, and disseminated intravascular coagulation can be a result of systemic sepsis. Bleeding manifestations (Gum bleeding, Echemotic patches)
Thrombocytopenia, and disseminated intravascular coagulation can be a result of systemic sepsis.
Collapse This is due to hypotension caused by peripheral vasodilation. Collapse
This is due to hypotension caused by peripheral vasodilation.
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. 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.

Clinicals - Examination

Fact Explanation
Fever This is typically a high fever 38C<.This is due to mediators released by the bacteria as well as the host defense system. Fever
This is typically a high fever 38C<.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. 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. Tachypnoea
This due to respiratory stimulation following hypoxia and hypercarbia. This can also be an early feature of sepsis.
Warm peripheries This is due to peripheral vasodilation. Warm peripheries
This is due to peripheral vasodilation.
Hypotension This is due to peripheral vasodilation.This sign indicates the onset of septic shock,which is a complication. Hypotension
This is due to peripheral vasodilation.This sign indicates the onset of septic shock,which is a complication.
Dull percussion note This can be the result of: multi lobar consolidation, lobar collapse, pleural effusion Dull percussion note
This can be the result of: multi lobar consolidation, lobar collapse, pleural effusion
Reduced air entry This can be the result of: multi lobar consolidation, lobar collapse, pleural effusion Reduced air entry
This can be the result of: multi lobar consolidation, lobar collapse, pleural effusion
Broncial breating This is due to air flow in patent bronchioles while there is surrounding consolidation. 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. Coarse crackles
This occurs due to opening of collapsed airways.
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 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
Gum bleeding and ecchymosis. Thrombocytopenia, and disseminated intravascular coagulation can be a result of systemic sepsis. Gum bleeding and ecchymosis.
Thrombocytopenia, and disseminated intravascular coagulation can be a result of systemic sepsis.
Abdominal distention Paralytic ileus is a complication of systemic sepsis. Abdominal distention
Paralytic ileus is a complication of systemic sepsis.
Reduced GCS This is a complication of sepsis, which indicates cerebral involvement. Reduced GCS
This is a complication of sepsis, which indicates cerebral involvement.

Investigations - Diagnosis

Fact Explanation
Full blood count and differential count. There can be leucocytosis or leucopenia because of the effect of staphylococcal toxins. Full blood count and differential count.
There can be leucocytosis or leucopenia because of the effect of staphylococcal toxins.
C-reactive protein This is a acute phase protein and it is often elevated very high. C-reactive protein
This is a acute phase protein and it is often elevated very high.
Blood culture,Gram staining and antibiogram This identifies bacteremia,
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.
Blood culture,Gram staining and antibiogram
This identifies bacteremia,
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..
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..
Chest X-Ray It shows multilobular cavitating alveolar infiltrates Chest X-Ray
It shows multilobular cavitating alveolar infiltrates
CT thorax Cavitations, pleural effusions, pneumatoceles and pneumothoraces can be confirmed by a computed tomography scan CT thorax
Cavitations, pleural effusions, pneumatoceles and pneumothoraces can be confirmed by a computed tomography scan
Microarrays to identify PVL and other staphylococcal toxins superantigens Helps in identifying MRSA. Microarrays to identify PVL and other staphylococcal toxins superantigens
Helps in identifying MRSA.

Investigations - Management

Fact Explanation
Chest X Ray Indicates the level of resolution of pneumonia, should be performed after 6 weeks. Chest X Ray
Indicates the level of resolution of pneumonia, should be performed after 6 weeks.
Pulse oxymetry This Indicates the level of oxygen saturation.The lover level of adequate saturation is 94% 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)
Pulse oxymetry
This Indicates the level of oxygen saturation.The lover level of adequate saturation is 94% 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% 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%
Plasma urea level This is used to calculate CURB 65 score. Plasma urea level
This is used to calculate CURB 65 score.
Albumin level This is an indicator of severity (less than<35 g/L) Albumin level
This is an indicator of severity (less than<35 g/L)
Coagulation screen: PT,APTT,Platelet count There is coagulopathy DIC can be identified. Coagulation screen: PT,APTT,Platelet count
There is coagulopathy DIC can be identified.

Management - Supportive

Fact Explanation
Oxygen The saturation should maintain between 94% and 98%.The levels should be between 88%-92% in a COPD. Oxygen
The saturation should maintain between 94% and 98%.The levels should be between 88%-92% in a COPD.
Intravenous fluids Required in hypotensive patients with volume depletion Intravenous fluids
Required in hypotensive patients with volume depletion
Physiotherapy. Chest physiotherapy is needed in sputum retention Physiotherapy.
Chest physiotherapy is needed in sputum retention
Analgesia. (paracetamol or non-steroidal anti-inflammatory Drugs) It minimizes
pleuritic pain, and minimize sputum retention, atelectasis or secondary
infection.
Analgesia. (paracetamol or non-steroidal anti-inflammatory Drugs)
It minimizes
pleuritic pain, and minimize sputum retention, atelectasis or secondary
infection.
Nutritional supplementation This is considered in severe disease, (by a dietician.) Nutritional supplementation
This is considered in severe disease, (by a dietician.)
Thromboprophylaxis If admitted for >12 hours
subcutaneous LMW heparin should
be given (unless contraindicated )exist and TED stockings
Thromboprophylaxis
If admitted for >12 hours
subcutaneous LMW heparin should
be given (unless contraindicated )exist and TED stockings
Admission to hospital If staph pneumonia is suspecting(specially MRSA), CURB 65 score is 2hospitalization is needed. Admission to hospital
If staph pneumonia is suspecting(specially MRSA), CURB 65 score is 2hospitalization is needed.
ICU admission If complicated (Septic shock,DIC), CURB 65 score more than 3, patient should be admitted to an ICU. ICU admission
If complicated (Septic shock,DIC), CURB 65 score more than 3, 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)
Precautions taken in MRSA management.
1.Hand hygiene
2.Patient isolation
3.Contact precautions(Patient placement,Glows,Droplet precautions-Masks)

Management - Specific

Fact Explanation
Regeim For community acquired patients Amoxycillin PLUS clarithromycin (IV if oral not possible)
• Penicillin allergy:
levofloxacin



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 )

Amoxycillin, co-amoxiclav and cephalosporin are broad spectrum antibiotics. They are bactericidal in action.

Clarithromycin has more gram positive action and it is bacteriostatic

Levofloxacin is has more gram negative action and it is bactericidal
Regeim For community acquired patients
Amoxycillin PLUS clarithromycin (IV if oral not possible)
• Penicillin allergy:
levofloxacin



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 )

Amoxycillin, co-amoxiclav and cephalosporin are broad spectrum antibiotics. They are bactericidal in action.

Clarithromycin has more gram positive action and it is bacteriostatic

Levofloxacin is has more gram negative action and it is bactericidal
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

Amoxycillin, co-amoxiclav and cephalosporin are broad spectrum antibiotics. They are bactericidal in action.

Clarithromycin has more gram positive action and it is bacteriostatic

Levofloxacin is has more gram negative action and it is bactericidal
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

Amoxycillin, co-amoxiclav and cephalosporin are broad spectrum antibiotics. They are bactericidal in action.

Clarithromycin has more gram positive action and it is bacteriostatic

Levofloxacin is has more gram negative action and it is bactericidal
For HA-MRSA or CA-MRSA pneumonia IV vancomycin or
clindamycin ,,

Vancomycin is bactericidal in action and has good gram positive cover

Clindamycin has good gram positive cover and bacteriostatic in action.
For HA-MRSA or CA-MRSA pneumonia
IV vancomycin or
clindamycin ,,

Vancomycin is bactericidal in action and has good gram positive cover

Clindamycin has good gram positive cover and bacteriostatic in action.
Management of lung abcesses CT-guided percutaneous drainage is the initial treatment of choice for patients with failed medical treatment with prolonged antibiotic treatment. Management of lung abcesses
CT-guided percutaneous drainage is the initial treatment of choice for patients with failed medical treatment with prolonged antibiotic treatment.
Management of pleural effusion The treatment options include therapeutic 1.thoracentesis,
2.drainage catheter placement,
3.fibrinolytic therapy, 4.pleurodesis,
Management of pleural effusion
The treatment options include therapeutic 1.thoracentesis,
2.drainage catheter placement,
3.fibrinolytic therapy, 4.pleurodesis,
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
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

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  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. BENNETT,Peter N.BROWN,Morris J ed.CLINICAL PHARMACOLOGY.10 th ed.London:CHURCHILL LIVINGSTONE ELSEVIER.2008 .pp.188-207
  3. 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
  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
  5. 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
  6. 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
  7. 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
  8. 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
  9. KUMAR, Parveen. CLARK, Michael.Kumar & Clark’s Clinical Medicine.8th Edition.London.Elsevier.2012.pp.833-839
  10. KUMAR, Parveen. CLARK, Michael.Kumar & Clark’s Clinical Medicine.8th Edition.London.Elsevier.2012.pp.833-839
  11. KUMAR, Parveen. CLARK, Michael.Kumar & Clark’s Clinical Medicine.8th Edition.London.Elsevier.2012.pp.833-839
  12. KUMAR, Parveen. CLARK, Michael.Kumar & Clark’s Clinical Medicine.8th Edition.London.Elsevier.2012.pp.833-839
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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