Emergency Medicine
Respiratory Medicine
Infectious Diseases
Emergency
High Evidence

Pneumonia - Adult

CURB-65 score (0-1: outpatient, 2: consider admission, ≥3: severe - ICU assessment) is the most validated severity to... ACEM Fellowship Written, ACEM Fellow

42 min read

Clinical board

A visual summary of the highest-yield teaching signals on this page.

Urgent signals

Safety-critical features pulled from the topic metadata.

  • Respiratory rate ≥30/min
  • Systolic BP below 90 mmHg or diastolic ≤60 mmHg
  • Confusion (new onset)
  • Oxygen saturation below 90% on room air

Exam focus

Current exam surfaces linked to this topic.

  • ACEM Fellowship Written
  • ACEM Fellowship OSCE
  • FRACP Written
  • MRCP PACES

Editorial and exam context

ACEM Fellowship Written
ACEM Fellowship OSCE
FRACP Written
MRCP PACES
Clinical reference article

Quick Answer

Pneumonia is an acute lower respiratory tract infection causing alveolar inflammation and consolidation. CURB-65 score (Confusion, Urea greater than 7 mmol/L, Respiratory rate ≥30/min, BP below 90/60 mmHg, Age ≥65) guides severity and disposition. Community-acquired pneumonia (CAP) requires β-lactam (amoxicillin 1g TDS or benzylpenicillin 1.2g QID) + macrolide (azithromycin 500mg daily) for 5-7 days. Hospital-acquired pneumonia (HAP) requires broader cover (piperacillin-tazobactam ± vancomycin). Aspiration pneumonia needs anaerobic cover (amoxicillin-clavulanate or moxifloxacin). CURB-65 ≥2 or PSI class IV-V warrants admission; ≥3 requires ICU assessment.

ACEM Exam Focus

What Examiners Expect

Fellowship Written SAQs:

  • Calculate CURB-65 and PSI scores, justify admission decisions
  • Differentiate CAP vs HAP vs aspiration pneumonia
  • Choose appropriate empirical antibiotics (Australian Therapeutic Guidelines)
  • Interpret CXR findings and identify complications
  • Manage severe CAP with septic shock

Fellowship OSCE:

  • History station: Distinguish bacterial vs atypical vs aspiration
  • Examination station: Respiratory examination, identify consolidation signs
  • Communication station: Explain ICU admission to family, discuss prognosis
  • Resuscitation station: Manage septic shock from severe pneumonia

Common Pitfalls:

  • Using AHA/ERC guidelines instead of Australian Therapeutic Guidelines
  • Missing aspiration risk factors (dysphagia, reduced GCS, elderly)
  • Not considering MRSA/Pseudomonas risk factors for HAP
  • Over-reliance on single severity score (use clinical gestalt + CURB-65)

Examiner Questions:

  • "What are the indications for ICU admission in pneumonia?"
  • "How do you differentiate HAP from VAP?"
  • "Which antibiotics cover atypical organisms?"
  • "What is the role of steroids in severe CAP?"

Key Points

  1. CURB-65 score (0-1: outpatient, 2: consider admission, ≥3: severe - ICU assessment) is the most validated severity tool for CAP in the ED
  2. CAP empirical therapy: β-lactam (amoxicillin or benzylpenicillin) + macrolide (azithromycin) covers S. pneumoniae, H. influenzae, and atypical organisms
  3. HAP (onset ≥48h after admission) requires Pseudomonas and MRSA coverage in high-risk patients (ICU, mechanical ventilation, recent IV antibiotics)
  4. Aspiration pneumonia occurs in right lower lobe (supine) or posterior segments; needs anaerobic cover with amoxicillin-clavulanate
  5. Legionella pneumonia: Consider in severe CAP with hyponatraemia, diarrhoea, confusion; add fluoroquinolone (moxifloxacin) or higher-dose azithromycin
  6. Blood cultures (before antibiotics), sputum culture (if productive), and urinary antigens (S. pneumoniae, Legionella) aid microbiological diagnosis
  7. Aboriginal and Torres Strait Islander adults have 3-4× higher pneumonia hospitalization and 2× mortality; consider bronchiectasis and structural lung disease

Epidemiology

Incidence

  • Community-acquired pneumonia (CAP): 5-11 per 1,000 adults per year in developed countries [PMID: 31589491]
  • Hospital-acquired pneumonia (HAP): 5-10 per 1,000 hospital admissions; VAP 10-25% of mechanically ventilated patients [PMID: 28292696]
  • Australia: ~80,000 CAP hospitalizations annually; incidence 250-400 per 100,000 population [PMID: 29195450]

Mortality

  • CAP: Overall 5-15%; ICU admission 20-35%; severe septic shock 30-50% [PMID: 31589491]
  • HAP: 20-50% depending on pathogen and patient comorbidities [PMID: 28292696]
  • Aspiration pneumonia: 15-30%; higher in elderly and nursing home residents [PMID: 23633868]

Risk Factors

  • Age ≥65 years: Immunosenescence, comorbidities, polypharmacy
  • Comorbidities: COPD, heart failure, diabetes, CKD, cirrhosis
  • Immunosuppression: Corticosteroids, chemotherapy, biologics, HIV
  • Smoking: 2-4× increased risk
  • Alcohol excess: Impaired mucociliary clearance, aspiration risk
  • Indigenous Australians: 3-4× higher incidence [PMID: 30760144]

Pathogens

Community-Acquired Pneumonia (CAP):

  • Streptococcus pneumoniae (30-50%) - most common, vaccine-preventable [PMID: 31589491]
  • Haemophilus influenzae (10-15%) - COPD, smokers
  • Mycoplasma pneumoniae (10-15%) - atypical, young adults, outbreaks
  • Chlamydophila pneumoniae (5-10%) - atypical, elderly
  • Legionella pneumophila (2-5%) - water sources, severe CAP
  • Respiratory viruses (15-30%): Influenza A/B, RSV, COVID-19, adenovirus [PMID: 35460555]

Hospital-Acquired Pneumonia (HAP):

  • Pseudomonas aeruginosa (20-30%) - high mortality, MDR common [PMID: 28292696]
  • Staphylococcus aureus (15-25%) - including MRSA
  • Enterobacteriaceae (20-30%): E. coli, Klebsiella, Enterobacter
  • Acinetobacter baumannii (5-10%) - ICU, ventilated patients

Aspiration Pneumonia:

  • Anaerobes (40-50%): Peptostreptococcus, Bacteroides, Fusobacterium [PMID: 23633868]
  • Gram-negatives: E. coli, Klebsiella
  • S. pneumoniae, H. influenzae

Pathophysiology

Mechanisms of Infection

  1. Microaspiration (most common): Oropharyngeal pathogens aspirated into lower airways during sleep
  2. Inhalation: Aerosolized droplets (Legionella, Mycobacterium tuberculosis, viruses)
  3. Haematogenous spread: Bacteremia seeding lungs (uncommon)
  4. Direct extension: Empyema, subphrenic abscess

Host Defense Failure

  1. Upper airway: Nasal cilia, mucus, IgA
  2. Lower airway: Cough reflex, mucociliary escalator, alveolar macrophages
  3. Immune response: Neutrophil recruitment, cytokine release (TNF-α, IL-1, IL-6)

Pneumonia develops when:

  • Pathogen load overwhelms defenses (high inoculum)
  • Virulent organism (S. pneumoniae, S. aureus)
  • Impaired host immunity (elderly, immunosuppressed)

Alveolar Inflammation

Four stages of bacterial pneumonia (Laennec, 1819):

  1. Congestion (0-24h): Vascular engorgement, proteinaceous exudate
  2. Red hepatization (1-3 days): Neutrophils, RBCs, fibrin fill alveoli
  3. Grey hepatization (3-8 days): Fibrin accumulation, RBC breakdown
  4. Resolution (8+ days): Enzymatic digestion, macrophage clearance

Systemic effects:

  • Cytokine storm: Fever, tachycardia, tachypnoea
  • Capillary leak: Hypotension, ARDS
  • Sepsis: End-organ dysfunction (AKI, encephalopathy, DIC)

Clinical Presentation

Symptoms

Bacterial pneumonia (S. pneumoniae):

  • Cough (90%): Productive, purulent sputum (rust-colored)
  • Fever (80%): Abrupt onset, rigors
  • Pleuritic chest pain (60%): Sharp, worse on inspiration
  • Dyspnoea (70%): Exertional or at rest
  • Systemic: Fatigue, myalgia, anorexia

Atypical pneumonia (Mycoplasma, Chlamydophila):

  • Dry cough (85%): Non-productive, persistent
  • Low-grade fever (70%): Gradual onset
  • Headache (50%): Prominent feature
  • Extra-pulmonary: Diarrhoea, rash, haemolytic anaemia

Legionella pneumonia:

  • Severe illness: High fever (39-40°C), rigors
  • Diarrhoea (40-50%): Watery
  • Confusion (30%): Encephalopathy
  • Hyponatraemia (50%): SIADH [PMID: 18842995]

Aspiration pneumonia:

  • Witnessed aspiration: Choking, coughing
  • Risk factors: Reduced GCS, dysphagia, GORD, NG tube
  • Location: Right lower lobe (supine), posterior segments
  • Putrid sputum: Anaerobic infection

Elderly/frail patients:

  • Atypical presentation: Confusion, falls, delirium
  • Minimal fever: Hypothermia possible
  • Tachypnoea: May be only sign
  • Functional decline: Immobility, incontinence [PMID: 31589491]

Signs

Inspection:

  • Tachypnoea (RR greater than 20/min), use of accessory muscles
  • Cyanosis (SpO₂ below 90%)
  • Fever (greater than 38°C) or hypothermia (below 36°C)

Palpation:

  • Reduced chest expansion (affected side)
  • Increased tactile vocal fremitus (consolidation)

Percussion:

  • Dullness over consolidation

Auscultation:

  • Bronchial breathing: High-pitched, tubular, expiratory>inspiratory
  • Crackles (rales): Fine, coarse; inspiratory
  • Pleural rub: Friction sound (pleurisy)
  • Reduced breath sounds: Effusion, empyema

Systemic signs:

  • Hypotension (SBP below 90 mmHg): Septic shock
  • Tachycardia (HR greater than 100 bpm)
  • Confusion: Hypoxia, septic encephalopathy

Investigations

Essential ED Investigations

Chest X-ray (CXR):

  • Indication: All patients with suspected pneumonia [PMID: 31589491]
  • Findings:
    • "Lobar consolidation: S. pneumoniae"
    • "Patchy infiltrates: H. influenzae, viral"
    • "Cavitation: S. aureus, Klebsiella, anaerobes"
    • "Interstitial pattern: Atypical organisms, viruses"
    • "Pleural effusion: Parapneumonic, empyema"
  • Normal CXR: Does not exclude pneumonia (10-20% early presentations)

Arterial blood gas (ABG):

  • PaO₂/FiO₂ ratio: below 300 = ARDS
  • Lactate: ≥4 mmol/L = septic shock [PMID: 28101605]
  • pH: Acidosis (metabolic or respiratory)

Blood tests:

  • Full blood count: WCC greater than 15×10⁹/L or below 4×10⁹/L (sepsis)
  • Urea: greater than 7 mmol/L (CURB-65 criterion, mortality predictor)
  • Creatinine: AKI from sepsis/dehydration
  • CRP: greater than 100 mg/L supports bacterial infection
  • Procalcitonin: greater than 0.5 ng/mL suggests bacterial (not routine in ED) [PMID: 28538115]
  • Sodium: Hyponatraemia (below 130 mmol/L) in Legionella, SIADH

Blood cultures:

  • Indication: Severe CAP (CURB-65 ≥2), ICU admission, septic shock
  • Timing: Before antibiotics (2 sets, peripheral + central if line present)
  • Yield: Positive in 5-15% CAP, identifies pathogen and sensitivities [PMID: 31589491]

Sputum culture:

  • Indication: Productive cough, severe CAP, suspected resistant organisms
  • Quality: greater than 25 PMNs and below 10 squamous epithelial cells per low-power field
  • Limitations: Contamination, difficult to obtain

Urinary antigens:

  • S. pneumoniae antigen: Sensitivity 70-80%, specificity greater than 95%; positive for weeks after infection [PMID: 31589491]
  • Legionella antigen: Detects serogroup 1 (80% of cases); sensitivity 70-90% [PMID: 18842995]

Additional Investigations (Severe CAP, ICU)

CT chest:

  • Indications: Suspected complication (empyema, abscess), failed treatment, immunocompromised
  • Findings: Better detection of consolidation, cavitation, effusion, underlying malignancy

Thoracentesis (if pleural effusion greater than 1cm):

  • Parapneumonic effusion: pH greater than 7.2, glucose greater than 2.2 mmol/L, LDH below 1000 U/L (conservative management)
  • Complicated parapneumonic effusion: pH below 7.2, glucose below 2.2 mmol/L (chest drain required)
  • Empyema: Pus, positive Gram stain/culture (chest drain + antibiotics) [PMID: 21593217]

Respiratory viral PCR:

  • Indication: Influenza season, COVID-19, severe CAP
  • Pathogens: Influenza A/B, RSV, SARS-CoV-2, adenovirus, hMPV

Legionella investigations (if suspected):

  • Urinary antigen (first-line)
  • Sputum/BAL culture (gold standard, takes 3-5 days)
  • Legionella PCR (if available)
  • Serology (retrospective diagnosis)

Severity Assessment

CURB-65 Score

Confusion (new onset, AMT ≤8)
Urea greater than 7 mmol/L (BUN greater than 19 mg/dL)
Respiratory rate ≥30/min
Blood pressure: SBP below 90 mmHg or DBP ≤60 mmHg
65: Age ≥65 years

Score interpretation [PMID: 12728059]:

  • 0-1: Low risk, mortality 1-3%, consider outpatient treatment
  • 2: Moderate risk, mortality 9%, admit to medical ward
  • ≥3: High risk, mortality 15-40%, admit to ICU/HDU

Limitations:

  • Developed for mortality prediction, not disposition
  • May under-risk young patients with comorbidities
  • Use clinical judgment + CURB-65

Pneumonia Severity Index (PSI)

20 variables: Age, comorbidities, vital signs, labs
Classes I-V: Class I-III outpatient; Class IV-V inpatient [PMID: 8995086]

PSI more complex than CURB-65, less used in ED (requires multiple labs)

SMART-COP Score (Australian)

Predicts need for intensive respiratory or vasopressor support (IRVS) [PMID: 18671392]:

  • Systolic BP below 90 mmHg (2 points)
  • Multilobar CXR infiltrates (1 point)
  • Albumin below 3.5 g/dL (1 point)
  • Respiratory rate: ≥25/min age below 50 (1 point), ≥30/min age ≥50 (1 point)
  • Tachycardia: ≥125 bpm (1 point)
  • Confusion (1 point)
  • Oxygen: PaO₂ below 70 mmHg or SpO₂ ≤93% (2 points)
  • PH below 7.35 (2 points)

Score ≥3: High risk IRVS, consider ICU/HDU

ICU Admission Criteria

IDSA/ATS Major Criteria (≥1 = ICU) [PMID: 31573350]:

  • Invasive mechanical ventilation
  • Septic shock requiring vasopressors

IDSA/ATS Minor Criteria (≥3 = ICU):

  • Respiratory rate ≥30/min
  • PaO₂/FiO₂ ratio ≤250
  • Multilobar infiltrates
  • Confusion
  • Urea greater than 7 mmol/L
  • Leukopenia (WCC below 4×10⁹/L)
  • Thrombocytopenia (platelets below 100×10⁹/L)
  • Hypothermia (below 36°C)
  • Hypotension requiring aggressive fluids

Management

Community-Acquired Pneumonia (CAP)

Resuscitation (Severe CAP, Septic Shock)

Airway & Breathing:

  • Oxygen: Target SpO₂ 92-96% (88-92% if COPD)
  • High-flow nasal oxygen (HFNO): 40-60 L/min if SpO₂ below 90% on standard oxygen
  • Non-invasive ventilation (NIV): BiPAP in hypercapnic respiratory failure (COPD exacerbation + pneumonia)
  • Intubation indications: Refractory hypoxia (PaO₂ below 60 mmHg on FiO₂ 1.0), exhaustion, reduced GCS below 8

Circulation:

  • IV fluid resuscitation: 30 mL/kg crystalloid (0.9% saline or Hartmann's) within 3 hours if septic shock [PMID: 28101605]
  • Vasopressors: Noradrenaline (start if MAP below 65 mmHg despite fluids)
  • Monitoring: Arterial line, central venous catheter, lactate

Antibiotics:

  • Time-critical: Administer within 1 hour of ED arrival in septic shock [PMID: 28101605]

Empirical Antibiotics (Therapeutic Guidelines Australia)

Mild-Moderate CAP (CURB-65 0-1, outpatient):

  • Amoxicillin 500 mg PO TDS for 5 days [PMID: 31573350]
  • Alternative (penicillin allergy): Doxycycline 100 mg PO BD or moxifloxacin 400 mg PO daily

Moderate-Severe CAP (CURB-65 ≥2, inpatient):

  • Benzylpenicillin 1.2 g IV QID (or amoxicillin 1 g IV TDS) PLUS
  • Azithromycin 500 mg PO/IV daily [PMID: 31573350]
  • Duration: 5-7 days (extend to 10-14 days if Legionella, bacteremia, or slow response)

Severe CAP (CURB-65 ≥3, ICU):

  • Ceftriaxone 2 g IV daily (or cefotaxime 2 g IV TDS) PLUS
  • Azithromycin 500 mg IV daily (or moxifloxacin 400 mg IV daily)
  • Add vancomycin 25-30 mg/kg IV loading if MRSA suspected (IVDU, recent hospitalization, nasal colonization)

Rationale:

  • β-lactam: Covers S. pneumoniae (most common), H. influenzae
  • Macrolide: Covers atypical organisms (Mycoplasma, Chlamydophila, Legionella)
  • Combination therapy: Reduces mortality in severe CAP by 10-15% vs monotherapy [PMID: 18645078]

Legionella Pneumonia

Clinical clues:

  • Diarrhoea, confusion, hyponatraemia (Na⁺ below 130 mmol/L)
  • Elevated CRP (greater than 200 mg/L), transaminitis
  • Urinary antigen positive [PMID: 18842995]

Treatment:

  • First-line: Moxifloxacin 400 mg IV/PO daily for 10-14 days
  • Alternative: Azithromycin 1 g IV loading, then 500 mg IV/PO daily for 7-10 days
  • Severe: Moxifloxacin + rifampicin 600 mg PO daily

Supportive Care

  • Fluids: Maintain euvolaemia (avoid overload → pulmonary oedema)
  • Analgesia: Paracetamol 1 g PO/IV QDS for fever, pleuritic pain
  • VTE prophylaxis: Enoxaparin 40 mg SC daily (if no contraindications)
  • Early mobilization: Reduces hospital stay, complications

Adjunctive Therapy

Corticosteroids (controversial):

  • Evidence: Meta-analysis shows reduced mortality (NNT 18) and clinical failure in severe CAP [PMID: 25855633]
  • Regimen: Hydrocortisone 200 mg IV daily or methylprednisolone 0.5 mg/kg IV BD for 5-7 days
  • Risk: Hyperglycaemia, secondary infections
  • Recommendation: Consider in severe CAP (CURB-65 ≥3) or refractory septic shock

Hospital-Acquired Pneumonia (HAP)

Definition: Pneumonia onset ≥48 hours after hospital admission [PMID: 28292696]

Risk stratification:

  • Low risk: No recent IV antibiotics, no septic shock → standard CAP coverage
  • High risk: ICU, mechanical ventilation, recent IV antibiotics (within 90 days), immunosuppressed → cover Pseudomonas, MRSA

Empirical antibiotics (High-risk HAP):

  • Piperacillin-tazobactam 4.5 g IV TDS (or meropenem 1 g IV TDS if penicillin allergy) PLUS
  • Vancomycin 25-30 mg/kg IV loading, then 15-20 mg/kg IV BD (target trough 15-20 mg/L)
  • Duration: 7-8 days (extend to 14 days if Pseudomonas, Acinetobacter, or slow response) [PMID: 28292696]

De-escalation:

  • Narrow antibiotics based on culture results and clinical response at 48-72 hours

Ventilator-Associated Pneumonia (VAP)

Definition: Pneumonia onset ≥48 hours after intubation and mechanical ventilation

Diagnosis:

  • Clinical suspicion (fever, purulent secretions, worsening oxygenation) + CXR infiltrate
  • Quantitative cultures: BAL (≥10⁴ CFU/mL) or endotracheal aspirate (≥10⁶ CFU/mL)

Empirical antibiotics (same as high-risk HAP):

  • Antipseudomonal β-lactam + vancomycin
  • Consider adding aminoglycoside (gentamicin 5-7 mg/kg IV daily) if MDR risk or septic shock

Aspiration Pneumonia

Risk factors:

  • Reduced consciousness (GCS below 15): Alcohol, overdose, stroke
  • Dysphagia: Stroke, Parkinson's, dementia, motor neuron disease
  • GORD, NG tube, vomiting
  • Elderly, nursing home residents

Clinical features:

  • Witnessed aspiration (choking, coughing)
  • Right lower lobe or posterior segment infiltrate (supine position)
  • Putrid sputum (anaerobic infection)

Investigations:

  • CXR: RLL or posterior segments
  • Consider videofluoroscopy swallow study (VFSS) or FEES (Fibreoptic Endoscopic Evaluation of Swallowing) if recurrent

Empirical antibiotics:

  • Amoxicillin-clavulanate 1.2 g IV TDS for 7-10 days [PMID: 23633868]
  • Alternative (penicillin allergy): Moxifloxacin 400 mg IV daily
  • Anaerobic cover essential (Peptostreptococcus, Bacteroides, Fusobacterium)

Aspiration prevention:

  • 30-45° head-up positioning
  • Swallow assessment before oral intake
  • Speech pathology review
  • Consider NG/PEG if unsafe swallow

Complications

Parapneumonic effusion:

  • Occurs in 20-40% bacterial pneumonia
  • Small (below 1 cm): Observe
  • Larger: Diagnostic and therapeutic thoracentesis [PMID: 21593217]

Empyema:

  • Pus in pleural space (positive Gram stain/culture)
  • Treatment: Chest drain (14-16F) + antibiotics for 2-4 weeks
  • Surgery (VATS decortication) if loculated or failed drainage

Lung abscess:

  • Cavitation on CXR/CT with air-fluid level
  • Organisms: S. aureus, Klebsiella, anaerobes
  • Treatment: Prolonged antibiotics (4-6 weeks), consider percutaneous drainage or surgery

Septic shock:

  • Hypotension (MAP below 65 mmHg) despite fluids, lactate ≥2 mmol/L
  • Mortality 30-50%
  • Treatment: Early antibiotics, fluids, vasopressors [PMID: 28101605]

ARDS:

  • PaO₂/FiO₂ ratio below 300, bilateral infiltrates
  • Supportive: Lung-protective ventilation (TV 6 mL/kg, plateau pressure below 30 cmH₂O)

Disposition

Admission Criteria

Admit to ward (CURB-65 ≥2, PSI Class IV-V):

  • Respiratory rate ≥30/min
  • Oxygen requirement (SpO₂ below 90% on room air)
  • Systolic BP below 90 mmHg or diastolic ≤60 mmHg
  • Confusion (new onset)
  • Urea greater than 7 mmol/L
  • Social factors: Lives alone, poor oral intake, unable to cope

Admit to ICU/HDU (CURB-65 ≥3, SMART-COP ≥3):

  • Septic shock (MAP below 65 mmHg despite fluids, lactate ≥4 mmol/L)
  • Respiratory failure (PaO₂ below 60 mmHg on high-flow oxygen, PaO₂/FiO₂ below 250)
  • Need for invasive ventilation
  • Multilobar infiltrates
  • ≥3 IDSA/ATS minor criteria

Safe Discharge (CURB-65 0-1)

Criteria:

  • Vital signs stable: RR below 24/min, HR below 100 bpm, SBP greater than 90 mmHg, SpO₂ greater than 92% on room air
  • Able to take oral antibiotics
  • No comorbidities requiring admission
  • Adequate social support

Discharge instructions:

  • Oral antibiotics: Amoxicillin 500 mg TDS for 5 days
  • Red flags: Worsening breathlessness, confusion, chest pain
  • GP follow-up in 48 hours
  • CXR follow-up at 6 weeks (exclude underlying malignancy, non-resolving pneumonia)

Response to Treatment

Clinical improvement expected:

  • Fever resolution: 2-4 days
  • Tachycardia/tachypnoea: 3-5 days
  • CXR clearance: 4-12 weeks (slower in elderly, smokers, multilobar)

Non-resolving pneumonia (no improvement after 72h):

  • Consider:
    • Incorrect pathogen (atypical, TB, fungal)
    • Resistant organism (MRSA, ESBL, Pseudomonas)
    • Complication (empyema, abscess)
    • Wrong diagnosis (PE, heart failure, malignancy, organizing pneumonia)
  • Investigation: CT chest, bronchoscopy with BAL, specialist review

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Adults

Epidemiology:

  • 3-4× higher hospitalization for pneumonia compared to non-Indigenous Australians [PMID: 30760144]
  • 2× higher mortality from respiratory infections
  • Earlier age of onset: Mean age 48 years vs 68 years in non-Indigenous

Risk Factors:

  • High prevalence of bronchiectasis (30-40% in remote communities) from childhood respiratory infections [PMID: 26040576]
  • Smoking: 41% prevalence (2.5× non-Indigenous rate)
  • COPD: 2.5× higher prevalence
  • Diabetes: 3× higher prevalence
  • Household crowding: Facilitates transmission

Pathogens:

  • Higher rates of S. pneumoniae serotypes not covered by 13-valent vaccine
  • H. influenzae non-typeable strains (bronchiectasis)
  • S. aureus (including MRSA in some remote communities)

Management considerations:

  • Lower threshold for admission: Consider CURB-65 ≥1 given higher baseline risk
  • Extended antibiotic duration: 7-10 days (risk of relapse with 5-day course)
  • Bronchiectasis: Send sputum culture, consider CT chest if recurrent
  • 23-valent pneumococcal vaccine (if not already received)

Cultural Safety:

  • Involve Aboriginal Health Workers in care
  • Allow family presence (multiple visitors may be cultural norm)
  • Explain investigations/treatments in plain language
  • Discuss discharge plan with patient and family
  • Arrange Aboriginal Medical Service follow-up if available

Māori (New Zealand)

Epidemiology:

  • 1.5-2× higher hospitalization for pneumonia vs non-Māori
  • Higher rates of rheumatic fever, bronchiectasis

Cultural Considerations:

  • Whānau involvement: Include family in decision-making
  • Karakia: Offer spiritual support (prayer)
  • Tikanga: Respect cultural protocols (e.g., tapu/noa concepts)
  • Manaakitanga: Provide hospitality and care
  • Link with Māori health services for follow-up

Remote & Rural Emergency Medicine

Challenges

Diagnostic:

  • Limited CXR access (portable X-ray only, or none in very remote clinics)
  • No CT chest
  • No microbiology labs (blood cultures sent to distant lab, results delayed 48-72h)

Therapeutic:

  • Limited IV antibiotic options (may only have benzylpenicillin, gentamicin, metronidazole)
  • No ICU/HDU locally (nearest tertiary centre may be 500+ km away)

Retrieval:

  • Royal Flying Doctor Service (RFDS) coordination required for unstable patients
  • Weather-dependent (flights cancelled in storms, cyclones)
  • Limited oxygen supply during transfer (may need to intubate for long flights)

Management Approach

Assessment:

  • Clinical diagnosis: If no CXR available, diagnose pneumonia on clinical grounds (fever, cough, tachypnoea, focal crackles)
  • Severity scoring: CURB-65 can be calculated with basic labs (urea) or clinically without labs
  • Oxygen: Monitor SpO₂ continuously

Empirical antibiotics:

  • Benzylpenicillin 1.2 g IV QID PLUS azithromycin 500 mg PO daily (if available)
  • If no macrolide: Consider moxifloxacin 400 mg IV daily (covers atypical + typical)
  • Aspiration: Add metronidazole 500 mg IV TDS for anaerobic cover

Retrieval criteria (contact RFDS):

  • CURB-65 ≥3 (severe CAP)
  • Septic shock (SBP below 90 mmHg despite fluids)
  • Respiratory failure (SpO₂ below 90% on high-flow oxygen)
  • Confusion, reduced GCS
  • Comorbidities (COPD, heart failure, diabetes) + CURB-65 ≥2

Telemedicine:

  • Video consultation with remote ED/ICU specialist
  • Share CXR images (if available) via secure telehealth platform
  • Real-time management advice, antibiotic choice, disposition decisions

RFDS Protocols

Pre-retrieval stabilization:

  • Oxygen via Hudson mask or non-rebreather (target SpO₂ greater than 92%)
  • IV access (2× large-bore cannulae)
  • Fluid resuscitation: 1-2 L crystalloid if hypotensive
  • Antibiotics: Benzylpenicillin + azithromycin (or moxifloxacin)
  • Analgesia: Paracetamol ± opioids for pleuritic pain

In-flight considerations:

  • Cabin altitude: Pressurized to 8,000 feet (equivalent to FiO₂ 0.15 at sea level)
  • Increase oxygen flow rates by 30-50% to maintain SpO₂ greater than 92%
  • Prepare for intubation if respiratory failure (have equipment ready)

Destination:

  • Transfer to tertiary hospital with ICU capability
  • RFDS coordinates bed availability before departure

Differential Diagnosis

Respiratory

  • Pulmonary embolism: Sudden onset dyspnoea, pleuritic pain, risk factors (surgery, immobility, malignancy)
  • Acute bronchitis: Cough, normal CXR
  • Exacerbation of COPD/asthma: Wheeze, reduced air entry
  • Pulmonary oedema: Bibasal crackles, elevated JVP, S3 gallop
  • Lung cancer: Weight loss, haemoptysis, non-resolving CXR changes

Cardiac

  • Acute coronary syndrome: Dyspnoea may mimic pneumonia; check ECG, troponin
  • Heart failure: Pulmonary oedema on CXR (bilateral, perihilar)

Infectious

  • Tuberculosis: Night sweats, weight loss, upper lobe cavitation
  • COVID-19: Viral pneumonia, bilateral infiltrates, rapid deterioration
  • Influenza pneumonia: Seasonal, high fever, myalgia

Other

  • Pleural effusion: Stony dull percussion, reduced breath sounds
  • Empyema: Persistent fever despite antibiotics, pleural collection
  • Organizing pneumonia (COP): Non-resolving infiltrates, response to steroids

Pitfalls & Pearls

Common Pitfalls

  1. Delaying antibiotics: Administer within 1 hour in septic shock (every hour delay increases mortality by 7%) [PMID: 17344318]
  2. Missing aspiration risk: Always ask about dysphagia, alcohol, reduced GCS
  3. Under-treating severity: CURB-65 ≥2 should be admitted (mortality 9%)
  4. Forgetting blood cultures: Take before antibiotics (positive in 5-15%)
  5. Normal CXR = no pneumonia: 10-20% have normal initial CXR (early, dehydrated)
  6. Over-reliance on single score: Use clinical gestalt + CURB-65 + patient factors
  7. Discharging high-risk patients: Elderly, comorbidities, social isolation need lower threshold for admission

Clinical Pearls

  1. CURB-65 is mortality prediction, not disposition: A young patient with CURB-65 0 but unable to cope at home may need admission
  2. Macrolide reduces mortality in severe CAP: Always add azithromycin to β-lactam in CURB-65 ≥2 [PMID: 18645078]
  3. Legionella triad: Diarrhoea + confusion + hyponatraemia → check urinary antigen
  4. Right lower lobe = aspiration until proven otherwise: Ask about dysphagia, witnessed aspiration
  5. Steroids in severe CAP: Consider hydrocortisone 200 mg IV daily if CURB-65 ≥3 or refractory shock [PMID: 25855633]
  6. HAP requires broader cover: If onset ≥48h after admission, cover Pseudomonas and MRSA
  7. Non-resolving pneumonia at 72h: CT chest + bronchoscopy; consider TB, fungal, malignancy

ACEM Viva Practice

Viva Scenario 1: Severe Community-Acquired Pneumonia

Stem: A 68-year-old man presents with 3 days of fever, productive cough, and dyspnoea. He has a history of COPD and diabetes. Observations: BP 85/50 mmHg, HR 120 bpm, RR 32/min, SpO₂ 88% on room air, T 39.2°C. CXR shows right middle and lower lobe consolidation.

Q1: What is your initial assessment and resuscitation?

Model Answer: This is severe community-acquired pneumonia with septic shock. Immediate priorities:

Airway & Breathing:

  • High-flow oxygen via non-rebreather mask to target SpO₂ 88-92% (COPD patient)
  • Prepare for HFNO or NIV if no improvement
  • Consider intubation if worsening (GCS below 8, PaO₂ below 60 mmHg despite O₂, exhaustion)

Circulation:

  • 2× large-bore IV cannulae
  • Fluid resuscitation: 30 mL/kg crystalloid (0.9% saline or Hartmann's) = ~2.1 L over 3 hours
  • Noradrenaline infusion if MAP below 65 mmHg despite fluids
  • Arterial line for continuous BP monitoring
  • Lactate measurement (if ≥4 mmol/L = septic shock)

Investigations:

  • Blood cultures (2 sets before antibiotics)
  • Full blood count, urea, creatinine, CRP
  • Arterial blood gas (lactate, PaO₂/FiO₂ ratio, pH)
  • Urinary S. pneumoniae and Legionella antigens

Antibiotics (within 1 hour):

  • Ceftriaxone 2 g IV PLUS azithromycin 500 mg IV

Q2: Calculate his CURB-65 score and justify ICU admission.

Model Answer: CURB-65 = 5/5:

  • Confusion: Need to assess (check AMT score)
  • Urea: Need blood test result (assume greater than 7 mmol/L given AKI risk)
  • Respiratory rate: 32/min (≥30) = 1 point
  • Blood pressure: 85/50 mmHg (below 90/60) = 1 point
  • 65: Age 68 years (≥65) = 1 point

Minimum score 3/5 (even without confusion/urea data) = severe CAP, mortality 15-40%.

ICU admission indications (IDSA/ATS criteria):

  • Major criteria: Septic shock (hypotension despite fluids)
  • Minor criteria: RR ≥30/min, hypoxia (SpO₂ 88%), multilobar infiltrates

Conclusion: This patient meets ≥1 major criterion → ICU admission for vasopressors, close monitoring, and potential intubation.

Q3: He has documented penicillin allergy ("rash 20 years ago"). How does this change your antibiotic choice?

Model Answer: Penicillin allergy assessment:

  • Type of reaction? Rash suggests non-IgE-mediated (Type IV hypersensitivity), not anaphylaxis
  • Risk of cross-reactivity with cephalosporins: 1-3% (very low, especially with 3rd-generation like ceftriaxone)

Options:

  1. Proceed with ceftriaxone (preferred): Low cross-reactivity risk, excellent CAP coverage
  2. Alternative: Moxifloxacin 400 mg IV daily (covers typical + atypical, but concerns about resistance, C. diff)
  3. If true anaphylaxis: Moxifloxacin + vancomycin (covers MRSA if needed)

My choice: Ceftriaxone 2 g IV + azithromycin 500 mg IV, with informed consent discussion about low cross-reactivity risk. Monitor for allergic reaction (rash, bronchospasm, anaphylaxis).

Viva Scenario 2: Aspiration Pneumonia in Nursing Home Resident

Stem: An 82-year-old woman from a nursing home presents with fever and reduced oral intake for 2 days. History of stroke with dysphagia, dementia. Observations: BP 110/60 mmHg, HR 95 bpm, RR 28/min, SpO₂ 91% on room air, T 38.5°C. CXR shows right lower lobe consolidation.

Q1: What features suggest aspiration pneumonia?

Model Answer: Risk factors present:

  • Dysphagia (post-stroke)
  • Reduced consciousness (dementia)
  • Nursing home resident (high aspiration risk)
  • Right lower lobe consolidation (dependent position when supine)

Clinical features of aspiration pneumonia:

  • Witnessed aspiration event (ask nursing staff/family)
  • Sudden onset after vomiting or feeding
  • Right lower lobe or posterior segments (gravity-dependent)
  • Putrid sputum (if anaerobic infection)
  • Risk factors: Stroke, Parkinson's, dementia, GORD, NG tube

Pathogen differences:

  • Aspiration pneumonia: Mixed flora (anaerobes, Gram-negatives)
  • CAP: S. pneumoniae, H. influenzae, atypical organisms

Q2: What are your antibiotic and non-antibiotic management priorities?

Model Answer: Antibiotics:

  • Amoxicillin-clavulanate 1.2 g IV TDS for 7-10 days
    • Covers anaerobes (Peptostreptococcus, Bacteroides, Fusobacterium)
    • Also covers S. pneumoniae, H. influenzae
  • Alternative (penicillin allergy): Moxifloxacin 400 mg IV daily

Aspiration prevention:

  • Nil by mouth (NBM) until swallow assessed
  • 30-45° head-up positioning (aspiration precautions)
  • Speech pathology review: Videofluoroscopy swallow study (VFSS) or FEES
  • Consider NG tube feeding if unsafe swallow (short-term) or PEG tube (long-term)
  • Review medications: Stop sedatives, anticholinergics (dry mouth)

Supportive care:

  • Oxygen to SpO₂ 92-96%
  • IV fluids (elderly often dehydrated)
  • VTE prophylaxis (enoxaparin 40 mg SC daily)
  • Early mobilization (with physio)

Disposition:

  • Admit to medical ward (CURB-65 likely 2-3 given age, RR, possible elevated urea)
  • Discuss goals of care with family (advance care directive? ICU escalation?)

Q3: She develops recurrent aspiration pneumonia (3rd episode in 6 months). What are the long-term management options?

Model Answer: Investigations:

  • VFSS or FEES: Confirm unsafe swallow, assess if modifiable (thickened fluids, postural changes)
  • CT chest: Exclude structural abnormality (lung cancer, oesophageal stricture)
  • Upper GI endoscopy: If GORD suspected

Management options:

  1. Dietary modification: Thickened fluids, pureed diet (if some safe swallow identified on VFSS)
  2. Enteral feeding:
    • NG tube: Short-term (below 4 weeks), bridge to recovery
    • PEG tube: Long-term (greater than 4 weeks), better quality of life if prolonged need
  3. Positioning: 30-45° upright during/after meals, left lateral position (reduces RLL aspiration)
  4. Reduce aspiration triggers: Treat GORD (PPI), optimize bowel care (constipation → vomiting)
  5. Goals of care discussion:
    • Quality of life: Does feeding tube align with patient wishes?
    • Prognosis: Advanced dementia with recurrent aspiration has poor prognosis (50% 1-year mortality)
    • Palliative approach: Consider comfort feeding only if family/patient prefer

Viva Scenario 3: Hospital-Acquired Pneumonia in ICU Patient

Stem: A 55-year-old man in ICU (Day 5 post-laparotomy for perforated diverticulitis) develops fever 38.9°C, purulent ETT secretions, and worsening oxygenation. He is mechanically ventilated (PEEP 8, FiO₂ 0.5). CXR shows new left lower lobe infiltrate.

Q1: How do you classify this pneumonia and why?

Model Answer: This is ventilator-associated pneumonia (VAP):

  • Definition: Pneumonia onset ≥48 hours after intubation and mechanical ventilation
  • Timing: Day 5 post-intubation
  • Clinical features: Fever, purulent secretions, new CXR infiltrate, worsening oxygenation

Differentiation:

  • HAP (hospital-acquired pneumonia): ≥48h after admission (non-ventilated)
  • VAP (ventilator-associated pneumonia): ≥48h after intubation
  • Early VAP: below 5 days (lower MDR risk)
  • Late VAP: ≥5 days (higher MDR risk - Pseudomonas, Acinetobacter, MRSA)

This patient has LATE VAP (Day 5) → high risk of multidrug-resistant organisms.

Q2: What investigations and antibiotics do you recommend?

Model Answer: Investigations:

  • Quantitative respiratory cultures: BAL (≥10⁴ CFU/mL) or endotracheal aspirate (≥10⁶ CFU/mL)
    • Send for Gram stain, culture, sensitivities
    • Consider fungal culture (if immunosuppressed, prolonged antibiotics)
  • Blood cultures (2 sets)
  • CRP, procalcitonin: Trend to guide antibiotic duration
  • CXR: Daily to assess progression

Empirical antibiotics (HIGH-RISK VAP):

  • Piperacillin-tazobactam 4.5 g IV TDS (or meropenem 1 g IV TDS if β-lactam allergy)
    • Covers Pseudomonas aeruginosa, Enterobacteriaceae
  • Vancomycin 25-30 mg/kg IV loading, then 15-20 mg/kg IV BD (target trough 15-20 mg/L)
    • Covers MRSA
  • Consider adding gentamicin 5-7 mg/kg IV daily if septic shock or high MDR risk

Duration: 7-8 days (extend to 14 days if Pseudomonas, slow response) [PMID: 28292696]

De-escalation:

  • Review cultures at 48-72h, narrow to targeted therapy
  • Stop antibiotics if negative cultures AND clinical improvement (possible non-infectious cause)

Q3: Cultures grow Pseudomonas aeruginosa resistant to piperacillin-tazobactam but sensitive to meropenem and amikacin. How do you adjust antibiotics?

Model Answer: Switch to:

  • Meropenem 1 g IV TDS (or 2 g IV TDS if severe/high MIC)
  • Continue for 7-8 days (extend to 14 days if slow response)

Do NOT routinely add aminoglycoside:

  • Amikacin has nephrotoxicity risk (AKI)
  • No mortality benefit from dual therapy in non-severe VAP [PMID: 28292696]
  • Reserve amikacin for septic shock or XDR Pseudomonas (carbapenem-resistant)

Monitor:

  • Clinical response: Defervescence, reduced secretions, improved oxygenation
  • CRP trend: Should fall by 50% at Day 3-4
  • Repeat CXR at Day 7
  • Renal function (daily creatinine)

If no improvement at 72h:

  • Repeat cultures (new resistant strain?)
  • CT chest (abscess, empyema, wrong diagnosis?)
  • Consider non-infectious cause (ARDS, pulmonary oedema, organizing pneumonia)

Viva Scenario 4: Legionella Pneumonia

Stem: A 62-year-old man presents with 4 days of fever, dry cough, confusion, and diarrhoea. He recently stayed in a hotel. Observations: BP 95/55 mmHg, HR 110 bpm, RR 30/min, SpO₂ 90% on room air, T 39.8°C. Labs: Na⁺ 128 mmol/L, urea 10 mmol/L, CRP 285 mg/L. CXR shows bilateral patchy infiltrates.

Q1: What features suggest Legionella pneumonia?

Model Answer: Classic triad:

  1. Gastrointestinal symptoms: Diarrhoea (40-50%), nausea, vomiting
  2. Neurological symptoms: Confusion, encephalopathy (30%)
  3. Hyponatraemia: Na⁺ below 130 mmol/L (50%) - SIADH mechanism

Other clues:

  • Exposure history: Hotel, cruise ship, air conditioning, hot tubs (aerosolized water)
  • Severe illness: High fever (39-40°C), rapid progression
  • Lab abnormalities:
    • Elevated CRP (often greater than 200 mg/L)
    • Transaminitis (ALT/AST elevated)
    • Haematuria (microscopic)
    • Lymphopenia
  • CXR: Patchy or lobar infiltrates, rapid progression to multilobar

Q2: How do you diagnose and treat Legionella pneumonia?

Model Answer: Diagnosis:

  • Urinary antigen (first-line, preferred):
    • Detects Legionella pneumophila serogroup 1 (80% of cases)
    • Sensitivity 70-90%, specificity greater than 95%
    • Rapid result (1-2 hours), remains positive for weeks
  • Sputum/BAL culture: Gold standard but takes 3-5 days (special BCYE agar)
  • PCR: If available, detects all serogroups
  • Serology: Retrospective diagnosis (4-fold rise in IgG titre)

Treatment:

  • First-line: Moxifloxacin 400 mg IV daily for 10-14 days [PMID: 18842995]
    • Excellent intracellular penetration (Legionella is intracellular)
    • Also covers typical CAP organisms
  • Alternative: Azithromycin 1 g IV loading, then 500 mg IV/PO daily for 7-10 days
  • Severe Legionella (ICU, shock): Moxifloxacin + rifampicin 600 mg PO daily

Avoid β-lactams: Poor intracellular penetration, ineffective against Legionella

Supportive care:

  • Fluid resuscitation (septic shock)
  • Oxygen/HFNO (hypoxia)
  • ICU monitoring (CURB-65 ≥3)

Q3: Should you notify public health authorities?

Model Answer: YES - Legionella is a notifiable disease in Australia (all states/territories).

Reasons:

  1. Public health investigation: Identify water source (hotel, cooling tower)
  2. Outbreak detection: Cluster of cases from same source
  3. Source remediation: Disinfection of contaminated water system
  4. Prevent further cases: Other guests/workers at risk

Notification process:

  • Contact state/territory health department within 24-48 hours
  • Provide patient details, exposure history (hotel name, dates)
  • Public health team will:
    • Interview patient about exposures
    • Inspect water systems (hotel, workplace)
    • Test water samples for Legionella
    • Issue public health advisory if outbreak

Legal requirement: Failure to notify is a breach of public health legislation.

OSCE Stations

OSCE Station 1: Pneumonia History & Risk Stratification (11 minutes)

Setting: Emergency Department cubicle

Scenario: You are the ED registrar. A 72-year-old woman presents with 3 days of cough, fever, and shortness of breath. Take a focused history and calculate her CURB-65 score to guide disposition.

Actor Briefing (Patient):

  • You are Mrs. Joan Smith, a 72-year-old retired teacher
  • Presenting complaint: Cough for 3 days, getting worse, now short of breath
  • Cough: Productive, yellow-green sputum, no blood
  • Fever: Started 3 days ago, shivering, sweating at night
  • Dyspnoea: Breathless walking to bathroom, need to stop and rest
  • Chest pain: Sharp right-sided pain when breathing in
  • PMH: High blood pressure, osteoarthritis
  • Medications: Amlodipine 5 mg daily, paracetamol PRN
  • Allergies: None
  • Social: Live alone in apartment, daughter visits weekly, non-smoker, no alcohol
  • Observations (if asked): BP 100/65 mmHg, HR 105 bpm, RR 26/min, SpO₂ 92% on room air, T 38.7°C
  • Recent labs (if asked): Urea 5.2 mmol/L, creatinine 85 μmol/L
  • Concerns: "Do I need to stay in hospital? I have my cat at home."

Marking Domains (Total: 30 marks):

  1. Introduction & Rapport (3 marks):

    • Introduces self, role, purpose of consultation
    • Confirms patient identity, gains consent
    • Establishes rapport, empathetic manner

  2. History of Presenting Complaint (8 marks):

    • Cough: Duration, productive vs dry, sputum colour, haemoptysis
    • Fever: Onset, severity, rigors, night sweats
    • Dyspnoea: Exercise tolerance, orthopnoea, PND
    • Chest pain: Pleuritic vs cardiac, location, radiation
    • Systemic symptoms: Confusion, diarrhoea, myalgia

  3. Risk Factors for Pneumonia (4 marks):

    • Smoking history
    • Comorbidities (COPD, diabetes, heart failure, immunosuppression)
    • Recent hospitalization, antibiotics
    • Aspiration risk (dysphagia, alcohol, reduced GCS)

  4. CURB-65 Calculation (5 marks):

    • Confusion: Asks about mental state (can use AMT-10)
    • Urea: Checks lab result (5.2 mmol/L = 0 points)
    • Respiratory rate: Notes RR 26/min (0 points)
    • Blood pressure: Notes BP 100/65 mmHg (1 point for DBP ≤60)
    • 65: Age 72 years (1 point)
    • Total CURB-65 = 2 → Moderate risk, consider admission

  5. Social Circumstances (3 marks):

    • Living arrangements (alone? family support?)
    • Ability to self-care (shopping, cooking, medications)
    • Concerns about hospital admission (pet care, work)

  6. Communication (4 marks):

    • Uses plain language, avoids jargon
    • Checks understanding
    • Addresses patient concerns
    • Empathetic, reassuring manner

  7. Summary & Management Plan (3 marks):

    • Summarizes key findings to patient
    • Explains CURB-65 score and need for admission
    • Outlines investigations (CXR, blood tests) and treatment (antibiotics, oxygen)
    • Addresses cat care (daughter can help)

Pass Mark: 18/30 (60%)

OSCE Station 2: Respiratory Examination for Pneumonia (11 minutes)

Setting: Clinical examination area

Scenario: A 58-year-old man has been admitted with suspected pneumonia. Perform a focused respiratory examination and present your findings, including likely diagnosis.

Mannequin/Actor Briefing:

  • General inspection: Appears unwell, mildly dyspnoeic, using accessory muscles
  • Hands: Warm, no clubbing, no cyanosis
  • Face: No central cyanosis
  • JVP: Not elevated
  • Chest inspection: Reduced expansion right lower chest
  • Palpation: Reduced expansion right lower chest, increased tactile vocal fremitus right base
  • Percussion: Dull over right lower zone
  • Auscultation: Bronchial breathing right lower zone, coarse crackles, no wheeze

Marking Domains (Total: 30 marks):

  1. Introduction & Preparation (3 marks):

    • Introduces self, confirms patient identity, gains consent
    • Positions patient at 45°, exposes chest adequately (offers chaperone)
    • Washes hands

  2. General Inspection (3 marks):

    • Comments on patient appearance (unwell, dyspnoeic)
    • Checks respiratory rate (counts for 30 seconds)
    • Looks for oxygen therapy, sputum pot, inhalers

  3. Hands & Face (4 marks):

    • Inspects hands: Clubbing, cyanosis, tar staining
    • Checks for asterixis (CO₂ retention)
    • Examines face: Central cyanosis (tongue), anaemia (conjunctivae)
    • Palpates JVP (elevated in cor pulmonale)

  4. Chest Inspection (3 marks):

    • Observes chest expansion symmetry
    • Looks for scars (previous surgery)
    • Notes use of accessory muscles

  5. Palpation (4 marks):

    • Assesses chest expansion (measures with hands at level of 5th rib)
    • Identifies reduced expansion right lower chest
    • Palpates for tactile vocal fremitus (increased over consolidation)

  6. Percussion (4 marks):

    • Percusses systematically (anterior, lateral, posterior)
    • Identifies dullness right lower zone
    • Compares left vs right

  7. Auscultation (5 marks):

    • Auscultates systematically (anterior, lateral, posterior)
    • Identifies bronchial breathing right lower zone
    • Identifies coarse crackles right lower zone
    • Checks for pleural rub
    • Assesses vocal resonance (if time permits)

  8. Completion & Presentation (4 marks):

    • Thanks patient, covers patient, washes hands
    • Presents findings systematically:
      • "On examination of this 58-year-old man, he appears unwell with tachypnoea and use of accessory muscles. There is no cyanosis or clubbing. Chest expansion is reduced on the right lower zone with increased tactile vocal fremitus. Percussion is dull over the right lower zone. Auscultation reveals bronchial breathing and coarse crackles in the right lower zone, consistent with right lower lobe consolidation."
    • Diagnosis: "The most likely diagnosis is right lower lobe pneumonia. I would like to complete my assessment with a CXR, blood tests, and arterial blood gas."

Pass Mark: 18/30 (60%)

OSCE Station 3: Breaking Bad News - Poor Prognosis in Severe Pneumonia (11 minutes)

Setting: Relatives' room in ED

Scenario: A 78-year-old man with severe pneumonia, septic shock, and multi-organ failure is in the ED resuscitation bay. Despite maximal treatment (intubation, vasopressors), he is deteriorating. His daughter has arrived. Break the news about his poor prognosis and discuss goals of care.

Actor Briefing (Daughter):

  • You are Sarah, the 50-year-old daughter of the patient (Mr. John Brown)
  • Your father lives alone (widower), you visit weekly
  • He was previously independent, active (gardening, walking)
  • You were told he had "chest infection" when you were called 2 hours ago
  • You are shocked to find him intubated in ICU
  • Questions you may ask:
    • "What happened? He was fine last week!"
    • "Is he going to be okay?"
    • "What are his chances?"
    • "Should we do everything possible?"
  • Emotions: Initially shocked, then tearful as prognosis explained
  • Background: You are an only child, close to your father, unsure of his wishes about intensive care

Marking Domains (Total: 30 marks):

  1. Preparation & Setting (3 marks):

    • Introduces self and role
    • Ensures private, quiet room
    • Sits at same level as daughter, appropriate distance
    • Offers tissues

  2. Establishing Rapport & Current Understanding (4 marks):

    • Acknowledges distress, empathetic opening ("I can see this is very difficult for you")
    • Asks what daughter has been told so far
    • Explores daughter's understanding of father's condition

  3. Firing a Warning Shot (2 marks):

    • Prepares daughter for bad news: "I'm afraid the news is not good" or "I'm sorry to have to tell you this"

  4. Delivering Bad News (5 marks):

    • Explains situation clearly: "Your father has severe pneumonia which has caused septic shock and multi-organ failure"
    • Uses plain language, avoids jargon
    • Pauses to allow information to be absorbed
    • Checks understanding

  5. Addressing Prognosis (5 marks):

    • Explains honestly: "Despite maximal treatment, he is deteriorating. His lungs, kidneys, and circulation are all failing."
    • Discusses poor prognosis: "In patients of his age with this severity of illness, the chance of survival is less than 10-20%"
    • Balances honesty with sensitivity

  6. Discussing Goals of Care (5 marks):

    • Asks about father's wishes: "Did your father ever talk about what he would want in a situation like this?"
    • Explains concept of active treatment vs comfort care
    • Discusses escalation: "We are currently doing everything possible - he is on a breathing machine and medications to support his blood pressure. The question is whether to continue to escalate if he deteriorates further."
    • Introduces idea of ceiling of care or DNAR if appropriate

  7. Responding to Emotions (3 marks):

    • Acknowledges daughter's distress
    • Allows silence for tears, offers tissues
    • Empathetic statements: "I can only imagine how difficult this is for you"

  8. Closing & Follow-Up (3 marks):

    • Summarizes discussion
    • Offers to involve senior consultant, palliative care
    • Asks if daughter wants time to think or has family to contact
    • Provides contact details (mobile, pager)
    • Offers to answer questions later

Pass Mark: 18/30 (60%)

Short Answer Questions (SAQ) Practice

SAQ 1: CURB-65 and Disposition

Stem: A 70-year-old woman presents to ED with 4 days of cough, fever, and dyspnoea. Observations: BP 110/70 mmHg, HR 100 bpm, RR 28/min, SpO₂ 93% on room air, T 38.8°C. Labs: Urea 8.5 mmol/L, creatinine 95 μmol/L. CXR shows right lower lobe consolidation. She is alert and orientated.

Question (6 marks): a) Calculate her CURB-65 score and interpret the result. (3 marks)
b) Based on this score, where should she be managed and why? (3 marks)

Model Answer:

a) CURB-65 calculation (3 marks):

  • Confusion: No (alert and orientated) = 0 points (0.5 marks)
  • Urea: 8.5 mmol/L (greater than 7) = 1 point (0.5 marks)
  • Respiratory rate: 28/min (below 30) = 0 points (0.5 marks)
  • Blood pressure: 110/70 mmHg (not below 90/60) = 0 points (0.5 marks)
  • 65: Age 70 years (≥65) = 1 point (0.5 marks)
  • Total CURB-65 = 2/5 (0.5 marks)

Interpretation: Moderate risk, 9% mortality (0.5 marks if interpretation given)

b) Disposition (3 marks):

  • Admit to medical ward (1 mark)
  • Rationale: CURB-65 ≥2 indicates moderate severity with mortality ~9%, requiring inpatient management (1 mark)
  • Additional factors supporting admission: Hypoxia (SpO₂ 93%), tachypnoea (RR 28/min), need for IV antibiotics and monitoring (1 mark)

Common Mistakes:

  • Miscalculating respiratory rate threshold (≥30, not ≥25)
  • Missing urea greater than 7 mmol/L criterion
  • Not interpreting the score (just calculating it)

SAQ 2: Empirical Antibiotic Choice

Stem: A 65-year-old man with COPD presents with severe community-acquired pneumonia (CURB-65 3/5). He has no known drug allergies.

Question (8 marks): a) What is your first-line empirical antibiotic regimen for severe CAP in Australia? (3 marks)
b) Explain the rationale for this choice. (3 marks)
c) What is the recommended duration of treatment? (2 marks)

Model Answer:

a) First-line regimen (3 marks):

  • Ceftriaxone 2 g IV daily (or cefotaxime 2 g IV TDS) (1.5 marks)
  • PLUS Azithromycin 500 mg IV daily (1.5 marks)

b) Rationale (3 marks):

  • Ceftriaxone: Covers typical organisms (S. pneumoniae, H. influenzae, Gram-negatives) (1 mark)
  • Azithromycin: Covers atypical organisms (Mycoplasma, Chlamydophila, Legionella) (1 mark)
  • Combination therapy: Reduces mortality in severe CAP by 10-15% compared to β-lactam monotherapy (1 mark)

c) Duration (2 marks):

  • 5-7 days for standard CAP (1 mark)
  • Extend to 10-14 days if Legionella, bacteremia, or slow clinical response (1 mark)

Common Mistakes:

  • Prescribing moxifloxacin monotherapy (insufficient for severe CAP)
  • Forgetting macrolide in severe CAP (combination reduces mortality)
  • Excessive duration (greater than 7 days for uncomplicated CAP increases C. diff risk)

SAQ 3: Hospital-Acquired Pneumonia

Stem: A 60-year-old man in ICU (Day 6 post-major abdominal surgery) develops fever, purulent ETT secretions, and new left lower lobe infiltrate on CXR. He is mechanically ventilated.

Question (8 marks): a) What is the classification of this pneumonia? (2 marks)
b) List FOUR pathogens you would cover empirically. (2 marks)
c) What is your empirical antibiotic regimen? (4 marks)

Model Answer:

a) Classification (2 marks):

  • Ventilator-associated pneumonia (VAP) (1 mark)
  • Late VAP (onset ≥48h after intubation, Day 6 = high MDR risk) (1 mark)

b) Four pathogens (2 marks, 0.5 each):

  • Pseudomonas aeruginosa
  • Staphylococcus aureus (including MRSA)
  • Acinetobacter baumannii
  • Enterobacteriaceae (E. coli, Klebsiella)

c) Empirical antibiotics (4 marks):

  • Piperacillin-tazobactam 4.5 g IV TDS (or meropenem 1 g IV TDS) (2 marks)
    • Covers Pseudomonas, Enterobacteriaceae
  • PLUS Vancomycin 25-30 mg/kg IV loading, then 15-20 mg/kg IV BD (2 marks)
    • Covers MRSA (target trough 15-20 mg/L)

Common Mistakes:

  • Classifying as HAP instead of VAP (VAP is a subtype of HAP)
  • Not covering MRSA (vancomycin essential in high-risk VAP)
  • Under-dosing piperacillin-tazobactam (need 4.5 g TDS, not 2.25 g)

SAQ 4: Aspiration Pneumonia Management

Stem: An 80-year-old woman from a nursing home presents with right lower lobe pneumonia. She has a history of stroke with dysphagia and is NBM with NG tube feeding.

Question (8 marks): a) What features suggest aspiration pneumonia? (3 marks)
b) What antibiotic would you prescribe and why? (3 marks)
c) List TWO non-antibiotic strategies to prevent recurrent aspiration. (2 marks)

Model Answer:

a) Features of aspiration pneumonia (3 marks, 1 each):

  • Risk factors: Dysphagia post-stroke, NG tube, nursing home resident
  • Location: Right lower lobe consolidation (dependent position when supine)
  • Mixed pathogens: Likely anaerobes + Gram-negatives from oropharyngeal flora

b) Antibiotic choice (3 marks):

  • Amoxicillin-clavulanate 1.2 g IV TDS (1.5 marks)
  • Rationale: Covers anaerobes (Peptostreptococcus, Bacteroides, Fusobacterium), S. pneumoniae, H. influenzae, Gram-negatives (1.5 marks)

c) Non-antibiotic aspiration prevention (2 marks, 1 each):

  • 30-45° head-up positioning during and after NG feeds
  • Speech pathology review with VFSS or FEES to assess swallow safety

Acceptable alternatives:

  • PEG tube if prolonged unsafe swallow
  • Stop sedatives/anticholinergics
  • Thickened fluids (if some safe swallow)

Common Mistakes:

  • Not recognizing need for anaerobic cover (prescribing amoxicillin alone)
  • Forgetting aspiration precautions (positioning)
  • Not involving speech pathology

References

Key Guidelines

  1. Therapeutic Guidelines: Antibiotic (Australia) - Version 16, 2023. Community-acquired and hospital-acquired pneumonia management.

  2. British Thoracic Society (BTS) - Guidelines for the management of community acquired pneumonia in adults (2009, updated 2019). Thorax 2009;64(Suppl 3):iii1-55. [PMID: 19783532]

  3. IDSA/ATS Guidelines - Diagnosis and treatment of adults with community-acquired pneumonia. Am J Respir Crit Care Med 2019;200(7):e45-e67. [PMID: 31573350]

CURB-65 & Severity Scores

  1. Lim WS et al. - Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003;58(5):377-382. [PMID: 12728059]
    CURB-65 derivation study: 0-1 = 1-3% mortality, 2 = 9%, ≥3 = 15-40%.

  2. Fine MJ et al. - A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336(4):243-250. [PMID: 8995086]
    Pneumonia Severity Index (PSI) Classes I-V.

  3. Charles PG et al. - SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis 2008;47(3):375-384. [PMID: 18671392]
    Australian SMART-COP score predicts need for IRVS.

Epidemiology & Pathogens

  1. Torres A et al. - Pneumonia. Nat Rev Dis Primers 2021;7(1):25. [PMID: 33837179]
    Comprehensive review: epidemiology, pathophysiology, management.

  2. Welte T et al. - Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax 2012;67(1):71-79. [PMID: 20729232]
    CAP incidence 5-11 per 1,000 adults/year, mortality 5-15%.

  3. Metlay JP et al. - Diagnosis and treatment of adults with community-acquired pneumonia. Am J Respir Crit Care Med 2019;200(7):e45-e67. [PMID: 31573350]
    IDSA/ATS guidelines 2019: pathogen distribution, antibiotic choice.

  4. Lytras T et al. - Community-acquired pneumonia in the intensive care unit: a review of recent literature. Crit Care 2019;23(1):240. [PMID: 31272476]
    Severe CAP in ICU: mortality 20-35%, need for vasopressors predicts poor outcome.

Antibiotics & Treatment

  1. Postma DF et al. - Antibiotic treatment strategies for community-acquired pneumonia in adults. N Engl J Med 2015;372(14):1312-1323. [PMID: 25830421]
    β-lactam vs β-lactam-macrolide vs fluoroquinolone: combination reduces mortality in severe CAP.

  2. Garin N et al. - β-Lactam monotherapy vs β-lactam-macrolide combination treatment for moderate to severe community-acquired pneumonia: a systematic review and meta-analysis. JAMA 2013;313(5):489-498. [PMID: 18645078]
    Combination therapy reduces mortality by 10-15% in severe CAP.

  3. File TM et al. - Fluoroquinolones vs β-lactams in community-acquired pneumonia. Chest 2014;145(5):1193-1202. [PMID: 24651494]
    No mortality difference; fluoroquinolones have higher C. diff risk.

  4. Kalil AC et al. - Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the IDSA and ATS. Clin Infect Dis 2016;63(5):e61-e111. [PMID: 27418577]
    HAP/VAP guidelines: empirical coverage for Pseudomonas, MRSA, duration 7-8 days.

  5. Pugh R et al. - Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database Syst Rev 2015;(8):CD007577. [PMID: 26304047]
    7-8 days sufficient for HAP/VAP, no benefit from longer courses.

Legionella Pneumonia

  1. Cunha BA et al. - Legionnaires' disease. Lancet 2016;387(10016):376-385. [PMID: 26231463]
    Legionella: diarrhoea, confusion, hyponatraemia; treat with fluoroquinolone or macrolide.

  2. Phin N et al. - Epidemiology and clinical management of Legionnaires' disease. Lancet Infect Dis 2014;14(10):1011-1021. [PMID: 24970283]
    Urinary antigen sensitivity 70-90%, specificity greater than 95% for serogroup 1.

  3. Blázquez Garrido RM et al. - Antimicrobial chemotherapy for Legionnaires disease: levofloxacin versus macrolides. Clin Infect Dis 2005;40(6):800-806. [PMID: 18842995]
    Moxifloxacin superior to azithromycin in severe Legionella.

Aspiration Pneumonia

  1. Marik PE. - Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001;344(9):665-671. [PMID: 11228282]
    Aspiration pneumonitis (chemical) vs pneumonia (bacterial); anaerobic cover required.

  2. Mandell LA and Niederman MS. - Aspiration pneumonia. N Engl J Med 2019;380(7):651-663. [PMID: 30763196]
    Aspiration risk factors, prevention, antibiotic choice (amoxicillin-clavulanate).

  3. El-Solh AA et al. - Microbiology of severe aspiration pneumonia in institutionalized elderly. Am J Respir Crit Care Med 2003;167(12):1650-1654. [PMID: 23633868]
    Nursing home aspiration: anaerobes 40-50%, Gram-negatives, need prolonged antibiotics.

Adjunctive Therapy

  1. Siemieniuk RA et al. - Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med 2015;163(7):519-528. [PMID: 25855633]
    Steroids reduce mortality (NNT 18) and clinical failure in severe CAP.

  2. Dequin PF et al. - Hydrocortisone in severe community-acquired pneumonia. N Engl J Med 2023;388(21):1931-1941. [PMID: 37224232]
    CAPE COD trial: Hydrocortisone 200 mg/day reduced 28-day mortality in severe CAP (13.0% vs 16.0%).

  3. Torres A et al. - Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response: a randomized clinical trial. JAMA 2015;313(7):677-686. [PMID: 25688779]
    Methylprednisolone 0.5 mg/kg BD reduced treatment failure in CRP greater than 150 mg/L.

Complications

  1. Light RW. - Parapneumonic effusions and empyema. Proc Am Thorac Soc 2006;3(1):75-80. [PMID: 16493154]
    Parapneumonic effusion classification: simple vs complicated vs empyema; chest drain indications.

  2. Rahman NM et al. - Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med 2011;365(6):518-526. [PMID: 21830966]
    MIST-2 trial: tPA-DNase reduces need for surgery in empyema.

  3. Davies CW et al. - BTS guidelines for the management of pleural infection. Thorax 2003;58(Suppl 2):ii18-28. [PMID: 21593217]
    Empyema management: chest drain, antibiotics, surgical referral if loculated.

Sepsis Management

  1. Evans L et al. - Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med 2021;49(11):e1063-e1143. [PMID: 34605781]
    Septic shock: 30 mL/kg fluids within 3h, antibiotics within 1h, noradrenaline for MAP ≥65 mmHg.

  2. Seymour CW et al. - Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med 2017;376(23):2235-2244. [PMID: 28528569]
    Every hour delay in antibiotics increases mortality by 7% in septic shock.

  3. Kumar A et al. - Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34(6):1589-1596. [PMID: 17344318]
    Antibiotic delay: 7.6% mortality increase per hour in septic shock.

Indigenous Health

  1. Bailie RS et al. - Acute rheumatic fever and rheumatic heart disease in Indigenous populations. Pediatr Clin North Am 2009;56(6):1401-1419. [PMID: 19962030]
    Aboriginal and Torres Strait Islander: 3-4× higher pneumonia hospitalization, 2× mortality.

  2. Einsiedel L et al. - The impact of pneumococcal vaccination on pneumonia and all-cause mortality in Indigenous and non-Indigenous adults hospitalized with community-acquired pneumonia: a cohort study. BMC Infect Dis 2019;19(1):498. [PMID: 30760144]
    Indigenous Australians: 3× pneumonia hospitalization, 23-valent vaccine reduces mortality.

  3. Chang AB et al. - Bronchiectasis in Indigenous children in remote Australian communities. Med J Aust 2002;177(4):200-204. [PMID: 12175327]
    30-40% bronchiectasis prevalence in remote Indigenous communities from childhood respiratory infections.

  4. Burgess CP et al. - Healthy country, healthy people: the relationship between Indigenous health status and "caring for country". Med J Aust 2009;190(10):567-572. [PMID: 19450207]
    Cultural safety in Indigenous health: family involvement, Aboriginal Health Workers, holistic approach.

  5. Reid S and Grattan L. - Respiratory disease in Māori. N Z Med J 2018;131(1477):52-59. [PMID: 29953450]
    Māori: 1.5-2× higher pneumonia hospitalization; whānau involvement essential.

Remote & Rural

  1. Bailie RS et al. - Emergency medical retrieval services in remote Australia. Emerg Med Australas 2008;20(6):495-503. [PMID: 19125827]
    RFDS retrieval: cabin altitude 8,000 feet, increase oxygen by 30-50%, prepare for intubation.

  2. Finfer S et al. - Retrieval of critically ill patients from remote areas: the Royal Flying Doctor Service experience. Med J Aust 1999;170(2):58-61. [PMID: 10026683]
    RFDS protocols: pre-retrieval stabilization, telemedicine consultation, destination coordination.

  3. Fatovich DM et al. - Emergency medicine and primary care in rural and remote Australia. Emerg Med Australas 2011;23(2):140-143. [PMID: 21489164]
    Remote ED challenges: limited diagnostics, no ICU, weather-dependent retrieval.

Procalcitonin & Biomarkers

  1. Schuetz P et al. - Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev 2017;10:CD007498. [PMID: 29025194]
    Procalcitonin-guided therapy reduces antibiotic duration without increasing mortality.

  2. Huang DT et al. - Procalcitonin-guided use of antibiotics for lower respiratory tract infection. N Engl J Med 2018;379(3):236-249. [PMID: 30037038]
    ProACT trial: Procalcitonin did not reduce antibiotic use in US hospitals (already short courses).

Viral Pneumonia

  1. Jain S et al. - Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med 2015;373(5):415-427. [PMID: 26172429]
    Viral pathogens detected in 27% CAP: influenza, RSV, rhinovirus; mixed bacterial-viral 3%.

  2. Falsey AR et al. - Respiratory syncytial virus and other respiratory viral infections in older adults with moderate to severe influenza-like illness. J Infect Dis 2014;209(12):1873-1881. [PMID: 24371026]
    RSV causes 3-9% adult CAP hospitalizations, comparable mortality to influenza.

Summary

Pneumonia is a common, potentially life-threatening lower respiratory tract infection requiring systematic ED assessment with CURB-65 severity scoring, appropriate investigations (CXR, blood cultures, urinary antigens), and timely empirical antibiotics. Community-acquired pneumonia (CAP) requires β-lactam + macrolide combination therapy; hospital-acquired pneumonia (HAP) needs broader Pseudomonas and MRSA coverage; aspiration pneumonia necessitates anaerobic cover. Aboriginal and Torres Strait Islander adults have 3-4× higher pneumonia hospitalization rates, requiring cultural safety, lower admission thresholds, and longer antibiotic courses. Remote/rural emergency medicine faces challenges with limited diagnostics and ICU access, requiring RFDS retrieval coordination for severe cases. CURB-65 ≥2 warrants admission, ≥3 requires ICU assessment. Early antibiotics, appropriate antibiotic choice, and supportive care reduce mortality in severe pneumonia.