Welcome, PharmD students, to this MCQ quiz on Community-Acquired Pneumonia (CAP)! CAP is a common and potentially serious infection of the lungs acquired outside of healthcare settings. As pharmacists, your understanding of the common pathogens, clinical presentation, diagnostic approaches, severity assessment, and evidence-based antimicrobial treatment guidelines is crucial for optimizing patient outcomes and promoting antimicrobial stewardship. This quiz will test your knowledge on these key aspects of managing CAP. Let’s begin!
1. Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma acquired:
- a) During a hospital stay of more than 48 hours.
- b) In an outpatient setting or within 48 hours of hospital admission, in a patient not residing in a long-term care facility.
- c) Only in immunocompromised individuals.
- d) Exclusively by viral pathogens.
Answer: b) In an outpatient setting or within 48 hours of hospital admission, in a patient not residing in a long-term care facility.
2. The most common bacterial pathogen responsible for CAP in adults is:
- a) Mycoplasma pneumoniae
- b) Haemophilus influenzae
- c) Streptococcus pneumoniae (pneumococcus)
- d) Legionella pneumophila
Answer: c) Streptococcus pneumoniae (pneumococcus)
3. Which of the following are considered “atypical” bacterial pathogens that can cause CAP?
- a) Staphylococcus aureus and Klebsiella pneumoniae.
- b) Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila.
- c) Streptococcus pyogenes and Moraxella catarrhalis.
- d) Escherichia coli and Pseudomonas aeruginosa.
Answer: b) Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila.
4. Common signs and symptoms of CAP include all of the following EXCEPT:
- a) Cough (often productive), fever, and chills.
- b) Dyspnea (shortness of breath) and pleuritic chest pain.
- c) Severe joint pain and swelling.
- d) Tachypnea, tachycardia, and abnormal lung sounds (e.g., crackles).
Answer: c) Severe joint pain and swelling.
5. Which diagnostic test is generally considered essential for confirming the diagnosis of pneumonia and assessing its extent?
- a) Sputum Gram stain and culture
- b) Chest X-ray (CXR)
- c) Complete blood count (CBC)
- d) Arterial blood gas (ABG)
Answer: b) Chest X-ray (CXR)
6. The CURB-65 score is a severity assessment tool for CAP. The “C” stands for:
- a) Cough
- b) Comorbidities
- c) Confusion (new onset)
- d) C-reactive protein
Answer: c) Confusion (new onset)
7. In addition to Confusion, Urea (>7 mmol/L or BUN >19-20 mg/dL), Respiratory rate (≥30 breaths/min), and Blood pressure (systolic <90 mmHg or diastolic ≤60 mmHg), what does “65” in CURB-65 represent?
- a) A target oxygen saturation level.
- b) Age ≥ 65 years.
- c) A minimum white blood cell count.
- d) The number of lobes affected on CXR.
Answer: b) Age ≥ 65 years.
8. For an otherwise healthy outpatient adult with CAP and no recent antibiotic use or risk factors for drug-resistant S. pneumoniae (DRSP), a recommended empiric antibiotic regimen according to many guidelines might be:
- a) Intravenous vancomycin.
- b) Oral amoxicillin, doxycycline, or a macrolide (if local pneumococcal resistance is low).
- c) Oral ciprofloxacin.
- d) Oral metronidazole.
Answer: b) Oral amoxicillin, doxycycline, or a macrolide (if local pneumococcal resistance is low).
9. Which class of antibiotics is often recommended as part of a combination regimen (e.g., with a beta-lactam) for inpatient treatment of CAP to ensure coverage of atypical pathogens?
- a) Aminoglycosides
- b) Sulfonamides
- c) Macrolides (e.g., azithromycin) or Doxycycline
- d) Oxazolidinones
Answer: c) Macrolides (e.g., azithromycin) or Doxycycline
10. Respiratory fluoroquinolones (e.g., levofloxacin, moxifloxacin) have activity against S. pneumoniae (including some DRSP) and atypical pathogens. They are often considered for:
- a) All cases of mild CAP as first-line therapy.
- b) Outpatients with comorbidities, inpatients (non-ICU), or as an alternative in beta-lactam allergic patients.
- c) Only viral pneumonia.
- d) Only Gram-negative infections.
Answer: b) Outpatients with comorbidities, inpatients (non-ICU), or as an alternative in beta-lactam allergic patients.
11. The Pneumonia Severity Index (PSI) is another tool used to stratify risk in CAP patients and helps to determine:
- a) The specific causative pathogen.
- b) The most appropriate site of care (e.g., outpatient, inpatient ward, ICU).
- c) The duration of antibiotic therapy.
- d) The need for antiviral therapy.
Answer: b) The most appropriate site of care (e.g., outpatient, inpatient ward, ICU).
12. When is microbiological testing (e.g., sputum culture, blood culture, urinary antigen tests) generally recommended for CAP?
- a) For all outpatients with mild CAP.
- b) For patients with severe CAP, those requiring ICU admission, or if risk factors for specific pathogens (e.g., MRSA, Pseudomonas) are present.
- c) Only if the patient has a cough.
- d) Never, as empiric therapy is always sufficient.
Answer: b) For patients with severe CAP, those requiring ICU admission, or if risk factors for specific pathogens (e.g., MRSA, Pseudomonas) are present.
13. Urinary antigen tests are commercially available for the rapid detection of which two common CAP pathogens?
- a) Mycoplasma pneumoniae and Chlamydia pneumoniae
- b) Streptococcus pneumoniae and Legionella pneumophila serogroup 1
- c) Haemophilus influenzae and Moraxella catarrhalis
- d) Influenza virus and Respiratory Syncytial Virus (RSV)
Answer: b) Streptococcus pneumoniae and Legionella pneumophila serogroup 1
14. Which of the following is a common risk factor for acquiring CAP?
- a) Young age (e.g., 20-30 years) with no medical problems.
- b) Advanced age, chronic comorbidities (e.g., COPD, heart failure, diabetes), immunosuppression, smoking.
- c) Regular exercise and a healthy diet.
- d) Never having received any vaccinations.
Answer: b) Advanced age, chronic comorbidities (e.g., COPD, heart failure, diabetes), immunosuppression, smoking.
15. For an inpatient with CAP admitted to a general medical ward (non-ICU), a common empiric antibiotic regimen is:
- a) Oral amoxicillin alone.
- b) Intravenous ceftriaxone plus azithromycin, OR intravenous levofloxacin/moxifloxacin monotherapy.
- c) Intravenous vancomycin plus piperacillin/tazobactam for all patients.
- d) Oral doxycycline alone.
Answer: b) Intravenous ceftriaxone plus azithromycin, OR intravenous levofloxacin/moxifloxacin monotherapy.
16. Empiric coverage for Methicillin-resistant Staphylococcus aureus (MRSA) in CAP should be considered for patients with:
- a) No known risk factors.
- b) Specific risk factors such as prior MRSA infection/colonization, recent hospitalization with IV antibiotics, or locally validated risk factors for severe CAP.
- c) Only a productive cough.
- d) A negative nasal MRSA screen.
Answer: b) Specific risk factors such as prior MRSA infection/colonization, recent hospitalization with IV antibiotics, or locally validated risk factors for severe CAP. (Nasal screen helps but doesn’t rule out completely, especially for pneumonia).
17. Empiric coverage for Pseudomonas aeruginosa in CAP should be considered for patients with:
- a) No underlying lung disease.
- b) Specific risk factors such as structural lung disease (e.g., bronchiectasis, cystic fibrosis), recent broad-spectrum antibiotic use, or severe CAP.
- c) Only a mild fever.
- d) A history of seasonal allergies.
Answer: b) Specific risk factors such as structural lung disease (e.g., bronchiectasis, cystic fibrosis), recent broad-spectrum antibiotic use, or severe CAP.
18. The typical duration of antibiotic therapy for uncomplicated CAP in outpatients who are responding well is often:
- a) 1-2 days.
- b) 3 days.
- c) A minimum of 5 days, and patient should be afebrile for 48-72 hours and clinically stable.
- d) At least 14 days for all cases.
Answer: c) A minimum of 5 days, and patient should be afebrile for 48-72 hours and clinically stable.
19. Which vaccines are important for the prevention of CAP in susceptible populations?
- a) Hepatitis B and HPV vaccines.
- b) Influenza vaccine (annually) and pneumococcal vaccines (e.g., PCV13/15/20, PPSV23 for appropriate age/risk groups).
- c) Measles, Mumps, Rubella (MMR) vaccine.
- d) Only the tetanus vaccine.
Answer: b) Influenza vaccine (annually) and pneumococcal vaccines (e.g., PCV13/15/20, PPSV23 for appropriate age/risk groups).
20. A patient with CAP who is hypoxic (low oxygen saturation) would benefit most from which supportive care measure?
- a) Cough suppressants
- b) Supplemental oxygen therapy
- c) High-dose corticosteroids
- d) Fluid restriction
Answer: b) Supplemental oxygen therapy
21. Which of the following is a common symptom of Mycoplasma pneumoniae (“walking pneumonia”) infection?
- a) Abrupt onset of high fever and severe rigors.
- b) Productive cough with purulent sputum.
- c) Gradual onset, persistent dry cough, headache, malaise; often milder than typical bacterial pneumonia.
- d) Bloody diarrhea.
Answer: c) Gradual onset, persistent dry cough, headache, malaise; often milder than typical bacterial pneumonia.
22. Legionella pneumophila infection (Legionnaires’ disease) is often associated with exposure to contaminated water systems and can present with CAP along with:
- a) Prominent skin rash.
- b) Gastrointestinal symptoms (e.g., diarrhea, nausea) and neurological changes (e.g., confusion).
- c) Severe joint pain.
- d) Only mild upper respiratory symptoms.
Answer: b) Gastrointestinal symptoms (e.g., diarrhea, nausea) and neurological changes (e.g., confusion).
23. The decision to switch a hospitalized CAP patient from IV to oral antibiotics is typically based on:
- a) A fixed duration of 3 days of IV therapy for all patients.
- b) Clinical improvement (e.g., resolution of fever, improving symptoms), hemodynamic stability, and ability to tolerate oral intake.
- c) The patient’s insurance coverage.
- d) The availability of the oral formulation only.
Answer: b) Clinical improvement (e.g., resolution of fever, improving symptoms), hemodynamic stability, and ability to tolerate oral intake.
24. Which of the following is NOT a typical causative pathogen of CAP?
- a) Streptococcus pneumoniae
- b) Influenza virus
- c) Candida albicans (more common in severely immunocompromised or as a secondary infection, not typical primary CAP in immunocompetent)
- d) Haemophilus influenzae
Answer: c) Candida albicans
25. The “A” in SCHOLAR-MAC when assessing a patient with cough and fever might include asking about:
- a) The color of their sputum.
- b) Medications that could cause cough or immunosuppression, and allergies to antibiotics.
- c) The onset of symptoms.
- d) What makes the cough worse.
Answer: b) Medications that could cause cough or immunosuppression, and allergies to antibiotics.
26. Which of the following is a potential complication of severe CAP?
- a) Improved lung function.
- b) Respiratory failure, sepsis, lung abscess, or pleural effusion.
- c) Resolution of all comorbidities.
- d) Decreased risk of future infections.
Answer: b) Respiratory failure, sepsis, lung abscess, or pleural effusion.
27. A common physical examination finding consistent with lobar pneumonia (consolidation) is:
- a) Hyperresonance on percussion.
- b) Diffuse wheezing throughout all lung fields.
- c) Dullness to percussion and crackles (rales) over the affected area.
- d) Absent breath sounds globally.
Answer: c) Dullness to percussion and crackles (rales) over the affected area.
28. For CAP treatment, “respiratory fluoroquinolones” (e.g., levofloxacin, moxifloxacin) are distinguished from older fluoroquinolones (e.g., ciprofloxacin) by their enhanced activity against:
- a) Pseudomonas aeruginosa only.
- b) Streptococcus pneumoniae and atypical pathogens.
- c) Anaerobic bacteria.
- d) Only Gram-negative enteric bacilli.
Answer: b) Streptococcus pneumoniae and atypical pathogens.
29. A key aspect of antimicrobial stewardship in managing CAP is:
- a) Using the broadest spectrum antibiotics for the longest possible duration in all patients.
- b) Avoiding all diagnostic testing to save costs.
- c) Selecting appropriate empiric therapy, de-escalating to narrower-spectrum agents once susceptibilities are known, and ensuring appropriate duration of therapy.
- d) Treating all viral respiratory infections with antibiotics.
Answer: c) Selecting appropriate empiric therapy, de-escalating to narrower-spectrum agents once susceptibilities are known, and ensuring appropriate duration of therapy.
30. A patient with CAP is considered clinically stable for potential discharge or switch to oral therapy when they meet criteria such as:
- a) Resolution of cough completely.
- b) Normalization of vital signs (temperature, heart rate, respiratory rate, blood pressure, oxygen saturation) and ability to eat.
- c) A normal chest X-ray (which can lag behind clinical improvement).
- d) A white blood cell count of exactly 7,000 cells/mm³.
Answer: b) Normalization of vital signs (temperature, heart rate, respiratory rate, blood pressure, oxygen saturation) and ability to eat.
31. Moraxella catarrhalis is a Gram-negative diplococcus that is a common cause of CAP, particularly as a component of:
- a) Infections in severely immunocompromised patients only.
- b) Exacerbations of chronic bronchitis and pneumonia in patients with underlying lung disease.
- c) Foodborne outbreaks.
- d) Urinary tract infections.
Answer: b) Exacerbations of chronic bronchitis and pneumonia in patients with underlying lung disease.
32. When assessing a patient for CAP, inquiring about recent travel history is important because:
- a) It determines their insurance coverage.
- b) It may suggest exposure to specific or unusual pathogens not common locally (e.g., MERS-CoV, certain fungal pathogens).
- c) All travelers require prophylactic antibiotics.
- d) It helps choose the flavor of medication.
Answer: b) It may suggest exposure to specific or unusual pathogens not common locally (e.g., MERS-CoV, certain fungal pathogens).
33. Sputum Gram stain and culture for CAP patients is most useful if:
- a) It is collected after several days of antibiotic therapy.
- b) It is a good quality specimen (many WBCs, few squamous epithelial cells) and is processed promptly.
- c) The patient has no cough.
- d) It is contaminated with saliva.
Answer: b) It is a good quality specimen (many WBCs, few squamous epithelial cells) and is processed promptly.
34. Which of the following is a common reason for treatment failure in CAP?
- a) The patient is too young.
- b) Infection with a resistant pathogen, incorrect initial diagnosis, non-infectious cause, or development of a complication.
- c) The antibiotic was too expensive.
- d) The patient preferred tablets over capsules.
Answer: b) Infection with a resistant pathogen, incorrect initial diagnosis, non-infectious cause, or development of a complication.
35. A patient with CAP who has a history of aspiration (e.g., due to stroke, alcoholism) might require empiric antibiotic coverage that includes activity against:
- a) Only atypical pathogens.
- b) Anaerobic bacteria from the oral cavity, in addition to typical CAP pathogens.
- c) Fungal organisms primarily.
- d) Only Streptococcus pneumoniae.
Answer: b) Anaerobic bacteria from the oral cavity, in addition to typical CAP pathogens.
36. The term “walking pneumonia” is often colloquially used to describe a milder form of CAP typically caused by:
- a) Streptococcus pneumoniae
- b) Pseudomonas aeruginosa
- c) Mycoplasma pneumoniae or Chlamydia pneumoniae
- d) Staphylococcus aureus
Answer: c) Mycoplasma pneumoniae or Chlamydia pneumoniae
37. CURB-65 score of 0 or 1 generally suggests that the patient with CAP:
- a) Requires ICU admission.
- b) Is at high risk of mortality.
- c) Can likely be treated as an outpatient.
- d) Definitely has a viral infection.
Answer: c) Can likely be treated as an outpatient.
38. For CAP patients requiring ICU admission (non-pseudomonal, non-MRSA risk), a recommended IV empiric regimen often includes:
- a) IV amoxicillin alone.
- b) A beta-lactam (e.g., ceftriaxone, cefotaxime, or ampicillin/sulbactam) PLUS either a macrolide or a respiratory fluoroquinolone.
- c) Oral doxycycline monotherapy.
- d) IV clindamycin alone.
Answer: b) A beta-lactam (e.g., ceftriaxone, cefotaxime, or ampicillin/sulbactam) PLUS either a macrolide or a respiratory fluoroquinolone.
39. What is an important counseling point regarding azithromycin for CAP?
- a) It must be taken with dairy products to enhance absorption.
- b) Potential for QTc prolongation and drug interactions (though fewer than erythromycin/clarithromycin for CYP enzymes).
- c) It primarily covers anaerobic bacteria.
- d) It always requires therapeutic drug monitoring.
Answer: b) Potential for QTc prolongation and drug interactions (though fewer than erythromycin/clarithromycin for CYP enzymes).
40. The rationale for using a macrolide in combination with a beta-lactam for many inpatient CAP regimens is primarily to provide reliable coverage for:
- a) Anaerobic bacteria.
- b) Atypical pathogens (e.g., Mycoplasma, Chlamydia, Legionella).
- c) Methicillin-resistant Staphylococcus aureus (MRSA).
- d) Fungal co-infections.
Answer: b) Atypical pathogens (e.g., Mycoplasma, Chlamydia, Legionella).
41. Which patient factor would increase the risk for drug-resistant Streptococcus pneumoniae (DRSP) in CAP?
- a) Age less than 2 years or greater than 65 years.
- b) Beta-lactam, macrolide, or fluoroquinolone therapy within the past 3-6 months.
- c) Medical comorbidities (e.g., chronic heart, lung, liver, or renal disease; diabetes; alcoholism; malignancy; asplenia).
- d) All of the above.
Answer: d) All of the above.
42. What is the primary mechanism of action of macrolide antibiotics like azithromycin?
- a) Inhibition of bacterial cell wall synthesis.
- b) Inhibition of bacterial protein synthesis by binding to the 50S ribosomal subunit.
- c) Inhibition of DNA gyrase.
- d) Disruption of bacterial folic acid metabolism.
Answer: b) Inhibition of bacterial protein synthesis by binding to the 50S ribosomal subunit.
43. A “pleural effusion” is a potential complication of CAP, characterized by:
- a) Air in the pleural space.
- b) Excess fluid accumulation in the pleural space.
- c) Inflammation of the pericardium.
- d) Formation of a lung abscess.
Answer: b) Excess fluid accumulation in the pleural space.
44. One of the main challenges in managing CAP is:
- a) The lack of any effective antibiotics.
- b) The wide range of potential pathogens and the increasing prevalence of antimicrobial resistance.
- c) The fact that chest X-rays are never useful.
- d) That CAP only affects elderly patients.
Answer: b) The wide range of potential pathogens and the increasing prevalence of antimicrobial resistance.
45. If empiric therapy for CAP is failing, what is a critical next step for the healthcare team?
- a) Continue the same regimen for another week.
- b) Re-evaluate the diagnosis, obtain further diagnostic tests (e.g., cultures, imaging), and consider broadening or changing antimicrobial therapy based on new findings or suspected resistance.
- c) Discontinue all antibiotics immediately.
- d) Add a potent antiviral agent.
Answer: b) Re-evaluate the diagnosis, obtain further diagnostic tests (e.g., cultures, imaging), and consider broadening or changing antimicrobial therapy based on new findings or suspected resistance.
46. Which component of the clinical assessment for CAP helps determine if the patient is experiencing hypoxia?
- a) Blood pressure measurement.
- b) Pulse oximetry (oxygen saturation) or arterial blood gas analysis.
- c) Temperature reading.
- d) Auscultation of bowel sounds.
Answer: b) Pulse oximetry (oxygen saturation) or arterial blood gas analysis.
47. The most common route of transmission for pathogens causing CAP is:
- a) Bloodborne transmission.
- b) Inhalation of aerosolized droplets or aspiration of oropharyngeal secretions.
- c) Fecal-oral route.
- d) Vector-borne transmission (e.g., ticks, mosquitoes).
Answer: b) Inhalation of aerosolized droplets or aspiration of oropharyngeal secretions.
48. Which of these factors is NOT explicitly part of the CURB-65 severity score?
- a) Confusion
- b) Urea level
- c) Oxygen saturation level
- d) Age ≥ 65
Answer: c) Oxygen saturation level (While critical for overall assessment, it’s not a direct component of the CURB-65 acronym itself. Some modified versions or other scores like PSI do incorporate it).
49. A key role for pharmacists in managing CAP involves:
- a) Performing chest X-rays.
- b) Counseling patients on medication adherence, potential side effects, and the importance of follow-up.
- c) Prescribing initial antibiotic therapy independently in all settings.
- d) Administering all IV antibiotics at home.
Answer: b) Counseling patients on medication adherence, potential side effects, and the importance of follow-up.
50. For a patient with CAP who has risk factors for Pseudomonas aeruginosa (e.g., structural lung disease), an appropriate empiric IV regimen might include:
- a) IV ceftriaxone plus azithromycin.
- b) An anti-pseudomonal beta-lactam (e.g., piperacillin-tazobactam, cefepime, ceftazidime, or meropenem) PLUS an anti-pseudomonal fluoroquinolone or aminoglycoside.
- c) IV vancomycin alone.
- d) Oral amoxicillin.
Answer: b) An anti-pseudomonal beta-lactam (e.g., piperacillin-tazobactam, cefepime, ceftazidime, or meropenem) PLUS an anti-pseudomonal fluoroquinolone or aminoglycoside.