Presentation on theme: "Outline Diagnosis of CAP Site of care? Tools for risk assessment? Diagnostic tests needed? Management of severe CAP ? Community-Acquired Pneumonia:"— Presentation transcript:
Outline Diagnosis of CAP Site of care? Tools for risk assessment? Diagnostic tests needed? Management of severe CAP ? Community-Acquired Pneumonia: A Clinical case scenario A Clinical case scenario
Presentation A 66-year-old man accompanied by his wife, arrived at the Emergency Department complaining of shortness of breath, fever, and cough.
His symptoms started 8 days ago with mild fever, cough, myalgia, headache & sore throat were he received antipyretic, antihistaminic and cough syrup after consulting his family doctor through a telephone call. Symptoms
Symptoms After initial improvement, he had a worsening of symptoms starting 3 days ago with productive cough, pleuritic chest pain, fever, chills and malaise. Last night he developed dyspnea and high fever, so he decided to come to the Emergency Department today.
Medical History X-smoker 2 years (30 pack years). COPD. Type 2 diabetes. Medications include Inhaled salbutamol (100 μg)+ beclomethasone diproprionate (50 μg) 2 puffs x 3. Sustained released theophylline (200mg cap 1x2). Gliclcazide (80mg tab. 1x1).
Examination Confused. Temperature: 39.0°C. Blood pressure: 120/70. Pulse rate: 120 bpm. Respiratory rate: 30 per minute. Clinical signs of right upper zone consolidation and bilateral scattered rhonchi. No cyanosis, pedal edema or jugular venous distension is noted.
Diagnosis Dose this patient have Community-Acquired Pneumonia (CAP)?
Definition of CAP not hospitalized or living in a long-term care facility for ≥ 2 weeks. Infection of the lung parenchyma in a person who is not hospitalized or living in a long-term care facility for ≥ 2 weeks.
CAP: Diagnosis suggestive “In addition to a constellation of suggestive clinical featuresinfiltrate clinical features, a demonstrable infiltrate by chest radiograph or other imaging with or without supporting technique, with or without supporting microbiological data microbiological data, is required for the diagnosis of pneumonia.” Clinical features: Productive cough, dyspnea, fever, clinical signs of consolidation Radiological findings: Consolidation
CAP – Risk Factors for Pneumonia Elderly Smoking COPD Extreme weather Overcrowding Alcoholism DM Renal insufficiency CHF Chronic liver disease Immunossuppresio n Loss of consciousness Seizures
What is the value of CXR in CAP? Establish Dx Evaluation of severity e.g. multilobar or bilateral, pleural effusion. Co-existing conditions e.g. bronchial obstruction, abscess. Pattern
Diagnostic testing “Recommendations for diagnostic testing remain controversial.” No convincing data that they improve outcomes. Outpatient setting: optional Inpatient setting: Critically ill CAP Specific pathogens (suspected)
What testing would you do? Pretreatment: Sputum: Gram staining and culture. Expectorated sputum should be deep cough specimen obtained before antibiotic treatment and it should be rapidly transported and processed within a few hours of collection.* Expectorated sputum should be deep cough specimen obtained before antibiotic treatment and it should be rapidly transported and processed within a few hours of collection.* Blood cultures (2 sets) 2 sets of blood cultures should be drawn before initiation of antibiotic therapy during the first 24 hour.*
CAP: When to start empiric therapy? As soon as possible in ED CAP: delay-to-AB> 4h after arrival Increased mortality Increased LOS
Recommended empirical antibiotics for CAP: Inpatient, ICU ttt b-lactam plus either azithromycin or a respiratory fluoroquinolone (cefotaxime, ceftriaxone) Levofloxacin 750mg/24h + Ceftriaxone 1gm /12h IV
2 hours after ICU admission 2 hours after ICU admission Sputum (gram stain) →Gram-positive diplococcus Value of Gram stain First, it broadens initial empirical coverage for less common etiologies, such as infection with S. aureus or gram-negative organisms. * Second, it can validate the subsequent sputum culture result. A positive Gram stain was highly predictive of a subsequent positive culture.*
Day 3 Sputum culture & Sensitivity: Streptococcus pneumoniae Sensitive Sensitive → Cefotaxime, Ceftraixone and Levofloxacin. Susceptibility testing should guide antibiotic choice when results are available. Continue on the same antibiotics
Day 3: The patient's condition began to improve, but fever persisted. Day 5: The patient was a febrile for the first time. Normal oral intake started. Cough, dyspnea grade & chest wheezes improved. Pulse 90 bpm, B/P 140/80. WBC 6,800/μl with 3% bands. BUN 18 mg/dl, creatinine1.4 mg/dl, 2 PPBS 170mg/dl. O 2 Sat.% on RA: 93%. Transferred to ward.
Switch from intravenous to oral therapy? Afebrile No abnormal GIT absorption Cough & respiratory distress improved WBC returning to normal Levofloxacin 750 mg tab/24hr
Day 8: Clinically stable Afebrile for 3days. CXR: partial resolution. Blood culture: No growth up till now.
CAP: Duration of Therapy? A minimum of 5 days… “A minimum of 5 days… Afebrile for 48-72 h … Afebrile for 48-72 h … No more than 1 CAP- No more than 1 CAP- associated sign of clinical instability’’
Day 9: Discharged and antibiotic stopped. Recommendations ℜ / pneumococcal polysaccharide vaccination ℜ / During next influenza season, influenza vaccination. ℜ / ttt COPD & DM. FU CXR after 1 week.