Presentation on theme: "Pneumonia Charles B. Lehman, MD College of Community Health Sciences"— Presentation transcript:
1 Pneumonia Charles B. Lehman, MD College of Community Health Sciences University of Alabama
2 Diagnosing pneumonia Clinical evaluation Chest x-ray with or without microbial testing
3 Clinical evaluation Common clinical features: Cough Fever Pleuritic chest painDyspneaSputum productionGI: nausea, vomiting, diarrheaMental status changes
4 Clinical evaluation Physical exam: Lab findings: 80% will be febrile Tachypnea, especially in elderly patientsTachycardiaAudible cracklesEvidence of consolidationLab findings:Leukocytosis with left shiftLeukopenia can occur and is an ominous sign
5 Clinical evaluation: chest x-ray Radiologic evaluationPresence of infiltrate on plain chest x-ray is gold standard for diagnosisShould be obtained whenever diagnosis is suspectedRecommendations less clear when viral infection suspected but should be obtained in patients with an abnormal vital sign, especially tachypnea.
6 Lobar consolidationLeft lower lobe opacity in patient with pneumococcal pneumonia.
7 Interstitial infiltrates Nodular opacities in the right lower lobe in patient with mycoplasma pneumonia.
9 CavitationLung abscess with air-fluid level in right lung in first image. Next image is of necrotizing pneumonia in the left lung
10 Clinical evaluation: chest x-ray Considerable variation in reading between different radiologistsEven more between ED physicians and radiologistsHigh-resolution CT is a much better test but generally not necessary to make a diagnosis.
11 Clinical evaluation: chest x-ray Other causes for chest x-ray which can look like pneumoniaMalignancyHemorrhagePulmonary edemaPulmonary embolism with infarctionInflammation due to non-infectious causesCT can be used to clarify cases when clinical picture is consistent with pneumonia but chest x-ray is negative.
12 Clinical evaluation: microbial testing Outpatients: testing is optionalHospitalized patients with specific indications should have blood cultures and sputum Gram stain and culture.Severe CAP requiring ICU admission should have blood cultures, Legionella and pneumococcus urinary antigen tests and sputum culture.Other tests indicated with specific findings
14 Clinical evaluation: microbial testing Blood cultures Blood cultures are positive in 7 to 16% of hospitalized patients with S. pneumococcus accounting for 2/3 of positive cultures.Arguments to obtain blood cultures:Establishes a diagnosis when likely pathogen foundIn many cases is the only test done and is primary source for microbiologic data for many hospitalsIsolates are an important resource for tracking resistance patterns in S. pneumoniae which provide data for evaluating vaccines.Arguments against:Relatively low rate of positivesRarely lead to modification of therapy
16 Clinical evaluation Predisposing conditions Altered mental status which can lead to micro/macro aspiration (stroke, seizure, intoxication, anesthesia)SmokingAlcoholHypoxemiaAcidosisToxic inhalationsPulmonary edemaUremiaMalnutrition
17 Clinical evaluation: predisposing conditions Immunosuppresive agentsMechanical obstruction of a bronchusAdvanced ageCystic fibrosisBronchiectasisCOPDHIVViral respiratory tract infection, especially influenzaLung cancer
18 Microbiology: bacteria S. pneumoniae: most common causeH. influenzae: more common in elderly and patients with underlying pulmonary disease (COPD, cystic fibrosis)M. pneumoniae: most common atypical cause, highest rates in school-aged children, military recruits and college students.C. pneumoniaeLegionella: transmitted by aerosols containing the bacteria such as showers, grocery store misters, cooling towers, whirlpool spas and fountains.
19 Microbiology: bacteria Gram negative bacilliE. coliSerratiaK. pneumoniaeAcinetobacterP. aeruginosaEnterobacterUncommon in CAP except in patients with severe disease requiring ICU admission
20 Microbiology: bacteria S. aureusUsually in older adults or younger patients who are recovering from influenzaAssociated with severe necrotizing pneumoniaGroup A streptococcusCan cause fulminant pneumonia with early empyema even in young competent hosts.Anaerobes (aspiration and lung abscess)Neisseria meningitidisM. tuberculosis
21 Microbiology: viruses InfluenzaCan cause primary pneumonia, more likely to cause secondary bacterial pneumoniaParainfluenza virusesRSVAdenovirusHuman metapneumovirusSevere acute respiratory syndrome (SARS)Middle East respiratory syndrome coronavirus (MERS-CoV)Other coronaviruses
22 Microbiology: viruses Hantavirus (ARDS)Avian influenza: considered a possible source for next global influenza pandemic.Varicella
23 Microbiology: fungi Usually occur in immunocompromised hosts NeutropeniaImmunosuppressive therapyHIVUsually endemic to particular areas
24 Microbiology: fungi Cryptococcus Histoplasma Found world-wideInfection often asymptomatic in immunocompetent hostsHistoplasmaMost common in Ohio and Mississippi River valleysLess than 5% develop symptoms with low-level exposureCoccidioides (Sonoran desert regions)AspergillosisP. jirovecii
26 Inpatient vs. outpatient treatment Hospital admission rates vary widelyRates often are not related to local disease severityPhysicians often overestimate patient risk of short-term mortalityMany unnecessary admissions as a result
27 Inpatient vs. outpatient treatment Pneumonia Severity Index Step 1 risk factors:Age > 50Coexisting conditions: cancer, CHF, cerebrovascular disease, renal disease or liver diseasePhysical exam: AMS, heart rate >= 125, respiratory rate >= 30, SBP < 90, temperature < 35 (95) or > 40 (104)If one or more Step 1 risk factors are present then evaluation proceeds to Step 2.
29 Inpatient vs. outpatient treatment Pneumonia Severity Index Class I: no predictorsClass II: <= 70Class III: 71–90Class IV:Class V: > 130
30 PSI and mortality by class PointsMortalityINo predictors0.1II<= 700.6III71-900.9IV91-1309.3V> 13027.0
31 Inpatient vs. outpatient treatment Pneumonia Severity Index Measuring impact using Pneumonia PORT cohortStrategy 1: outpatient therapy for class I or II, brief observation for class III and admission for class IV or V:31% fewer admissions19% more would have been assigned to observation4.3% admitted to ICU< 1% mortality
32 Inpatient vs. outpatient treatment Pneumonia Severity Index Measuring impact using Pneumonia PORT cohortStrategy 2: same as strategy 1 except that all patients with hypoxemia were admitted:26% reduction in admissions13% assigned to observation1.6% admitted to ICUMortality < 1%Either set of recommendations would have recommended inpatient therapy for 5 of the 6 patients who died following an initial course of outpatient therapy.
33 Inpatient vs. outpatient treatment Pneumonia Severity Index CAPITAL trial (Canada)Admission rate for low risk (class I, II or III) patients dropped from 49 to 31%No negative effects on patient quality of life or adverse medical outcomes (ICU admission, mortality, readmission or complications).EDCAP (US)Increased proportion of low-risk patients treated in outpatient settingNo statistically significant difference in safety outcomes
34 Inpatient vs. outpatient treatment CURB-65 score ConfusionUrea (BUN > 20)Respiratory rate (>30)Blood pressure (SBP < 90 or DBP < 60)Age > 650-1: outpatient treatment2: admission>= 3 should be assessed for ICU admission
35 Inpatient vs. outpatient treatment Severe CAP score Major criteria:pH < 7.30 (13 points)SBP < 90 (11 points)Minor criteria:RR > 30 (9)PaO2/FiO2 < 250 (6)BUN > 30 (5)Age > 80 (5)Multilobar/bilateral infiltrates (5)Score > 10 predicts progression to severe CAP
36 CAP: outpatient treatment Empiric therapy Chest x-ray which demonstrates pneumoniaRisk stratification with CURB-65 or PSIDistinguish CAP from HCAPMicrobiologic testing is optionalBlood culturesSputum if quality sample can be obtained
37 CAP: outpatient treatment Empiric therapy Co-morbidityAlcoholismCOPDPost-CVA aspirationPost-obstruction of bronchiInfluenzaLocal resistance of S. pneumoniae to macrolides > 25%
38 CAP: outpatient treatment Empiric therapy No co-morbidities, local macrolide resistance < 25%Azithromycin 500 x 1 dose then 250 mg/dayClarithromycin 500 mg BID for 7 daysIf patient had antibiotics within 3 months:Above plus amoxicillin 1 gm TID or Augmentin 1000/ tabs BIDLevofloxacin 750 mg qDIf co-morbidity present:Levofloxacin 750 mg qD x 5 days
39 CAP: inpatient treatment Non-ICU patients S. pneumoniae most common pathogenRespiratory virusesLess common:M. pneumoniaeH. influenzaeC. pneumoniaeLegionella
42 CAP: inpatient treatment Empiric therapy, ICU patients Patients admitted to an ICU are more likely to have resistant pathogens including community-associated MRSA and LegionellaSuspicion for P. aeruginosaChronic or structural lung diseaseKnown prior colonizationSuspicion for CA-MRSAPost-influenzaIV drug useGram (+) cocci in clusters on Gram stain
44 CAP: inpatient treatment Empiric therapy, ICU patients If P. aeruginosa suspected:Beta-lactam (Cefepime 2 gm q12 or Zosyn gm q4 or ceftazidime 2 gm q8 or meropenem 1 gm q8)Fluoroquinolone (levofloxacin 750 q24 or ciprofloxacin 400 q8) or tobramycin 5 mg/kg q24 and azithromycin 500 q24
45 CAP: inpatient treatment Response to therapy Some improvement usually seen within 48 to 72 hoursResolution of symptoms and radiographic findings takes longerCrackles can persist for weeksAs many as 87% of patients continue to report at least one symptom at 39 daysTakes 6-8 weeks for a chest x-ray to clear and can take up to 12 weeks in patients with underlying lung disease
46 CAP: inpatient treatment Change to oral therapy Clinical improvementHemodynamically stableNormally functioning GI tract
47 CAP: inpatient treatment Choice of oral therapy Base on culture results if possibleUse oral medications from same drug classNo need to cover for S. aureus or gram (-) bacilli unless isolated from a good quality sputum specimenChoice depends on risk of resistant S. pneumoniae and the initial IV regimen
48 CAP: inpatient treatment Duration of hospitalization Can go home when:On oral medicationsNo other active medical problemsAppropriate environment for dischargeNot necessary to keep patient for observation after changing to oral antibiotics.
49 CAP: inpatient treatment Duration of therapy Minimum of 5 daysShould be afebrile for 48 hoursNo more than 1 clinical instability factorHeart rate > 100Respiratory rate > 24SBP < 90
50 CAP: inpatient treatment Duration of therapy Longer duration needed if:Initial therapy was not active against a subsequently identified pathogenExtrapulmonary infection identified (meningitis, endocarditis)P. aeruginosa, S. aureus or Legionella infectionsNecrotizing pneumonia, empyema or lung abscess
51 CAP: inpatient treatment Non-responding patients Progressive pneumonia or clinical deteriorationRequirement of ventilator supportDevelopment of septic shockAbsence of delay of achieving clinical stability after 72 hours
52 CAP: inpatient treatment Non-responding patients Unusual organisms not covered by empiric therapyPatient-related factorsSeverity of illnessNeoplasiaAspiration pneumoniaNeurologic diseaseInfectious complicationsEmpyemaSuperimposed nosocomial pneumonia
53 HAP, VAP and HCAP Hospital-acquired (nosocomial) pneumonia 48 hours or more after admission, did not appear present on admissionVentilator-associated pneumonia48-72 hours after endotracheal intubationHealthcare-associated pneumoniaIV therapy, wound care or IV chemotherapy within 30 daysResidence in a nursing home or other long-term care facilityHospitalization in an acute care hospital for 2 or more days within the last 90 daysAttendance at a hospital or hemodialysis clinic within 30 days
54 HAP, VAP and HCAPDrug selection should be based on risk factors for multi-drug resistant organismsRecent antibiotic therapyResident flora in the hospital or ICUPresence of underlying diseasesAvailable culture data
55 HAP, VAP and HCAP MRSA Vancomycin or linezolid should be added Should be discontinued if not isolated in culturesIf MSSA later isolated should replace above with nafcillin or oxacillin
56 HAP, VAP and HCAP Other considerations Combination therapy for Gram (-) organisms often used but no conclusive evidence to support this practiceLegionella should be covered, especially if known to be present in the hospital water supplyAnaerobes in patients with recent abdominal surgery or aspiration
57 HCAP Etiologies S. aureus (often MRSA) Gram (-) enterics which may be MDR (E. coli, K. pneumoniae, enterobacter, Serratia)P. aeruginosaAcinetobacter
58 HCAP Empiric treatment Vancomycin mg/kg q8-12Cefepime 2 gm 12 or Zosyn 4.5 gm q6 or meropenem 1 gm q8Doripenem should not be usedLinezolid 600 IV q12 can be substituted for vancomycinIf Legionella suspected should use a fluoroquinolone or add azithromycin 500 mg q24
59 HCAP Empiric treatment Controversy exists regarding uniqueness of HCAPDuration of therapy is not well-definedTherapy should be streamlined once culture results area available
60 HAP/VAP SubtypesEarly-onset: no other risk factors for MDR, < 5 days in the hospitalS. pneumoniae, S. aureus, H. influenzae, enteric Gram (-) bacilliLate onset: >= 5 days in the hospital, risk factors for MDR organismsS. aureus, often MRSAGram (-) entericsESKAPE organisms (E. coli, Serratia, Klebsiella, acinetobacter, pseudomonas and enterobacter) etiology in about 80% of patients