Pneumonia SAHD Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists June 2010

Learning objectives Recognise the Clinical features of pneumonia Demonstrate appropriate use of CURB-65 severity scoring index Know the main causes of Community acquired pneumonia Interpret laboratory results and apply to Clinical decisions Understand the key principles of antibiotic prescribing

Are you feeling Excited about the session Apprehensive about the session Apathetic about the session Go away and leave me alone of 5

Are you Male Female of 5

What is your favourite speciality? Medicine Surgery Pathology GP Other…and offended! of 5

How well do you think you could deal with a patient in ED with a Chest Infection? Superbly Well Adequately Poorly Rather not say of 5

Presentation of pneumonia Fever/chills/sweats/rigors Cough Productive of sputum – clear/purulent/blood stained etc. Dyspnoea Pleuritic chest pain Malaise Anorexia and vomiting Headache Myalgia Diarrhoea

Chest examination Anatomic Landmarks The Extrathoracic Examination Chest Inspection, Palpation, Percussion Chest Auscultation

Clinical signs of pneumonia Pyrexia Tachypnoea Cyanosis – rare Altered mental state Consolidation Dull percussion note Inspiratory crepitations Bronchial breathing Increased vocal resonance and tactile vocal fremitus (voice vibration felt with the hand greater over areas of consolidation) Whispering pectoriloquy (increased loudness of voice over area of consolidation when auscultating)

Infective exacerbation of COPD Please exclude a diagnosis of Infective exacerbation of COPD before treating for Community Acquired Pneumonia (CAP) Infective Exacerbation of COPD – past history of COPD ↑ dyspnoea ↑ sputum volume increased sputum purulence

Classification of pneumonias Typical vs Atypical ??IS THIS VALID?? Community acquired (CAP) vs hospital acquired (HAP) Lobar vs Bronchopneumonia Aspiration pneumonia Immunocompromised host pneumonia There is often difficulty in placing a pneumonia into one category or another

Management of pneumonia Depends on severity and co-morbidity (particularly CAP) Formally assess severity CURB-65 Supportive treatment essential IV fluids Oxygen Analgesia need for ventilation? Investigations Antibiotic therapy

Complications of pneumonia Bacteraemia/Septicaemia……death Lung abscess Parapneumonic effusion/empyema

Which criteria are included in CURB-65 severity scoring Cyanosis Urea Respiratory rate Base excess 65% O2 required of 5

Severity: CURB-65 Confusion: new confusion AMT <8 Urea >7mmol/l Respiratory rate: >=30/min Blood pressure: sys <90 or dias <60 >65 years old Hypoxia Arterial pO2 <8Kpa Multilobar disease

CURB-65

Implications of CURB-65 Severe pneumonia is CURB-65 >3 Score of 3 = mortality 17%, Score of 4 = mortality 41.5%, Score of 5 = mortality 57% Need admission and IV antibiotics Non-severe pneumonia CURB-65 0 or 1 Score of 1 = Mortality 3.2% O/p treatment with oral antibiotics CURB 2 – Needs clinical judgement in hospital Mortality 13%

MAU Audit Zoe Campbell F2 SHO Only those with Severe pneumonia according to CURB criteria should receive IV antibiotics 18 out of 25 patients received IV antibiotics 18 patients were classified mild/mod (? Oral antibiotics) 7 patients were classified severe (? IV antibiotics) I.V. Oral Mild/ Moderate Severe

Investigations of Pneumonia CXR O2 saturation +/- gases Microbiology… Biochemistry Urea LFT CRP Haematology FBC: WBC, plts, ?clotting

What microbiology samples would you send on a patient with severe CAP? Sputum Nose swab Urinary Antigen Serology Blood Culture of 5

Send appropriate samples

Sputum: microscopy Sputum appearance? Mucoid/Salivary/Blood stained/Green/Yellow etc Gram stain??: Sputum/BAL etc. Special stains: TB/PCP etc.

Sputum: culture and sensitivity

Blood culture Blood cultures should be taken from anyone with severe pneumonia Sterile technique vital Inoculate into blood culture bottles, aerobic and anaerobic Automated blood culture machine for 5 days Please take before pt on antibiotics!!!

Others BAL/Pleural fluid more of a reliable sample than sputum Serology-Acute and convalescent phase (0 and 14 days). A useful test for Mycoplasma, Chlamydia, Legionella, Coxiella, Influenza etc. Antigen detection: Immunoflourescence (eg RSV from NPAs) Urine for legionella/pneumococcal antigen

BTS guidelines All patients admitted with severe CAP should have Blood cultures Sputum culture Legionella antigen All patients admitted with non-severe CAP need Sputum cultures (unless have had recent course of antibiotics)

Which bacteria are common causes of CAP Escherichia coli Streptococcus pneumoniae Haemophilus influenzae Coagulase negative staphylococci Moraxella catarrhalis of 5

Organisms causing Pneumonia Viruses – Influenza, parainfluenza Community acquired pneumonia Streptococcus pneumoniae Mycoplasma pneumoniae Haemophilus influenzae Legionella pneumophila Moraxella catarhalis Chlamydia psittaci Staphylococcus aureus Coxiella burnetti Hospital acquired Pneumonia Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumanii etc

CAP causative organisms

Streptococcus pneumoniae Gram positive streptococcus, commensal flora. Need to distinguish infection from colonisation Acute pyogenic infection Rapidly progressing infection often associated with bacteraemia Often fatal in elderly/immunocompromised. Capsule is the most important virulence factor Capsular based vaccines available for at risk groups

Hospital acquired pneumonia Often after courses of antibiotics At risk patients Possibly ventilated Enteric gram negative bacilli –E.coli, K.pneumoniae etc Pseudomonas aeruginosa MRSA

Chest Infection Possible choices Amoxicillin Augmentin Cefuroxime Ciprofloxacin Ceftazidime Tazocin Meropenem +/- erythromycin/clarithromycin (Atypical cover)

And Atypicals!

Coventry and Warwickshire Treatment Guidelines (Hospital)

Community acquired pneumonia Strep. pneumoniae ~ 30 - 40% Haemophilus influenzae ~ 5 - 10% Staph. aureus ~ 0.5 - 5% Severity of infection (CURB-65 score) Determines need for IV or oral treatment Determines need for broad vs narrow cover

Don’t forget atypicals in CAP! Legionella pneumophila ~ 1 - 5% Mycoplasma pneumoniae ~ 1 - 10% Chlamydophila pneumoniae < 10% ? Chlamydia psittaci, Coxiella < 2% Viruses including Influenza < 15% Addition of Macrolide e.g. erythromycin or clarithromycin Tetracycline e.g. doxycycline (Ciprofloxacin)

Chest Infection Recommendation

Chest Infection recommendation

Mid session interval You have 5 minutes, the attendance book will be available for signing on your return

Which of the following do you do when prescribing antibiotics Review pts previous microbiology results Document indication and duration/review date in the patients notes Write indication on drug chart Write review or stop date on drug chart Review antibiotic at 48hrs and change to oral if appropriate of 5

How well do you think you could deal with a patient in ED with a Chest Infection? Superbly Well Adequately Poorly Rather not say of 5