HACK. these are a few of my favourite respiratory infections Brendan Munn Emergency Residents’ Academic Day August 13 2009 CALGARY EMERGENCY MEDICINE TEACHING.

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Presentation transcript:

HACK. these are a few of my favourite respiratory infections Brendan Munn Emergency Residents’ Academic Day August CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Objectives 1.review common respiratory infections 2.myths and just enough EBM 3.provide an approach to the above 4.discuss some cases 5.minimize powerpoint CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Respiratory Tract Infections CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Respiratory Tract Infections CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Approach 1.is this pneumonia? 2.what tests should i order? 3.is this pneumonia special? 4.what f*ing antibiotic(s?) should i start? 5.should this patient be admitted? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

case 1 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 64F with cough, fever x 1 week O/E : febrile, RR 32

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

“Does this patient have Community Acquired Pneumonia? Diagnosing Pneumonia by History and Physical Examination” Metlay JP, Kapoor WN, Fine MJ. JAMA Nov 5;278(17): NO specific symptoms for dx pneumonia NO fever, tachypnea, tachycardia is Sn

Special Populations CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Special Populations CALGARY EMERGENCY MEDICINE TEACHING ROUNDS CAP VAP HAP HCAP HIV TB ASPIRATION AECOPD

case 2 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 64F with cough, fever x 1 week O/E : febrile, RR 32, LLL crackles PMHx : nil

Sputum Cultures - Evidence CALGARY EMERGENCY MEDICINE TEACHING ROUNDS only 20% yield no correlation C&S with gram or with BC misses atypicals nosocomial risk does not change antibiotics or outcome ATS07 guidelines : for all “complicated” Roson B, Clin Infect Dis 2000

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Disposition - Evidence CALGARY EMERGENCY MEDICINE TEACHING ROUNDS (1)Pneumonia Severity Index (PSI) online calculators available limitations - 20 factors, CAP Fine, MJ. NEJM, 1997 Jan

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

curb 65 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS CConfusion UUremia >7mmol/L RRespiratory Rate > 30 BBP > 90 (S) or >60 (D) 65 Age >65 Lim, WS. Thorax, 2003 May

case 3 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 64F with L THA O/E : febrile, RR 32, LLL crackles

Blood Cultures - Evidence CALGARY EMERGENCY MEDICINE TEACHING ROUNDS <10% yield in CAP 50% false positive in ED only 2% positive once antibiotics limited data for inpatient if immune N ATS07 guidelines : for all “complicated” Corbo J, BMJ 2004

case 4 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 64F diabetic receiving daily foot wound care at home with cough, fever x1 week O/E : febrile, RR 32, LLL crackles

HCAP RF CALGARY EMERGENCY MEDICINE TEACHING ROUNDS hospitalization >2d in preceding 90 days long-term care facilit resident home infusion or wound care therapy chronic dialysis family member with drug resistant bug

MDR RF CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Antibiotics within the preceding 90 days Current hospitalization of ≥ 5 days High frequency of antibiotic resistance in the community or in the specific hospital unit Immunosuppressive disease and/or therapy Presence of risk factors for HCAP

case 5 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 28M with cough x 6 weeks, worsening SOB O/E : febrile, RR 32

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

case 7 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 64F alcoholic w cough, fever x 1 week O/E : febrile, RR 32, RLL opacity

case 8 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Review 1.is this pneumonia? hx/phys poor, gestalt and a monkey, CXR 2.what tests should i order? good empiric abx > sputum and blood cx 3.is this pneumonia special? know your categories and risk factors if VAP/HCAP/HAP evaluate MDR risk always consider HIV, TB

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Review 4.what f*ing antibiotic(s?) should i start? empiric coverage of common organisms 5.should this patient be admitted? use the PSI or at worst use CURB65 and feces

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS References 1.Tintinalli 2.Up To Date 3.EMRAP 4.ATS CAP and HAP Guidelines 2007