Transcript Pneumonia - HCPro Blogs

Pneumonia
ELEANOR PAGLIA, MD
NO DISCLOSURES
Medical Case
75 yo male presents with fever and shortness
of breath. Symptoms began 2 days ago. He
was noted to have worsening shortness of
breath with ambulation as well as cough
(nonproductive). Today fever to 101.4.
PMHx:
HTN
HLP
Parkinson’s Disease
Goals
 Review MD approach to pneumonia diagnosis
 Understand the gap between MD thought process and
CDS thought process
 Review the most common types of in-hospital
pneumonia
 Hints on when to query for more specific terminology
Medical Case
Medical Case
Recently admitted to an outside hospital two
months ago for a fall and ankle fracture. He
spent 2 weeks in STR before returning
home. Has been doing well at home with
PT/OT and VNA.
Medical Case
Assessment and Plan:
(1) Pneumonia – History, exam and imaging
point to this diagnosis. We must consider
his recent admission as well as his
Parkinson’s Disease in deciding which
antibiotics to choose. Will treat with broad
spectrum antibiotics in order to cover for
HCAP. Will also need to cover anaerobes in
addition to the community organisms. Plan
to send blood cultures, sputum cultures and
follow WBC and temperature curve closely.
Medical Case
Assessment and Plan:
(1) Pneumonia – History, exam and imaging
point to this diagnosis. We must consider
his recent admission as well as his
Parkinson’s Disease in deciding which
antibiotics to choose. Will treat with broad
spectrum antibiotics in order to cover for
HCAP. Will also need to cover anaerobes in
addition to the community organisms. Plan
to send blood cultures, sputum cultures and
follow WBC and temperature curve closely.
Translation Please….
Assessment and Plan:
(1) Pneumonia – History, exam and imaging
point to this diagnosis. We must consider
his recent admission as well as his
Parkinson’s Disease in deciding which
antibiotics to choose. Will treat with broad
spectrum antibiotics in order to cover for
HCAP. Will also need to cover anaerobes in
addition to the community organisms. Plan
to send blood cultures, sputum cultures and
follow WBC and temperature curve closely.
Translation Please….
“consider his recent admission”
→
→
Possible pseudomonas pneumonia
Possible MRSA pneumonia
“Parkinson’s Disease” “anaerobes”
→
Possible aspiration pneumonia
“community organisms”
→
Possible community acquired pneumonia
Medical Case
DDX (all of these are possible):
(1) Community Acquired Pneumonia
(2) HealthCare Associated Pneumonia (HCAP)
Pseudomonas
MRSA
(3) Aspiration Pneumonia
Medical Team elects to use Vancomycin,
Piperacillin/Tazobactam, Azithromycin.
This combination will treat all possibilities.
Community acquired pneumonia (CAP)
 Pneumonia acquired outside of hospitals and
extended-care facilities. Patients who have not had
exposure to health care system.
Community Acquired Pneumonia (CAP)
PATHOGENS
 Streptococcus pneumoniae
 Haemophilus influenzae
 Legionella spp.
 Moraxella catarrhalis
 Chlamydia pneumoniae
 Mycoplasma
 Influenza/RSV/Parainfluenza
Streptococcus Pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Community Acquired Pneumonia
(NOT MRSA or pseudomonas)
Fluoroquinolone based regimen:

Moxifloxacin

Levofloxacin
-ORCephalosporin + Macrolide

Ceftriaxone + azithromycin
Healthcare Associated Pneumonia (HCAP)
Identify possible multi-drug resistant pathogens:
 Hospitalization for ≥ 2 days in the preceding 90 days
 Residence in a nursing home or extended care facility
 Home infusion therapy (including antibiotics)
 Chronic dialysis within 30 days
 Home wound care
 Family member with multidrug-resistant pathogen
Healthcare Associated Pneumonia (HCAP)
PATHOGENS
 Staph aureus: MRSA > MSSA
 Gram negative bacilli:
 Klebsiella, Enterobacter, Pseudomonas, E.Coli
 Similar to HAP (Hospital) and VAP (Ventilator)
Healthcare Associated Pneumonia (HCAP)
PATHOGENS
 Staph aureus: MRSA > MSSA
 Gram negative bacilli:
 Klebsiella, Enterobacter, Pseudomonas, E.Coli
 Similar to HAP (Hospital) and VAP (Ventilator)
Ventilator (VAP) and Hospital (HAP) Pneumonia
Ventilator-associated
Hospital-acquired
 Pneumonia that occurs
 Pneumonia that occurs
more than 48 hours
after endotracheal
intubation
more than 48 hours
after admission
Healthcare Associated Pneumonia (HCAP)
PATHOGENS
 Staph aureus: MRSA > MSSA
 Gram negative bacilli:
 Klebsiella, Enterobacter, Pseudomonas, E.Coli
 Similar to HAP (Hospital) and VAP (Ventilator)
Staphylococcus Aureus
Pseudomonas aeruginosa
Healthcare Associated Pneumonia
 MRSA coverage:
 Vancomycin 15 mg/kg IV q12h (trough >15-20 ug/mL)
 Linezolid 600 mg IV q12h
Healthcare Associated Pneumonia
 PLUS Antipseudomonal beta-lactams (IV):
 Ceftazidime (94%)
 Piperacillin/Tazopactam (Zosyn) (96%)
 Cefepime (91%)
 Imipenem (95%)
 Meropenem (95%)
 Fluroquinolones (Cipro/Levoflox) - (80%)
Healthcare Associated Pneumonia
Anti-MRSA:
Antipseudomonal:





Cefepime
Ceftazidime
Imipenem
Meropenem
Piperacillin/Tazobactam

+

Vancomycin
Linezolid
Aspiration Pneumonia
 Pathogens:
 Caused by bacteria that normally reside in the upper
airways or stomach.


Community-acquired: mainly anaerobes and streptococci,
consider GNR.
Healthcare-associated: anticipate Gram negatives, Staph
aureus +/- anaerobes.
Aspiration Pneumonia
Treatment:
Clindamycin – covers strep and anaerobes
Piperacillin-tazobactam – covers strep and anaerobes
and adds GNR, if need to be covered.
Carbapenem – “big guns”, anaerobes, GPC and GNR
Back to our case…
CDS Considerations
 MDs will often NOT use CDI terms.
 MD focus is on risk of MDRs.
 If more than one possible, will treat for all.
 Often, sputum is not sent or obtained too late
to be helpful (so treatment is empiric).
When to QUERY?
MRSA
Pseudomonas
 Hospital/STR recently
 Hospital/STR
 Vancomycin/Linezolid
 COPD
 GPC on blood Cx
 Cystic Fibrosis
 HCAP/VAP/HAP
 Ceftazidime
 Cefepime
 Pip/Taz (Zosyn)
 HCAP/VAP/HAP
When to QUERY?
Anaerobic
 Dementia
 Neurologic Condition
 Drugs/ETOH
 Clindamycin
 Pip/Taz (Zosyn)
 Ceftazidime
 Cefepime
Thank You
 Review MD approach to pneumonia diagnosis
 Understand the gap between MD thought process and
CDS thought process
 Review the most common types of in-hospital
pneumonia
 Hints on when to query for more specific terminology