Transcript Community Acquired Pneumonia

Community-Acquired
Pneumonia
Nilesh Patel, D.O.
October 8, 2008
St. Joseph’s Regional Medical Center
Emergency Medicine Conference
Objectives
 Epidemiology
 Pathophysiology
 Signs/Symptoms
 Diagnostics
 Treatments
 Disposition
Questions we will answer…
 What is the definition of CAP?
 What are the most common organisms in CAP?
 Do blood cultures affect management?
 What is the optimal timing of antibiotic therapy in
CAP?
 What are the antibiotic choices for CAP?
 What are the admission criteria? Who can go
home?
Other
 Next hour…
– Atypical pneumonias
– Viral pneumonias
– PCP/Other fungal pneumonias
 What we will not talk about…
– Pediatric pneumonias
– HAP/HCAP
Community-Acquired
Pneumonia (CAP): Definition
 Infection of pulmonary parenchyma
 Pneumonia acquired in the community
– Excludes hospitals (HAP)
– Excludes extended care facilities (HCAP)
– Typical
– Atypical
Epidemiology
 4 million cases/year in U.S.
 600,000 - 1 million hospitalizations
 12 cases per 1,000 adults/year
 6th leading cause of death in U.S.
 Leading cause of death due to infectious
cause
 Mortality ranges from 1-20%
 Mortality increased in certain populations
Pathophysiology
 Aspiration of oropharyngeal organisms
 Inhalation of infected aerosols
 Hematogenous spread from extra-
pulmonary sites
 Contiguous spread
 Direct inoculation
Pathophysiology
 Lobar pneumonia
 Interstitial pneumonia
 Bronchopneumonia
 Multi-lobar pneumonia
 Cavitary pneumonia
 Necrotizing pneumonia
 Lung Abscess
Pathophysiology
 TYPICAL Organisms
– Streptococcus pneumoniae
– Haemophilus influenza
– Streptococcus pyogenes
– Klebsiella pneumoniae
– Moraxella catarrhalis
– Staph aureus
– Enterobacteriaceae/Gram negative bacilli
 Anaerobic organisms (aspiration)
– Fusobacterium sp.
– Prevotella sp.
– Bacteroides sp.
Pathophysiology
 ATYPICAL Organsims
– Mycoplasma pneumoniae
– Chlamydia pneumoniae
– Chlaymida sp.
– Legionella sp.
– Respiratory viruses
– Others
Pathophysiology
Strep pneumo
Strep pneumo
 Gram positive lancet-shaped, encapsulated
diplococcus
 “Most common cause of CAP”
 Multiple serotypes
 High mortality if untreated >> Sepsis
Strep pneumo
 Signs/Symptoms
– Abrupt onset/ill appearance
– Cough (rust colored sputum)
– Fever/Chills
– Chest pain/SOB
– Tachypnea/Tachycardia
 CXR
– Lobar infiltrate
– Bulging fissure
 Treatments
– PCN
– Cephalosporin
Strep pneumo
H flu
H flu
 Gram negative pleomorphic rods
 Encapsulated/Unencapsulated forms
 Serotypes a-f
 “2nd most common cause of CAP”
 Common pathogen in COPD patients
 May also lead to sepsis
H flu
 Signs/Symptoms
– Immunosuppresed/Debilitated patient
– Productive cough
– Fever
– Chest pain
– SOB
 CXR
– Patchy alveolar infiltrates
 Treatment
– Cephalosporins
– Augmentin
– Macrolide (Azithromycin)
H flu
H flu

H flu
Symptoms/Signs (Typicals)
 Productive cough
 Shortness of breath
 Chest pain
 Subjective fever/chills
 N/V
 Back pain
 Abdominal pain
 Abnormal VS
 Rales/Rhonchi/Wheez
 Decreased breath
sounds
 Dullness to percussion
 Increased tactile
fremitus
 Bronchial breath
sounds
 Egophany
Symptoms/Signs (Atypicals)
 Dry Cough
 +- Abnormal VS
 Chest pain/SOB
 Rales/Rhonchi/Wheez
 Extra-pulmonary
symptoms;
Constitutional
symptoms
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–
–
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N/V/D
Headache
Myalgias
Fatigue
Symptoms/Signs
 American Journal of EM 2006: 25, 631-36
– Retrospective, multi-center
– 421 patients diagnosed with CAP
– VS abnormalities were most significant
predictors of CAP
– Hypoxia had strongest association
– Greater # of VS abnormalities >> Higher
prevalence of CAP
– Age also significantly associated with CAP
Diagnostics
 Labs
– CBC
– BMP
 Imaging
– CXR
– CT scans
 Cultures
– Blood
– Sputum
 Other tests
– ABG/EKG
– Urine antigen tests
Diagnostics
 IV
 Oxygen
 Monitor (pulse ox)
Diagnostics: WBC count
 WBC count
– Normal count does not r/o pneumonia
– Elevated/Decreased >> Bacterial pneumonia
– Look for Left Shift!
Diagnostics: CXR
 Findings
– Infiltrates
– Pleural effusions
– Abscess’/Cavities
– Bulging fissures
– Atelectasis
– Air bronchograms
 Other findings
– PTX
– Pleural thickening/Scarring
– Pulmonary edema
– Lymphadenopathy/Masses
Diagnostics: CXR
 Normal CXR
– Immunocompromised
– Dehydrated
– Early infection
 American Journal of Medicine Sept. 2004: 117,
305-11
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2706 patients
911 patients with pneumonia and (–)CXR
These patients were older, increased co-morbidities
These patients had similar rates of + sputum/blood
cultures
– These patients had a similar mortality
Diagnostics: CXR
 Respiratory Medicine May 2006: 100, 926-
32
– 192 patients with pneumonia
– Excellent IR for lobes involved, extent of
infiltrate, pleural effusion
– Poor IR for pattern of infiltrate
– Minimal relation found between cultured
pathogens and radiologic features of infiltrate
on CXR
Diagnostics: CT scan
 CT scan
– Alternative diagnoses
– Unresolved cases
– Complications suspected
– Concerning CXR
– Treatment failure
Diagnostics: Cultures
 Sputum gram stain/culture
– Change antibiotic therapy
– Unusual pathogens/antibiotic resistance issues
– Do not change antibiotics/outcomes
– Cost
– Process issues
 Sputum cultures?
– Are sputum cultures useful in ED?
– Are sputum cultures useful in ICU?
– Do antibiotics affect yield of sputum?
Diagnostics: Cultures
 Sputum cultures: Recommendations
– Outpatient
• Optional
– Inpatient
• Optional
• Recommended when result may change therapy
– Recommended
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ICU admission/Severe CAP
Failure of outpatient therapy
Cavitary infiltrates (suspect TB)
Alcoholism
Severe COPD
Pleural effusion
Positive urinary antigen for Legionella/Strep pneumo
Diagnostics: Cultures
 Blood Cultures
– Yield pathogen 5-15%
– Blood cultures often do not change management
– Most commonly isolated organism…Strep pneumo
– High false positive rate
– Yield of blood cultures decreased by 50% by prior
antibiotic therapy
– Optional
– Recommended
•
•
•
•
Severe CAP
Immunodeficient states (asplenia, liver disease, HIV)
Indications for sputum cultures
Chest 2003
Diagnostics: Cultures
 Blood Cultures
– Chest 2003: 123, 1142-1150
– Emergency Medicine Journal 2003: 20, 521-23
– Emergency Medicine Journal 2004: 21, 446-48
– Academic Emergency Medicine June 2006: 13,
740-45
– Journal of Emergency Medicine July 2007: 33,
1-8
Treatments
 Supportive therapies
 Antibiotics (outpatient/inpatient)
 ICU therapies
 Antibiotic resistance
 Timing to antibiotics (6 hours)
Treatments
 Annals of Emergency Medicine July 2001: 38,
107-113…”Clinical Policy for the Management
and Risk Stratification of CAP in Adults in the
Emergency Department”
– www.acep.org
 Clinical Infectious Disease March 2007: 44, S27-
72…”Infectious Disease Society of America/ATS
Consensus Guidelines on the Management of
CAP”
Treatments: Basics/Supportive
 ABCs
 IV/Oxygen/Monitor
 Albuterol nebulized
 BIPAP
 Intubation
 IVF
 Steroids
Treatments: Antibiotics
 Empiric Antibiotics
– Based on most likely pathogen
– Local antimicrobial resistance patterns
– Antibiotics recommended by class
 Pathogen specific Antibiotics
– Consider specific risk factors
Treatments: Antibiotics
 Outpatient
 Healthy patients
– MACROLIDE (Zithromax, Clarithromycin)
– DOXYCYCLINE
 Co-morbid patients
– BETA LACTAM + MACROLIDE
– FLUOROQUINOLONE (Avelox, Levaquin)
Treatments: Antibiotics
 Inpatient
 FLUOROQUINOLONE (Levaquin,
Avelox)
 BETA LACTAM + MACROLIDE
(Ceftriaxone/Cefotaxime + Zithromax)
Treatments: Antibiotics
 Inpatient, ICU
 BETA LACTAM (Ceftriaxone/
Cefotaxime/Unasyn) + Either MACROLIDE or
FLUOROQUINOLONE
 PCN allergic: AZTREONAM +
FLUOROQUINOLONE
 Pseudomonas
– ZOSYN, CEFEPIME, IMIPENEM, MEROPENEM +
FLUOROQUINOLONE OR MACROLIDE +
AMINOGLYCOSIDE
 CA-MRSA
– Add VANCOMYCIN or LINEZOLID
Treatments: Antibiotics
 Anaerobic coverage
– Not needed in majority of CAP cases
– Indications
•
•
•
•
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Classic aspiration syndromes
LOC
Drug/ETOH overdose
Seizure
Hx of gingival disease/Esophageal dysmotility
– Antibiotics
• CLINDAMYCIN or FLAGYL
Treatments: Antibiotic
Resistance
 Drug-resistant Strep pneumo (DRSP)
 Community-acquired Methicillin resistant
Staph aureus (CA-MRSA)
Timing to Antibiotics
 “Lots of Press”…JCAHO/CMS
 JAMA 1997
– Decreased mortality in patients > 65 y/o antibiotics
within 8 hours
 Archives of IM 2004
– Decreased mortality antibiotics within 4 hours
 2008???
Timing to Antibiotics
 Chest March 2007: 131, 1865-69
 Annals of EM: May 2007: 49, 553-59
 Annals of EM: May 2007: 49, 561-63
 Clinical Infectious Disease March 2007: 44, S27-
72
– “Do not recommend a specific time window for
delivery of first antibiotic dose”
 ACEP News July 2007…”Studies Challenge 4-
Hour Antibiotic Guideline for CAP”
Timing to Antibiotics
 Physician…Antibiotics should be
administered as soon as possible once CAP
is diagnosed/considered likely
 JCAHO…Antibiotics within 6 hours for
CAP
Disposition
 WHO STAYS…WHO CAN WE
DISCHARGE???
 NEJM January 1997: 336, 243-50
– PORT cohort study
– Prediction rule derived in 14,000 patients
– Prediction rule validated in 40,000 patients
– Predicts patients with increased 30 day mortality
– Helps ER physicians with admission/discharge
decisions
– PNEUMONIA SEVERITY INDEX (PSI)
Disposition
 CURB-65 criteria (British Thoracic
Society)….1,068 patients
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Confusion
Uremia
Respiratory rate
Blood pressure (low)
> 65 y/o
CAP 2008
 Epidemiology of CAP has remained stable
 Typicals and atypicals—the lines are
blurred
 Patient risk factors
 Diagnostics
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WBC count
Sputum cultures
Blood cultures
Urine antigen tests
CAP 2008
 Treatment
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Outpatient (healthy, co-morbid)
Inpatient
Inpatient (ICU, risk factors)
HAP, HCAP (ask the ?’s)
 ED treatment considerations
– Empiric coverage
– Blood cultures prior to antibiotic therapy
– Antibiotics in 6 hours
 Drug resistance
– DRSP, CA-MRSA
Summary
 Epidemiology
– Common problem
 Pathophysiology
– Strep pneumo most common
– Typicals/Atypicals
 Signs/Symptoms
– Cough (productive, nonproductive)
– SOB/cp
– Fever
– Abnormal VS
– Abnormal lung exam
Summary
 Diagnostics
– CXR with infiltrate
– Sputum GS/cultures
– Blood cultures
 Treatments
– ABC
– IV/O2/Monitor
– Antibiotics
 Disposition
– PSI, Curb-65 criteria