Transcript Clinical Scenario

Community-Acquired Pneumonia:
A Clinical case scenario
Outline
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Diagnosis of CAP
Site of care?
Tools for risk assessment?
Diagnostic tests needed?
Management of severe CAP ?
Presentation
A
66-year-old
man
accompanied by his wife,
arrived at the Emergency
Department complaining
of
shortness
of
breath,
fever, and cough.
Symptoms
His symptoms started 8 days ago
with mild fever, cough, myalgia,
headache & sore throat were he
received
antipyretic,
antihistaminic and cough syrup
after consulting his family doctor
through a telephone call.
Symptoms
 After
initial improvement, he had a
worsening of symptoms starting 3 days
ago with productive cough, pleuritic chest
pain, fever, chills and malaise.
 Last night he developed dyspnea and
high fever, so he decided to come to the
Emergency Department today.
Medical History
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X-smoker 2 years (30 pack years).
COPD.
Type 2 diabetes.
Medications include
 Inhaled salbutamol (100 μg)+ beclomethasone
diproprionate (50 μg) 2 puffs x 3.
 Sustained released theophylline (200mg cap
1x2).
 Gliclcazide (80mg tab. 1x1).
Examination
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Confused.
Temperature: 39.0°C.
Blood pressure: 120/70.
Pulse rate: 120 bpm.
Respiratory rate: 30 per minute.
Clinical signs of right upper zone consolidation and
bilateral scattered rhonchi.
 No cyanosis, pedal edema or jugular venous
distension is noted.
Chest X-ray
Diagnosis
Dose this patient have
Community-Acquired
Pneumonia (CAP)?
Definition of CAP
 Infection of the lung parenchyma in a
person who is not hospitalized or
living in a long-term care facility for
≥ 2 weeks.
CAP: Diagnosis
Clinical features:
Productive cough, dyspnea, fever,
clinical signs of consolidation
Radiological findings:
Consolidation
“In addition to a constellation of suggestive
clinical features, a demonstrable infiltrate
by chest radiograph or other imaging
technique, with or without supporting
microbiological data, is required for the
diagnosis of pneumonia.”
CAP – Risk Factors for Pneumonia
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Elderly
Smoking
COPD
Extreme weather
Overcrowding
Alcoholism
DM
Renal insufficiency
CHF
Chronic liver
disease
 Immunossuppresio
n
 Loss of
consciousness
 Seizures
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What is the value of CXR in CAP?
 Establish Dx
 Evaluation of severity
e.g. multilobar or bilateral, pleural effusion.
 Co-existing conditions
e.g. bronchial obstruction, abscess.
 Pattern
Infiltrate Patterns and Pathogens
Initial investigations at ER:
 Hgb 13.4 gm/dl, Hct 40%.
 WBC 15,800/μl with 88% polymorphonuclear
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cells, 8% bands.
Na+ 137 mEq/L, K+ 3.7 mEq/L.
BUN 32 mg/dl, creatinine1.8 mg/dl.
RBG 260 mg/dl.
Arterial blood gas (room air):
pH 7.38, PCO 2 53 mmHg, PO 2 58mmHg, O 2 Sat.% 89%
CAP – Management based on PSI Score
Would you hospitalize him?
Assess the ability to safely and reliably take oral
medication & the availability of outpatient support
resources
CURB 65 score
Thorax 2003,58:377
(If study performed)
Pneumonia
Severity Index
(PSI) score
<60mmHg / SO 2 <90%
Calculation of risk assessment (PSI score)
PSI= 146 Class V→ ICU
What testing would you do?
Diagnostic testing
 “Recommendations for diagnostic testing remain controversial.”
 No convincing data that they improve outcomes.
 Outpatient setting: optional
 Inpatient setting:
 Critically ill CAP
 Specific pathogens (suspected)
Diagnostic testing: Critically ill CAP
 Sputum: Gram staining and culture.
 Blood cultures.
 Urinary antigen tests for Legionella &
Streptococcus pneumoniae.
 ± others
 FOB+BAL / Endotracheal tube aspirate
 Thoracentesis
 TNA
What testing would you do?
Pretreatment:
 Sputum: Gram staining and culture.
Expectorated sputum should be deep cough specimen obtained
before antibiotic treatment and it should be rapidly transported and
processed within a few hours of collection.*
 Blood cultures (2 sets)
2 sets of blood cultures should be drawn before initiation of
antibiotic therapy during the first 24 hour.*
What treatment would you prescribe?
General & supportive
Therapy
Antibiotic
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Fluid / diet
Antipyretics (Paracetamol IV)
Sugar blood chart & Insulin accordingly
Cough syrup
SR theophylline
Inhalation ttt → salbutamol + ipratropium bromide
O2 therapy → NP 2 L/min
Empiric Antibiotic ttt
What antibiotics are appropriate?
CAP: When to start empiric therapy?
 As soon as possible in ED
 CAP: delay-to-AB> 4h after arrival
 Increased mortality
 Increased LOS
Recommended empirical antibiotics
for CAP: Inpatient, ICU ttt
b-lactam plus either azithromycin or a
respiratory fluoroquinolone
(cefotaxime, ceftriaxone)
Levofloxacin 750mg/24h + Ceftriaxone 1gm /12h IV
2 hours after ICU admission
Sputum (gram stain)
→Gram-positive diplococcus
Value of Gram stain
 First, it broadens initial empirical coverage for less common etiologies,
such as infection with S. aureus or gram-negative organisms. *
 Second, it can validate the subsequent sputum culture result. A positive
Gram stain was highly predictive of a subsequent positive culture.*
Day 3
 Sputum culture & Sensitivity: Streptococcus pneumoniae
 Sensitive→ Cefotaxime, Ceftraixone and Levofloxacin.
 Susceptibility testing should guide antibiotic choice when results are
available.
 Continue on the same antibiotics
 Day 3:
 The patient's condition began to improve, but fever persisted.
 Day 5:
 The patient was a febrile for the first time.
 Normal oral intake started.
 Cough, dyspnea grade & chest wheezes improved.
 Pulse 90 bpm, B/P 140/80.
 WBC 6,800/μl with 3% bands.
 BUN 18 mg/dl, creatinine1.4 mg/dl, 2 PPBS 170mg/dl.
 O 2 Sat.% on RA: 93%.
 Transferred to ward.
Switch from intravenous to oral
therapy?
Afebrile
 No abnormal GIT absorption
 Cough & respiratory distress improved
 WBC returning to normal
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Levofloxacin 750 mg tab/24hr
 Day 8:
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Clinically stable
Afebrile for 3days.
CXR: partial resolution.
Blood culture:
 No growth up till now.
CAP: Duration of Therapy?
“A minimum of 5 days…
Afebrile for 48-72 h …
No more than 1 CAPassociated sign of
clinical instability’’
 Day 9:
 Discharged and antibiotic stopped.
 Recommendations
 ℜ/ pneumococcal polysaccharide vaccination
 ℜ/ During next influenza season, influenza
vaccination.
 ℜ/ ttt COPD & DM.
 FU CXR after 1 week.