Transcript - UNM Internal Medicine Resident Wiki

Crash Course in Internal Medicine:
Community Acquired Pneumonia
Residents Thursday School
07/24/2014
J Rush Pierce Jr, MD, MPH
Division of Hospital Medicine, UNM
Outline
• Case based discussion that will cover
– Diagnosis
– Management
• How to quickly access resources
• Management based on
– IDSA/ATS CAP (2007) guidelines
– HCAP/VAP/HAP (2005) guidelines
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Case 1
• 50 yo man w/ 2 days of fatigue and malaise
and 1 day of cough and yellow and red
sputum. 6 hours ago he had a shaking chill,
dyspnea and right-sided pleuritic chest pain.
PMHx + only for HTN, meds = lisinopril. On
exam appears ill and c/o chest pain. BP =
100/60, HR = 105 RR= 24 T=39 saO2 = 88% on
RA. There is dullness to percussion at the right
lung base posteriorly and lung sounds sound
weird at right base.
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Thinking about Case 1
• What historical features are helpful in
understanding this illness?
• What physical exam features are helpful and
how might additional examination features be
of further help?
• How do we organize our approach to this kind
of illness?
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Assessing the history
• 50 yo man w/ 2 days of fatigue and malaise
and 1 day of cough and yellow and red
sputum. 6 hours ago he had a shaking chill,
dyspnea and right-sided pleuritic chest pain.
PMHx + only for HTN, meds = lisinopril. On
exam appears ill and c/o chest pain. BP =
100/60, HR = 105 RR= 24 T=39C SaO2 = 88%
on RA. There is dullness to percussion at the
right lung base posteriorly and lung sounds
sound weird at right base.
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Categories of illnesses that cause
fever
•
•
•
•
•
•
Infectious Diseases
Collagen – vascular diseases
Malignancy
Drugs
Metabolic diseases
Tissue destruction
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Further assessing the history
• 50 yo man w/ 2 days of fatigue and malaise and 1 day of
cough and yellow and red sputum. 6 hours ago he had a
shaking chill, dyspnea and right-sided pleuritic chest pain.
PMHx + only for HTN, meds = lisinopril. On exam appears ill
and c/o chest pain. BP = 100/60, HR = 105 RR= 24 T=39 SaO2
= 88% on RA. There is dullness to percussion at the right lung
base posteriorly and lung sounds sound weird at right base.
• Red sputum
• Pleuritic chest pain
• Shaking chill
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Shaking Chills and Bacteremia
Source: Taniguchi et al.: Shaking chills and high body
temperature predict bacteremia. SpringerPlus 2013;2:624.
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Usefulness of the physical exam
• 50 yo man w/ 2 days of fatigue and malaise and 1 day of
cough and yellow and red sputum. 6 hours ago he had a
shaking chill, dyspnea and right-sided pleuritic chest pain.
PMHx + only for HTN, meds = lisinopril. On exam appears ill
and c/o chest pain. BP = 100/60, HR = 105 RR= 24 T=39 saO2
= 88% on RA. There is dullness to percussion at the right lung
base posteriorly and lung sounds sound weird at right base.
• dullness to percussion at the right lung base
• weird lung sounds at right lung base
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Percussing the posterior thorax
Source:http://sciweb.hfcc.net/biology/ap/233/2
33lecture/intro/surface/thorax/pulmonary.html
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Causes of dullness to percussion
Source: http://meded.ucsd.edu/clinicalmed/lung.htm
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Bronchial breathing
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Physical exam signs of
consolidation
•
•
•
•
•
Bronchial breath sounds
Tactile fremitus
Bronchophony
Egophony
Whispered pectoriloquy
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Pleural space complications of
pneumonia
`
Empyema
Complicated
parapneumonic
effusion
Simple
parapneumonic
effusion
Gross appearance
of pleural fluid
Pus
Clear - cloudy
Clear - cloudy
Pleural fluid WBC
> 10,000
< 10,000
< 10,000
Pleural fluid LDH
> 1,000
< 1,000
> 1,000
Pleural fluid pH
< 7.2
< 7.2
> 7.2
Pleural fluid Gram
stain
May be positive
negative
negative
Pleural fluid Culture May be positive
negative
negative
CT appearance
Loculations,
thickened pleura
Free flowing
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Loculations,
thickened pleura
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Thinking about pneumonia: 5 steps
1.
2.
3.
4.
5.
Make a diagnosis of pneumonia
Put into initial clinical classification
Decide site of care
Tests for etiology
Initial empiric therapy
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Resources
• Guidelines available
– UNMH site
(https://hospitals.health.unm.edu/intranet/Index.cfm)
– IDSA website – guidelines available for download to Palm or
iPhone (http://www.idsociety.org/Content.aspx?id=9088)
• Up-to-Date (varies some from guidelines)
• Sanford Guide – generally follows guidelines
• Adult Community-Acquired Pneumonia Order Set
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Case 2
• 65 y/o male smoker has 2 days of chills,
dyspnea, and purulent sputum. He has no risk
factors for HIV, donates blood 3x/year (most
recently one month ago) and does not take
any medications. T = 38.1, BP = 110/60, HR =
95, RR = 20, SaO2 = 89% RA. Examination
shows no abnormalities. CXR is read as
“minimal streaking at lung bases, atelectasis
vs. early pneumonia”
• Does this patient have pneumonia?
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Thinking about pneumonia: 5 steps
1.
2.
3.
4.
5.
Make a diagnosis of pneumonia
Put into initial clinical classification
Decide site of care
Tests for etiology
Initial empiric therapy
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Step 1. Diagnose pneumonia
• Hx:
Sensitivity
Fever/chills
85%
Dyspnea
70%
Purulent sputum
50%
Any of above
70 – 90%
Specificity
40 – 50%
• PE: VS most useful in predicting severity
• CXR is gold standard - may be normal in up to
7% on admission; assume pneumonia present
if convincing hx and focal PE
• Suspected pneumonia with neg CXR –
consider f/u CXR or CT (more sensitive)
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Case 2
• 65 y/o male smoker has 2 days of chills,
dyspnea, and purulent sputum. He has no risk
factors for HIV, donates blood 3x/year (most
recently one month ago) and does not take
any medications. T = 38.1, BP = 110/60, HR =
95, RR = 20, SaO2 = 89% RA. Examination
shows crackles at right lung base. CXR is read
as “minimal streaking at lung bases,
atelectasis vs. early pneumonia”
• Does this patient have pneumonia? Maybe
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Thinking about pneumonia: 5 steps
1.
2.
3.
4.
5.
Make a diagnosis of pneumonia
Put into initial clinical classification
Decide site of care
Tests for etiology
Initial empiric therapy
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Step 2:
Initial clinical classification
1. Major immunodeficiency
2. Tuberculosis (suspected or established)
3. Relatively normal hosts without TB (location
at time of infection)
• Community-acquired (CAP)
• Healthcare-associated (HCAP) or Hospital acquired (HAP) –
includes ventilator-acquired (VAP)
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Case 3
• 55 y/o homeless man from Mexico has 2 days
of chills, night sweats, dyspnea, and purulent
sputum without hemoptysis. He has not lost
weight. He has no risk factors for HIV, takes no
medications, and is not diabetic, no prev
hospitalizations. Exam reveals T = 38.1, BP =
110/60, HR = 95, RR = 20, SaO2 = 89% RA,
crackles at the right base.
• Should I order airborne isolation?
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www.meddean.luc.edu
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When to suspect TB
(Intern Survival Guide)
• If two or more sxs
–
–
–
–
Hemoptysis
Cough > 2 weeks
Night sweats
Wt loss > 10 # in 3 mos
Response to suspected TB
Order airborn isolation
and CXR
• If suspicious CXR (any of
these)
– Upper lobe infiltrates
Order AFB smears,
– Miliary pattern
cultures (does not have
– Cavitary lesions
to be qAM!)
– Nodular infiltrate Crash Course in IM: Pneumonia
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CAP vs HCAP/VAP/HCAP
• Healthcare-associated pneumonia (HCAP)
–
–
–
–
–
In hospital > 1 day within past 90 days
Nursing home/SNF/LTAC
Dialysis or outpt hosp within past 30 days
IV antibiotics or chemo, wound care within 30 days
(Family member with MDRO)
• HAP– occurs > 48 hrs after admission & not
incubating at time of admission
• VAP – occurs more than 48 – 72 hrs after
intubation
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Case 3
• 55 y/o homeless man from Mexico has 2 days
of chills, night sweats, dyspnea, and purulent
sputum without hemoptysis. He has not lost
weight. He has no risk factors for HIV, takes no
medications, and is not diabetic, no prev
hospitalizations. Exam reveals T = 38.1, BP =
110/60, HR = 95, RR = 20, SaO2 = 89% RA,
crackles at the right base.
• Should I order airborne isolation?
• What is his initial classification?
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Step 2:
Initial clinical classification
1. Major immunodeficiency
2. Tuberculosis (suspected or established)
3. Relatively normal hosts without TB (location
at time of infection)
• Community-acquired pneumonia (CAP)
• Healthcare-associated pneumonia (HCAP) or Hospital
acquired pneumonia (HAP) – includes ventilator-acquired
(VAP)
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Thinking about pneumonia: 5 steps
1.
2.
3.
4.
5.
Make a diagnosis of pneumonia
Put into initial clinical classification
Decide site of care
Tests for etiology
Initial empiric therapy
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Case 4
• 65 y/o female smoker has 2 days of chills,
dyspnea, & purulent sputum. No significant
PMHx. She has felt and eaten poorly. T = 38.1,
BP = 110/60, HR = 95, RR = 20, SaO2 = 89%
RA, crackles at the right apex. She is not
confused. WBC = 15K, H/H = 14.5/42, Na =
128, K = 3.5, Cl = 105, CO2 = 20. BUN/creat =
32/1.4. CXR shows RUL infiltrate.
• Can I send this patient home?
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CURB-65
• Developed by British Thoracic Society
• Confusion, BUN >20, Respiratory rate >30, BP
<90 syst or <60 diast, age >64
– Score = 0 – 1 OUTPT
– Score = 2 WARD
– Score = 3 ICU
 Other subjective factors = safely and reliably take
oral meds, availability of support services
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Pneumonia Severity Index (PSI)
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Case 4
• 65 y/o female smoker has 2 days of chills,
dyspnea, & purulent sputum. No significant
PMHx. She has felt and eaten poorly. T = 38.1,
BP = 110/60, HR = 95, RR = 20, SaO2 = 89%
RA, crackles at the right apex. She is not
confused. WBC = 15K, H/H = 14.5/42, Na =
128, K = 3.5, Cl = 105, CO2 = 20. BUN/creat =
32/1.4. CXR shows RUL infiltrate.
• CURB-65 = 2; admit to ward
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ICU admission = one major or 3 minor
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Thinking about pneumonia: 5 steps
1.
2.
3.
4.
5.
Make a diagnosis of pneumonia
Put into initial clinical classification
Decide site of care
Tests for etiology
Initial empiric therapy
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Case 4
• 65 y/o female smoker has 2 days of chills,
dyspnea, & purulent sputum. No significant
PMHx. She drinks alcohol everyday. T = 38.1,
BP = 110/60, HR = 95, RR = 20, SaO2 = 89%
RA, crackles at the right base. She is not
confused. WBC = 15K, H/H = 14.5/42, Na =
128, K = 3.5, Cl = 105, CO2 = 20. BUN/creat =
32/1.4. CXR shows RUL infiltrate.
• What etiologic tests do I order?
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Diagnostic tests for etiology
• Why not etiologic tests for everyone?
• Outpt – Get SaO2; Routine tests for etiology
are optional
• Inpt - Blood and sputum cultures
recommended for most (but not all)
• ICU - blood and sputum cultures, and
Legionella and pneumococcal UAT
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Thinking about pneumonia: 5 steps
1.
2.
3.
4.
5.
Make a diagnosis of pneumonia
Put into initial clinical classification
Decide site of care
Tests for etiology
Initial empiric therapy
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Case 5
• 24 y/o previously healthy female has 2 days of
chills, dyspnea, & purulent sputum. No
significant PMHx. T = 38.1, BP = 110/60, HR =
95, RR = 20, SaO2 = 92% RA, crackles at the
right base. CBC and Chem 7 normal. CXR =
early RLL pneumonia
• What antibiotics should I order?
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Empiric Rx of outpatient CAP
• Healthy and no antibiotics in past 3 months
– Macrolide OR doxycycline
• If cardiopulmonary dz, Beta-lactam rx in past 3
mos, alcoholism, immunosuppressive rx, or
exposure to child in day-care
– Respiratory quinolone OR
– beta – lactam (high dose amoxicillin or Augmentin) +
macrolide or doxycycline
• Duration of rx = 7 days (may be less with good
response or if use azithro)
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Outpatient RX of CAP
• Candidates for outpt therapy
– Low PSI or CURB-65
– Not crazy
– Likely to be compliant, can get meds and F/U
• Follow-up
– Return if T > 101 or fail to resolve fever in 48 hours
– Outpatient visit in 10 – 14 days
– CXR in 1 – 2 months
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Case 4
• 65 y/o male smoker has 2 days of chills,
dyspnea, & purulent sputum. No significant
PMHx. He has felt and eaten poorly. T = 38.1,
BP = 110/60, HR = 95, RR = 20, SaO2 = 89%
RA, crackles at the right base. He is not
confused. WBC = 15K, H/H = 14.5/42, Na =
128, K = 3.5, Cl = 105, CO2 = 20. BUN/creat =
32/1.4. CXR shows RUL infiltrate
• What antibiotics do you order?
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Empiric Rx of inpatient CAP – no special
considerations
• Inpatient – ward:
– respiratory quinolone
OR
– (ceftriaxone or ceftazidime) + (azithro or doxy)
• ICU –
– (ceftriaxone or ceftazidime) + (IV azithro or
respiratory quinolone)
– If PCN allergic use aztreonam + respiratory
quinolone
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Empiric inpatient Rx of CAP – special
considerations
• Pseudomonas
– suggestive gram stain, bronchiectasis, freq exacs of COPD +
prior antibiotic rx
– Regimens:
– (Zosyn or merepenam) + cipro
OR
– (Zosyn or merepenam or aztreonam) + aminoglycoside +
respiratory quinolone
• MRSA
– suggestive gram stain, ESRD, IVDU, prior influenza, prior
antibiotics esp quinolones, or much MRSA in community
– Regimen: Add linezolid OR vancomycin
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Case 4 - continued
• 65 y/o female 2 days ago with RUL pneumonia
and treated with ceftriaxone and
azithromycin. On rounds is feeling better,
eating, not confused. T = 37.9, HR = 102, BP =
105/75, RR = 12, SaO2 = 88% on room air
• When I can I switch to an oral regimen and
what regimen?
• When can the pt go home?
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Switching to oral
• If specific pathogen identified, switch to
narrow spectrum therapy
• When clinically improving, hemodynamically
stable, able to take orals, switch to oral rx – if
no pathogen, often azithro alone
• Duration = at least 5 days, and until afebrile
for two days, and have only one sign of clinical
instability. If pathogen is Pseudomonas treat
at least 14 days
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Timing of discharge
Readmission rate or death: no instability = 10%; 1 instability = 14%; 2+ instabilities = 46%
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Pneumonia – before they go home
• Smoking cessation
• Vaccination
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Questions?
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Empiric therapy of HCAP/HAP/VAP
with MDR risk factors
cefepime, ceftazadime, imipenam, or Zosyn
PLUS
ciprofloxacin, levofloxacin, or aminoglycoside
• If MRSA concerns add linezolid or vancomicin
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Switching to oral therapy for
HCAP/HAP/VAP
Pseudo: if sens
cipro +
Aug/doxy/clinda
MRSA:
sensitivities
cipro + Aug/doxy/clinda OR moxi
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Aspiration
• When to use: observed/suspected aspiration +
fever or leucocytosis or infiltrate
• Regimens:
– Unasyn + (doxy OR azithro)
Augmentin or
clinda
– Respiratory quinolone
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Non-responding pneumonia –
definition (15%)
• Progressive pneumonia on CXR with clinical
deterioration, acute respiratory failure and/or
shock occurring in first 72 hours
• Delay in achieving clinical stability
– Median time = 3 days
– ¼ require > 5 days
• Non-resolution of infiltrate > 30 days after
hospitalization [different problem]
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Clinical response to nonresponding pneumonia
• Reevaluate initial microbiologic results – consider
UAT
• Reassess risk factors for infection with unusual
organism
• Repeat blood cultures for worsening pneumonia or
clinical deterioration
• Look for secondary infections (catheter, urinary, skin)
• Get CT to R/O PTE, thoracentesis to R/O empyema,
bronchoscopy to R/O unusual pathogens
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