Transcript Intern Report 7.6.16

Intern Report
Tony Hung
Modified from presentation by
Selim Krim, MD, Assistant Professor at TTUHSC
Case 1
A 62-year-old male presents to ER complaining of cough, fever,
and difficulty breathing, which developed overnight. He has no
symptoms of rhinorrhea, sore throat, or earache. He is not a
smoker and has no history of asthma or recent antibiotic use. He
is a business executive who travels extensively and just
returned from Arizona.
Case 1
On physical examination, he appears flushed but otherwise alert
and oriented. He is 5-11,180 lbs and has a blood pressure of
110/70 mmHg, a heart rate of 90 beats per minute, a respiratory
rate of 24 breaths per minute, and a body temperature of 39 ºC.
Lung sounds reveal a mild dullness in right base, no increased
tympany, and coarse breath sounds with mild rales in right
posterior lung base. He is not wheezing. The rest of his exam is
normal.
Based on your history and physical
exam what is your diagnosis?
Diagnosis of Pneumonia
Signs and symptoms
Diagnosis of Pneumonia
Signs and symptoms
Subjective fever
Cough with or without sputum
Dyspnea
Chest discomfort
Sweats
Rigors
Fever/ hypothermia
Tachypnea
Tachycardia
Increased tactile fremitus
Dullness to percussion
Decreased breath sound
Presence of rales or crackles
Diagnosis of Pneumonia
Signs and symptoms
Subjective fever
Cough with or without sputum
Dyspnea
Chest discomfort
Sweats
Rigors
Fever/ hypothermia
Tachypnea
Tachycardia
Increased tactile fremitus
Dullness to percussion
Decreased breath sound
Presence of rales or crackles
Overall, physician judgment is moderately
accurate for diagnosis of pneumonia,
especially for ruling it out (LR+ = 2.0, negative
likelihood ratio [LR–] = 0.24)
Diagnosis of Pneumonia
Signs and symptoms
Subjective fever
Cough with or without sputum
Dyspnea
Chest discomfort
Sweats
Rigors
Fever/ hypothermia
Tachypnea
Tachycardia
Increased tactile fremitus
Dullness to percussion
Decreased breath sound
Presence of rales or crackles
Atypical pneumonia??
Diagnosis of Pneumonia
Signs and symptoms
Subjective fever
Cough with or without sputum
Dyspnea
Chest discomfort
Sweats
Rigors
Fever/ hypothermia
Tachypnea
Tachycardia
Increased tactile fremitus
Dullness to percussion
Decreased breath sound
Presence of rales or crackles
Atypical pneumonia
Headaches (CNS symptoms)
Diarrhea (GI symptoms)
High fever
Male sex
Multli-lobar
Diagnosis of Pneumonia
Signs and symptoms
Subjective fever
Cough with or without sputum
Dyspnea
Chest discomfort
Sweats
Rigors
Fever/ hypothermia
Tachypnea
Tachycardia
Increased tactile fremitus
Dullness to percussion
Decreased breath sound
Presence of rales or crackles
What about older patient??
COPD??
HIV??
Recent Travel??
Cruise Ships??
Fall/Winter Season??
Epidemiology
MCQ
• Which of the following statements is true about communityacquired pneumonia?
• Pneumonia and influenza combined is the eighth leading cause
of death in the United States and the most common cause of
infection-related mortality
• Only 400 cases of community-acquired pneumonia (CAP) occur
each year
• The estimated annual economic burden of CAP in the United
States exceeds $17
MCQ
•
Streptococcus pneumoniae is identified in up to what percentage
of community-acquired pneumonia cases?
•
40%
•
60%
•
80%
Identified Pathogens in Community-acquired
Pneumonia
Pathogen
•
•
•
•
•
•
•
•
•
•
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus
Gram-negative bacilli
Legionella species
Mycoplasma pneumoniae
Chlamydia pneumoniae
Viruses
Aspiration
Others
Percentage
20-60%
3-10%
3-5%
3-10%
2-8%
1-6%
4-6%
2-15%
6-10%
3-5%
MCQ
• What is the most likely pathogenic mechanism in this patient's
pneumonia?
•
•
•
•
Aspiration of oropharyngeal contents
Hematogenous deposition
Reactivation
Inhalation of infectious particles
Pathogenetic mechanisms in Pneumonia
•
•
•
•
•
Inhalation of infectious particles
Aspiration of oropharyngeal or gastric content
Hematogenous deposition
Invasion from infection in contiguous structures
Reactivation
Common
Common
Uncommon
Rare
More common in
Immunocompromised hosts
MCQ
•
What is the next most important step in this patient's care?
•
•
•
•
•
Empiric therapy with a fluoroquinolone
Chest x-ray
Sputum culture
Hospitalization
CBC, glucose, BUN, Na tests
An infiltrate on lung imaging, usually CXR, is
required for the diagnosis of CAP; therefore,
the test should be performed in patients with
clinically suspected CAP
Extent of radiographic findings may help
identify the severity of illness and assist with
initial point-of-care decisions
Diagnostic tests
• Chest x-ray essential (AP and Lateral)
– Lobar consolidation, cavitation, and pleural effusions suggest a
bacterial etiology
– Diffuse parenchymal involvement is more often associated with
Legionella or viral pneumonia.
Diagnostic tests
What about labs?
• Routine laboratory testing to establish an etiology in
outpatients with CAP is usually unnecessary
HOWEVER
evaluation for specific pathogens that would alter standard
empiric therapy should be performed when the presence of
such pathogens is suspected on the basis of clinical and
epidemiologic clues
• Hypoglycemia (blood glucose level less than 70 mg per dL
[3.89 mmol per L]) at presentation is associated with
increased 30-day mortality even after adjustment for other
variables, including comorbid illness and Pneumonia Severity
Index (PSI) score
WBC?
CRP?
Pro-Calcitonin?
Blood Cultures?
• Blood cultures are not recommended for most hospitalized
patients with CAP
Unless…
severe CAP
A study comparing 125 patients with CAP caused by
pneumococcal bacteremia and 1,847 patients with
nonbacteremic CAP found no increase in poor outcomes
among those with bacteremia
false-positive blood culture results have been associated with
prolonged hospitalization and more vancomycin use
• Sputum culture?
Adapted with permission from Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society
consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S40
Infectious Diseases Society of America/American
Thoracic Society (IDSA/ATS) guidelines recommend
that sputum specimens be obtained before the
initiation of antibiotic therapy in inpatients.
Adapted with permission from Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society
consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S40
Adapted with permission from Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society
consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S40
Urine antigen tests are helpful when an adequate
sputum culture is unobtainable or when antibiotic
therapy has already been started.
Urine antigen test only detects Legionella serogroup
1, is that a problem??
Adapted with permission from Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society
consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S40
Serogroup 1 causes 80 to 95 percent of CAP from
Legionella; the test is 70 to 90 percent sensitive and
99 percent specific for serogroup 1.
Urine antigen test results are positive on the first day
of illness and remain positive for several weeks.
Adapted with permission from Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society
consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S40
The sensitivity of the pneumococcal urine antigen test is ???
with a specificity ???
Adapted with permission from Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society
consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S40
The sensitivity of the pneumococcal urine antigen test is ???
with a specificity ???
In general, urine antigen tests are better at ruling in disease
when positive; a negative test result does not rule out
infection with a specific pathogen given its somewhat limited
sensitivity.
Adapted with permission from Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society
consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S40
Should this patient be admitted?
Case 1
A 62-year-old white male presents complaining of cough, fever,
and difficulty breathing, which developed during the night. He
has no symptoms of rhinorrhea, sore throat, or earache. He is
not a smoker and has no history of asthma or recent antibiotic
use. He is a business executive who travels extensively and just
returned from California.
Case 1
On physical examination, he appears flushed but otherwise alert
and oriented. He is 5-11,180 lbs and has a blood pressure of
110/70 mmHg, a heart rate of 90 beats per minute, a respiratory
rate of 24 breaths per minute, and a body temperature of 39 ºC.
Lung sounds reveal a mild dullness in right base, no increased
tympany, and coarse breath sounds with mild rales in right
posterior lung base. He is not wheezing. The rest of his exam is
normal.
• Management of CAP depends on the patient's severity of
illness; underlying medical conditions and risk factors, such as
smoking; and ability to adhere to a treatment plan.
British Thoracic Society
A SMART-COP score of 3 or more points identifies 92 percent of those who will receive
intensive respiratory or vasopressor support
How would you treat this patient?
What if he has …
Chronic heart, lung, liver, renal disease. DM, etoh. Cancer.
Asplenia. Antibiotics use in the past 3 month?
Case 1 (Part 2)
Empiric therapy with an oral macrolide was prescribed, and the
patient was sent home. Two days later, he presents at the
emergency room with shaking chills and fever, increasingly
productive cough, and difficulty breathing.
His vital signs are as follow: BP 110/60 mmHg, body
temperature 40.5° C, pulse rate 126 beats/min, and respiration
rate 28 breaths/min. He is alert and oriented. His exam again
reveals rales and dullness in the right lower posterior lung fields
without wheezing. Chest x-ray shows a focal infiltrate in the right
lower lung and a small pleural effusion.
Would you admit this patient now?
What is the typical duration of therapy?
• Duration of therapy for patients with CAP has traditionally been 10 to
14 days, but more recent evidence suggests a shorter course of up to
seven days is equally effective.
• Hospitalized patients may be switched from intravenous to oral
antibiotic therapy after they have clinical improvement and are able
to tolerate oral medications.
• An early switch from intravenous to oral antibiotics after three days in
patients with severe CAP has been shown to be effective and may
decrease length of hospital stay.
When would you consider discharging
your patient?
Discharge Criteria
• Candidates for discharge should have no more than one of the
following poor prognostic indicators:
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Temperature > 37.8 degrees Celsius
Pulse > 100 beats per minute
Respiratory rate > 24 per minute
Systolic blood pressure < 90 mmHg
Oxygen saturation < 90 percent
Inability to maintain oral intake
Thank You
Key Points
•
Community-acquired pneumonia can be treated empirically
with oral antibiotics in the outpatient setting (in patients with
low risk category)
•
Patients younger than age 50 who have no comorbid health
problems and who present with minimal signs and symptoms
of possible pneumonia can safely be treated without the need
for further testing.
•
A macrolide or doxycycline is the treatment of choice for
healthy patients younger than age 60 who have presumed
pneumonia. Fluoroquinolones are not recommended in these
patients because of increasing problems with antibiotic
resistance.
Key Points
• In all patients in whom pneumonia is suspected, a chest x-ray
should be ordered to provide diagnostic evidence with which to
distinguish different patterns of infiltrates.
• The need for in-patient care can be determined by professional
judgment, based on the patient's signs and symptoms; however, a
risk factor calculation can be helpful in determining those with high
predicted mortality.
• Obtaining blood cultures within 24 hours of admission and starting
antibiotics within 4 hours of admission have been shown to reduce
30-day mortality and are considered quality indicators.
Key Points
• Because 30% to 50% of patients with community-acquired
pneumonia never have a pathogen identified, it is recommended
that empiric therapy selection be based on presumed organisms and
their sensitivities, history of exposure, other comorbid health
conditions, and x-ray findings.
• Aggressive testing including cultures, serology testing, and other
rapid assays to determine the causative pathogen are appropriate
for most inpatients. More invasive testing, including bronchoscopy,
should be reserved for deteriorating patients in whom no etiology
has been determined.