PneumoniaRiaz RahmanDestiny Univ.

student presentation:

Question 1An HIV+ patient with a CD-4+ count of 802 is found to be hypoxic on room air. Chest X-ray shows multi-lobular consolidation. What is the most likely causative organism?A. Moraxella catarrhalisB. Klebsiella pneumoniaeC. Staphylococcus aureusD. Streptococcus pneumoniaeE. Mycobacterium tuberculosis

Pre-Test

Question 2A 47 year old homeless alcoholic male presents to your clinic complaining of insidious onset dry cough. He describes his sputum as “red jelly.” Chest x-ray shows a bulging fissure. What is the most likely diagnosis?A. Aspiration PneumoniaB. Acute BronchitisC. Ventilator Associated PneumoniaD. Hospital Acquired PneumoniaE. Adult Respiratory Distress Syndrome

Pre-Test

Question 3A 62 year old male presents with a non-productive cough of 2 weeks duration. Physical exam reveals wheezing, rhonchi, crackles. The patient has a normal pulse in but a high fever. What type of pneumonia is most likely?A. Typical Community Acquired PneumoniaB. Hospital Acquired PneumoniaC. Atypical Community Acquired PneumoniaD. Ventilator Associated Pneumonia

Pre-Test

Question 4An HIV+ patient who has a CD-4+ count of 52 presents with acute onset cough and fever. He does not take antiretroviral meds or TMP-SMX, is hypoxic on room air, and has a diffuse bilateral infiltrate on chest film. What is the most likely causative organism? A. Streptococcus pneumoniaeB. Pneumocystis cariniiC. Aspergillis fumigatusD. Coccidiodes E. Mucormycosis

Pre-Test

Question 5An elderly man presents w/ pneumonia, GI disturbance, bradycardia, and hyponatremia. What is the most likely causative organism?A. Streptococcus pneumoniaeB. Staphlococcus aureusC. Legionella pneumophiliaD. Coxiella burnetti

Pre-Test

Case Study 58 yo male presents to walk-in clinic c/o 24-hour history of

fever, chills, productive cough, and episode of rigors last night. PMH: COPD, diabetes, smoking 2 packs/day (75 pack years

lifetime). Meds: combination steroid/long-acting beta agonist inhaler,

tiotropium bromide and albuterol, as needed. Physical exam: tactile fremitus, expiratory wheezes and rhonchi. Vitals: BP 168/92, HR 128, RR 32, T 101.3°F pulse oximetry 87%

(RA). Patient is placed on 4 liters O2, and albuterol via nebulizer. His

O2 sat increases to 94%, his RR decreases to 24, and pulse decreases to 112.

As the patient is still mildly hypoxic, tachypneic, tachycardic) and requiring supplemental oxygen, he is admitted to a local hospital.

Chest x-ray reveals right lower lobe infiltrate and a white blood cell count of 17,000/mm3. Sputum culture reveals S. pneumoniae.

The patient is placed on moxifloxacin 400 mg daily for 7 days and is started on prednisone and albuterol via small-volume nebulizer.

He rapidly improves and is discharged 3 days later with instructions to finish antibiotics/steroids and to follow-up with PCP.

Pre-Test

Pneumonia Lower respiratory tract infection:

Inflammatory condition of the lung which primarily affects alveoli. It is usually caused by infection

Typical symptoms include a cough, chest pain, fever, and difficulty breathing

D/dx: URI, Acute Bronchitis, Lung Abscess Epidemiology:

8th leading cause of death in the U.S. Affects ~450 million people globally per year (seven

percent of the world population) Results in ~4 million deaths worldwide, mostly in

third-world countries

Introduction

Classification Community Acquired Pneumonia (CAP)

Occurs in the community or within the first 72 hours of hospitalization; Can be typical or atypical

Most common bacterial pathogen is S. Pneumoniae (60%) Hospital Acquired Pneumonia (HAP)

Occurs during hospitalization after first 72 hours Gram-negative bacilli (Pseudomonas, Klebsiella, E. coli,

Enterobacter, Serratia, Acinetobacter, & S. aureus, including MRSA)

Acid suppression (PPI use) may increase risk Ventilator Associated Pneumonia

Aspiration Pneumonia Chemical pneumonitis due to aspiration of gastric contents Bacterial pneumonia ≥24–72 h later, due to aspiration of

oropharyngeal microbes Outpatients: typical oral flora (Strep, S. aureus, anaerobes) Inpatients or chronically ill: GNR and S. aureus

Introduction

Other Common EtiologiesIntroduction

Presentation CauseYoung, Healthy Patients Mycoplasma, Chlamydia,

ViralRecent Viral Syndrome Staphylococcus AureusAlcoholics; Aspirators Klebsiella; other GNRCOPD H. influenzae, M. catarrhalisGastrointestinal Symptoms; Confusion; Elderly; Smokers

Legionella

Persons present at the birth of an animal

Coxiella burnetii

Arizona construction workers

Coccidoidomycosis

HIV with <200 CD4+ cells

Pneumocystis (PCP)

Nursing Home Resident Pseudomonas

Clinical Symptoms “Typical” CAP

Acute onset of fever, productive cough w/ purulent sputum, dyspnea, pleuritic pain

“Atypical” CAP: originally described as culture (-) Insidious onset of dry (nonproductive) cough Extrapulmonary sx: Nausea, Vomiting, diarrhea,

headache, myalgias, sore throat) Ventilator Associated Pneumonia

Fever, Hypoxia Increasing secretions

Work-Up

Clinical Signs “Typical” CAP

Tachycardia, tachypnea Late inspiratory crackles, bronchial

breath sounds, increased tactile and vocal fremitus, dullness on percussion

Pleural friction rub: associated with pleural effusion

“Atypical” CAP Pulse–temperature dissociation:

normal pulse in the setting of high fever is suggestive of atypical CAP.

Wheezing, rhonchi, crackles

Work-Up

Diagnosis Best initial diagnostic test: Chest x-ray Most accurate test: Sputum Gram stain

and Sputum Bacterial culture Initial workup

1. All cases of respiratory disease (fever, cough, sputum) should have a chest x-ray (PA & Lateral) and oximeter ordered with the first screen.

2. If there is shortness of breath, also order oxygen with the first screen.

3. If there is shortness of breath and/or hypoxia, order an ABG.

4. CBC w/ diff, Electrolytes, BUN/Cr, glc, LFTs

Work-Up

Imaging Typical CAP – Lobar Consolidation on CXR Atypical CAP - Patchy interstitial pattern on CXR

Work-Up

(From Erkonen WE, Smith WL. Radiology 101: The Basics and Fundamentals of Imaging. Philadelphia, PA: Lippincott Williams & Wilkins, 1998:110, Figure 6-54A and B.)

Other Considerations Additional microbiologic studies

Mycoplasma: PCR of throat or sputum/BAL before first abx

Legionella: urine Ag S. pneumoniae: urinary Ag MTb: induced sputum for AFB stain and mycobact.

Cx PCP: Induced sputum for PCP if HIV+ or known T

cell-mediated immunity; HIV test if 15–54 y Bronchoscopy: consider if pt is immunosuppressed,

critically ill, failing to respond, or has chronic pneumonia.

Decision to Admit Outpatient versus inpatient monitoring; ICU or no

ICU. The pneumonia severity index (PSI) is used to risk-

stratify In general elderly, hypoxic patients with or without

a fever should be admitted. Consider the ICU, depending on severity of hypoxia.

Work-Up

Risk Factor PORT Score

Sex

Men +Age (yrs)Women +(Age-10)

Comorbidities

Nursing Home +10Neoplasm +30Liver Disease +20CHF +10CVA +10Renal Disease +10

Exam

∆Mental Status +20RR > 30 +20SBP < 90 +20T<35 or >40 +15HR > 125 +10

Management

Risk Factor PSI ScoreLabs

pH<7.35 +30BUN>30 +20Na<130 +20Glucose>250 +10Hct <30 +10PaO2 <60 +10SaO2<90 +10Pleural Effusion

+10

Risk StratificationPneumonia SeverityIndex (PSI)

PrognosisClas

sTotal PSI

Score Risk Mortality Suggested triage

I<70 (Age 50, no comorbidities)

Low 1% Outpatient

II <70 Low 1% OutpatientIII 71–90 Low 2.8% Brief inpatientIV 91–130 Moderate 8.2% InpatientV >130 High 29.2% ICU

Management

Clinical scenario Empiric treatment guidelinesOutpatient No recent abx: macrolide OR

doxycyclineRecent abx: [macrolide AND (high-dose amox /clav or 2nd-gen. ceph.)] OR [respiratory FQ]

Community-acquired, Hospitalized

[3rd-gen. ceph. AND macrolide] OR [respiratory FQ]

Community-acquired, hospitalized, ICU

[3rd-gen. ceph. or amp-sulbactam] AND [macrolide or FQ] (assuming no risk for Pseudomonas)

Hosp-acquired & risk for MDR pathogens

[Antipseudomonal PCN or ceph. or carbapenem] AND [FQ or (gentamicin azithromycin)] AND [vancomycin or linezolid]

Immunosuppressed [As above] ± [TMP-SMX ] ± [steroids to cover PCP]

Aspiration (3rd-gen. ceph. or FQ) ± [clindamycin or metronidazole]

Treatment

Prevention Pneumococcal Vaccine:

Persons >65 years of age High-Risk medical illness (heart

disease, sickle cell disease, pulmonary disease, diabetes, or alcoholic cirrhosis, or asplenic individuals)

Influenza Vaccine: give yearly to people at increased risk for complications and health care workers

VAP precautions: HOB 30, chlorhexidine rinse; aspiration precautions in high-risk Pts

Maintenance

Pleural effusion “parapneumonic effusions" Can be seen in more than 50% of patients with CAP

on routine CXR. Empyema is infrequent in these patients.

Most of these effusions have an uncomplicated course and resolve with treatment of the pneumonia with antibiotics.

Thoracentesis should be performed if the effusion is significant (>1 cm on lateral decubitus film). Send fluid for Gram stain, culture, pH, cell count, determination of glucose, protein, and LDH levels.

Pleural empyema occurs in 1% to 2% of all cases of CAP (up to 7% of hospitalized patients with CAP). See Chapter 2.

Acute respiratory failure may occur if the pneumonia is severe.

Complications

Question 6A 37 year old female presents with tachycardia, tachypnea, late inspiratory crackles, bronchial breath sounds, increased tactile and vocal fremitus, dullness on percussion. What is the best initial test?A. Arterial Blood GasB. Sputum CultureC. Sputum Gram StainD. Chest X-rayE. Spiral CT

Post-Test

Question 7An otherwise healthy 29 year old male is diagnosed with Community Acquired Pneumonia on an outpatient basis. His PSI score is <50. He states he has not recently been on any antibiotics. What is the best first-line therapy?A. Ampicillin-SulbactamB. CeftriaxoneC. Ceftriaxone and CiprofloxacinD. DoxycyclineE. Moxifloxacin

Post-Test

Question 8A 34 year old male presents with pesistent dry cough, weakness and malaise. Pulmonary infiltrates are visualized on CXR. 3mL of patient’s blood is added to anticoagulated tube and placed into ice water. Several minutes later, clumping is detected inside the tube. What is the most likely causative organism? A. Mycoplasma B. UreaplasmaC. Streptococcus pneumoniaeD. Pneumocystis carinii

Post-Test

Question 9A 72 year old nursing home resident is admitted for community-acquired pneumonia. The patient is found to have a PSI Score of 140. What is the patient’s relative mortality risk?A. No RiskB. Low RiskC. Intermediate RiskD. High Risk

Post-Test

Question 10A 54 year old male smoker is admitted for inpatient treatment of typical community-acquired pneumonia. Excess fluid is visualized between the visceral and parietal pleura on CXR. What is the most likely complication?A. Pleural EmpyemaB. Pleural EmphysemaC. Pleural EffusionD. Pleural Confusion

Post-Test

References Arnold FW, Summersgill JT, Lajoie AS, et al. A worldwide perspective of atypical

pathogens in community-acquired pneumonia. Am J Respir Crit Care Med 2007; 175:1086.

File TM. Community-acquired pneumonia. Lancet 2003; 362:1991. File TM Jr, Niederman MS. Antimicrobial therapy of community-acquired

pneumonia. Infect Dis Clin North Am 2004; 18:993. Johnstone J, Mandell L. Guidelines and quality measures: do they improve

outcomes of patients with community-acquired pneumonia? Infect Dis Clin North Am 2013; 27:71.

Lim WS, Macfarlane JT, Boswell TC, et al. Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines. Thorax 2001; 56:296.

Malcolm C, Marrie TJ. Antibiotic therapy for ambulatory patients with community-acquired pneumonia in an emergency department setting. Arch Intern Med 2003; 163:797.

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:S27.

Marrie TJ, Shariatzadeh MR. Community-acquired pneumonia requiring admission to an intensive care unit: a descriptive study. Medicine (Baltimore) 2007; 86:103.

Marrie TJ, Poulin-Costello M, Beecroft MD, Herman-Gnjidic Z. Etiology of community-acquired pneumonia treated in an ambulatory setting. Respir Med 2005; 99:60.

Read RC. Evidence-based medicine: empiric antibiotic therapy in community-acquired pneumonia. J Infect 1999; 39:171.

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