Project: Ghana Emergency Medicine Collaborative

Document Title: Pneumonia in the ED

Author(s): Phil Bossart (University of Utah), MD 2012

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Pneumonia in the EDPneumonia in the ED

Phil Bossart MDPhil Bossart MD

University of UtahUniversity of Utah

Salt Lake CitySalt Lake City

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Types of PneumoniaTypes of Pneumonia

CAP community acquired CAP community acquired pneumoniapneumonia

HAP hospital acquired pneumoniaHAP hospital acquired pneumonia

HCAP health care associated HCAP health care associated pneumoniapneumonia

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Community Acquired Community Acquired PneumoniaPneumonia

Indications for Admission to hospitalIndications for Admission to hospital

PSI Pneumonia Severity IndexPSI Pneumonia Severity Index

CURB 65 Confusion, Uremia (BUN > CURB 65 Confusion, Uremia (BUN > 20mg/dl or 7 mmol/L, RR >30, BP 20mg/dl or 7 mmol/L, RR >30, BP sys <90 or diastolic < 60, Age >65.sys <90 or diastolic < 60, Age >65.

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CURB 65CURB 65

Some use CRB 65Some use CRB 650 – 1 home treatment0 – 1 home treatment1 Admit to hospital1 Admit to hospital>> 3 Admit to ICU 3 Admit to ICU

Prediction rules are Prediction rules are aids only aids only Many other issues ( co-morbidities, Many other issues ( co-morbidities,

social factors)social factors)

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Causes of pneumoniaCauses of pneumonia PneumococcusPneumococcus Haemophilus influenzaeHaemophilus influenzae Atypical Bacteria (mycoplasma, Atypical Bacteria (mycoplasma,

chlamydia, legionella)chlamydia, legionella) Oropharyngeal aerobes and anaerobes Oropharyngeal aerobes and anaerobes

( asp)( asp) Resp VirusesResp Viruses StaphStaph Gram neg bacteriaGram neg bacteria TBTB

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Diagnosis of PneumoniaDiagnosis of Pneumonia

Clinical cough, fever, chest painClinical cough, fever, chest pain Rales, hypoxiaRales, hypoxia Radiologic findings – chest x-ray is Radiologic findings – chest x-ray is

not 100% sensitivenot 100% sensitive

Clinical diagnosis – no single tests Clinical diagnosis – no single tests gives definitive answer.gives definitive answer.

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Source undetermined

Source undetermined

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These are PA and lateral films of RML pneumonia (arrows). Note the indistinct borders, air bronchograms, and silhouetting of the right heart border. Pneumococcal pneumonia

Source undetermined

Source undetermined

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· Aspiration, no matter what the type, usually occurs in the gravity dependent portions of the lung

§ Lower lobes, especially right-sided, including and especially the superior segments of the lower lobes

· Because of the larger caliber and straighter course of the right main bronchus

§ Posterior segments of the upper lobes

§ Aspiration which occurs while the person is prone may be seen in the right upper lobe and middle lobe or the lingula

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PCP

Source undetermined

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Pneumocystis jiroveci (formerly carinii) pneumonia: chest X ray with bilateral, diffuse granular opacities

Source undetermined

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Mycoplasma pneumonia

Emperic TreatmentEmperic Treatment

IDSA infectious disease society of IDSA infectious disease society of americaamerica

ATS american thoracic societyATS american thoracic society BTS british thoracic societyBTS british thoracic society

IDSA/ATS : in patient treatment: anti-IDSA/ATS : in patient treatment: anti-pneumococcal fluoroquinolone pneumococcal fluoroquinolone (levofloxicin) or (betalactam plus (levofloxicin) or (betalactam plus macrolide)macrolide)

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IDSA/ATS guidelinesIDSA/ATS guidelines

If suspect pseudomonas: add If suspect pseudomonas: add piperacillin-tazobactam or imipenempiperacillin-tazobactam or imipenem

If suspect MRSA: add vanc or linezolidIf suspect MRSA: add vanc or linezolid

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British Thoracic SocietyBritish Thoracic Society

Amoxicillin 500 tid or Doxycycline Amoxicillin 500 tid or Doxycycline 200mg load then 100mg q day.200mg load then 100mg q day.

Much cheaper Much cheaper

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Timing of Antibiotics in EDTiming of Antibiotics in ED

Retrospective studies suggested decrease Retrospective studies suggested decrease mortality if abx given within 4 horusmortality if abx given within 4 horus

Lead to Lead to ““standardstandard”” in U.S.A. ERs in U.S.A. ERs

Lead to overuse of abxLead to overuse of abx

Now rec 6 hoursNow rec 6 hours

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Out patient treatmentOut patient treatment

Zithro or doxycyclineZithro or doxycycline Levofloxacin if sicker patient or more Levofloxacin if sicker patient or more

complicatedcomplicated

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Aspiration PneumoniaAspiration Pneumonia

Most pneumonia is from Most pneumonia is from ““aspirationaspiration””

Larger amount of aspiration causing Larger amount of aspiration causing ““pneumonitispneumonitis””

Anaerobes are less virulent bacteriaAnaerobes are less virulent bacteria

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Aspiration PneumoniaAspiration Pneumonia

Reduced consciousnessReduced consciousness DysphagiaDysphagia GERDGERD NG feedingsNG feedings

Gastric acid suppression meds – assoc Gastric acid suppression meds – assoc with increased risk of pneumoniawith increased risk of pneumonia

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Chemical PneumonitisChemical Pneumonitis

Aspiration of substances toxic to Aspiration of substances toxic to lungs separate from bacterial lungs separate from bacterial infectioninfection

Diagnosis is presumptive based on Diagnosis is presumptive based on hx and chest Xrayhx and chest Xray

Supportive careSupportive care

Most do fine but risk of ARDS and Most do fine but risk of ARDS and pneumoniapneumonia

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Aspiration PneumoniaAspiration Pneumonia

Anaerobic bacteria from gingivaAnaerobic bacteria from gingiva More common with poor dentitionMore common with poor dentition Most commonly evolves slowlyMost commonly evolves slowly May present late with lung abscess, May present late with lung abscess,

empyema, pulmonary necrosisempyema, pulmonary necrosis Treatment: Clinda or Augmentin or Treatment: Clinda or Augmentin or

PCN + MetroPCN + Metro

2222

Pulmonary TBPulmonary TB

Eighth leading cause of death Eighth leading cause of death Effective medical therapy for over 50 Effective medical therapy for over 50

years yet: lack of access to dx and years yet: lack of access to dx and rx, coexistence with HIV, drug rx, coexistence with HIV, drug resistance.resistance.

TBI : inhalation, asymptomatic, TBI : inhalation, asymptomatic, noninfectious, called latent TB. Will noninfectious, called latent TB. Will have pos PPD or TST.have pos PPD or TST.

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EpidemiologyEpidemiology

About one third of population is About one third of population is infectedinfected

About 1.3 million deaths in 2007About 1.3 million deaths in 2007 Prevalence is decreasing but slowlyPrevalence is decreasing but slowly MDR –TB : resistant to INH or RIFMDR –TB : resistant to INH or RIF XDR – TB: resist to INH, RIF, XDR – TB: resist to INH, RIF,

Fluoroquinolones, and Fluoroquinolones, and aminoglycosides or Capreomycin.aminoglycosides or Capreomycin.

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Primary Pulmonary TuberculosisPrimary Pulmonary Tuberculosis

Symptoms occurring around time of Symptoms occurring around time of inoculation. inoculation.

Generally mild and usually feverGenerally mild and usually fever Most people are asymptomaticMost people are asymptomatic Hilar adenopathy or mid/lower lung Hilar adenopathy or mid/lower lung

infiltratesinfiltrates

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Reactive TBReactive TB

Chronic TB, post primary TB, Chronic TB, post primary TB, recrudescent TB, endogenous TBrecrudescent TB, endogenous TB

In USA this is 90% of TB in non HIV In USA this is 90% of TB in non HIV patientspatients

Typically insidious: fever, cough, Typically insidious: fever, cough, weight loss, fatigue, night sweats.weight loss, fatigue, night sweats.

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Reactive TBReactive TB

Chest X ray : apical infiltrates, may Chest X ray : apical infiltrates, may see cavities with air fluid levels. see cavities with air fluid levels.

5% may have normal Chest x-ray – 5% may have normal Chest x-ray – esp HIV patientsesp HIV patients

Endobronchial TB – may mimic Endobronchial TB – may mimic asthmaasthma

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Source undetermined

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25 year old Indian girl presented with cough and hemoptysis. CXR showed consolidation with cavitations in the right upper zone.

Source undetermined

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20 year-old female with history of chronic productive cough and weight loss. Pulmonary tuberculosis - Cavitary lesion

Source undetermined 3030

Pulmonary TuberculosisGhon ComplexSub pleural nodule with mediastinal adenopathy.

Source undetermined

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The Ghon complex is seen here at closer range. Primary tuberculosis is the pattern seen with initial infection with tuberculosis in children. Reactivation, or secondary tuberculosis, is more typically seen in adults.

Source undetermined 3232

Widespread hematogenous dissemination of Mycobacterium TuberculosisSo named because the nodules are the size of millet seeds (1-5mm with a mean of 2 mm) Miliary TB represents only 1-3% of all cases of TB

Extra-pulmonary TBExtra-pulmonary TB

Lymphadenitis: cervical, mediastinal, Lymphadenitis: cervical, mediastinal, axillary nodesaxillary nodes

Pleural TBPleural TB CNS TBCNS TB PeritonitisPeritonitis PericarditisPericarditis Skeletal: Thoracolumbar spine ( Potts Skeletal: Thoracolumbar spine ( Potts

disease)disease) Miliary TB: hematogenous spreadMiliary TB: hematogenous spread

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TB DiagnosisTB Diagnosis

TST, Mantoux test, PPDTST, Mantoux test, PPD Diameter of induration at 48-72 hrs.Diameter of induration at 48-72 hrs. Delayed type hypersensitivityDelayed type hypersensitivity Takes 2 – 12 weeks to turn positiveTakes 2 – 12 weeks to turn positive False positives: BCG vaccine, other False positives: BCG vaccine, other

mycobacteriummycobacterium False negatives: anery, advanced False negatives: anery, advanced

age, immune suppression, etc.age, immune suppression, etc.3434

TB DiagnosisTB Diagnosis

About 10 % of immunocompetent About 10 % of immunocompetent people with LTBI will develop TB in people with LTBI will develop TB in life time.life time.

Greatest risk ( 5%) in first 2 years.Greatest risk ( 5%) in first 2 years. Serum IGRAs - Interferon gamma Serum IGRAs - Interferon gamma

release assays – measures IFG release assays – measures IFG release after exposure to M release after exposure to M tuberculosis-specific antigens. tuberculosis-specific antigens.

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TB diagnosis TB diagnosis

Smear microscopySmear microscopy Most rapid and least expensiveMost rapid and least expensive AFB stainingAFB staining NNA nucleic acid amplification testNNA nucleic acid amplification test Culture: liquid 1 – 3 weeks, solid up Culture: liquid 1 – 3 weeks, solid up

to 6 weeksto 6 weeks

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TB treatmentTB treatment

Latent TB: INH for 9 monthsLatent TB: INH for 9 months Active TB : DOT (direct observation Active TB : DOT (direct observation

therapy)therapy)

Initial phase of 4 drugs Initial phase of 4 drugs for 2 months followed by 4 – 7 for 2 months followed by 4 – 7 months continuation phasemonths continuation phase

TB with HIV: Only a few differences. TB with HIV: Only a few differences. 3737