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How Do I Think About Pneumonia?. Resident ’ s Thursday School 07/25/2013 J Rush Pierce Jr, MD, MPH Division of Hospital Medicine, UNM. Outline. Review resources Case based discussion that will cover Diagnosis Treatment Based on IDSA/ATS CAP (2007) guidelines - PowerPoint PPT Presentation
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How Do I Think About Pneumonia?
Resident’s Thursday School07/25/2013
J Rush Pierce Jr, MD, MPHDivision of Hospital Medicine, UNM
Outline• Review resources
• Case based discussion that will cover– Diagnosis– Treatment
• Based on– IDSA/ATS CAP (2007) guidelines– HCAP/VAP/HAP (2005) guidelines
How Do I Think About Pneumonia?07/25/2013 2
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
How Do I Think About Pneumonia?07/25/2013 3
07/25/2013 4How Do I Think About Pneumonia?
Case 1• 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”
• Should I treat with antibiotics?
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Does this patient have pneumonia?
• Hx:
• 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)
How Do I Think About Pneumonia?07/25/2013 7
Sensitivity Specificity
Fever/chills 85%
Dyspnea 70%
Purulent sputum 50%
Any of above 70 – 90% 40 – 50%
Thinking about pneumonia: 4 steps
1. Put into initial clinical classification2. Decide site of care3. Tests for etiology4. Initial empiric therapy
How Do I Think About Pneumonia?07/25/2013 8
Step 1:Initial clinical classification
1. Major immunodeficiency2. 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)
How Do I Think About Pneumonia?07/25/2013 9
Case 2
• 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. 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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07/25/2013 11How Do I Think About Pneumonia?
When to suspect TB(Intern Survival Guide)
• If two or more sxs– Hemoptysis– Cough > 2 weeks– Night sweats– Wt loss > 10 # in 3 mos
• If suspicious CXR (any of these)– Upper lobe infiltrates– Miliary pattern– Cavitary lesions– Nodular infiltrate
Response to suspected TB
Order airborn isolation and CXR
Order AFB smears, cultures (does not have to be qAM!)
How Do I Think About Pneumonia?07/25/2013 12
Step 1:Initial clinical classification
1. Major immunodeficiency2. 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)
How Do I Think About Pneumonia?07/25/2013 13
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
How Do I Think About Pneumonia?07/25/2013 14
Case 2
• The patient has never been hospitalized, resides at home, does not take dialysi, has not received chemotherapy, and his spouse has not been sick
07/25/2013 How Do I Think About Pneumonia? 15
Step 1:Initial clinical classification
1. Major immunodeficiency2. 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)
How Do I Think About Pneumonia?07/25/2013 16
Thinking about pneumonia: 4 steps
1. Put into initial clinical classification2. Decide site of care3. Tests for etiology4. Initial empiric therapy
How Do I Think About Pneumonia?07/25/2013 17
Case 3• 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 apex. 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.
• Can I send this patient home?
07/25/2013 How Do I Think About Pneumonia? 18
www.meddean.luc.edu 07/25/2013 19How Do I Think About Pneumonia?
07/25/2013 20How Do I Think About Pneumonia?
Pneumonia Severity Index (PSI)
How Do I Think About Pneumonia?07/25/2013 21
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
How Do I Think About Pneumonia?07/25/2013 22
ICU admission = one major or 3 minor
How Do I Think About Pneumonia?07/25/2013 23
Thinking about pneumonia: 4 steps
1. Put into initial clinical classification2. Decide site of care3. Tests for etiology4. Initial empiric therapy
How Do I Think About Pneumonia?07/25/2013 24
Case 3 - continued• 65 y/o male smoker has 2 days of chills,
dyspnea, & purulent sputum. No significant PMHx. He drinks alcohol everyday. 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 etiologic tests do I order?
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07/25/2013 26How Do I Think About Pneumonia?
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
How Do I Think About Pneumonia?07/25/2013 27
How Do I Think About Pneumonia?07/25/2013 28
How Do I Think About Pneumonia?07/25/2013 29
Thinking about pneumonia: 4 steps
1. Put into initial clinical classification2. Decide site of care3. Tests for etiology4. Initial empiric therapy
How Do I Think About Pneumonia?07/25/2013 30
Case 4• 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. CBNC 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)
How Do I Think About Pneumonia?07/25/2013 33
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
How Do I Think About Pneumonia?07/25/2013 34
Case 3 - continued• 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?
07/25/2013 How Do I Think About Pneumonia? 35
07/25/2013 36How Do I Think About Pneumonia?
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
quinoloneHow Do I Think About Pneumonia?07/25/2013 37
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
How Do I Think About Pneumonia?07/25/2013 38
Case 3 - continued• 65 y/o male 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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07/25/2013 40How Do I Think About Pneumonia?
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
How Do I Think About Pneumonia?07/25/2013 41
Timing of discharge
Readmission rate or death: no instability = 10%; 1 instability = 14%; 2+ instabilities = 46%
How Do I Think About Pneumonia?07/25/2013 42
Pneumonia – before they go home
• Smoking cessation• Vaccination
How Do I Think About Pneumonia?07/25/2013 43
CAP – What’s New
• Increasing recognition of viral pathogens• Consideration of environmental exposures as
risk factor for CAP• Use of PCR (and other tests) to guide initial
antibiotic choice• Use of inflammatory markers to help with
diagnosis and guide therapy• Vaccine efficacy
How Do I Think About Pneumonia?07/25/2013 44
Questions?
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Empiric therapy of HCAP/HAP/VAP with MDR risk factors
cefepime, ceftazadime, imipenam, or ZosynPLUS
ciprofloxacin, levofloxacin, or aminoglycoside
• If MRSA concerns add linezolid or vancomicin
How Do I Think About Pneumonia?07/25/2013 46
Switching to oral therapy for HCAP/HAP/VAP
Pseudo: if sens cipro + Aug/doxy/clinda
MRSA: sensitivities
cipro + Aug/doxy/clinda OR moxiHow Do I Think About Pneumonia?07/25/2013 47
Aspiration
• When to use: observed/suspected aspiration + fever or leucocytosis or infiltrate
• Regimens: – Unasyn + (doxy OR azithro) Augmentin or
clinda– Respiratory quinolone
How Do I Think About Pneumonia?07/25/2013 48
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]
How Do I Think About Pneumonia?07/25/2013 49
Clinical response to non-responding 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
How Do I Think About Pneumonia?07/25/2013 50