How Do I Think About Pneumonia?

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


https://hospitals.health.unm.edu/intranet/Index.cfm

http://www.idsociety.org/Content.aspx?id=9088

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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)


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


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)


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?



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!)




at time of infection)• Community-acquired (CAP)• Healthcare-associated (HCAP) or Hospital acquired (HAP) –

includes ventilator-acquired (VAP)


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


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




at time of infection)• Community-acquired pneumonia (CAP)• Healthcare-associated pneumonia (HCAP) or Hospital

acquired pneumonia (HAP) – includes ventilator-acquired (VAP)





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?


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Pneumonia Severity Index (PSI)


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


ICU admission = one major or 3 minor





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?



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







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?



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)


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


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?



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


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?



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


Timing of discharge

Readmission rate or death: no instability = 10%; 1 instability = 14%; 2+ instabilities = 46%


Pneumonia – before they go home

• Smoking cessation• Vaccination


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


Questions?


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


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


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]


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


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How Do I Think About Pneumonia?