Community acquired pneumonia
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Community Acquired Pneumonia. Dr. Leena Mane PGY3 Resident Emory Family Medicine. Objectives. Name the common infectious causes of pneumonia in US Discuss the evidence based workup for pneumonia List the criteria for deciding on outpatient vs inpatient vs ICU Rx of pneumonia

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Community Acquired Pneumonia

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Community Acquired Pneumonia

Dr. Leena Mane

PGY3 Resident

Emory Family Medicine


Objectives

  • Name the common infectious causes of pneumonia in US

  • Discuss the evidence based workup for pneumonia

  • List the criteria for deciding on outpatient vs inpatient vs ICU Rx of pneumonia

  • Name the evidence based antibiotics for treatment


Outline

  • Epidemiology and etiology

  • Diagnosis

  • Admission decision

  • The workup for C.A.P.

  • Treatment- what to use, how to use,how long

  • Recovery


Epidemiology

  • 7 th most common cause of death in U.S.

  • 5.6 million cases annually

  • Annual Health care cost 8.4 billion

  • Definition- pneumonia not acquired in a hospital or long term care facility


Etiology of C.A.P

  • No etiology in ~ 50 %

  • > 2 etiologies in 2-5%

  • S. Pneumonia in : 2/3 of bacterial cases

    or 20 % of all cases

  • H. Influenzae ( non typeable)

  • Mycoplasma pneumonia

  • Chlamydia p ~12%

  • Influenza

  • Legionella ~ 5%


Atypical Pneumonia

  • Age (years)- less than 40

  • Onset- Gradual, coryzal prodrome

  • Cough- Paroxysmal, hacking non productive

  • Sputum- Minimal, mucoid

  • Rigors- Absent

  • Fever- Usually less than 39.5 °C


Atypical Pneumonia ctd

  • Consolidation- Usually absent

  • Leucocytosis - usually absent

  • Chest x-ray- Initially interstitial, may progress to air space involvement


Atypical pneumonia


Acute Bacterial Pneumonia

  • Age ( in yrs) : less than 5, over 40

  • Onset : Abrupt

  • Cough : Productive

  • Sputum : Rusty & Purulent

  • Rigors : Frequently present

  • Fevers : > 39.5° c

  • Consolidation: present

  • Leucocytosis : 15- 25,000 with neutrophilia

  • Chest X-ray : alveolar with air bronchograms.


When To Suspect Which Bug…..


Causes & sign & symptoms

  • S pneumonia – episodes of rigor, pleurisy,

    elderly , alcoholic

  • H. Influenzae -- COPD

  • M. catarhalis – COPD

  • Anaerobic -- Putrid Sputum

  • Influenza -- Winter epidemic

  • Chlamydia P -- S.T, HA, hoarseness


Causes , Sign & symptoms

  • PCP -- Immunocompromised patients

  • Legionella – Severe illness, compromised host, Neg G.S.,organ transplant, outbreaks related with water source.

  • Mycoplasma P – 2-4 wks of prodrome, dry cough


Cough/dyspnea /fever = CXR

EBM – II ( moderate)

Diagnosis


Admit or not

2 step decision rules


Step 1

  • Assign to risk class I

    OR

  • Risk classes II- IV


Risk Class I

  • < 50 years of age

  • have none of five co- morbid conditions that increase mortality

  • Neoplasm

  • CHF

  • Renal disease

  • Cerebrovascular disease

  • Liver disease


Step approach

  • If not in class I

    Go on to Step 2

    ( assign to one of classes II- V )


Step 2

  • Assess patient’s severity index and assign a score

  • Demographics

  • Co- morbidities

  • P. E. findings

  • Lab findings


Demographics

Characteristics Points

Age

Male age( in years)

Female age ( in years)- 10

Nursing home age ( in years) + 10

Residents


Co- morbidities

Diseases Points

Neoplasm + 30

Liver disease + 20

CHF + 10

CVD + 10

Renal disease + 10


Physical exam

Finding Points

AMS + 20

RR> 30 + 20

SBP<90mm + 20

T<35 or > 40 + 15

P> 125 + 10


Laboratory

Findings Points

Ph<7.35 + 30

Na< 130 + 20

Hct < 30% + 10

PO2< 60 + 10

Pleural effusion + 10


The" whole ‘ Shootin’ Match "

Patient Assigned points

Demographics

Co- morbidities

P. E. finding

Lab finding


Stratification of Risk Score

Risk Initial Treatment Risk class Based on

Low Outpatient I Algorithm

Outpatient II < 70 points

Medium Observation III 71-90 points

Inpatient IV 91- 130 point

High Inpatient (ICU) V > 130


Other considerations

  • Psychosocial contraindication to outpatient Rx

  • Compliance problems

  • Substance abuse

  • Cognitive impairment

  • Poor social support


Risk class mortality

Risk class Mortality

I 0. 1 % - outpatient

II 0. 6 % - outpatient

III 2.8 % - inpatient

IV 8.2 % - inpatient

V 29.2 % - inpatient


P. S. I.

  • Pneumonia severity index can serve as general guideline for management , clinical judgment should always supersede the prognostic scores.


Sensitivity & Specificity of diagnostics tests

Diagnostics Tests Sensitivity Specificity

Chlamydia

Rapid PCR( sputum) 30-90 >95

Serology( rise in Ab) 10 – 100 -

Sputum Cx 10- 80 >95

Gm Neg rods

Sputum GM stain 15- 100 11- 100


Sensitivity & specificity ctd

Tests Sensitivity Specificity

H. Inf, Moraxella

Sputum Cx 20- 79 20- 79

Influenza

Rapid DFA 22-75 90

Legionella

DFA 22- 75 90

PCR 83- 100 >95

Serum acute titer 10- 27 >85

Urinary Ag 55- 90 > 95


Sensitivity & Specificity Ctd

Tests Sensitivity Specificity

Mycoplasma

Antibody Titers 75-95 >90

Cold Agglutinins 50- 60 -

PCR 30- 95 >95

Pneumococcal Pneumoniae

Chest X-ray 40 -

Sputum Cx 20- 79 20- 79

Sputum Gm stain 15- 100 11- 100


Blood Culture

  • Positive blood cultures had no correlations with severity of disease and outcome

  • Current ATS guidelines recommend that patient hospitalized for suspected CAP receive two sets of blood cultures.

  • However are not necessary for outpatient diagnosis


Inpatient work up

Inpatient

Sputum Cx Level II ( moderate)

Bld Cx Level I ( High)

BMP Level II

LFTs Level II

PO2 Level II


Sputum

  • Level II evidence

  • Low power exam

  • Acceptable specimen

  • < 10 epithelial cells

  • > 25 PMNs


Normal sputum

Moraxella catarrahalis

Sputum samples


H. Influezae

Klebsiella pneumoniae

Sputum Samples


Pseudomonas

Strep Pneumoniae


Target etiology

Watch for resistance pattern

Be aware of co- morbidities

Treatment


What to use

  • Outpatient

  • Macrolides

  • Fluroquinolones

  • Doxycycline


Management of CAP

Management of CAP


What to use

  • Inpatient-

  • Fluroquinolones alone

  • Extended spectrum cephalosporins + macrolides

    Level II evidence


What to Use

  • ICU patients

  • One of Cefotaxime, Ceftraixone, amp- sulbactum or pipercillin – tazobactum

    Plus

  • One of macrolides or fluroquinolones


Bug & Treatment

Pathogen Abx

S. Pneumoniae Pen G, amoxicillin

fluroquinolones

H Influenzae bactrim, cefotaxime,

rocephin/carbapenam

S. Aureus nafcillin /vancomycin


Bug & Treatment

Pathogen Abx

Klebsiella carbapenams or 3rd

gen cephalosporins

Pseudomonas aminoglycoside plus

antipse. Penicillins or

Ceftazidime

Chlamydia Doxy or quinolones

Legionella Azithromycin or quinolones

Anaerobes Clindamycin


Recovery

Symtoms Time period

Subjective Response 1-3 days

Fever without bacteremia - 2.5 days

with bacteremia – 6-7 days


Recovery

Symptoms Time period

CXR non elderly 30 days

older patients 6-8 wks

Legionella 12 wks

Fatigue non elderly 30- 45 days

elderly 90 days


Pneumococcal vaccine

Influenza vaccine

Prevention


Bibliography

  • Diagnosis & treatment of CAP- aafp 2006

  • IDSA/ATS consensus guidelines on management of community acquired pneumonia in adults


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