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Crash Course in Internal Medicine: Community Acquired Pneumonia

Crash Course in Internal Medicine: Community Acquired Pneumonia. Residents Thursday School 07/24/2014 J Rush Pierce Jr, MD, MPH Division of Hospital Medicine, UNM. Outline. Case based discussion that will cover Diagnosis Management How to quickly access resources Management based on

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Crash Course in Internal Medicine: Community Acquired Pneumonia

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  1. Crash Course in Internal Medicine: Community Acquired Pneumonia Residents Thursday School 07/24/2014 J Rush Pierce Jr, MD, MPH Division of Hospital Medicine, UNM

  2. Outline • Case based discussion that will cover • Diagnosis • Management • How to quickly access resources • Management based on • IDSA/ATS CAP (2007) guidelines • HCAP/VAP/HAP (2005) guidelines Crash Course in IM: Pneumonia

  3. Case 1 • 50 yo man w/ 2 days of fatigue and malaise and 1 day of cough and yellow and red sputum. 6 hours ago he had a shaking chill, dyspnea and right-sided pleuritic chest pain. PMHx + only for HTN, meds = lisinopril. On exam appears ill and c/o chest pain. BP = 100/60, HR = 105 RR= 24 T=39 saO2 = 88% on RA. There is dullness to percussion at the right lung base posteriorly and lung sounds sound weird at right base. Crash Course in IM: Pneumonia

  4. Thinking about Case 1 • What historical features are helpful in understanding this illness? • What physical exam features are helpful and how might additional examination features be of further help? • How do we organize our approach to this kind of illness? Crash Course in IM: Pneumonia

  5. Assessing the history • 50 yo man w/ 2 days of fatigue and malaise and 1 day of cough and yellow and red sputum. 6 hours ago he had a shaking chill, dyspnea and right-sided pleuritic chest pain. PMHx + only for HTN, meds = lisinopril. On exam appears ill and c/o chest pain. BP = 100/60, HR = 105 RR= 24 T=39C SaO2 = 88% on RA. There is dullness to percussion at the right lung base posteriorly and lung sounds sound weird at right base. Crash Course in IM: Pneumonia

  6. Categories of illnesses that cause fever • Infectious Diseases • Collagen – vascular diseases • Malignancy • Drugs • Metabolic diseases • Tissue destruction Crash Course in IM: Pneumonia

  7. Further assessing the history • 50 yo man w/ 2 days of fatigue and malaise and 1 day of cough and yellow and red sputum. 6 hours ago he had a shaking chill, dyspnea and right-sided pleuritic chest pain. PMHx + only for HTN, meds = lisinopril. On exam appears ill and c/o chest pain. BP = 100/60, HR = 105 RR= 24 T=39 SaO2 = 88% on RA. There is dullness to percussion at the right lung base posteriorly and lung sounds sound weird at right base. • Red sputum • Pleuritic chest pain • Shaking chill Crash Course in IM: Pneumonia

  8. Shaking Chills and Bacteremia Source: Taniguchi et al.: Shaking chills and high body temperature predict bacteremia. SpringerPlus 2013;2:624. Crash Course in IM: Pneumonia

  9. Usefulness of the physical exam • 50 yo man w/ 2 days of fatigue and malaise and 1 day of cough and yellow and red sputum. 6 hours ago he had a shaking chill, dyspnea and right-sided pleuritic chest pain. PMHx + only for HTN, meds = lisinopril. On exam appears ill and c/o chest pain. BP = 100/60, HR = 105 RR= 24 T=39 saO2 = 88% on RA. There is dullness to percussion at the right lung base posteriorly and lung sounds sound weird at right base. • dullness to percussion at the right lung base • weird lung sounds at right lung base Crash Course in IM: Pneumonia

  10. Percussing the posterior thorax Source:http://sciweb.hfcc.net/biology/ap/233/233lecture/intro/surface/thorax/pulmonary.html Crash Course in IM: Pneumonia

  11. Causes of dullness to percussion Source: http://meded.ucsd.edu/clinicalmed/lung.htm Crash Course in IM: Pneumonia

  12. Bronchial breathing Crash Course in IM: Pneumonia

  13. Physical exam signs of consolidation • Bronchial breath sounds • Tactile fremitus • Bronchophony • Egophony • Whispered pectoriloquy Crash Course in IM: Pneumonia

  14. Pleural space complications of pneumonia Crash Course in IM: Pneumonia

  15. Thinking about pneumonia: 5 steps • Make a diagnosis of pneumonia • Put into initial clinical classification • Decide site of care • Tests for etiology • Initial empiric therapy Crash Course in IM: Pneumonia

  16. 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 Crash Course in IM: Pneumonia

  17. Case 2 • 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” • Does this patient have pneumonia? Crash Course in IM: Pneumonia

  18. Thinking about pneumonia: 5 steps • Make a diagnosis of pneumonia • Put into initial clinical classification • Decide site of care • Tests for etiology • Initial empiric therapy Crash Course in IM: Pneumonia

  19. Step 1. Diagnose 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) Crash Course in IM: Pneumonia

  20. Case 2 • 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 crackles at right lung base. CXR is read as “minimal streaking at lung bases, atelectasis vs. early pneumonia” • Does this patient have pneumonia? Maybe Crash Course in IM: Pneumonia

  21. Thinking about pneumonia: 5 steps • Make a diagnosis of pneumonia • Put into initial clinical classification • Decide site of care • Tests for etiology • Initial empiric therapy Crash Course in IM: Pneumonia

  22. Step 2:Initial clinical classification • Major immunodeficiency • Tuberculosis (suspected or established) • Relatively normal hosts without TB (location at time of infection) • Community-acquired (CAP) • Healthcare-associated (HCAP) or Hospital acquired (HAP) – includes ventilator-acquired (VAP) Crash Course in IM: Pneumonia

  23. Case 3 • 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, no prev hospitalizations. 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? Crash Course in IM: Pneumonia

  24. www.meddean.luc.edu Crash Course in IM: Pneumonia

  25. 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!) Crash Course in IM: Pneumonia

  26. 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 Crash Course in IM: Pneumonia

  27. Case 3 • 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, no prev hospitalizations. 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? • What is his initial classification? Crash Course in IM: Pneumonia

  28. Step 2:Initial clinical classification • Major immunodeficiency • Tuberculosis (suspected or established) • 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) Crash Course in IM: Pneumonia

  29. Thinking about pneumonia: 5 steps • Make a diagnosis of pneumonia • Put into initial clinical classification • Decide site of care • Tests for etiology • Initial empiric therapy Crash Course in IM: Pneumonia

  30. Case 4 • 65 y/o female smoker has 2 days of chills, dyspnea, & purulent sputum. No significant PMHx. She has felt and eaten poorly. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA, crackles at the right apex. She 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? Crash Course in IM: Pneumonia

  31. 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 Crash Course in IM: Pneumonia

  32. Pneumonia Severity Index (PSI) Crash Course in IM: Pneumonia

  33. Case 4 • 65 y/o female smoker has 2 days of chills, dyspnea, & purulent sputum. No significant PMHx. She has felt and eaten poorly. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA, crackles at the right apex. She 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. • CURB-65 = 2; admit to ward Crash Course in IM: Pneumonia

  34. ICU admission = one major or 3 minor Crash Course in IM: Pneumonia

  35. Thinking about pneumonia: 5 steps • Make a diagnosis of pneumonia • Put into initial clinical classification • Decide site of care • Tests for etiology • Initial empiric therapy Crash Course in IM: Pneumonia

  36. Case 4 • 65 y/o female smoker has 2 days of chills, dyspnea, & purulent sputum. No significant PMHx. She drinks alcohol everyday. T = 38.1, BP = 110/60, HR = 95, RR = 20, SaO2 = 89% RA, crackles at the right base. She 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? Crash Course in IM: Pneumonia

  37. 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 Crash Course in IM: Pneumonia

  38. Crash Course in IM: Pneumonia

  39. Crash Course in IM: Pneumonia

  40. Thinking about pneumonia: 5 steps • Make a diagnosis of pneumonia • Put into initial clinical classification • Decide site of care • Tests for etiology • Initial empiric therapy Crash Course in IM: Pneumonia

  41. Case 5 • 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. CBC and Chem 7 normal. CXR = early RLL pneumonia • What antibiotics should I order? Crash Course in IM: Pneumonia

  42. 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) Crash Course in IM: Pneumonia

  43. 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 Crash Course in IM: Pneumonia

  44. Case 4 • 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? Crash Course in IM: Pneumonia

  45. 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 quinolone Crash Course in IM: Pneumonia

  46. 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 espquinolones, or much MRSA in community • Regimen: Add linezolid OR vancomycin Crash Course in IM: Pneumonia

  47. Case 4 - continued • 65 y/o female 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? Crash Course in IM: Pneumonia

  48. 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 Crash Course in IM: Pneumonia

  49. Timing of discharge Readmission rate or death: no instability = 10%; 1 instability = 14%; 2+ instabilities = 46% Crash Course in IM: Pneumonia

  50. Pneumonia – before they go home • Smoking cessation • Vaccination Crash Course in IM: Pneumonia

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