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  1. Pneumonia, Empyema, and TB Meira Louis MargrietGreidanus

  2. Format for Today • Group work x 30 minutes (3 groups) • Cases as a large group • Case I: Community Acquired Pneumonia • Case II: Health Care Associated Pneumonia • Case III: Para-pneumonic effusion • Case IV: TB • Questions

  3. Pneumonia

  4. Case I 43 year old male, previously healthy • Cough x 6 days, productive of green sputum • Febrile x 4 days • Now feeling progressively more SOB • No home meds, no allergies 38.0 115 18 130/75 94% ORA

  5. In-patient vs Out-Patient?

  6. PORT score

  7. http://www.mdcalc.com/

  8. CURB-65

  9. Do they work?

  10. What tests?

  11. Which bugs?

  12. Which drugs? outpatient

  13. Which drugs? inpatient Same as outpatient with comorbidities!

  14. Which drugs? ICU Same as outpatient with comorbidities!

  15. Drugs and special populations

  16. So, when do I worry about the extra coverage?

  17. Time to antibiotics

  18. Length of antibiotics? 5

  19. Other things to think about...

  20. Case II 63 yo male, history of COPD, DM, HTN, CHF • Cough x 3 days, productive of yellow sputum • Febrile x 4 days • Now feeling progressively more SOB • Meds: Lasix, ASA, ramipril, insulin • Hospitalized x 5 days for COPD (6 weeks ago) 38.2 83 26 105/64 93% ORA

  21. VS

  22. What’s different about HCAP?

  23. What makes a patient riskier?

  24. Empiric Antibiotics for HCAP? • An antipseudomonal cephalosporin or β-lactam (cefepime, ceftazidime, pip-tazo) • Plus a fluoroquinolone (ciprofloxacin, levofloxacin) • Plus an agent active against MRSA (linezolid or vancomycin) = fluoroquinolone or azithromycin

  25. Para-Pneumonic Effusions

  26. Case III 45yo female, mild HTN, hyperlipidemia • Unwell x few weeks, episodic fevers,cough • Sent in by GP to r/o PE as completed full course of Azithromycin withno improvement. • Progressive SOB and chest pain 36.5 105 20 145/82 91% ORA

  27. What is it?

  28. When should it be suspected?

  29. How to image?

  30. To treat or not to treat?

  31. So, I poked it, does that help?

  32. When does the pH lie?

  33. If I need to drain, does tube size matter?

  34. TB

  35. Case IV 29yo male, previously healthy • Recently returned from India after 6 month visit (immigrated several years ago) • Unwell x few weeks, episodic fevers, weight loss • Completed course of Levofloxacin, no change 37.5 115 22 120/82 92% ORA

  36. Primary TB vs Reactivated TB

  37. 10

  38. So, what am I looking for?

  39. Complications of TB

  40. Extra Pulmonary Complications Neuro Cardiac Renal MSK GI GU