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Pneumonia SAHD

Pneumonia SAHD. Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists June 2010. Learning objectives. Recognise the Clinical features of pneumonia Demonstrate appropriate use of CURB-65 severity scoring index Know the main causes of Community acquired pneumonia

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Pneumonia SAHD

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  1. Pneumonia SAHD Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists June 2010

  2. Learning objectives • Recognise the Clinical features of pneumonia • Demonstrate appropriate use of CURB-65 severity scoring index • Know the main causes of Community acquired pneumonia • Interpret laboratory results and apply to Clinical decisions • Understand the key principles of antibiotic prescribing

  3. 0 of 5 Are you feeling • Excited about the session • Apprehensive about the session • Apathetic about the session • Go away and leave me alone

  4. 0 of 5 Are you • Male • Female

  5. 0 of 5 What is your favouritespeciality? • Medicine • Surgery • Pathology • GP • Other…and offended!

  6. 0 of 5 How well do you think you could deal with a patient in ED with a Chest Infection? • Superbly • Well • Adequately • Poorly • Rather not say

  7. Presentation of pneumonia • Fever/chills/sweats/rigors • Cough • Productive of sputum – clear/purulent/blood stained etc. • Dyspnoea • Pleuritic chest pain • Malaise • Anorexia and vomiting • Headache • Myalgia • Diarrhoea

  8. Chest examination • Anatomic Landmarks • The Extrathoracic Examination • Chest Inspection, Palpation, Percussion • Chest Auscultation

  9. Clinical signs of pneumonia • Pyrexia • Tachypnoea • Cyanosis – rare • Altered mental state • Consolidation • Dull percussion note • Inspiratory crepitations • Bronchial breathing • Increased vocal resonance and tactile vocal fremitus (voice vibration felt with the hand greater over areas of consolidation) • Whispering pectoriloquy (increased loudness of voice over area of consolidation when auscultating)

  10. Infective exacerbation of COPD • Please exclude a diagnosis of Infective exacerbation of COPD before treating for Community Acquired Pneumonia (CAP) • Infective Exacerbation of COPD – past history of COPD • ↑ dyspnoea • ↑ sputum volume • increased sputum purulence

  11. Classification of pneumonias • Typical vs Atypical ??IS THIS VALID?? • Community acquired (CAP) vs hospital acquired (HAP) • Lobar vs Bronchopneumonia • Aspiration pneumonia • Immunocompromised host pneumonia • There is often difficulty in placing a pneumonia into one category or another

  12. Management of pneumonia • Depends on severity and co-morbidity (particularly CAP) • Formally assess severity CURB-65 • Supportive treatment essential • IV fluids • Oxygen • Analgesia • need for ventilation? • Investigations • Antibiotic therapy

  13. Complications of pneumonia • Bacteraemia/Septicaemia……death • Lung abscess • Parapneumonic effusion/empyema

  14. 0 of 5 Which criteria are included in CURB-65 severity scoring • Cyanosis • Urea • Respiratory rate • Base excess • 65% O2 required

  15. Severity: CURB-65 • Confusion: new confusion AMT <8 • Urea >7mmol/l • Respiratory rate: >=30/min • Blood pressure: sys <90 or dias <60 • >65 years old • Hypoxia Arterial pO2 <8Kpa • Multilobar disease

  16. CURB-65

  17. Implications of CURB-65 • Severe pneumonia is CURB-65 >3 • Score of 3 = mortality 17%, • Score of 4 = mortality 41.5%, • Score of 5 = mortality 57% • Need admission and IV antibiotics • Non-severe pneumonia CURB-65 0 or 1 • Score of 1 = Mortality 3.2% • O/p treatment with oral antibiotics • CURB 2 – Needs clinical judgement in hospital • Mortality 13%

  18. Oral Severe Mild/ Moderate I.V. MAU AuditZoe Campbell F2 SHO • Only those with Severe pneumonia according to CURB criteria should receive IV antibiotics • 18 out of 25 patients received IV antibiotics • 18 patients were classified mild/mod (? Oral antibiotics) • 7 patients were classified severe (? IV antibiotics)

  19. Investigations of Pneumonia • CXR • O2 saturation +/- gases • Microbiology… • Biochemistry • Urea • LFT • CRP • Haematology • FBC: WBC, plts, ?clotting

  20. 0 of 5 What microbiology samples would you send on a patient with severe CAP? • Sputum • Nose swab • Urinary Antigen • Serology • Blood Culture

  21. Send appropriate samples

  22. Sputum: microscopy • Sputum appearance? • Mucoid/Salivary/Blood stained/Green/Yellow etc • Gram stain??: Sputum/BAL etc. • Special stains: TB/PCP etc.

  23. Sputum: culture and sensitivity

  24. Blood culture • Blood cultures should be taken from anyone with severe pneumonia • Sterile technique vital • Inoculate into blood culture bottles, aerobic and anaerobic • Automated blood culture machine for 5 days • Please take before pt on antibiotics!!!

  25. Others • BAL/Pleural fluid more of a reliable sample than sputum • Serology-Acute and convalescent phase (0 and 14 days). A useful test for Mycoplasma, Chlamydia, Legionella, Coxiella, Influenza etc. • Antigen detection: Immunoflourescence (eg RSV from NPAs) • Urine for legionella/pneumococcal antigen

  26. BTS guidelines • All patients admitted with severe CAP should have • Blood cultures • Sputum culture • Legionella antigen • All patients admitted with non-severe CAP need • Blood cultures • Sputum cultures (unless have had recent course of antibiotics)

  27. 0 of 5 Which bacteria are common causes of CAP • Escherichia coli • Streptococcus pneumoniae • Haemophilus influenzae • Coagulase negative staphylococci • Moraxella catarrhalis

  28. Organisms causing Pneumonia Viruses – Influenza, parainfluenza Community acquired pneumonia Streptococcus pneumoniae Mycoplasma pneumoniae Haemophilus influenzae Legionella pneumophila Moraxella catarhalis Chlamydia psittaci Staphylococcus aureusCoxiella burnetti Hospital acquired Pneumonia Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumanii etc

  29. CAP causative organisms

  30. Streptococcus pneumoniae • Gram positive streptococcus, commensal flora. Need to distinguish infection from colonisation • Acute pyogenic infection • Rapidly progressing infection often associated with bacteraemia • Often fatal in elderly/immunocompromised. Capsule is the most important virulence factor • Capsular based vaccines available for at risk groups

  31. Hospital acquired pneumonia • Often after courses of antibiotics • At risk patients • Possibly ventilated • Enteric gram negative bacilli –E.coli, K.pneumoniae etc • Pseudomonas aeruginosa • MRSA

  32. Chest Infection • Possible choicesAmoxicillin Augmentin Cefuroxime Ciprofloxacin Ceftazidime Tazocin Meropenem • +/- erythromycin/clarithromycin (Atypical cover)

  33. And Atypicals!

  34. Coventry and Warwickshire Treatment Guidelines (Hospital)

  35. Community acquired pneumonia • Strep. pneumoniae ~ 30 - 40% • Haemophilus influenzae ~ 5 - 10% • Staph. aureus ~ 0.5 - 5% • Severity of infection (CURB-65 score) • Determines need for IV or oral treatment • Determines need for broad vs narrow cover

  36. Don’t forget atypicals in CAP! • Legionella pneumophila ~ 1 - 5% • Mycoplasma pneumoniae ~ 1 - 10% • Chlamydophila pneumoniae < 10% ? • Chlamydia psittaci, Coxiella < 2% • Viruses including Influenza< 15% • Addition of • Macrolide e.g. erythromycin or clarithromycin • Tetracycline e.g. doxycycline • (Ciprofloxacin)

  37. Chest Infection Recommendation

  38. Chest Infection recommendation

  39. Mid session interval You have 5 minutes, the attendance book will be available for signing on your return

  40. 0 of 5 Which of the following do you do when prescribing antibiotics • Review pts previous microbiology results • Document indication and duration/review date in the patients notes • Write indication on drug chart • Write review or stop date on drug chart • Review antibiotic at 48hrs and change to oral if appropriate

  41. 0 of 5 How well do you think you could deal with a patient in ED with a Chest Infection? • Superbly • Well • Adequately • Poorly • Rather not say

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