Pneumonia - Download as PowerPoint by sammyc2007

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									      Pneumonia
       Tammy Wichman MD
  Assistant Professor of Medicine
      Pulmonary-Critical Care
Creighton University Medical Center
 The #1 cause of death in the United States
  from infectious disease is:
 A. Meningitis
 B. Pneumonia
 C. Gastroenteritis
 D. Urinary Tract Infections
 E. Toe fungus
                       Pneumonia
 Most  deadly infectious disease in the U.S.
 6th leading cause of death
 Average mortality 14%
 $20 billion/year in U.S.1
 Community acquired pneumonia affects
  ~4 million patients and results in 10 million
  physician visits, 1 million hospitalizations,
  and >50,000 deaths annually
 1 File Chest 2004; 125:1888-1901
         Defense Mechanisms
  80% of cells lining central airways are ciliated,
   pseudostratified,
  columnar epithelial cells
 Each ciliated cell contains
  about 200 cilia that beat in
  coordinated waves about
  1000x/minute
 So the lower respiratory tract
  is normally sterile
     Pneumonia Pathophysiology
   Microbial pathogens enter the lung by:
   Aspiration of organisms from oropharynx
        More common in patients with impaired level of consciousness:
         alcoholics, IVDA, seizures, stroke, anesthesia, swallowing disorders,
         NG tubes, ETT
        Gram positive and anaerobes: Strep pneumo, H flu, Mycoplasma,
         Moraxella, Actinomyces
        Gram negatives:
          • more likely with hospitalization, debility, alcoholism, DM, and advanced age
          • Source may be stomach which can become colonized with these organisms
            with use of H2blockers
   Inhalation of Infectious Aerosols
        Influenza, Legionella, Psittacosis, Histoplasmosis, TB
   Hematogenous Dissemination
        Staph aureus
        Fusobacterium infections of the retropharyngeal tissues: Lemierre’s
         syndrome
   Direct inoculation and Contiguous Spread
        Tracheal intubation, stab wounds
At the left the alveoli are filled with a neutrophilic exudate that
corresponds to the areas of consolidation seen grossly with the
bronchopneumonia. This contrasts with the aerated lung on the right
of this photomicrograph.
             What is pneumonia?
   Infection of the lower respiratory tract

   Which of the following is NOT a symptom of pneumonia?
   A. Cough
   B. Shortness of breath
   C. Fever
   D. Abdominal pain
   E. Chest tightness
   F. Confusion
   G. Hot, erythematous 1st toe
         Clinical presentation
 Pneumonia should be considered in any patient
  who has newly acquired respiratory symptoms:
  cough, sputum production, dyspnea, especially if
  accompanied by fever and abnormal breath
  sounds and crackles
 In elderly or immunocompromised, pneumonia
  may present with confusion, failure to thrive,
  worsening of underlying chronic illness, falling
      Pneumonia Symptoms
 “Typical”  pneumonia: sudden onset of
  fever, cough productive of purulent
  sputum, pleuritic chest pain
 “Atypical”: gradual onset, dry cough,
  prominence of extrapulmonary symptoms:
  headache, myalgias, fatigue, sore throat,
  nausea, vomiting
 Includes diverse entities and has limited
  clinical value
              Pneumonia
 Which of the following is NOT a sign of
  pneumonia?
 A. Dullness to percussion
 B. Tracheal deviation
 C. Bronchial breath sounds
 D. Egophany, increased tactile fremitus
 E. Late inspiratory crackles
            Pneumonia Diagnosis
   Radiography: CXR
       confirm the presence and location of the pulmonary
        infiltrate
       assess the extent of the infection
       detect pleural involvement, pulmonary cavitation, or
        lymphadenopathy
   May be normal when the patient is unable to
    mount an inflammatory response
    (immunocompromised) or is in the early stage of
    an infiltrative process (hematogenous S. aureus
    pneumonia)
   A 64 year old female with DM and HTN is
    admitted to 4600 with RLL pneumonia. T 39.3
    HR 118 R 28 BP 110/60 Sats 92% on 4 L NC.
    She has crackles in her RLL. You should:
   A. Order a sputum gram stain and culture. Wait
    for the results before ordering antibiotics.
   B. Order a sputum gram stain and culture.
    Empirically start Ceftriaxone and Azithromycin.
   C. Order a sputum gram stain and culture.
    Empirically start Vancomycin and Zosyn.
   D. Start Ceftriaxone and Azithromycin.
            Pneumonia Diagnosis
 Sputum gram stain and culture:
 Controversial: no rapid, easily done, accurate,
  cost-effective method to allow immediate results
 Expectorated sputum is frequently contaminated
  by oropharyngeal flora
       Low power magnification to assess squamous
        epithelial cells
       Culture and sensitivity are only accurate if there are
        <10 epi’s per low power field
       Best results if the specimen contains >25 WBCs per
        LPF
   If patient has a productive cough, send sputum
    for gram stain and culture: could be of use in
    directing treatment if patient fails to respond to
    empiric therapy
   Same patient. What other tests do you want?
   Blood cultures.
   Urine cultures.
   Urine for Legionella antigen.
   Urine for pneumococcal antigen.
   Urine for chlamydia antigen.
   HIV test.
   Bronchoscopy with culture of respiratory
    secretions.
       Pneumonia Diagnosis
 Blood cultures are positive in 11% of patients
  with CAP, more commonly in patients with
  severe illness
 Urine antigen assays for L pneumophila
  serogroup 1 can be done easily and rapidly.
  Sensitivity 70% Specificity >90%
 Assay for pneumococcal urinary antigen :
  sensitivity 50-80% and specificity 90%
 Responsible pathogen is not defined in as many
  as 50% of patients
   In February, a 55yo F with rheumatoid arthritis
    and chronic bronchitis presents to the office with
    a cough productive of green sputum, a fever and
    generalized myalgias x 2 days. T 101.6 HR 110
    R 24 BP 125/80. On exam, she has crackles in
    her LLL and dullness to percussion. You should
   A. Give her a presciption for Azithromycin
   B. Check her O2 sats and order a CXR
   C. Check her for Influenzae A
   D. Order a CBC, BMP, LFTs
   E. A, B, and C
   F. B, C, and D
   G. B and C
        Pneumonia Diagnosis
 Routine laboratory tests: CBC, electrolytes,
  hepatic enzymes) are of little value in
  determining the etiology of pneumonia, but may
  have prognostic significance and influence the
  decision to hospitalization. Should be
  considered in patients who may need
  hospitalization, >65 yr, or with coexisting illness.
 All admitted patients should have oxygen
  saturation assessed by oximetry
         Pneumonia Diagnosis
 Invasivetesting: percutaneous
 transthoracic needle aspiration or
 bronchoscopy are not routinely
 recommended.
     May be helpful in:
       • immunocompromised hosts
       • suspected tuberculosis in the absence of
         productive cough
       • non-resolving pneumonia
       • pneumonia associated with suspected neoplasm
         or foreign body
       • suspected Pneumocystis carinii
   Which of the following findings would indicate an
    increased risk of death in patients with
    community-acquired pneumonia?
   A. BUN <8 mmol/L
   B. Diastolic blood pressure >70 mm Hg
   C. Respiratory rate >30 breaths per minute
   D. Unilobar lung infiltrate
   E. PO2 = 65 mm Hg while breathing room air
 Pneumonia
 Severity
 Index
Pneumonia
 Severity
  Index
          Site of Treatment

 Class  I or II: Outpatient treatment
 Class III: Potential outpatient or brief
  inpatient observation
 Class IV and V: Inpatient
 Physician decision making: medical and
  psychosocial comorbidities, ability to take
  po, substance abuse, ability to do ADLs
                  CURB 65
 Confusion
 Urea level (>19)
 Respiratory rate (>30)
 Blood Pressure SBP< 90 or DBP <60
 Age


 Excellent   indicator for mortality
 Allof the following are reasons to admit a
  patient with pneumonia to the ICU
  EXCEPT:
 A. Need for mechanical ventilation
 B. Shock requiring pressors
 C. High WBC count with bandemia
 D. Decreased urine output
                   ICU Admission
   Minor Criteria
       RR>30/min
       PaO2/FiO2 <250
       Multilobar pneumonia
       Systolic BP <90
       Diastolic BP <60
   Major Criteria
       Need for mechanical ventilation
       Increase in the size of infiltrates by >50% within 48hrs
       Septic shock
       Acute renal failure (uop <80ml in 4 h or serum
        Cr>2.0)
   In April, a 45yo F with HTN presents to the office
    with fever x 3 days and a cough. T 102.5 HR 95
    R 22 BP 130/80 Sats 94% on RA. CXR shows
    RUL infiltrate.
   A. You should check a CBC, BMP, and LFTs
    and consider admitting her based on the results
   B. You should admit her for 24 hour observation
   C. You should check for Influenzae A
   D. The most likely organisms are Strep
    pneumonia, Mycoplasma, Chlamydia, and H. flu
    and she should be treated with Azithromycin or
    Doxycycline
        Group I: Outpatients
     No cardiopulmonary disease
        No modifying factors
Organism:                 Treatment:
Streptococcus pneumonia   Advanced generation
Mycoplasma pneumonia        macrolide(azithromycin or
Chlamydia pneumonia         clarithromycin)
Hemophilus influenzae     OR doxycycline
Miscellaneous
Legionella
Mycobacterium
Fungi
 All of the following have been identified as
  risk factors for community-acquired
  Legionella pneumonia EXCEPT:
 A. Cigarette smoking
 B. Chronic pulmonary disease
 C. Acquired immunodeficiency syndrome
 D. Advanced age
 E. Chronic illness, including diabetes, liver
  disease, and renal disease
   A 68 yo M with DM, HTN, CAD, is admitted to
    the hospital with community acquired
    pneumonia. He is recently retired from the
    insurance industry and has been caring for his
    grandson several mornings a week. He doesn’t
    smoke but he does drink 2-3 cocktails every
    night. T 101.6 HR 85 R 22 BP 95/60 Sats 92%
    on 3L NC. CXR shows an infiltrate in the lingula.
    He is at risk for
   A. Penicillin resistant pneumococus
   B. Pseudomonas
   C. MRSA
   D. Enteric gram negatives
Modifying Factors that Increase the
    Risk of infection with Specific

                        Pathogens
 Penicillin-resistant pneumococci
       Age >65
       B-lactam therapy within the past 3 months
       Alcoholism
       Immune suppressive illness (including tx with corticosteroids)
       Multiple medical comorbidities: DM, CRI, CHF, CAD, malignancy,
        chronic liver disease
       Exposure to a child in a day care center
   Enteric gram negatives
       Residence in a nursing home
       Underlying cardiopulmonary disease
       Multiple medical comorbidities
       Recent antibiotic therapy
   Pseudomonas aeruginosa
       Structural lung disease (bronchiectasis)
       Corticosteroid therapy (>10mg prednisone/day)
       Broad spectrum antibiotic therapy for > 7 days in past month
       Malnutrition
 The mortality rate for patients with nursing
  home-acquired pneumonia is:
 A. 10%
 B. 20%
 C. 40%
 D. 60%
 E. 80%
       Group II: Outpatient, with
    cardiopulmonary disease, and/or
         other modifying factors
   Organism:                 Therapy:
   Strep pneumonia           B -lactam (oral
   Mycoplasma                 cefpodoxime, cefuroxime,
   Chlamydia                  high-dose amoxicillin,
                               amoxicillin/clavulanate or
   Mixed infection            parenteral ceftriaxone
   Hemophilus influenzae    PLUS
   Enteric gram-negatives    Macrolide or doxycycline
   Viruses
   Miscellaneous            OR
   Moraxella, Legionella,    Antipneumococcal
    anaerobes, TB, fungi       fluoroquinolone
           Group III: Inpatients

 Organism                   Therapy:
 Strep pneumonia           1. Intravenous B -lactam:
 Hemophilus influenzae      cefotaxime, ceftriaxone,
 Mycoplasma
                             ampicillin/sulbactam,
                             high-dose amipicillin
 Chlamydia
                            PLUS
 Mixed infection
                            Intravenous or oral
 Enteric gram-negatives
                             macrolide or doxycycline
 Aspiration
                            OR
 Virus
                            2. Antipneumococcal
 Miscellaneous              fluoroquinolone
   A 45 year old female with lupus is admitted to
    the ICU with community acquired pneumonia
    and septic shock. She was intubated in the ER
    due to hypoxemic respiratory failure. Currently,
    T 102 HR 125 R 28 BP 90/60 on Dopamine.
    She should be started on:
   A. Vancomycin and Zosyn
   B. Levofloxacin
   C. Ceftriaxone and Levofloxacin
   D. Doxycycline and Gentamicin
                  ICU Patients
   Organisms:               Therapy:
   Strep pneumonia          1. Intravenous B -lactam:
   Legionella                cefotaxime, ceftriaxone,
   Hemophilus influenzae     ampicillin/sulbactam,
                              high-dose amipicillin
   Enteric gram-negative
                             PLUS either
    bacilli
                             Intravenous or oral
   Staphylococcus aureus
                              macrolide or doxycycline
   Mycoplasma
                             or
   Respiratory Viruses
                             Antipneumococcal
   Miscellaneous             fluoroquinolone
ICU Patients with Risks for
Pseudomonas aeruginosa
                 1. Selected iv
                  antipseudomonal B -lactam
                  (cefepime, imipenem,
                  meropenem,
                  piperacillin/tazobactam)
                 PLUS iv antipseudomonal
                  quinolone
                 OR
                 2. Selected iv
                  antipseudomonal B -lactam
                  PLUS iv aminoglycoside PLUS
                  either iv macrolide or iv
                  nonpseudomonal
                  fluoroquinolone
 The  organism(s) most commonly found in
  patients with nosocomial pneumonia is
  (are):
 A. Aerobic Gram-negative rods
 B. Staphylococcus aureus
 C. Legionella species
 D. Streptococcus pneumoniae
 E. Haemophilus influenzae
    Hospital-Acquired Pneumonia
   Enteric aerobic gram       Antipseudomonal
    negative bacilli            cephalosporin (cefepime,
   Pseudomonas                 ceftazidime) OR
    aeruginosa                  Antipseudomonal
   Staphylococcus aureus       carbepenem OR B -
                                lactam/B -lactamase
   Oral anaerobes              inhibitor
                               PLUS
                               Antipseudomonal
                                fluoroquinolone OR
                                aminoglycoside
                               PLUS
                                Vancomycin or Linezolid
   The mechanism thought to account for most
    cases of nosocomial pneumonia includes:
   A. Inhalation of infected aerosols from
    respiratory equipment
   B. Hematogenous spread from another infected
    site outside the lung
   C. Spread from a contiguous infected site
   D. Aspiration of pathogen-laden oropharyngeal
    secretions
   E. Inhalation of infected droplet nuclei from
    other patients in the area
 Which  of the following has been
  demonstrated to reduce the incidence of
  nosocomial pneumonia?
 A. Nasogastric tubes
 B. Enteral feedings
 C. Hand washing
 D. Isolation of patients with pneumonia
 E. Antacids
   Metastasis to skin and
                                  Staph aureus
    CNS
   Hyponatremia, AMS,
    renal and hepatic             Histoplasma
    dysfunction
   Night sweats, weight          Legionella
    loss
   Erythema multiforme,          Mycoplasma
    hemolytic anemia,
    encephalitis, transverse
    myelitis                      Nocardia
   Erythema nodosum
   Increased risk after          TB
    Influenzae pneumonia
 The  organism most commonly associated
  with life-threatening community acquired
  pneumonia is:
 A. Streptococcus pneumoniae
 B. Legionella pneumophila
 C. Klebsiella pneumoniae
 D. Pseudomonas aeruginosa
 E. Staphylococcus aureus
            Strep pneumonia
   Encapsulated lancet shaped diplococcus
   Causes up to 50% of community acquired
    pneumonia
   Patients present with acute onset of hard,
    shaking chills and pleuritic chest pain
   Usually have high WBC, however may have very
    low WBC if overwhelming infection
   Sputum may be rusty colored
   CXR often shows lobar consolidation
   If bacteremic, mortality is 30%
    Drug Resistant Strep pneumonia
   Prevalence continues to increase worldwide:
       PCN resistant 18-22%
       macrolide resistant 24-32%
 Patients with high level resistance (penicillin MCI
  >4mg/mL) showed an increased risk of
  suppurative complications
 Most common mechanisms of resistance to
  macrolides are methylation of a ribosomal target
  encoded by erm gene and efflux of the
  macrolides by cell membrane protein
  transporter, encoded by mef gene
Predicting Antimicrobial Resistance
    in Invasive Pneumococcal
             Infections
  Clinical Infectious Diseases 2005;40:1288-97
 3339  patients
 Risk factors for penicillin-resistance or
  macrolide resistance: antibiotic use (PCN,
  TMP-SMX, and azithro) in last 3 months
 Risk factors for fluoroquinolone resistance:
  previous use of fluoroquinolones,
  residence in a NH; nosocomial acquisition
Percentage of Pneumococcal Isolates That Were Nonsusceptible to Various Antibiotics from
Children under Two Years of Age (Panel A) and Adults 65 Years of Age or Older (Panel B) with
                              Invasive Disease, 1999 to 2004




         Kyaw, M. H. et al. N Engl J Med 2006;354:1455-1463
               Clinical Course
   Target time for appropriate initiation of
    antimicrobials within 4 hours of admission
   Fever x 2-4 days
   Leukocytosis usually resolves by Day 4
   Abnormal physical findings (crackles) persist
    beyond 7 d in 20-40%
   CXR clears by 4 weeks in 60% patients
   Delayed resolution with increasing age, multiple
    coexisting illness, alcoholism, bacteremia
 When to switch to oral therapy
 Oral = iv: doxycycline, linezolid,
  quinolones
 Improvement in cough and dyspnea
 Afebrile
 WBC decreasing
 Functioning GI tract
 Patient can be discharged home the same
  day that clinical stability occurs and oral
  therapy is initiated.
                      Prevention
   Recommendations by CDC:
   Pneumococcal vaccine: age >65 or if
    chronically ill: CHF, COPD, DM, ETOH,
    cirrhosis, asplenia, long-term care facilities.
    Revaccinate after 5 years.
   Influenzae vaccine: age >65, residents of
    long-term care facilities, chronic pulmonary
    or cardiovascular disease, hospitalization in
    the preceding year, immunosuppression,
    pregnant women in 2nd or 3rd trimester
    during flu season

   Patients should be counseled during
    hospitalization regarding smoking cessation
Annual Incidence of Invasive Disease Caused by Penicillin-Susceptible and Penicillin-
Nonsusceptible Pneumococci among Children under Two Years of Age, 1996 to 2004




      Kyaw, M. H. et al. N Engl J Med 2006;354:1455-1463
Annual Incidence of Invasive Disease Caused by Penicillin-Nonsusceptible Pneumococci in
                     Persons Two Years of Age or Older, 1996 to 2004




        Kyaw, M. H. et al. N Engl J Med 2006;354:1455-1463
 Inimmunocompetent adults for whom the
  pneumococcal vaccine is indicated, the
  protection efficacy is:
 A. 0%
 B. 10%
 C. 30%
 D. 60%
 E. 80%
   A 34yo F with JRA presents to the office with a
    3 day history of a cough productive of yellow
    sputum, fever, and myalgias. On physical exam,
    she is mildly tachypneic but not in distress T 104
    HR 115 R 28 BP 105/60 Saturations 94% RA.
    Physical exam reveals rales in her LLL. She has
    dullness to percussion at her left base and
    increased tactile fremitus. The next step in her
    management is:
   A. Sputum gram stain
   B. Chest radiograph
   C. Give her a prescription for Augmentin
   D. Admit her to the hospital
 What   should she be treated with?
 A.   Vancomycin and Imepenem
 B.   Keflex
 C.   Azithromycin
 D.   Ceftriaxone
 E.   Levofloxacin
A 55yo with CHF presents to the ER with a
 1 day history of cough, fever, shaking
 chills, and weakness. She is obviously
 uncomfortable, with mildly increased work
 of breathing. T 100.8 HR 125 R 32 BP
 100/55 Saturations 86% on RA. Lungs
 have crackles in her right upper lobe. She
 has 1+ edema bilaterally. She is alert and
 oriented.
 You  should now obtain all of the following
  labs EXCEPT:
 A. CBC
 B. Electrolytes
 C. PT, PTT
 D. ABG
 E. Sputum culture
 F. Blood cultures
   ABG: pH 7.36 pCO2 42 pO2 50
   Na 134 K 4.3 Cl 95 HCO3 20 BUN 42 Cr 1.4
    glucose 145
   WBC 18.3 Hgb 10.3 Hct 32 Plt 130
   She should be:
   A. Given a prescription for Azithromycin and
    sent home
   B. Admitted to the hospital. Start Ceftriaxone
    and Azithromycin after she coughs up a sputum
    sample.
   C. Admitted to the hospital. Start Levofloxacin
    immediately
   D. Admitted to the ICU and started on
    mechanical ventilation
           PORT Score
 Age  55-10=45
 CHF       +10
 RR        +20
 HR 124    +10
 BUN        +20
 pO2        +10

           115     Class IV Mortality 8-9%
   A 70yo F resident of a nursing home is evaluated in the
    ER due to decreased mental status and hypothermia.
    She has a history of stroke and is currently taking only
    aspirin. She has been able to eat on her own and there
    have been no witnessed aspirations. She has not been
    treated recently with antibiotics. WBC 12 Hgb 12
    Electrolytes are normal and she has mild chronic renal
    insufficiency. CXR shows small interstitial infiltrate in
    RLL. She receives empiric treatment for community-
    acquired pneumonia. Therapy for which of the following
    should also be considered?
   A. Pseudomonas aeruginosa
   B. Anaerobic bacteria
   C. Enteric gram-negative organisms
   D. Aspergillus fumigatus
   E. Mycobacterium tuberculosis
A 28yo M presents to the ER with
 increasing shortness of breath and
 subjective fever and chills. In the ER,
 patient is in moderate respiratory distress.
 T 102 HR 140 R 38 BP 85/55 Sats 80%
 on RA. Lungs have rales throughout. He
 has no peripheral edema. He knows his
 name and knows he is in the ER but he is
 unsure of the date (thinks it is 2003).
 You should do all of the following
  EXCEPT:
 A. Start IVF wide open
 B. Get an ABG
 C. Wait on ABG before starting oxygen
 D. Order a CXR
 E. Admit to the ICU
   In carefully performed prospective studies on the
    etiology of community-acquired pneumonia, the
    organism most often identified in patients ill
    enough to require hospitalization is:
   A. Streptococcus pneumoniae
   B. Unknown
   C. Chlamydia pneumoniae
   D. Mycoplasma pneumoniae
   E. Haemophilus influenzae
 Inpatients with bacteremic pneumonia the
  organism most likely to be found is:
 A. Staphylococcus aureus
 B. Klebsiella pneumoniae
 C. Haemophilus influenzae
 D. Streptococcus pneumoniae
 E. Pseudomonas aeruginosa
   A 65 yo M develops bilateral lower lobe
    pneumonia and is treated as an outpatient with
    amoxicillin/clavulanic acid for 72hours. Despite
    this treatment, he deteriorates and is admitted to
    the hospital. Within 12 hours of admission, he
    develops respiratory failure requiring admission
    to the ICU, intubation, and mechanical
    ventilation. The organism most likely to account
    for the severity of disease despite treatment with
    Augmentin is:
   A. Moraxella catarrhalis
   B. Chlamydia pneumoniae
   C. Klebsiella pneumoniae
   D. Legionella pneumophila
   E. Streptococcus pneumoniae
               Pneumonia
 Common     infection
 Pathophysiology
 Clinical presentation
 Risk factors for mortality
 Treatment

								
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