CLINICAL APPROACH TO PNEUMONIA Dr Izham Cheong, FRCP Professor of Medicine, UNIVERSITI KEBANGSAAN MALAYSIA “ The most widespread & fatal of all acute diseases, pneumonia, is now Captain of the Men of Death” : Sir William Osler
CLINICAL APPROACH TO PNEUMONIA
Dr Izham Cheong, FRCPProfessor of Medicine, UNIVERSITI KEBANGSAAN
MALAYSIA
“ The most widespread & fatal of all acute diseases, pneumonia, is now Captain of the Men of Death” : Sir William Osler
Facts about pneumonia in USA• 6th most common cause of
death.• Increased by 59% between
1979 to 1994.• 2-3 million cases of CAP in 10
million visits.• 500,000 hospitalizations (258
per 100,000 pop).• 45,000 deaths (average 14%
hospitalised).• Cost : about $ US 4.5 billion.
JAMA 1996;275:189
MMWR 1997;46:556
Ten leading causes of hospitalization and death in Malaysia (2000)
Hospitalization (Total=1,559 280) Respiratory diseases 6.58%
Deaths (Total=29 447)Heart disease 15.10%Septicaemia 10.98CVA 9.47Accident 8.79Neoplasms 8.75Perinatal diseases 7.28GI diseases 4.69Pneumonia 4.33Renal disease 3.65Ill-defined diseases 3.62
CLINICAL APPROACH TO PNEUMONIA
Key points to remember
KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS PNEUMONIA
CAPTypicalS. pneumoniaeH. influenzaeM. catarrhalis
AtypicalL. pneumophilaM. pneumoniaeC. pneumoniaeC. psittacosiC. burnetti
HAP (VAP)Gram –veP. aeroginosaAcinetobacter spp.Proteus spp.Klebsiella spp.E. cloacaeP. maltophilaLegionella spp.
Gram +veS. aureus (MRSA)S. pneumoniaeOther streptococciS. epidermidis
Polymicrobial
NHAPGram –veKlebsiella spp.P. aeroginosa
Gram +veS. aureus
Anaerobes
1. EPIDEMIOLOGY OF RESPIRATORY PATHOGENS
KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS A PNEUMONIA
2. EARLY EMPIRIC TREATMENT IS ESSENTIAL BECAUSE NO SPECIFIC PATHOGEN CAN BE IDENTIFIED IN 30% to 70% OF PATIENTS.
Relationship of receiving an antibiotic withina time frame and 30-daymortality
Meehan TP, 1997
OR
of
30-d
Su
rviv
al (9
5%
CI)
KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS A PNEUMONIA
3.THE RISE IN ANTIBIOTIC RESISTANCE
Penicillin and macrolide resistantS. pneumoniae
ESBL-producing Klebsiella spp.
MDR pathogens: P. aeroginosa P. maltophila Enterobacter spp. Stenotrophomonas spp.
MRSA + VRSA
VRE
KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS A PNEUMONIA
4. CONTAIN COST WITHOUT NEGATIVELY AFFECTING MORTALITY
Minimize admissions
Oral antibiotics
Shorten hospitalization
CLINICAL APPROACH TO PNEUMONIA
What do I do?
mild severe
Clinical Approach to a Patient with CAP
History
Medicineislearnedbythe bedsideandnot inthe classroom
Sir William Osler (1849-1919)
HISTORY
1. WHICH CATEGORY?
CAP
NHAP
HAP (VAP)
2. CAN THE PATIENT BE IMMUNOCOMPROMISED?
HISTORY
DON’T TRUST ANY ONE NOWADAYS!!!
HISTORY3.ANY UNDERLYING LUNG DAMAGE?
HISTORY4. COMORBIDITY ?
“mimic” pneumoniaimpact on drug treatment
HISTORY6. WHAT IS HIS JOB?
Any andeverything!!
Pulmonary TB
Q feverAnthrax
HISTORY7. CONTACT WITH….
Chlamydia pneumoniae
Francisella tularensis
Yersinia pestis
HISTORY Legionellosis
IS IT SAFE TOTRAVEL??
HISTORY8. HIGH RISK BEHAVIOURS
““Yumm-Seng””
IVDU
smoking
HISTORY9. ASPIRATION ?
stroke
vomiting
unconcious/fits
Ryle’s tube
HISTORY10. WHAT DRUGS ARE YOU TAKING?
Amiodarone
Nitrofurantoin
Bleomycin
Chlorambucil
Procarbazine
BulsulfanCyclophosphamide
Aziathioprine
Methotrexate
Sulphonamides
Lung infiltrates
Heroin
Methadone
Chlorthiaxide
Contrast media
Pulmonary oedema
Clinical Presentation
Clinical Approach to a Patient with CAP
Typical pneumonia acute ill-looking,SOB fever and chills productive cough, leukocytosis pleurisy
Atypical pneumonia as above + extrapulmonary features CNS involvement: ENT involvement: M. pneumoniae
Diarrheas: M. pneumoniae or L. pneumophila Abdominal pain: L. pneumophila
Rash: C. psittacosis M. pneumoniae
Cutaneous findings
Erythema multiforme M. pneumoniaeMaculopapular rash MeaslesErythema nodosum C. pneumoniaeEcthyma gangrenosum M. tuberculosis
P. aeruginosa
Oral findings
Peridontal disease anaerobic pathogens Foul smelling sputum
Clinical Approach to a Patient with CAPPhysical examination
Neurologic disease
Absent gag AspirationAltered conciousnessRecent seizure
Cerebellar ataxia M. pneumoniaeL. pneumophila
Encephalitis M. pneumoniaeC. burnetti
Clinical Approach to a Patient with CAP
Physical examination
Differential Diagnosis of Common Radiographic Patterns in Patients with Pneumonia
Focal opacity Interstitial
S. pneumoniaeM. pneumoniaeL. pneumophilaC. pneumoniaeM. tuberculosisAspiration
Viral M. pneumoniaeP. cariniiC. psittaci
Differential Diagnosis of Common Radiographic Patterns in Patients with Pneumonia
Interstitial with lymphadenopathy
Cavitation
Epstein Barr virusF. tularensisC. psittasi
Anaerobic abscessS. aureusAerobic gram-neg bacilliM. tuberculosisC. neoformansN. asteroides and A. israelii
Differential Diagnosis of Common Radiographic Patterns in Patients with Pneumonia
Segmental pneumonia withlymphadenopathy
Miliary
M. tuberculosisFungal infection
M. tuberculosisH. capsulatumVaricella zooster
COMMUNITY-ACQUIRED PNEUMONIAWhich patient require hospitalization?
Respiratory rate > 30/min Diastolic hypotension Altered mental status Renal failure Age > 65 years Co-existing disease Leukopenia Severe anaemia Acidosis Hypoxaemia Multilobar involvement Systolic BP < 90mmHg PaO2/FIO < 250
Niederman, 1993; Barlett, 1995; Fine, 1995; Ewig, 1998
INTERNATIONAL GUIDELINES FOR EMPIRICAL ANTIMICROBIAL THERAPY
OF COMMUNITY-ACQUIRED PNEUMONIA
Guidelines Outpatient General ward ICU
European RespiratorySociety (1998)
penicillin or aminopenicillins
Alternatives: macrolodes tetracyclines
cephalosporins quinolones
(2nd or 3rd generation cephalosporin or -lactam/-lactamase inhibitor or IV penicillin) macrolide or 2nd generation quinolones;
2nd or 3rd generation cephalosporin + 2nd generation quinolones rifampicin
Infectious Diseases Societyof America (2000)
doxycycline macrolide
new floroquinolone
-lactam with macrolide
OR
new fluoroquinolone
Extended spectrum cephalosporin or –lactam/-lactamase inhibitor + either IV fluoroquinolone or IV macrolide (if structural lung disease cover P. aeroginosa)
WHAT DO IUSEFORMY PATIENTSWITHACOMMUNITY-ACQUIREDPNEUMONIA ?
HOW DO I EMPIRICALLY TREAT MY PATIENT WITH
COMMUNITY-ACQUIRED PNEUMONIA?
SETTING THERAPEUTIC OPTIONS
Ambulatory, not requiring hospitalization, age under 60 years
Oral macrolide (erythromycin or azithromycin)
Ambulatory, not requiring hospitalization, comorbidity or age over 60 years
Oral -lactam/-lactamase inhibitor + macrolideOROral antipneumococcal fluoroquinolone
Requiring hospitalization -lactam (sulperazone or ceftriaxone) + macrolide or antipneumococcal fluoroquinolone
Aspiration pneumonia requiring hospitalization
-lactam/-lactamase inhibitor alone(ampicillin/sulbactam, pipericillin/tazobactam))
Izham, 2002Empiric therapy (pathogen unknown or awaiting cultures)
MY EMPIRICAL THERAPY OF SEVERE CAP IN COMPROMISED HOST
Compromised host Usual pathogen Empiric therapy
Chronic alcoholics Oral anaerobesand/orKlebsiella spp.
3rd or 4th generation cephalosporinORmeropenam
Postviral influenzae S. aureus CloxacillinORvancomycin
HIV S. pneumoniaeSalmonellaLegionella
new fluoroquinolone
Congenital/acquired asplenia or hyposplenia
S. pneumoniaeN. meningitidisH. influenzae
-lactam/-lactamase inhibitorORmeropenam
Izham,2002
Why is pneumonia still a leading cause of morbidity and mortality ?
• Changing pathogens• Greater diagnostic difficulties• Widespread antibiotic resistance• Survival of patients at both
extremes of ages• Larger population of
compromised hosts• More hospital-acquired
pneumonia
Despite more and better antimicrobials
“Of all the diseases to which man is heir, those known in etiology, possible of cure, capable of prevention, are for the most part caused by infectious agents” -therefore
What shall I do with my next pneumonia?
Choose the right antibiotic.
Choose the right physician!!!!!!!!