Coventry and Warwickshire Pathology Pneumonia SAHD Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists June 2010.

Coventry and Warwickshire Pathology

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

• Interpret laboratory results and apply to Clinical decisions

• Understand the key principles of antibiotic prescribing


Are you feeling

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0% 0%0%0%0of5

1. Excited about the session

2. Apprehensive about the session

3. Apathetic about the session

4. Go away and leave me alone


Are you

Mal

e

Fem

ale

0% 0%

1. Male

2. Female

0of5


0% 50%

67% 50%

0%0%

33% 0%

0% 20% 40% 60% 80% 100% 120%

Go away and leave ...

Apathetic about th...

Apprehensive about...

Excited about the ...

Are you feeling

Male Female


What is your favouritespeciality?

Med

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1. Medicine

2. Surgery

3. Pathology

4. GP

5. Other…and offended!

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How well do you think you could deal with a patient in ED with a

Chest Infection?

Super

bly W

ell

Adeq

uatel

y

Poorly

Rat

her n

ot say

0% 0% 0%0%0%

1. Superbly

2. Well

3. Adequately

4. Poorly

5. Rather not say

0of5


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


Chest examination

• Anatomic Landmarks

• The Extrathoracic Examination

• Chest Inspection, Palpation, Percussion

• Chest Auscultation


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)


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


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


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


Complications of pneumonia

• Bacteraemia/Septicaemia……death

• Lung abscess

• Parapneumonic effusion/empyema


Which criteria are included in CURB-65 severity scoring

Cya

nosis

Ure

a

Res

pirato

ry ra

te

Bas

e ex

cess

65%

O2

requi

red

0% 0% 0%0%0%

1. Cyanosis

2. Urea

3. Respiratory rate

4. Base excess

5. 65% O2 required0of5


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


CURB-65


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%


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)

I.V.

Oral

Mild/Moderate

Severe


Investigations of Pneumonia

• CXR• O2 saturation +/- gases• Microbiology…• Biochemistry

– Urea– LFT– CRP

• Haematology– FBC: WBC, plts, ?clotting


What microbiology samples would you send on a patient with severe

CAP?

Sputu

m

Nose

swab

Urin

ary

Antigen

Ser

ology

Blo

od Cul

ture

0% 0% 0%0%0%

1. Sputum

2. Nose swab

3. Urinary Antigen

4. Serology

5. Blood Culture 0of5


Send appropriate samples


Sputum: microscopy• Sputum appearance?• Mucoid/Salivary/Blood

stained/Green/Yellow etc• Gram stain??: Sputum/BAL

etc.• Special stains: TB/PCP etc.


Sputum: culture and sensitivity


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!!!


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


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)


Which bacteria are common causes of CAP

Esc

heric

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oli

Stre

ptoc

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pne...

Hae

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influ

enza

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Coag

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Mora

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cat

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0% 0% 0%0%0%

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1. Escherichia coli

2. Streptococcus pneumoniae

3. Haemophilus influenzae

4. Coagulase negative staphylococci

5. Moraxella catarrhalis


Organisms causing Pneumonia

Viruses – Influenza, parainfluenza

Community acquired pneumoniaStreptococcus pneumoniae Mycoplasma

pneumoniaeHaemophilus influenzae Legionella pneumophilaMoraxella catarhalis Chlamydia psittaciStaphylococcus aureus Coxiella burnetti

Hospital acquired PneumoniaEscherichia coli, Klebsiella pneumoniae, Acinetobacter baumanii etc


CAP causative organisms


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


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


Chest Infection

• Possible choicesAmoxicillin

AugmentinCefuroximeCiprofloxacin

CeftazidimeTazocinMeropenem

• +/- erythromycin/clarithromycin (Atypical cover)


And Atypicals!







Coventry and Warwickshire Treatment Guidelines (Hospital)


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


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)


Chest Infection Recommendation


Chest Infection recommendation


Mid session interval

You have 5 minutes, the attendance book will be available

for signing on your return


Which of the following do you do when prescribing antibiotics

Rev

iew

pts

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1. Review pts previous microbiology results

2. Document indication and duration/review date in the patients notes

3. Write indication on drug chart

4. Write review or stop date on drug chart

5. Review antibiotic at 48hrs and change to oral if appropriate


How well do you think you could deal with a patient in ED with a

Chest Infection?

Super

bly W

ell

Adeq

uatel

y

Poorly

Rat

her n

ot say

0% 0% 0%0%0%

1. Superbly

2. Well

3. Adequately

4. Poorly

5. Rather not say

0of5

Coventry and Warwickshire Pathology Pneumonia SAHD Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists June 2010.

Documents

warwickshire pathology

warwickshire pathology

sys coventry

sensitivity slide

clotting slide

clinical features of

severity curb

oral antibiotics curb