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

Mar 26, 2015

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Coventry and Warwickshire Pathology Pneumonia SAHD Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists June 2010 Slide 2 Coventry and Warwickshire Pathology 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 Slide 3 Coventry and Warwickshire Pathology Are you feeling 0 of 5 1.Excited about the session 2.Apprehensive about the session 3.Apathetic about the session 4.Go away and leave me alone Slide 4 Coventry and Warwickshire Pathology Are you 1.Male 2.Female 0 of 5 Slide 5 Coventry and Warwickshire Pathology Slide 6 What is your favourite speciality? 1.Medicine 2.Surgery 3.Pathology 4.GP 5.Otherand offended! 0 of 5 Slide 7 Coventry and Warwickshire Pathology How well do you think you could deal with a patient in ED with a Chest Infection? 1.Superbly 2.Well 3.Adequately 4.Poorly 5.Rather not say 0 of 5 Slide 8 Coventry and Warwickshire Pathology 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 Slide 9 Coventry and Warwickshire Pathology Chest examination Anatomic Landmarks The Extrathoracic Examination Chest Inspection, Palpation, Percussion Chest Auscultation Slide 10 Coventry and Warwickshire Pathology 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) Slide 11 Coventry and Warwickshire Pathology 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 Slide 12 Coventry and Warwickshire Pathology 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 Slide 13 Coventry and Warwickshire Pathology 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 Slide 14 Coventry and Warwickshire Pathology Complications of pneumonia Bacteraemia/Septicaemiadeath Lung abscess Parapneumonic effusion/empyema Slide 15 Coventry and Warwickshire Pathology Which criteria are included in CURB-65 severity scoring 1.Cyanosis 2.Urea 3.Respiratory rate 4.Base excess 5.65% O2 required 0 of 5 Slide 16 Coventry and Warwickshire Pathology Severity: CURB-65 Confusion: new confusion AMT 7mmol/l Respiratory rate: >=30/min Blood pressure: sys Coventry and Warwickshire Pathology 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% Slide 19 Coventry and Warwickshire Pathology MAU Audit Zoe 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 Slide 20 Coventry and Warwickshire Pathology Investigations of Pneumonia CXR O2 saturation +/- gases Microbiology Biochemistry Urea LFT CRP Haematology FBC: WBC, plts, ?clotting Slide 21 Coventry and Warwickshire Pathology What microbiology samples would you send on a patient with severe CAP? 1.Sputum 2.Nose swab 3.Urinary Antigen 4.Serology 5.Blood Culture 0 of 5 Slide 22 Coventry and Warwickshire Pathology Send appropriate samples Slide 23 Coventry and Warwickshire Pathology Sputum: microscopy Sputum appearance? Mucoid/Salivary/Blood stained/Green/Yellow etc Gram stain??:Sputum/BAL etc. Special stains: TB/PCP etc. Slide 24 Coventry and Warwickshire Pathology Sputum: culture and sensitivity Slide 25 Coventry and Warwickshire Pathology 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!!! Slide 26 Coventry and Warwickshire Pathology 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 Slide 27 Coventry and Warwickshire Pathology 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) Slide 28 Coventry and Warwickshire Pathology Which bacteria are common causes of CAP 0 of 5 1.Escherichia coli 2.Streptococcus pneumoniae 3.Haemophilus influenzae 4.Coagulase negative staphylococci 5.Moraxella catarrhalis Slide 29 Coventry and Warwickshire Pathology Organisms causing Pneumonia Viruses Influenza, parainfluenza Community acquired pneumonia Streptococcus pneumoniaeMycoplasma pneumoniae Haemophilus influenzaeLegionella pneumophila Moraxella catarhalisChlamydia psittaci Staphylococcus aureusCoxiella burnetti Hospital acquired Pneumonia Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumanii etc Slide 30 Coventry and Warwickshire Pathology CAP causative organisms Slide 31 Coventry and Warwickshire Pathology 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 Slide 32 Coventry and Warwickshire Pathology 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 Slide 33 Coventry and Warwickshire Pathology Chest Infection Possible choices Amoxicillin Augmentin Cefuroxime Ciprofloxacin Ceftazidime Tazocin Meropenem +/- erythromycin/clarithromycin (Atypical cover) Slide 34 Coventry and Warwickshire Pathology And Atypicals! Slide 35 Coventry and Warwickshire Pathology Slide 36 Slide 37 Slide 38 Slide 39 Slide 40 Coventry and Warwickshire Treatment Guidelines (Hospital) Slide 41 Coventry and Warwickshire Pathology 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 Slide 42 Coventry and Warwickshire Pathology Dont 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) Slide 43 Coventry and Warwickshire Pathology Chest Infection Recommendation Slide 44 Coventry and Warwickshire Pathology Chest Infection recommendation Slide 45 Coventry and Warwickshire Pathology Mid session interval You have 5 minutes, the attendance book will be available for signing on your return Slide 46 Coventry and Warwickshire Pathology Which of the following do you do when prescribing antibiotics 0 of 5 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 Slide 47 Coventry and Warwickshire Pathology How well do you think you could deal with a patient in ED with a Chest Infection? 1.Superbly 2.Well 3.Adequately 4.Poorly 5.Rather not say 0 of 5