Pneumonia Michele Ritter, M.D. Argy – Feb. 2007
PneumoniaMichele Ritter, M.D.Argy Feb. 2007
Pneumonia DefinitionAn acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, accompanied by an acute infiltrate on CXR or auscultatory findings consistent with pneumonia
Pneumonia- SymptomsCough (productive or non-productive)DyspneaPleuritic chest painFever or hypothermiaMyalgiasChills/SweatsFatigueHeadacheDiarrhea (Legionella)URI, sinusitis (Mycoplasma)
Findings on ExamPhysical: Vitals: Fever or hypothermiaLung Exam: Crackles, rhonchi, dullness to percussion or egophany. Labs:Elevated WBCHyponatremia Legionella pneumoniaPositive Cold-Agglutinin Mycoplasma pneumonia
Chest X-rayRULRMLRLLLULLingulaLLLRULRMLRLLLULLingulaLLL
Chest X-ray Pneumonia
Chest X-ray - Pneumonia
Chest X-ray -- Pneumonia
Types of PneumoniaCommunity-Acquired (CAP)Health-Care Associated Pneumonia (HCAP)Hospitalization for > 2 days in the last 90 daysResidence in nursing home or long-term care facilityHome Infusion TherapyLong-term dialysis within 30 daysHome Wound CareExposure to family members infected with MDR bacteriaHospital-Acquired Pneumonia (HAP)Pneumonia that develops after 5 days of hospitalizationIncludes: Ventilator-Associated Pneumonia (VAP) Aspiration Pneumonia
Common Bugs for PneumoniaCommunity-AcquiredStreptococcus pneumoniaeMycoplasma pneumoniaeChlamydophila psittaci or pneumoniaeLegionella pneumophilaHaemophilus influenzaeMoraxella catarrhalisStaphylococcus aureusNocardiaMycobacterium tuberculosisInfluenzaRSVCMVHistoplasma, Coccidioides, BlastomycosisHCAP or HAPPseudomonas aeruginosaStaphylococcus aureus (Including MRSA)Klebsiella pneumoniaeSerratia marcescensAcinetobacter baumanii
Diagnosis of pathogenSputum Culture< 10 Squamous Epithelial Cells> 25 PMNsBlood Cultures Strep. pneumo urinary antigenLegionella urinary antigenHIV test?
Special Clues on Chest X-rayLobar pneumonia Strep. PneumoniaDiffuse interstitial infiltrates PneumocystisRUL infiltrate TuberculosisDiffuse interstitial infiltrates Tuberculosis in HIV
Inpatient or Outpatient Treatment of CAPPatients safety at homePORT scoreClinical Judgement
PORT Score
PORT Score
Treatment of CAPOutpatient: Macrolide (Azithromycin) Fluoroquinolone (Levaquin, Moxifloxacin) DoxycyclineInpatient:Beta-Lactam + MacrolideCeftriaxone + Azithromycin Fluoroquinolone (Levaquin, Moxifloxacin)For suspicion of highly resistant Strep. pneumoniae
Treatment of HCAP, HAP, VAPAntipseudomonal cephalosporin (Cefepime, Ceftazidime) + VancomycinAnti-pseudomonal Carbapenem (Imipenem, Meropenem) + VancomycinBeta-Lactamase/Beta-Lactamase Inhibitor (Pip-Tazo Zosyn) + Pseudomonal Fluoroquinolone (Cipro) + VancomycinAminoglycoside (Gentamycin, Amikacin) + Vancomycin
Special Cases!HIVPneumocystis jiroveciiMycobacterium tuberculosisCryptococcusHistoplasmosisTransplant PatientsFungi (Aspergillosis, Cryptococcus, Histoplasmosis)NocardiaCMVNeutropenic PatientsFungi ( Aspergillosis)Gram-negatives
More Special CasesSmokers: S. pneumo, H. influenzae, M. catarrhalisAlcoholics: S. pneumo, Klebsiella, anaerobesIV Drug User: S. aureus, Pneumocystis, anaerobesSplenectomy: encapsulated organisms (S. pneumo, H. influenzae)Cystic fibrosis: Pseudomonas, S. aureusDeer mouse exposure: HantavirusBat exposure: Histoplasma capsulatumRat exposure: Yersinia pestisRabbit exposure: Francisella tularensisBird Exposure: C. psitacci, Cryptococcus neoformansBioterrorism: Bacillus anthracis, F. tularensis, Y. pestis
Pneumococcal VaccineWhat does it cover? Protects against 23 serotypes of Strep. Pneumoniae (90% of invasive pneumonia infections)Who should get it?Anyone over age 65Anyone with chronic medical problem such as cancer, diabetes, heart disease, lung disease, alcoholism, cirrhosis, sickle cell disease, kidney failure, HIV, damaged spleen or no spleen, CSF leaks Anyone receiving cancer therapy, radiation, steroidsAlaskan natives and certain Native American populationsHow often to get it?Give second dose if >5 years from first dose if > 65, cancer, damaged spleen, kidney disease, HIV or any other condition lowering immune system function
MKSAP Questions A 45-year old male smokere presents with symptoms of cough, fever with temperature to 39 C, and yellow sputum of 2 days duration. He denies shortness of breath and has no chest pain. His symptoms were of gradual onset but have steadily worsened since they first appeared.
MKSAP Question #1 (cont.)Physical Exam:VS: 39.2 C, 110/75, 88, 22, 98% RAGen: Alert, oriented in NADResp: crackles at right lung base posteriorly
MKSAP Question #1 (cont.)
MKSAP Question #1 (cont.)What is the most appropriate drug therapy for this patient?Oral azithromycinOral CefuroximeOral penicillin GIntravenous ceftriaxone in your office, followed by oral cefpodoximeOral tetracycline
Question #2A 72-year-old female with a history of CHF, hypertension, and CRI presents to the ER with fever, productive cough (green sputum) and SOB for five days. She was seen by her outpatient doctor three days earlier and was started on a Z-pak, but has not improved. The patient lives by herself, and has never been hospitalized before.
Question # 2Physical Exam:VS: 38.4, 100/54, 122, 26, 95% on 2L NCGen: Alert, oriented, in NAD but a little winded.Resp: Decreased breath sounds at right lung base; + egophany at right base
Question # 2 (cont.)
Question #2 (cont.)Labs:WBC: 11.2, Hgb: 10.2, Hct: 30.6, Platelets: 240Sodium: 130, Potassium: 4.3, BUN: 36, Cr: 1.4
Question #2 (cont.)What is the best management for this patient?
Send home longer course of azithromycinSend home on oral LevofloxacinHospitalize and start on ZosynHospitalize and start on Ceftriaxone and AzithromycinHospitalize and start on Vancomycin and Imipenem
Question # 356-year-old female nursing home resident with a history of hypertension. Diabetes, ESRD on HD, PVD with bilateral BKA presents with 3 days of fever, with some mental status changes, per nursing home. Patient was also noted to have some recent coughing.
Question #3 (cont.)Physical Exam:VS: 39.6, 88/52, 129, 28, 88% on RAGen: Awake, but lethargic, oriented to person but not place or time.CV: tachy, no murmursResp: Diffuse rhonchi in both lung fields
Question # 3
Question #3What is the best therapy for this patient?IV Ceftriaxone with IV AzithromycinIV MoxifloxacinPO Azithromycin with IV ZosynIV Imipenem with IV VancomycinIV Azithromycin with IV Linezolid