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Community Acquired Pneumonia. 6 mil/year6th leading cause of death. Epidemiology. Mortalityoverall 13.7%hospitalized ambulatory: 5.1%hospitalized 13.6%pneumococcus 12.3%higher rates with G-, Staph. Prognostic Factors (?mortality). underlying neurologic disease, CHF, malignancyBUN>20RR>20
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1. Pneumonias By Mira Iliescu MD
2. Community Acquired Pneumonia 6 mil/year
6th leading cause of death
3. Epidemiology Mortality
overall 13.7%
hospitalized+ ambulatory: 5.1%
hospitalized 13.6%
pneumococcus 12.3%
higher rates with G-, Staph
4. Prognostic Factors(?mortality) underlying neurologic disease, CHF, malignancy
BUN>20
RR>20+ hypothermia+systolic hypotension
bacteremia
multilobar disease
5. (2) BTS- CURB criteria
confusion
BUN<19.6
RR> 30/min
BP diastolic<60mmHg
2 out of 3 ?mortality 9-21 fold
6. Poor outcome in CAP age>65 years
comorbid illness+ AMS
temp>38.5
sepsis+MODS
delays in Abx
atypical clinical presentation
7. PORT I, II outpatient
IV, V inpatient
III individualized decisions
8. Pathogenesis colonization of the orophryngx: G+, G-
inhlation: Legionella, TB, viruses
ARDS
? TNF, IL6, IL8
9. Pathogens Study 1
pneumoccocus 15%
H influenza 7.3%
atypical 8%
nondiagnosed 37% Study 2
M pneumoniae 29%
pneumococcus 12.6%
C pneumonia 8.9%
influenza 7.4%
H influenzae 6.6%
10. PCN Resistant and Drug Resistant Pneumococcus age >65
beta-lactam therapy in the last 3 mo
ETOH abuse
immunosuppressive disease/ steroid use
comorbidity
child in day care center
11. Enteric G- NH resident
cardio-pulm disease
comorbidities
recent abx therapy
12. Pseudomonas Aeruginosa Structural lung disease
steroid therapy (>10mg prednisone/day)
abx>7 days in the last month
malnutrition
13. Cardiopulmonary Pathology and Modifying Factors Present Absent
S pneumonia (DRSP) S pneumonia
H influenza H influenza
atypical M pneumonia
aerobic G- C pneumonia
Legionella viruses
Respiratory viruses Legionella
14. Risks Factors for P aerugionsa Present
S pneumonia
Legionella
H influenzae
enteric G-
S aureus
M pneuminia/ C pneumonia
viruses Absent
S pneumonia
Legionella
H influenza
enteric G-
S aureus
M pneumonia/ C pneumonia
viruses
15. Condition- Pathogen ETOH: S pneumoniae, anaerobs, G- bacilli
COPD/ smoker: S pn, H influ, M catarrhalis, S aureus
poor oral hygiene: anaerobs
bats: Histoplsma
birds: C psittaci, Histoplasma
rabbits: Francisella tularensis
16. (2) SW: coccidioidomycosis
farm animals: coxiella burnetti
large vol aspiration: anaerobs, chemical pn
IVDA: TB, S aureus, anaerobs
17. Pneumococcus Preceded by viral infection
mortality (hospitalized patients> 20%)
> 40% PRSP
intermediate: 0.12 mg/ml< MIC <2 mg/dl
high: MIC> 2MG/DL
INCREASED RISK OF DEATH MIC >4mg/dl
18. (2) Multiple drug resistance:
macrolide
trimethoprim- sulfa
cipro/ levofloxacin
19. Legionella Pneumophila G- organism/ urinary antigen
presentation may include
confusion
diarrhea
? LFT’s
bradicardia
hyponatremia
20. Mycoplasma Pneumonia Hemolytic anemia
myocarditis
hepatitis
meningoencephalitis
21. S aureus Complicates
influenza
right side endocarditis
pneumatocele
22. C pneumonia (TWAR agent) “adult croup”
copathogen
supportive therapy
23. Aspiration/ Lung Abscess Polymicrobial/ anaerobs
superior segment of lower lobes/ posterior segment of the upper lobe
cavity with ragged inner wall/ thick wall
lung abscess (edentulous)
lung malignancy
chronic aspiration
foreign body
24. Influenza RNA virus type A (more severe) and B
A: amantadine/ rimantadine
A, B: oseltamivir/ zanamivir
Pneumonia: S pneumo, S aureus, G-, H influenzae
25. HIV positive S pneumoniae, H influenzae, P aeruginosa
PCP, TB
26. Hantavirus Rodent
fulminant respiratory failure
high mortality
27. Diagnosis 15% positive blood cultures
sputum G stain
serology fourfold ?
BAL/ bx: HIV/ immunosuppressed patient
28. Therapy Criteria for early oral therapy:
absence of fever x 2 readings
unstable medical illness absent
decline WBC
improving symptoms
29. Cardiopulmonary Disease/ Modifying Factors Present:
IV betalactam with pneumococcal activity+ macrolide
antipneumococcal quinolone (gati, mofloxacin) Absent
IV azuthromycin
quinolone
doxy+ beta lactam
30. Severe CAP +/- P aeruginosa Risks Present:
cipro+ antipneumococcal, antipseudomonal beta lactam
Nonpseudomonal quinolone/macrolide+ beta lactam with antipseudomonal,antipneumococcal activity+aminoglycosid
Absent;
macrolide or quinolone+
beta lactam with antipneumococcal activity
31. Vaccination Pneumococcal vaccination
all patinets> 65
all patients with cardiopulmonary diseases, asplenia, HIV, hematologic malignancy
repeat after 5 years
32. (2) Influenza vaccination:
yearly
unvaccinated patients during influenza outbreak: vaccine+ antiviral for 2 weeks
33. Nosocomial Pneumonia Incidence
10% general surgery
20% mechanical ventilated: 1%/day in the first month
70% ARDS
34. Classification Early onset VAP
the first 4 days of mechanical ventilation
risk: 3% in the first 5 days
Late onset VAP
4 days
Mortality: 50%
35. Risk Factors Patients related
critical illness: septic shock
comorbidity: DM, CRF, COPD, surgery
sinusitis Therapy related:
sedatives
corticosteroids
antacids
cytotoxic meds
enteral feedig
ET tube
nasogastric tube
36. No risk factors/mild-moderate HAP/early severe HAP G - (non pseudomonal)
enterobacter
E colli
Klebsiella
Proteus
MRSA
S pneumonia/ H influenza
37. Risks factors/mild-moderate HAP/early-late HAP core pathogens
anaerobs
S aureus (coma, head trauma, DM, CRF)
Legionella (high dose steroids)
38. Risks factors/ severe HAP/ early- late HAP core pathogens
P aeruginosa
Acinetobacter
MRSA
39. Diagnosis Criteria
new/progressive infiltrate
2 of the following: fever, leukocytosis, purulent sputum
40. No Risks factors/mild-moderate HAP/early severe HAP Core antibiotics
cephalosporin: 2nd generation, nonpseuomonal 3rd generation, 4th generation
beta lactam/ beta lactamase inhibitor
PCN allergy: clinda/ quinolone+ aztreonam
41. Risk factors/ mild-moderate/early late HAP Core antibiotics +
clinda
vanco
42. Severe HAP Cipro or aminoglycoside +
anti pseudomonal pcn
beta lactam/beta lactamase
ceftazidime/ cefoperazone/cefepime
imipenem/ meropenem
aztreonam
+/- vanco
43. Monotherapy Severe HAP not caused by drug resistant organism
Piperacillin/ tazobactam
imipenem
meropenem
cefepime
ciprofloxacin
44. Prevention Prophylactic abx: not a standard of care
adapted ET tube allowing suctioning of supraglotic secretions