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Community Acquired Pneumonia

Community Acquired Pneumonia. Dr. Leena Mane PGY3 Resident Emory Family Medicine. Objectives. Name the common infectious causes of pneumonia in US Discuss the evidence based workup for pneumonia List the criteria for deciding on outpatient vs inpatient vs ICU Rx of pneumonia

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Community Acquired Pneumonia

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  1. Community Acquired Pneumonia Dr. Leena Mane PGY3 Resident Emory Family Medicine

  2. Objectives • Name the common infectious causes of pneumonia in US • Discuss the evidence based workup for pneumonia • List the criteria for deciding on outpatient vs inpatient vs ICU Rx of pneumonia • Name the evidence based antibiotics for treatment

  3. Outline • Epidemiology and etiology • Diagnosis • Admission decision • The workup for C.A.P. • Treatment- what to use, how to use,how long • Recovery

  4. Epidemiology • 7 th most common cause of death in U.S. • 5.6 million cases annually • Annual Health care cost 8.4 billion • Definition- pneumonia not acquired in a hospital or long term care facility

  5. Etiology of C.A.P • No etiology in ~ 50 % • > 2 etiologies in 2-5% • S. Pneumonia in : 2/3 of bacterial cases or 20 % of all cases • H. Influenzae ( non typeable) • Mycoplasma pneumonia • Chlamydia p ~12% • Influenza • Legionella ~ 5%

  6. Atypical Pneumonia • Age (years)- less than 40 • Onset- Gradual, coryzal prodrome • Cough- Paroxysmal, hacking non productive • Sputum- Minimal, mucoid • Rigors- Absent • Fever- Usually less than 39.5 °C

  7. Atypical Pneumonia ctd • Consolidation- Usually absent • Leucocytosis - usually absent • Chest x-ray- Initially interstitial, may progress to air space involvement

  8. Atypical pneumonia

  9. Acute Bacterial Pneumonia • Age ( in yrs) : less than 5, over 40 • Onset : Abrupt • Cough : Productive • Sputum : Rusty & Purulent • Rigors : Frequently present • Fevers : > 39.5° c • Consolidation: present • Leucocytosis : 15- 25,000 with neutrophilia • Chest X-ray : alveolar with air bronchograms.

  10. When To Suspect Which Bug…..

  11. Causes & sign & symptoms • S pneumonia – episodes of rigor, pleurisy, elderly , alcoholic • H. Influenzae -- COPD • M. catarhalis – COPD • Anaerobic -- Putrid Sputum • Influenza -- Winter epidemic • Chlamydia P -- S.T, HA, hoarseness

  12. Causes , Sign & symptoms • PCP -- Immunocompromised patients • Legionella – Severe illness, compromised host, Neg G.S.,organ transplant, outbreaks related with water source. • Mycoplasma P – 2-4 wks of prodrome, dry cough

  13. Cough/dyspnea /fever = CXR EBM – II ( moderate) Diagnosis

  14. Admit or not 2 step decision rules

  15. Step 1 • Assign to risk class I OR • Risk classes II- IV

  16. Risk Class I • < 50 years of age • have none of five co- morbid conditions that increase mortality • Neoplasm • CHF • Renal disease • Cerebrovascular disease • Liver disease

  17. Step approach • If not in class I Go on to Step 2 ( assign to one of classes II- V )

  18. Step 2 • Assess patient’s severity index and assign a score • Demographics • Co- morbidities • P. E. findings • Lab findings

  19. Demographics Characteristics Points Age Male age( in years) Female age ( in years)- 10 Nursing home age ( in years) + 10 Residents

  20. Co- morbidities Diseases Points Neoplasm + 30 Liver disease + 20 CHF + 10 CVD + 10 Renal disease + 10

  21. Physical exam Finding Points AMS + 20 RR> 30 + 20 SBP<90mm + 20 T<35 or > 40 + 15 P> 125 + 10

  22. Laboratory Findings Points Ph<7.35 + 30 Na< 130 + 20 Hct < 30% + 10 PO2< 60 + 10 Pleural effusion + 10

  23. The" whole ‘ Shootin’ Match " Patient Assigned points Demographics Co- morbidities P. E. finding Lab finding

  24. Stratification of Risk Score Risk Initial Treatment Risk class Based on Low Outpatient I Algorithm Outpatient II < 70 points Medium Observation III 71-90 points Inpatient IV 91- 130 point High Inpatient (ICU) V > 130

  25. Other considerations • Psychosocial contraindication to outpatient Rx • Compliance problems • Substance abuse • Cognitive impairment • Poor social support

  26. Risk class mortality Risk class Mortality I 0. 1 % - outpatient II 0. 6 % - outpatient III 2.8 % - inpatient IV 8.2 % - inpatient V 29.2 % - inpatient

  27. P. S. I. • Pneumonia severity index can serve as general guideline for management , clinical judgment should always supersede the prognostic scores.

  28. Sensitivity & Specificity of diagnostics tests Diagnostics Tests Sensitivity Specificity Chlamydia Rapid PCR( sputum) 30-90 >95 Serology( rise in Ab) 10 – 100 - Sputum Cx 10- 80 >95 Gm Neg rods Sputum GM stain 15- 100 11- 100

  29. Sensitivity & specificity ctd Tests Sensitivity Specificity H. Inf, Moraxella Sputum Cx 20- 79 20- 79 Influenza Rapid DFA 22-75 90 Legionella DFA 22- 75 90 PCR 83- 100 >95 Serum acute titer 10- 27 >85 Urinary Ag 55- 90 > 95

  30. Sensitivity & Specificity Ctd Tests Sensitivity Specificity Mycoplasma Antibody Titers 75-95 >90 Cold Agglutinins 50- 60 - PCR 30- 95 >95 Pneumococcal Pneumoniae Chest X-ray 40 - Sputum Cx 20- 79 20- 79 Sputum Gm stain 15- 100 11- 100

  31. Blood Culture • Positive blood cultures had no correlations with severity of disease and outcome • Current ATS guidelines recommend that patient hospitalized for suspected CAP receive two sets of blood cultures. • However are not necessary for outpatient diagnosis

  32. Inpatient work up Inpatient Sputum Cx Level II ( moderate) Bld Cx Level I ( High) BMP Level II LFTs Level II PO2 Level II

  33. Sputum • Level II evidence • Low power exam • Acceptable specimen • < 10 epithelial cells • > 25 PMNs

  34. Normal sputum Moraxella catarrahalis Sputum samples

  35. H. Influezae Klebsiella pneumoniae Sputum Samples

  36. Pseudomonas Strep Pneumoniae

  37. Target etiology Watch for resistance pattern Be aware of co- morbidities Treatment

  38. What to use • Outpatient • Macrolides • Fluroquinolones • Doxycycline

  39. Management of CAP Management of CAP

  40. What to use • Inpatient- • Fluroquinolones alone • Extended spectrum cephalosporins + macrolides Level II evidence

  41. What to Use • ICU patients • One of Cefotaxime, Ceftraixone, amp- sulbactum or pipercillin – tazobactum Plus • One of macrolides or fluroquinolones

  42. Bug & Treatment Pathogen Abx S. Pneumoniae Pen G, amoxicillin fluroquinolones H Influenzae bactrim, cefotaxime, rocephin/carbapenam S. Aureus nafcillin /vancomycin

  43. Bug & Treatment Pathogen Abx Klebsiella carbapenams or 3rd gen cephalosporins Pseudomonas aminoglycoside plus antipse. Penicillins or Ceftazidime Chlamydia Doxy or quinolones Legionella Azithromycin or quinolones Anaerobes Clindamycin

  44. Recovery Symtoms Time period Subjective Response 1-3 days Fever without bacteremia - 2.5 days with bacteremia – 6-7 days

  45. Recovery Symptoms Time period CXR non elderly 30 days older patients 6-8 wks Legionella 12 wks Fatigue non elderly 30- 45 days elderly 90 days

  46. Pneumococcal vaccine Influenza vaccine Prevention

  47. Bibliography • Diagnosis & treatment of CAP- aafp 2006 • IDSA/ATS consensus guidelines on management of community acquired pneumonia in adults

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