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Pneumonia SAHD

Pneumonia SAHD. Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists June 2009. Four Cases Case 1:. Case 1:. 67F, presents to A&E PC: SoB, increasing 3/7. Chest pain. Productive cough. PMH: RA on methotrexate, steroids. SH: Lives at home, ex-smoker.

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Pneumonia SAHD

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  1. Pneumonia SAHD Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists June 2009

  2. Four CasesCase 1:

  3. Case 1: • 67F, presents to A&E • PC: SoB, increasing 3/7. Chest pain. Productive cough. • PMH: RA on methotrexate, steroids. • SH: Lives at home, ex-smoker. • No allergies • o/e: P 100, RR 30, BP 170/70, T 38.5C • Coarse creps L base/mid, reduced AE on L

  4. Management ?Infection - pneumonia • Diff Diagnoses? • Investigations? • Admit? • Treatment? ?PE ?CCF ?Ca ?Others Blood samples Imaging Microbiology samples CURB-65 score Supportive Rx Specific Rx

  5. Blood tests • Test Result Unit Ref Range Abnormal • WBC 22.68  x10^9/l  4.00-11.00  H  • Hb 12.0  g/dl  12.0-15.0   • Plt 397  x10^9/l  140-400 • Neut 19.98  x10^9/l  2.00-7.00  H  • Lymp 0.95  x10^9/l  1.00-3.00  L  • C-Reactive Protein 253  mg/L  < 11  H  • Urea 18.8 mmol/l 2.6-6.6 H • Creatinine 269 umol/l 50-90 H • Other markers (LFT, TFT, Glucose, Ca2+) normal

  6. CXR

  7. CURB-65 >11 mmol/l

  8. Case 1: Summary • Pneumococcal pneumonia / bacteraemia • Predisposition • smoker / RA / steroids / Mtx / age • Investigations • Severity score • CURB-65 • Appropriate empirical antibiotics • Appropriate targeted antibiotics • Pneumococcal vaccine

  9. Case 2:

  10. Case 2: • 58 M, presents to A&E • PC: Cough, SoB, Headache, Diarrhoea. • PMH: Nil • History: • o/e P 90, BP 95/55, RR 26, T 37.4C • R basal creps. Smokes 40/day Tenerife 10 days ago Demolition worker Pigeon fancier

  11. Management ?Infection: (holiday / pigeons) • Diff Diagnoses? • Investigations? • Admit? • Treatment? ?Asbestos ?Ca ?Others Blood samples Imaging Blood culture Atypical serology Microbiology samples Legionella Ag CURB-65 score Supportive Rx Specific Rx

  12. Blood tests • Test Result Unit Ref Range Abnormal • WBC 12.92  x10^9/l  4.00-11.00  H  • Hb 15.4  g/dl  12.0-15.0   H • Plt 284  x10^9/l  140-400 • Neut 8.42  x10^9/l  2.00-7.00  H  • Lymp 1.74  x10^9/l  1.00-3.00    • C-Reactive Protein 123  mg/L  < 11  H  • Na128 mmol/l 135-143 L • K4.4 mmol/l 3.7-5.0 • Urea 12.4 mmol/l 2.6-6.6 H • Creatinine 108 umol/l 50-90 H • ALT 105 U/l 5-38 H • Bilirubin19 umol/l 3-20

  13. Case 2: • Switch to recommended antibiotics: • Erythromycin 500mg qds AND • Rifampicin 600mg bd • 14-21 day course. • Don’t forget to inform: • Public Health team

  14. Case 2: Summary • ‘Atypical’ pneumonia – Legionella • History • Travel, occupation, smoking, animals • Diarrhoea, hyponatraemia • Investigations • Severity score • Appropriate treatment • Public health

  15. Case 3:

  16. Case 3: • 55F, admitted via A&E • PC: SoBoE, worsened over 3/7 • PMH: Asthma, Emphysema • 80 pack year hx, EtOH ++ • Penicillin allergy > Rash • Meds: ‘inhalers – a blue one’ • o/e RR 22, T 37.5C, P85, BP 110/75 • Cyanotic, tar stains, accessory muscle use • Chest wheezy, crackles throughout

  17. Case 3: • Steroids • Oxygen, BiPAP • Salbutamol / Ipratropium nebs • Considered for home Oxygen • Discharged home • Flu / pneumococcal vaccines

  18. Complement Fixation Tests(Atypical serology) Antigen Acute Convalescent Influenza A <1/16 1/16 Influenza B 1/16 1/16 Adenovirus <1/16 1/256 Coxiella <1/16 <1/16 Chlamydia 1/16 1/16 Mycoplasma <1/16 <1/16

  19. Case 3: Summary • Patient with COPD and exacerbation • Often no bacterial infection present. • Pneumonia needs to be excluded • CFTs / Atypical serology of some help • Retrospective diagnosis • Appropriate antibiotics • Vaccines for at-risk patients

  20. Case 4:

  21. Case 4: • 83M, admitted 3 weeks ago • Run over on pelican crossing • SAH, multiple #s • Admitted to GCC, deteriorated • Needing more inotropes • Worse saturations, increasing oxygen req. • T 37.8, BP 100/60, WCC rising. • Recently had 10/7 of co-amoxiclav and gentamicin for ?UTI

  22. Blood cultures Respiratory sample Microbiology samples

  23. Recent antibiotics, so d/w microbiology. Meropenem / gentamicin started

  24. May represent line infection / colonisation only

  25. Case 4: • Central line (10 days old) • Changed for a new line • Single dose of vancomycin 1g • Meropenem 1g tds • 5/7 Rx • Improved slowly • Never able to tolerate weaning off ventilator.

  26. Case 4: Summary • Severe hospital-acquired pneumonia • Predispositions • ITU, ventilator, lying flat, head injury • Complicated antibiotic history • Misuse of antibiotics lead to resistant organism • Complicated resistant organisms • Discuss with microbiology

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