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Community-Acquired Pneumonia Nilesh Patel, D.O. October 8, 2008 St. Joseph’s Regional Medical Center Emergency Medicine Conference Objectives Epidemiology Pathophysiology Signs/Symptoms Diagnostics Treatments Disposition Questions we will answer… What is the definition of CAP? What are the most common organisms in CAP? Do blood cultures affect management? What is the optimal timing of antibiotic therapy in CAP? What are the antibiotic choices for CAP? What are the admission criteria? Who can go home? Other Next hour… – Atypical pneumonias – Viral pneumonias – PCP/Other fungal pneumonias What we will not talk about… – Pediatric pneumonias – HAP/HCAP Community-Acquired Pneumonia (CAP): Definition Infection of pulmonary parenchyma Pneumonia acquired in the community – Excludes hospitals (HAP) – Excludes extended care facilities (HCAP) – Typical – Atypical Epidemiology 4 million cases/year in U.S. 600,000 - 1 million hospitalizations 12 cases per 1,000 adults/year 6th leading cause of death in U.S. Leading cause of death due to infectious cause Mortality ranges from 1-20% Mortality increased in certain populations Pathophysiology Aspiration of oropharyngeal organisms Inhalation of infected aerosols Hematogenous spread from extra- pulmonary sites Contiguous spread Direct inoculation Pathophysiology Lobar pneumonia Interstitial pneumonia Bronchopneumonia Multi-lobar pneumonia Cavitary pneumonia Necrotizing pneumonia Lung Abscess Pathophysiology TYPICAL Organisms – Streptococcus pneumoniae – Haemophilus influenza – Streptococcus pyogenes – Klebsiella pneumoniae – Moraxella catarrhalis – Staph aureus – Enterobacteriaceae/Gram negative bacilli Anaerobic organisms (aspiration) – Fusobacterium sp. – Prevotella sp. – Bacteroides sp. Pathophysiology ATYPICAL Organsims – Mycoplasma pneumoniae – Chlamydia pneumoniae – Chlaymida sp. – Legionella sp. – Respiratory viruses – Others Pathophysiology Strep pneumo Strep pneumo Gram positive lancet-shaped, encapsulated diplococcus “Most common cause of CAP” Multiple serotypes High mortality if untreated >> Sepsis Strep pneumo Signs/Symptoms – Abrupt onset/ill appearance – Cough (rust colored sputum) – Fever/Chills – Chest pain/SOB – Tachypnea/Tachycardia CXR – Lobar infiltrate – Bulging fissure Treatments – PCN – Cephalosporin Strep pneumo H flu H flu Gram negative pleomorphic rods Encapsulated/Unencapsulated forms Serotypes a-f “2nd most common cause of CAP” Common pathogen in COPD patients May also lead to sepsis H flu Signs/Symptoms – Immunosuppresed/Debilitated patient – Productive cough – Fever – Chest pain – SOB CXR – Patchy alveolar infiltrates Treatment – Cephalosporins – Augmentin – Macrolide (Azithromycin) H flu H flu H flu Symptoms/Signs (Typicals) Productive cough Shortness of breath Chest pain Subjective fever/chills N/V Back pain Abdominal pain Abnormal VS Rales/Rhonchi/Wheez Decreased breath sounds Dullness to percussion Increased tactile fremitus Bronchial breath sounds Egophany Symptoms/Signs (Atypicals) Dry Cough +- Abnormal VS Chest pain/SOB Rales/Rhonchi/Wheez Extra-pulmonary symptoms; Constitutional symptoms – – – – N/V/D Headache Myalgias Fatigue Symptoms/Signs American Journal of EM 2006: 25, 631-36 – Retrospective, multi-center – 421 patients diagnosed with CAP – VS abnormalities were most significant predictors of CAP – Hypoxia had strongest association – Greater # of VS abnormalities >> Higher prevalence of CAP – Age also significantly associated with CAP Diagnostics Labs – CBC – BMP Imaging – CXR – CT scans Cultures – Blood – Sputum Other tests – ABG/EKG – Urine antigen tests Diagnostics IV Oxygen Monitor (pulse ox) Diagnostics: WBC count WBC count – Normal count does not r/o pneumonia – Elevated/Decreased >> Bacterial pneumonia – Look for Left Shift! Diagnostics: CXR Findings – Infiltrates – Pleural effusions – Abscess’/Cavities – Bulging fissures – Atelectasis – Air bronchograms Other findings – PTX – Pleural thickening/Scarring – Pulmonary edema – Lymphadenopathy/Masses Diagnostics: CXR Normal CXR – Immunocompromised – Dehydrated – Early infection American Journal of Medicine Sept. 2004: 117, 305-11 – – – – 2706 patients 911 patients with pneumonia and (–)CXR These patients were older, increased co-morbidities These patients had similar rates of + sputum/blood cultures – These patients had a similar mortality Diagnostics: CXR Respiratory Medicine May 2006: 100, 926- 32 – 192 patients with pneumonia – Excellent IR for lobes involved, extent of infiltrate, pleural effusion – Poor IR for pattern of infiltrate – Minimal relation found between cultured pathogens and radiologic features of infiltrate on CXR Diagnostics: CT scan CT scan – Alternative diagnoses – Unresolved cases – Complications suspected – Concerning CXR – Treatment failure Diagnostics: Cultures Sputum gram stain/culture – Change antibiotic therapy – Unusual pathogens/antibiotic resistance issues – Do not change antibiotics/outcomes – Cost – Process issues Sputum cultures? – Are sputum cultures useful in ED? – Are sputum cultures useful in ICU? – Do antibiotics affect yield of sputum? Diagnostics: Cultures Sputum cultures: Recommendations – Outpatient • Optional – Inpatient • Optional • Recommended when result may change therapy – Recommended • • • • • • • ICU admission/Severe CAP Failure of outpatient therapy Cavitary infiltrates (suspect TB) Alcoholism Severe COPD Pleural effusion Positive urinary antigen for Legionella/Strep pneumo Diagnostics: Cultures Blood Cultures – Yield pathogen 5-15% – Blood cultures often do not change management – Most commonly isolated organism…Strep pneumo – High false positive rate – Yield of blood cultures decreased by 50% by prior antibiotic therapy – Optional – Recommended • • • • Severe CAP Immunodeficient states (asplenia, liver disease, HIV) Indications for sputum cultures Chest 2003 Diagnostics: Cultures Blood Cultures – Chest 2003: 123, 1142-1150 – Emergency Medicine Journal 2003: 20, 521-23 – Emergency Medicine Journal 2004: 21, 446-48 – Academic Emergency Medicine June 2006: 13, 740-45 – Journal of Emergency Medicine July 2007: 33, 1-8 Treatments Supportive therapies Antibiotics (outpatient/inpatient) ICU therapies Antibiotic resistance Timing to antibiotics (6 hours) Treatments Annals of Emergency Medicine July 2001: 38, 107-113…”Clinical Policy for the Management and Risk Stratification of CAP in Adults in the Emergency Department” – www.acep.org Clinical Infectious Disease March 2007: 44, S27- 72…”Infectious Disease Society of America/ATS Consensus Guidelines on the Management of CAP” Treatments: Basics/Supportive ABCs IV/Oxygen/Monitor Albuterol nebulized BIPAP Intubation IVF Steroids Treatments: Antibiotics Empiric Antibiotics – Based on most likely pathogen – Local antimicrobial resistance patterns – Antibiotics recommended by class Pathogen specific Antibiotics – Consider specific risk factors Treatments: Antibiotics Outpatient Healthy patients – MACROLIDE (Zithromax, Clarithromycin) – DOXYCYCLINE Co-morbid patients – BETA LACTAM + MACROLIDE – FLUOROQUINOLONE (Avelox, Levaquin) Treatments: Antibiotics Inpatient FLUOROQUINOLONE (Levaquin, Avelox) BETA LACTAM + MACROLIDE (Ceftriaxone/Cefotaxime + Zithromax) Treatments: Antibiotics Inpatient, ICU BETA LACTAM (Ceftriaxone/ Cefotaxime/Unasyn) + Either MACROLIDE or FLUOROQUINOLONE PCN allergic: AZTREONAM + FLUOROQUINOLONE Pseudomonas – ZOSYN, CEFEPIME, IMIPENEM, MEROPENEM + FLUOROQUINOLONE OR MACROLIDE + AMINOGLYCOSIDE CA-MRSA – Add VANCOMYCIN or LINEZOLID Treatments: Antibiotics Anaerobic coverage – Not needed in majority of CAP cases – Indications • • • • • Classic aspiration syndromes LOC Drug/ETOH overdose Seizure Hx of gingival disease/Esophageal dysmotility – Antibiotics • CLINDAMYCIN or FLAGYL Treatments: Antibiotic Resistance Drug-resistant Strep pneumo (DRSP) Community-acquired Methicillin resistant Staph aureus (CA-MRSA) Timing to Antibiotics “Lots of Press”…JCAHO/CMS JAMA 1997 – Decreased mortality in patients > 65 y/o antibiotics within 8 hours Archives of IM 2004 – Decreased mortality antibiotics within 4 hours 2008??? Timing to Antibiotics Chest March 2007: 131, 1865-69 Annals of EM: May 2007: 49, 553-59 Annals of EM: May 2007: 49, 561-63 Clinical Infectious Disease March 2007: 44, S27- 72 – “Do not recommend a specific time window for delivery of first antibiotic dose” ACEP News July 2007…”Studies Challenge 4- Hour Antibiotic Guideline for CAP” Timing to Antibiotics Physician…Antibiotics should be administered as soon as possible once CAP is diagnosed/considered likely JCAHO…Antibiotics within 6 hours for CAP Disposition WHO STAYS…WHO CAN WE DISCHARGE??? NEJM January 1997: 336, 243-50 – PORT cohort study – Prediction rule derived in 14,000 patients – Prediction rule validated in 40,000 patients – Predicts patients with increased 30 day mortality – Helps ER physicians with admission/discharge decisions – PNEUMONIA SEVERITY INDEX (PSI) Disposition CURB-65 criteria (British Thoracic Society)….1,068 patients – – – – – Confusion Uremia Respiratory rate Blood pressure (low) > 65 y/o CAP 2008 Epidemiology of CAP has remained stable Typicals and atypicals—the lines are blurred Patient risk factors Diagnostics – – – – WBC count Sputum cultures Blood cultures Urine antigen tests CAP 2008 Treatment – – – – Outpatient (healthy, co-morbid) Inpatient Inpatient (ICU, risk factors) HAP, HCAP (ask the ?’s) ED treatment considerations – Empiric coverage – Blood cultures prior to antibiotic therapy – Antibiotics in 6 hours Drug resistance – DRSP, CA-MRSA Summary Epidemiology – Common problem Pathophysiology – Strep pneumo most common – Typicals/Atypicals Signs/Symptoms – Cough (productive, nonproductive) – SOB/cp – Fever – Abnormal VS – Abnormal lung exam Summary Diagnostics – CXR with infiltrate – Sputum GS/cultures – Blood cultures Treatments – ABC – IV/O2/Monitor – Antibiotics Disposition – PSI, Curb-65 criteria