Dr.Swati's Presentation on pneumonia management during the 3rd Ask A Doc Dinner

1. Pneumonia
Dr Swati Das
Consultant Pulmonologist

2. Is It Pnemonia?
Clinical Radiological

3.  Pneumonia is an acute infection of lung
parenchyma
 Can be subdivided into different types
according to epidemiological criteria

4. Epidemiological classification of
Pneumonia
 CAP: Community Acquired Pneumonia
 HCAP: Health Care Associated Pneumonia
 HAP or NP: Hospital Acquired Pneumonia
 VAP: Ventilator Associated Pneumonia

5. Incidence of CAP
 Unknown in the most of countries
 5-11/1000 adults in US & UK*
*Eur Respir Mon, 2009, 43, 111–132

6. Pneumonia: a difficult diagnosis ?

7. Mr. SM
 69 years
 Does not smoke (anymore since two years)
 No co-morbids
 Cough since five days
 Coughs up some green phlegm
 Looks unwell

8. Mr. SM
 Pulse 92 reg
 BP 130/90mm Hg
 RR 20/min
 Temp 38.5 C
 Percussion: normal
 Auscultation: some scattered rhonchi

9. Mr. SM
 Diagnosis?
 Acute bronchitis
 Pneumonia
 Exacerbation COPD

10. Aetiology Signs & Diagnosis
Bacterial symptoms Bronchitis
Viral Cough COPD
Tumor Fever Heart failure
Cardiac Crackles Pneumonia
Rales Lung cancer
Nothing specific

11. Searching for the correct diagnosis

12. Questions on diagnosis
 How to detect pneumonia?
 Diagnostic value of signs and symptoms ???
 Additional value of tests?

13. Most important tests

14. Diagnostic models
• Hopstaken et al
•Dry cough, diarrhoea, temp > 38 C
•If all three present: 76% CAP, if none present: 6%
• Diehr et al
•Absence of rhinorrhoea and sore throat, presence of night sweats,
myalgia, sputum all day, resp rate > 25, fever
• Score 1: 9% CAP, score 4, 27%, score 6 100%
• Khalil et al
•Cough, chest pain, shortness of breath, temp>38, heart rate>100,
Not Of help
Resp rate>20, pulse oximetry<95%
•Pos pred value 30%, neg pred value 99%
• Gonzales Ortiz et al
• pathologic auscultation, neutrophilia, pleural pain, dyspnoea
• pos pred value 23%, neg pred value 88%
• Melbye et al
• Absence of coryza and sore throat, presence of dyspnoea, chest pain, crackles
•Pos pred value 17%, neg pred value 79%

15. Additional tests
 Radiological investigations
 Tests to detect bacterial pathogens
 Gram stain, sputum c/s, blood c/s
 Urine test for Streptococcus pneumoniae
sen>70%,specificity>95%,
 Legionella antigen
 Tests to detect viral pathogens
 Test for influenza
 Biomarkers
 CRP
 Procalcitonine/adrenomodulin

16. Site of care ?

17. AD, 50 ys
 Hello doctor, … I’ve got fever and dry cough since two
days
 BP 120/70 HR 88r RR 18’ TEMP 39.0°C
 Breath sound diminished on right base
HOSPITAL ADMISSION?

18. Hospital admission?
1. No, mild clinical syndrome
2. Yes, high fever
3. What about history?
Otherwise healthy man

19. Hospital admission?
1. No, mild clinical syndrome in otherwise healthy man
Pneumonia = 4  medium risk = 10%

20. DFE, 34
• Fever (38.5°C) 2days
• Dry cough 3days
• Physical examination:
Chest x-ray
• non-ill; BP 130/80 HR 96r RR 20’
• rales right lung base
You - his physician –
decide …

21. … to hospitalise him
WHY?

22. History is lacking:
the patient underwent splenectomy 2 years before
He is immunocompromised
at risk for development of severe fulminant sepsis
(especially by S. pneumoniae and H. influenzae)

23. FP, 81 ys
• Fever (37.7°C) started one day before
• non-productive cough
• Non-ill; BP 120/85 HR 90 RR 20’
• Co-morbids-DM, CHF;
What would you do?

24. FP, 81 ys
1. admit to hospital
2. treat him as outpatient
admit to hospital: patient at risk for adverse outcome

26. Pneumonia + age + CHF + DM = 9  complications risk = 31%

27. DA, 63 ys
•Fever (37.9°C) started two days before
• non-productive cough
You - his physician - decide that your patient
is a candidate for hospital admission
Why?

28. DA, 63 ys, otherwise healthy
• Fever (37.9°C) started two days before
• non-productive cough
The speech is interrupted by frequent breaths
Hello doctor I’ve got fever and dry cough since two days
breath breath breath breath breath

29. CRB-65 predicts death from community-acquired pneumonia
•Analysis performed on 1343 patients (208 out-patients and 1135 hospitalized)
with all data sets completed for the calculation of CURB, CRB and CRB-65
•Validated in 1967 patients (482 out-patients and 1485 hospitalized)
Bauer TT et al. J Intern Med. 2006; 260:93-101

30. CURB–65 score
Score one point for presence of each Clinical feature (0 –
5)
1. Confusion
2. Urea > 7 mmol/l
3. Respiratory rate  30/min
4. Blood pressure (SBP <90 or DBP  60mmHg)
5. Age  65yrs
(Albumin < 30 g/dl had an OR 4.7 [2.5-8.7] <0.001)
Lim et al Thorax 2003;58:377-382

31. CURB 65
 0-1=Outpatient
 2=Hospital
 >=3 HDU/ICU

32. RESULTS: Overall 30-day mortality was 4.3% (0.6% in out-patients and 5.5% in hospitalized patients,
p<0.0001). Overall, the CURB, CRB and CRB-65 scores provided comparable predictions for death from CAP
CONCLUSIONS: Both the CURB and CRB-65 scores can be used in the hospital and
out-patients setting to assess pneumonia severity and the risk of death
Given that the CRB-65 is easier to handle, we favor the use of CRB-65 where blood
urea nitrogen is unavailable
Bauer TT et al. J Intern Med. 2006; 260:93-101

33. SCAP score
Major Minor
 RR >30 breaths/min — 9
points
 PaO2/FIO2 <250 mmHg — 6
 Arterial pH <7.30 — 13 points
points
 Systolic blood pressure <90
 BUN >30 mg/dL (10.7 mmol/L)
mmHg — 11 points
— 5 points
 Altered mental status — 5
points
 Age ≥80 years — 5 points
 Multilobar/bilateral infiltrates
on x-ray — 5 points
>=10 severe CAP

34. EMPIRIC TREATMENT?
YES !!!
Based on knowledge….
…..You need to know
 Epidemiology in YOUR area
 Rate of antibiotic resistance in YOUR area
Please do not forget Microbiology work
up……
EVEN IF IT COSTS….

35. Factors in empirical antibiotic choice for CAP
GEOGRAPHY
Spectrum of causative pathogen
Acquired antibiotic resistance
THE PATIENT
Illness severity
Other characteristics (eg age, vomiting)
THE ANTIBIOTIC
Randomised controlled trial
Drug side effects
Cost

36. GEOGRAPHICAL VARIATION IN
(32 prospective studies; n = 8211)
CAP %
0 10 20 30 40
S pneumoniae
H influenzae
Legionella
Staph aureus
GNEB
UK Europe AUS + NZ N America

37. GEOGRAPHICAL VARIATION IN
(32 prospective studies; n = 8211)
CAP %
0 5 10 15 20
M pneumoniae
C pneumoniae
C psittaci
C burnetii
Viruses
UK Europe AUS + NZ N America

38. ANTIBIOTIC THERAPY
S pneumoniae
H influenzae B-lactam
Macrolide
Mycoplasma Tetracycline
Chlamydia Fluoroquinolone
Legionella
Gram-negative
bacteria Cephalosporin

39. ATS/IDSA
INPATIENT – NON-ICU
Fluoroquinolone (strong recommendation; level I evidence)
-lactam + macrolide
(strong recommendation; level I evidence)
Mandell et al Clin Infect Dis 2007;44(Suppl 2):S27-S72

40. ATS/IDSA GUIDELINES
INPATIENT – ICU
-lactam +
Either Azithromycin (level II evidence)
or Fluoroquinolone (strong recommendation; level I evidence)
For Pseudomonas
Anti-pseudomonal -lactam +
Either cipro or levo (level II evidence)
or above -lactam + gentamicin + azithromycin
or above -lactam + antipneumococcal fluoroquinolone
(weak recommendation; level III evidence)
Mandell et al Clin Infect Dis 2007;44(Suppl 2):S27-S72

41. 34 yrs, Chinese; ER visit for fever and blood-tinged sputum

42. Risk factors for TB
Yes/No
IF YES NO QUINOLONES

45. Antibiotic within 6 hours
and oxygen therapy

46. Conclusion
 Clinical assessment
 Know your local epidemiology
 Be aware of national and international
outbreaks
 Never forget Mycobacterium tuberculosis