hack. these are a few of my favourite respiratory infections

HACK.these are a few of my favourite respiratory infections

Brendan MunnEmergency Residents’ Academic DayAugust 13 2009

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Objectives

1. review common respiratory infections

2. myths and just enough EBM

3. provide an approach to the above

4. discuss some cases

5. minimize powerpoint

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Respiratory Tract Infections

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Respiratory Tract Infections

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Approach

1. is this pneumonia?

2. what tests should i order?

3. is this pneumonia special?

4. what f*ing antibiotic(s?) should i start?

5. should this patient be admitted?

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case 1

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HPI : 64F with cough, fever x 1 week

O/E : febrile, RR 32

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“Does this patient have Community Acquired Pneumonia? Diagnosing Pneumonia by History and Physical Examination”

Metlay JP, Kapoor WN, Fine MJ.

JAMA. 1997 Nov 5;278(17):1440-5.

NO specific symptoms for dx pneumonia

NO fever, tachypnea, tachycardia is Sn

Special Populations

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Special Populations

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CAP

VAP

HAP

HCAP

HIV

TB

ASPIRATION

AECOPD

case 2

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HPI : 64F with cough, fever x 1 week

O/E : febrile, RR 32, LLL crackles

PMHx : nil

Sputum Cultures - Evidence

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only 20% yield

no correlation C&S with gram or with BC

misses atypicals

nosocomial risk

does not change antibiotics or outcome

ATS07 guidelines : for all “complicated”Roson B, Clin Infect Dis

2000

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Disposition - Evidence

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(1) Pneumonia Severity Index (PSI)

online calculators available

limitations - 20 factors, CAP

Fine, MJ. NEJM, 1997 Jan

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curb 65

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C Confusion

U Uremia >7mmol/L

R Respiratory Rate > 30

B BP > 90 (S) or >60 (D)

65 Age >65

Lim, WS. Thorax, 2003 May

case 3

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HPI : 64F with L THA

O/E : febrile, RR 32, LLL crackles

Blood Cultures - Evidence

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<10% yield in CAP

50% false positive in ED

only 2% positive once antibiotics

limited data for inpatient if immune N

ATS07 guidelines : for all “complicated”

Corbo J, BMJ 2004

case 4

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HPI : 64F diabetic receiving daily foot

wound care at home with cough,

fever x1 week

O/E : febrile, RR 32, LLL crackles

HCAP RF

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hospitalization >2d in preceding 90 days

long-term care facilit resident

home infusion or wound care therapy

chronic dialysis

family member with drug resistant bug

MDR RF

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Antibiotics within the preceding 90 days

Current hospitalization of ≥ 5 days

High frequency of antibiotic resistance in the community or in the specific hospital unit

Immunosuppressive disease and/or therapy

Presence of risk factors for HCAP

case 5

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HPI : 28M with cough x 6 weeks,

worsening SOB

O/E : febrile, RR 32

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case 7

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HPI : 64F alcoholic w cough, fever

x 1 week

O/E : febrile, RR 32, RLL opacity

case 8

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Review1. is this pneumonia?

hx/phys poor, gestalt and a monkey, CXR

2. what tests should i order?good empiric abx > sputum and blood cx

3. is this pneumonia special?know your categories and risk factors

if VAP/HCAP/HAP evaluate MDR risk

always consider HIV, TB

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Review

4. what f*ing antibiotic(s?) should i start?empiric coverage of common organisms

5. should this patient be admitted?use the PSI

or at worst use CURB65 and feces

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References1. Tintinalli

2. Up To Date

3. EMRAP

4. ATS CAP and HAP Guidelines 2007