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

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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


Respiratory Tract Infections


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?


case 1


HPI : 64F with cough, fever x 1 week

O/E : febrile, RR 32


“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


Special Populations


CAP

VAP

HAP

HCAP

HIV

TB

ASPIRATION

AECOPD

case 2


HPI : 64F with cough, fever x 1 week

O/E : febrile, RR 32, LLL crackles

PMHx : nil

Sputum Cultures - Evidence


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

Disposition - Evidence


(1) Pneumonia Severity Index (PSI)

online calculators available

limitations - 20 factors, CAP

Fine, MJ. NEJM, 1997 Jan

curb 65


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


HPI : 64F with L THA


Blood Cultures - Evidence


<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


HPI : 64F diabetic receiving daily foot

wound care at home with cough,

fever x1 week


HCAP RF


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


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


HPI : 28M with cough x 6 weeks,

worsening SOB

O/E : febrile, RR 32

case 7


HPI : 64F alcoholic w cough, fever

x 1 week

O/E : febrile, RR 32, RLL opacity

case 8



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


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


References1. Tintinalli

2. Up To Date

3. EMRAP

4. ATS CAP and HAP Guidelines 2007

hack. these are a few of my favourite respiratory infections

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