intern survival series lecture #6 - the wright center...shaping the future of healthcare | a brief...

Shaping the Future of Healthcare | www.thewrightcenter.org

Intern Survival Series Lecture #6

Most Common Medical Diagnosis: Pneumonia and CHF


Objectives

– Be familiar with the most common primary and secondary diagnosis encountered in medicine

– Be able to appropriately work up and treat various types of pneumonia

– Be able to identify and appropriately treat CHF


A Brief Note • This lecture series is not meant to be all inclusive

or totally comprehensive to all of medicine • It is not meant to supersede clinical judgment • It is not meant to replace daily reading or bedside

teaching • It is meant to act as a starting point for which to

grow from as new primary care physicians • It is a tool to help you survive the your new job


Most Frequent Primary Care, Inpatient Diagnosis

• 1)Pneumonia • 2)Congestive Heart Failure • 3)Osteoarthritis • 4)Coronary Artery Disease • 5)Septicemia • 6)Cardiac Dysrhythmias • 7)Chronic Obstructive Pulmonary Disease


Fastest Growing Inpatient Diagnosis in Medicine

• 1)Acute Renal Failure • 2)Anemia • 3)Diabetes Mellitus • 4)Malaise and Fatigue • 5)Pulmonary Heart Disease


Most Common Secondary Diagnosis

• 1)Hypertension • 2)Hyperlipidemia • 3)Fluid and electrolyte disorders • 4)Coronary Atherosclerosis • 5)Diabetes Mellitus • 6)Anemia • 7)Cardiac Dysrhythmias • 8)Esophageal Disorders


Pneumonia

• 2 Broad Categories – Community Acquired Pneumonia – Health Care Acquired/HA Pneumonia


Community Acquired Pneumonia • Common and potentially serious illness • associated with considerable morbidity and mortality

– particularly in elderly patients and those with significant comorbidities

• There is seasonal variation • Prevalence is greater during the winter months.

• Rates of pneumonia are higher for men than for women

• Bacterial vs Viral • Streptococcus pneumoniae is the most

common cause of pneumonia worldwide


Community Acquired Pneumonia • Diagnostic Approach

– clinical evaluation • Cough • Fever • Pleuritic chest pain • Dyspnea • Sputum production

– chest radiograph – +/- microbiologic testing


Community Acquired Pneumonia

• RADIOLOGIC EVALUATION – The presence of an infiltrate on plain chest radiograph is

considered the gold standard – A chest radiograph should be obtained in patients with

suspected pneumonia when possible – demonstrable infiltrate by chest radiograph or other

imaging technique is required for the diagnosis of pneumonia



• Radiologic Evidence


CAP • If the clinical evaluation does not support pneumonia

in a patient with an abnormal chest x-ray, other causes for the radiographic abnormalities must be considered – Malignancy – Hemorrhage – Pulmonary edema – Pulmonary embolism – Inflammation secondary to noninfectious causes



• Obtaining Microbial Evidence • For outpatients with CAP, routine diagnostic tests are

optional • Hospitalized patients with specific indications should have

blood cultures and sputum Gram stain and culture • Patients with severe CAP requiring ICU admission should

have blood cultures, Legionella/pneumococcus urinary antigen tests, and sputum culture – +/- viral panels (rapid infuenza a&b)


Community Acquired Pneumonia Initial Treatment of non hospitalized patients

with out any significant comorbidities – Empiric treatment is the normal – North American Guidelines Recommend

macrolides or doxycylcline • azithromycin 500mg PO x 1 day then 250mg PO x 4 days • clarithromycin 500mg PO BID x 5-10 days • doxycycline 100mg PO BID x 5-10 days


Community Acquired Pneumonia For non-hospitalized patients with comorbidities

or recent antibiotic use – fluoroquinolone as monotherapy – combination therapy with a beta-lactam plus a

macrolide or doxycycline


Community Acquired Pneumonia For hospitalized patients not requiring intensive care unit admission • Monotherapy with a respiratory fluoroquinolone

• Levaquin most commonly used

• Combination Tx w/ an anti-pneumococcal beta-lactam + macrolide – Cetriaxone, cefotamime, unasyn – PLUS – azithromycin, clarithromycin

• Coverage for drug-resistant pathogens, such as Pseudomonas or methicillin-resistant Staphylococcus aureus (MRSA), should be included in patients with risk factors



Hospitalized patients requiring ICU care – combination therapy with an anti-pneumococcal

beta-lactam – plus either IV azithromycin or a respiratory

fluoroquinolone – plus, if MRSA is suspected, linezolid or vancomycin


Healthcare-associated pneumonia (HCAP)

• Pneumonia that occurs in a non-hospitalized patient with extensive healthcare contact: – Intravenous therapy, wound care, or intravenous

chemotherapy within the prior 30 days – Residence in a nursing home or other long-term care

facility – Hospitalization in an acute care hospital for two or more

days within the prior 90 days – Attendance at a hospital or hemodialysis clinic within the

prior 30 days


Hospital Acquired Pneumonia

• Pneumonia that occurs 48 hours or more after admission

• did not appear to be incubating at the time of admission.


HCAP/HAP

• Workup – Very Similar to CAP

• Clinical Picture • Radiographic evidence • Blood Culture • Urinary Antigens

– Pneumococcal and legionella

• CBC, RFP, virus panels, etc


HCAP/HAP Treatment • Antimicrobial selection should be based upon

risk factors for multidrug-resistant (MDR) pathogens – recent antibiotic therapy (if any) – the resident flora in the hospital – the presence of underlying diseases – available culture data


HCAP/HAP

• For patients with risk factors for multi drug resistant pathogens, empiric broad-spectrum, multidrug therapy is recommended.

• Once the results of pre-therapy cultures are available, therapy should be narrowed based upon the susceptibility pattern of the pathogens identified


HCAP/HAP • Commonly Used Intravenous antibiotic regimens

– levofloxacin 750mg IV daily – piperacillin/tazobactam 4.5 g IV q 6 hrs

• If severely PCN allergic, Aztreonam often substituted

– vancomycin 15-20mg/kg IV q 12 • Can use linezolid in place of vanco if needed


Duration of therapy • De-escalation of therapy should be considered

after 48 to 72 hours • De-escalation should be based upon the

results of initial cultures and the clinical response of the patient

• A short duration of therapy (7 days) is sufficient for most patients with uncomplicated HAP/HCAP who have had a good clinical response


CHF: A Brief Overview


NYHA CHF Classification

• The New York Heart Association (NYHA). • This system assigns patients to one of four

functional classes Class I — symptoms of HF only at activity levels that

would limit normal individuals Class II — symptoms of HF with ordinary exertion Class III — symptoms of HF with less than ordinary

exertion Class IV — symptoms of HF at rest


Evolution of CHF (ACC/AHA)

• Stage A — High risk for HF, without structural heart disease or symptoms

• Stage B — Heart disease with asymptomatic left ventricular dysfunction

• Stage C — Prior or current symptoms of HF

• Stage D — Refractory end stage HF

Stages in the development of HF


Etiology • Systolic dysfunction

– Most common causes: – coronary (ischemic) heart disease – idiopathic dilated

cardiomyopathy (DCM) – hypertension – valvular disease

• Diastolic dysfunction – Most common causes: – Hypertension – ischemic heart disease – hypertrophic obstructive

cardiomyopathy – restrictive cardiomyopathy


Initial Testing #1: H&P for Clinical Signs & Symptoms, followed by……. • EKG:

– Identify evidence of previous MI, structural heart disease

– Identifies any underlying arrhythmias • CXR

– Look for cardiomegally, pulmonary congestion, pleural effusions


Initial Testing • BNP

– useful in distinguishing HF due to systolic/ diastolic dysfunction from other causes of dyspnea

– Most dyspneic patients with HF have values above 400 pg/mL, while values below 100 pg/mL have a very high negative predictive value

– Can also be elevated in pulmonary embolism, A-fib, LV dysfunction without exacerbation, and cor pulmonale

– http://www.nejm.org/doi/full/10.1056/NEJMoa031681 • RFP, CBC, LFTs • Echo

– Appropriate in patients with symptoms or when additional studies point towards cardiac disease


ACEI Treatment ACE INHIBITORS • CONSENSUS TRIAL (1987)

– First trial to demonstrate a mortality benefit of ACEI in CHF.

– All pts were Class IV & ½ were on spironlactone at time of enrollment.

– http://www.nejm.org/doi/full/10.1056/NEJM198706043162301

• SOLVD Trial (1991) – 16% reduction of risk of death in pts w/ EF<35% – http://www.nejm.org/doi/full/10.1056/NEJM1991080132

50501


BB Treatment

Beta Blockers • U.S. Carvedilol Heart Failure Study(1996)

– 1st trial to demonstrate a mortality benefit with betablockade in treatment of CHF

– Treatment with Carvedilol led to 65% lower risk of death compared w/ placebo.

– http://www.nejm.org/doi/full/10.1056/NEJM199605233342101


Diuretic Treatment DIURESIS STATEGY • DOSE(2011): Study designed to compare intermittent high dose bolus vs

continuous infusion of diuretics. Study found no significant difference. • Did illustrate TX strategies commonly used in acute CHF(initial 2x patients

normal PO dose at home. If unsuccessful w/ intermittent bolus, change patients to continuous infusion)

• http://www.nejm.org/doi/full/10.1056/NEJMoa1005419

Aldosterone Blockers • RALES (1999)

Showed mortality benefit in patients with stage III/VI CHF – Of note severe hyperkalemia occured in only 2% of patients – http://www.nejm.org/doi/full/10.1056/NEJM199909023411001

• EMPHASIS-HF (2010) – Demonstrates a 34% risk reduction in the risk of death in patients w CV causes in

patients with NYHA Class II – http://www.nejm.org/doi/full/10.1056/NEJMoa1009492


ICD Treatment

ICD Implantation: • MADIT Trial (1996)/MADIT II(2002)

– I)Showed mortality benefit w ICDs vs medical Tx – II)Showed pts w/ prior MI(>3months) &

LVEF<30%, should receive an ICD to reduce mortality.


Common Treatments of CHF • Beta Blockers

– carvedilol – metoprolol

• ACE Inhibitors – lisinopril – enalapril

• Diuretics – Lasix (furosemide), demadex (torsemide) – spironolactone

• ICD Implantation


• Questions?

intern survival series lecture #6 - the wright center...shaping the future of healthcare | a brief...

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