pneumonia 2006

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PneumoniaTammy Wichman MD

Assistant Professor of Medicine

Pulmonary-Critical CareCreighton University Medical Center

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The #1 cause of death in the United Statesfrom infectious disease is:

A. Meningitis

B. Pneumonia

C. Gastroenteritis

D. Urinary Tract Infections E. Toe fungus

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Pneumonia

Most deadly infectious disease in the U.S.

6th leading cause of death

Average mortality 14% $20 billion/year in U.S.1

Community acquired pneumonia affects

~4 million patients and results in 10 millionphysician visits, 1 million hospitalizations,and >50,000 deaths annually

1 File Chest 2004; 125:1888-1901

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Pneumonia Pathophysiology

Microbial pathogens enter the lung by: Aspiration of organisms from oropharynx

More common in patients with impaired level of consciousness:alcoholics, IVDA, seizures, stroke, anesthesia, swallowing disorders,NG tubes, ETT

Gram positive and anaerobes: Strep pneumo, H flu, Mycoplasma,

Moraxella, Actinomyces Gram negatives:

• more likely with hospitalization, debility, alcoholism, DM, and advanced age• Source may be stomach which can become colonized with these organisms

with use of H2blockers

Inhalation of Infectious Aerosols Influenza, Legionella, Psittacosis, Histoplasmosis, TB

Hematogenous Dissemination Staph aureus Fusobacterium infections of the retropharyngeal tissues: Lemierre’s

syndrome

Direct inoculation and Contiguous Spread Tracheal intubation, stab wounds

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At the left the alveoli are filled with a neutrophilic exudate thatcorresponds to the areas of consolidation seen grossly with thebronchopneumonia. This contrasts with the aerated lung on the rightof this photomicrograph.

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What is pneumonia?

Infection of the lower respiratory tract

Which of the following is NOT a symptom of pneumonia?

A. Cough

B. Shortness of breath

C. Fever

D. Abdominal pain

E. Chest tightness

F. Confusion

G. Hot, erythematous 1st toe

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Clinical presentation

Pneumonia should be considered in any patientwho has newly acquired respiratory symptoms:cough, sputum production, dyspnea, especially ifaccompanied by fever and abnormal breath

sounds and crackles In elderly or immunocompromised, pneumonia

may present with confusion, failure to thrive,worsening of underlying chronic illness, falling

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Pneumonia Symptoms

“Typical” pneumonia: sudden onset offever, cough productive of purulentsputum, pleuritic chest pain

“Atypical”: gradual onset, dry cough,prominence of extrapulmonary symptoms:headache, myalgias, fatigue, sore throat,nausea, vomiting

Includes diverse entities and has limitedclinical value

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Pneumonia

Which of the following is NOT a sign ofpneumonia?

A. Dullness to percussion

B. Tracheal deviation

C. Bronchial breath sounds

D. Egophany, increased tactile fremitus E. Late inspiratory crackles

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Pneumonia Diagnosis

Radiography: CXR confirm the presence and location of the pulmonary

infiltrate

assess the extent of the infection

detect pleural involvement, pulmonary cavitation, orlymphadenopathy

May be normal when the patient is unable tomount an inflammatory response

(immunocompromised) or is in the early stage ofan infiltrative process (hematogenous S. aureuspneumonia)

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A 64 year old female with DM and HTN isadmitted to 4600 with RLL pneumonia. T 39.3HR 118 R 28 BP 110/60 Sats 92% on 4 L NC.She has crackles in her RLL. You should:

A. Order a sputum gram stain and culture. Waitfor the results before ordering antibiotics. B. Order a sputum gram stain and culture.

Empirically start Ceftriaxone and Azithromycin.

C. Order a sputum gram stain and culture.Empirically start Vancomycin and Zosyn. D. Start Ceftriaxone and Azithromycin.

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Pneumonia Diagnosis

Sputum gram stain and culture: Controversial: no rapid, easily done, accurate,

cost-effective method to allow immediate results Expectorated sputum is frequently contaminated

by oropharyngeal flora Low power magnification to assess squamous

epithelial cells Culture and sensitivity are only accurate if there are

<10 epi’s per low power field

Best results if the specimen contains >25 WBCs perLPF

If patient has a productive cough, send sputumfor gram stain and culture: could be of use indirecting treatment if patient fails to respond to

empiric therapy

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Same patient. What other tests do you want?

Blood cultures.

Urine cultures.

Urine for Legionella antigen. Urine for pneumococcal antigen.

Urine for chlamydia antigen.

HIV test.

Bronchoscopy with culture of respiratorysecretions.

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Pneumonia Diagnosis

Blood cultures are positive in 11% of patientswith CAP, more commonly in patients withsevere illness

Urine antigen assays for L pneumophilaserogroup 1 can be done easily and rapidly.Sensitivity 70% Specificity >90%

Assay for pneumococcal urinary antigen :

sensitivity 50-80% and specificity 90% Responsible pathogen is not defined in as many

as 50% of patients

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In February, a 55yo F with rheumatoid arthritisand chronic bronchitis presents to the office witha cough productive of green sputum, a fever andgeneralized myalgias x 2 days. T 101.6 HR 110R 24 BP 125/80. On exam, she has crackles inher LLL and dullness to percussion. You should

A. Give her a presciption for Azithromycin

B. Check her O2 sats and order a CXR

C. Check her for Influenzae A

D. Order a CBC, BMP, LFTs

E. A, B, and C F. B, C, and D

G. B and C

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Pneumonia Diagnosis

Invasive testing: percutaneoustransthoracic needle aspiration orbronchoscopy are not routinely

recommended. May be helpful in:

• immunocompromised hosts

• suspected tuberculosis in the absence of

productive cough• non-resolving pneumonia

• pneumonia associated with suspected neoplasmor foreign body

• suspected Pneumocystis carinii

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Which of the following findings would indicate anincreased risk of death in patients withcommunity-acquired pneumonia?

A. BUN <8 mmol/L B. Diastolic blood pressure >70 mm Hg

C. Respiratory rate >30 breaths per minute

D. Unilobar lung infiltrate E. PO2 = 65 mm Hg while breathing room air

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Pneumonia

Severity

Index

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Site of Treatment

Class I or II: Outpatient treatment

Class III: Potential outpatient or brief

inpatient observationClass IV and V: Inpatient

Physician decision making: medical and

psychosocial comorbidities, ability to takepo, substance abuse, ability to do ADLs

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All of the following are reasons to admit apatient with pneumonia to the ICUEXCEPT:

A. Need for mechanical ventilation

B. Shock requiring pressors

C. High WBC count with bandemia

D. Decreased urine output

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ICU Admission

Minor Criteria RR>30/min PaO2/FiO2 <250 Multilobar pneumonia Systolic BP <90 Diastolic BP <60

Major Criteria Need for mechanical ventilation

Increase in the size of infiltrates by >50% within 48hrs Septic shock Acute renal failure (uop <80ml in 4 h or serum

Cr>2.0)

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In April, a 45yo F with HTN presents to the officewith fever x 3 days and a cough. T 102.5 HR 95

R 22 BP 130/80 Sats 94% on RA. CXR showsRUL infiltrate.

A. You should check a CBC, BMP, and LFTsand consider admitting her based on the results

B. You should admit her for 24 hour observation

C. You should check for Influenzae A

D. The most likely organisms are Strep

pneumonia, Mycoplasma, Chlamydia, and H. fluand she should be treated with Azithromycin orDoxycycline

Group I: Outpatients

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Group I: OutpatientsNo cardiopulmonary disease

No modifying factorsOrganism:

Streptococcus pneumonia

Mycoplasma pneumonia

Chlamydia pneumoniaHemophilus influenzae

Miscellaneous

Legionella

MycobacteriumFungi

Treatment:

Advanced generationmacrolide(azithromycin orclarithromycin)

OR doxycycline

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All of the following have been identified asrisk factors for community-acquiredLegionella pneumonia EXCEPT:

A. Cigarette smoking B. Chronic pulmonary disease

C. Acquired immunodeficiency syndrome

D. Advanced age E. Chronic illness, including diabetes, liver

disease, and renal disease

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A 68 yo M with DM, HTN, CAD, is admitted tothe hospital with community acquiredpneumonia. He is recently retired from the

insurance industry and has been caring for hisgrandson several mornings a week. He doesn’tsmoke but he does drink 2-3 cocktails everynight. T 101.6 HR 85 R 22 BP 95/60 Sats 92%

on 3L NC. CXR shows an infiltrate in the lingula.He is at risk for

A. Penicillin resistant pneumococus

B. Pseudomonas

C. MRSA

D. Enteric gram negatives

Modifying Factors that Increase the

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Modifying Factors that Increase theRisk of infection with Specific

Pathogens Penicillin-resistant pneumococci Age >65 B-lactam therapy within the past 3 months Alcoholism Immune suppressive illness (including tx with corticosteroids) Multiple medical comorbidities: DM, CRI, CHF, CAD, malignancy,

chronic liver disease Exposure to a child in a day care center

Enteric gram negatives Residence in a nursing home Underlying cardiopulmonary disease Multiple medical comorbidities Recent antibiotic therapy

Pseudomonas aeruginosa Structural lung disease (bronchiectasis) Corticosteroid therapy (>10mg prednisone/day) Broad spectrum antibiotic therapy for > 7 days in past month

Malnutrition

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The mortality rate for patients with nursinghome-acquired pneumonia is:

A. 10%

B. 20%

C. 40%

D. 60% E. 80%

Group II: Outpatient with

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Group II: Outpatient, withcardiopulmonary disease, and/or

other modifying factors Organism:

Strep pneumonia

Mycoplasma

Chlamydia

Mixed infection

Hemophilus influenzae

Enteric gram-negatives

Viruses

Miscellaneous

Moraxella, Legionella,anaerobes, TB, fungi

Therapy:

B -lactam (oralcefpodoxime, cefuroxime,high-dose amoxicillin,

amoxicillin/clavulanate orparenteral ceftriaxone

PLUS

Macrolide or doxycycline

OR

Antipneumococcalfluoroquinolone

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Group III: Inpatients

Organism

Strep pneumonia

Hemophilus influenzae

Mycoplasma Chlamydia

Mixed infection

Enteric gram-negatives

Aspiration Virus

Miscellaneous

Therapy:

1. Intravenous B -lactam:cefotaxime, ceftriaxone,ampicillin/sulbactam,

high-dose amipicillin

PLUS

Intravenous or oralmacrolide or doxycycline

OR

2. Antipneumococcalfluoroquinolone

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A 45 year old female with lupus is admitted tothe ICU with community acquired pneumoniaand septic shock. She was intubated in the ERdue to hypoxemic respiratory failure. Currently,

T 102 HR 125 R 28 BP 90/60 on Dopamine.She should be started on:

A. Vancomycin and Zosyn

B. Levofloxacin

C. Ceftriaxone and Levofloxacin

D. Doxycycline and Gentamicin

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ICU Patients

Organisms:

Strep pneumonia

Legionella

Hemophilus influenzae Enteric gram-negative

bacilli

Staphylococcus aureus

Mycoplasma Respiratory Viruses

Miscellaneous

Therapy:

1. Intravenous B -lactam:cefotaxime, ceftriaxone,ampicillin/sulbactam,

high-dose amipicillin

PLUS either

Intravenous or oralmacrolide or doxycycline

or

Antipneumococcalfluoroquinolone

ICU P ti t ith Ri k f

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ICU Patients with Risks forPseudomonas aeruginosa

1. Selected ivantipseudomonal B -lactam(cefepime, imipenem,meropenem,piperacillin/tazobactam)

PLUS iv antipseudomonalquinolone

OR

2. Selected ivantipseudomonal B -lactamPLUS iv aminoglycoside PLUSeither iv macrolide or ivnonpseudomonalfluoroquinolone

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The organism(s) most commonly found inpatients with nosocomial pneumonia is(are):

A. Aerobic Gram-negative rods

B. Staphylococcus aureus

C. Legionella species

D. Streptococcus pneumoniae

E. Haemophilus influenzae

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Hospital-Acquired Pneumonia

Enteric aerobic gramnegative bacilli

Pseudomonasaeruginosa

Staphylococcus aureus Oral anaerobes

Antipseudomonalcephalosporin (cefepime,ceftazidime) OR

Antipseudomonalcarbepenem OR B -lactam/B -lactamaseinhibitor

PLUS

Antipseudomonal

fluoroquinolone ORaminoglycoside

PLUSVancomycin or Linezolid

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The mechanism thought to account for mostcases of nosocomial pneumonia includes:

A. Inhalation of infected aerosols fromrespiratory equipment

B. Hematogenous spread from another infectedsite outside the lung

C. Spread from a contiguous infected site D. Aspiration of pathogen-laden oropharyngeal

secretions E. Inhalation of infected droplet nuclei from

other patients in the area

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Which of the following has beendemonstrated to reduce the incidence ofnosocomial pneumonia?

A. Nasogastric tubes

B. Enteral feedings

C. Hand washing

D. Isolation of patients with pneumonia

E. Antacids

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Staph aureus

Histoplasma

Legionella

Mycoplasma

Nocardia

TB

Metastasis to skin andCNS

Hyponatremia, AMS,renal and hepaticdysfunction

Night sweats, weight

loss Erythema multiforme,

hemolytic anemia,encephalitis, transverse

myelitis Erythema nodosum

Increased risk afterInfluenzae pneumonia

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The organism most commonly associatedwith life-threatening community acquiredpneumonia is:

A. Streptococcus pneumoniae

B. Legionella pneumophila

C. Klebsiella pneumoniae

D. Pseudomonas aeruginosa

E. Staphylococcus aureus

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Strep pneumonia

Encapsulated lancet shaped diplococcus Causes up to 50% of community acquired

pneumonia

Patients present with acute onset of hard,shaking chills and pleuritic chest pain

Usually have high WBC, however may have verylow WBC if overwhelming infection

Sputum may be rusty colored CXR often shows lobar consolidation

If bacteremic, mortality is 30%

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Drug Resistant Strep pneumonia

Prevalence continues to increase worldwide: PCN resistant 18-22%

macrolide resistant 24-32%

Patients with high level resistance (penicillin MCI>4mg/mL) showed an increased risk ofsuppurative complications

Most common mechanisms of resistance tomacrolides are methylation of a ribosomal targetencoded by erm gene and efflux of themacrolides by cell membrane proteintransporter, encoded by mef gene

Predicting Antimicrobial Resistance

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Predicting Antimicrobial Resistancein Invasive Pneumococcal

InfectionsClinical Infectious Diseases 2005;40:1288-97

3339 patients

Risk factors for penicillin-resistance ormacrolide resistance: antibiotic use (PCN,TMP-SMX, and azithro) in last 3 months

Risk factors for fluoroquinolone resistance:previous use of fluoroquinolones,residence in a NH; nosocomial acquisition

Percentage of Pneumococcal Isolates That Were Nonsusceptible to Various Antibiotics fromChild d T Y f A (P l A) d Ad lt 65 Y f A Old (P l B) ith

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Kyaw, M. H. et al. N Engl J Med 2006;354:1455-1463

Children under Two Years of Age (Panel A) and Adults 65 Years of Age or Older (Panel B) withInvasive Disease, 1999 to 2004

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Clinical Course

Target time for appropriate initiation ofantimicrobials within 4 hours of admission

Fever x 2-4 days

Leukocytosis usually resolves by Day 4 Abnormal physical findings (crackles) persist

beyond 7 d in 20-40%

CXR clears by 4 weeks in 60% patients Delayed resolution with increasing age, multiple

coexisting illness, alcoholism, bacteremia

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When to switch to oral therapy

Oral = iv: doxycycline, linezolid,quinolones

Improvement in cough and dyspnea

AfebrileWBC decreasing

Functioning GI tract

Patient can be discharged home the sameday that clinical stability occurs and oraltherapy is initiated.

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Prevention Recommendations by CDC:

Pneumococcal vaccine: age >65 or ifchronically ill: CHF, COPD, DM, ETOH,cirrhosis, asplenia, long-term care facilities.Revaccinate after 5 years.

Influenzae vaccine: age >65, residents oflong-term care facilities, chronic pulmonaryor cardiovascular disease, hospitalization inthe preceding year, immunosuppression,pregnant women in 2nd or 3rd trimester

during flu season

Patients should be counseled duringhospitalization regarding smoking cessation

Annual Incidence of Invasive Disease Caused by Penicillin Susceptible and Penicillin

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Annual Incidence of Invasive Disease Caused by Penicillin-Susceptible and Penicillin-Nonsusceptible Pneumococci among Children under Two Years of Age, 1996 to 2004

Annual Incidence of Invasive Disease Caused by Penicillin-Nonsusceptible Pneumococci in

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Annual Incidence of Invasive Disease Caused by Penicillin-Nonsusceptible Pneumococci inPersons Two Years of Age or Older, 1996 to 2004

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In immunocompetent adults for whom thepneumococcal vaccine is indicated, theprotection efficacy is:

A. 0%

B. 10%

C. 30%

D. 60%

E. 80%

A 34yo F with JRA presents to the office with a

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A 34yo F with JRA presents to the office with a3 day history of a cough productive of yellowsputum, fever, and myalgias. On physical exam,

she is mildly tachypneic but not in distress T 104HR 115 R 28 BP 105/60 Saturations 94% RA.Physical exam reveals rales in her LLL. She hasdullness to percussion at her left base andincreased tactile fremitus. The next step in hermanagement is:

A. Sputum gram stain

B. Chest radiograph C. Give her a prescription for Augmentin

D. Admit her to the hospital

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What should she be treated with?

A. Vancomycin and Imepenem

B. Keflex

C. Azithromycin

D. Ceftriaxone

E. Levofloxacin

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You should now obtain all of the followinglabs EXCEPT:

A. CBC

B. ElectrolytesC. PT, PTT

D. ABG

E. Sputum culture F. Blood cultures

ABG: pH 7 36 pCO2 42 pO2 50

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ABG: pH 7.36 pCO2 42 pO2 50 Na 134 K 4.3 Cl 95 HCO3 20 BUN 42 Cr 1.4

glucose 145

WBC 18.3 Hgb 10.3 Hct 32 Plt 130 She should be: A. Given a prescription for Azithromycin and

sent home

B. Admitted to the hospital. Start Ceftriaxoneand Azithromycin after she coughs up a sputumsample.

C. Admitted to the hospital. Start Levofloxacin

immediately D. Admitted to the ICU and started on

mechanical ventilation

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A 70yo F resident of a nursing home is evaluated in the

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A 70yo F resident of a nursing home is evaluated in theER due to decreased mental status and hypothermia.She has a history of stroke and is currently taking onlyaspirin. She has been able to eat on her own and there

have been no witnessed aspirations. She has not beentreated recently with antibiotics. WBC 12 Hgb 12Electrolytes are normal and she has mild chronic renalinsufficiency. CXR shows small interstitial infiltrate inRLL. She receives empiric treatment for community-acquired pneumonia. Therapy for which of the followingshould also be considered?

A. Pseudomonas aeruginosa

B. Anaerobic bacteria

C. Enteric gram-negative organisms D. Aspergillus fumigatus

E. Mycobacterium tuberculosis

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A 28yo M presents to the ER withincreasing shortness of breath andsubjective fever and chills. In the ER,

patient is in moderate respiratory distress.T 102 HR 140 R 38 BP 85/55 Sats 80%on RA. Lungs have rales throughout. He

has no peripheral edema. He knows hisname and knows he is in the ER but he isunsure of the date (thinks it is 2003).

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In carefully performed prospective studies on theetiology of community-acquired pneumonia, theorganism most often identified in patients illenough to require hospitalization is:

A. Streptococcus pneumoniae

B. Unknown

C. Chlamydia pneumoniae

D. Mycoplasma pneumoniae

E. Haemophilus influenzae

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In patients with bacteremic pneumonia theorganism most likely to be found is:

A. Staphylococcus aureus

B. Klebsiella pneumoniae

C. Haemophilus influenzae

D. Streptococcus pneumoniae

E. Pseudomonas aeruginosa

A 65 yo M develops bilateral lower lobe

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A 65 yo M develops bilateral lower lobepneumonia and is treated as an outpatient withamoxicillin/clavulanic acid for 72hours. Despite

this treatment, he deteriorates and is admitted tothe hospital. Within 12 hours of admission, hedevelops respiratory failure requiring admissionto the ICU, intubation, and mechanicalventilation. The organism most likely to account

for the severity of disease despite treatment with Augmentin is: A. Moraxella catarrhalis B. Chlamydia pneumoniae

C. Klebsiella pneumoniae D. Legionella pneumophila E. Streptococcus pneumoniae

P i

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Pneumonia

Common infection

Pathophysiology

Clinical presentation

Risk factors for mortality

Treatment

pneumonia 2006

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