pneumonia, empyema, and tb meira louis margriet greidanus
TRANSCRIPT
Pneumonia, Empyema, and TB
Meira LouisMargriet Greidanus
Format for Today
• Group work x 30 minutes (3 groups)• Cases as a large group– Case I: Community Acquired Pneumonia– Case II: Health Care Associated Pneumonia– Case III: Para-pneumonic effusion– Case IV: TB
• Questions
Pneumonia
Case I
43 year old male, previously healthy- Cough x 6 days, productive of green sputum- Febrile x 4 days- Now feeling progressively more SOB- No home meds, no allergies
38.0 115 18 130/75 94% ORA
In-patient vs Out-Patient?
PORT score
CURB-65
Do they work?
What tests?
Which bugs?
Which drugs? outpatient
Which drugs? inpatient
Same as outpatient with
comorbidities!
Which drugs? ICU
Same as outpatient with
comorbidities!
Drugs and special populations
So, when do I worry about the extra coverage?
Time to antibiotics
5Length of antibiotics?
Other things to think about...
Case II
63 yo male, history of COPD, DM, HTN, CHF- Cough x 3 days, productive of yellow sputum- Febrile x 4 days- Now feeling progressively more SOB- Meds: Lasix, ASA, ramipril, insulin- Hospitalized x 5 days for COPD (6 weeks ago)
38.2 83 26 105/64 93% ORA
VS
What’s different about HCAP?
What makes a patient riskier?
• An antipseudomonal cephalosporin or β-lactam (cefepime, ceftazidime, pip-tazo)
• Plus a fluoroquinolone (ciprofloxacin, levofloxacin) • Plus an agent active against MRSA (linezolid or vancomycin)
Empiric Antibiotics for HCAP?
=fluoroquinolone or azithromycin
Para-Pneumonic Effusions
Case III
45yo female, mild HTN, hyperlipidemia- Unwell x few weeks, episodic fevers, cough- Sent in by GP to r/o PE as completed full
course of Azithromycin with no improvement.- Progressive SOB and chest pain
36.5 105 20 145/82 91% ORA
What is it?
When should it be suspected?
How to image?
To treat or not to treat?
So, I poked it, does that help?
When does the pH lie?
If I need to drain, does tube size matter?
TB
Case IV
29yo male, previously healthy- Recently returned from India after 6 month
visit (immigrated several years ago)- Unwell x few weeks, episodic fevers, weight
loss- Completed course of Levofloxacin, no change
37.5 115 22 120/82 92% ORA
Primary TB vs Reactivated TB
10
So, what am I looking for?
Complications of TB
Extra Pulmonary Complications
Neuro
GU
MSK
Cardiac
Renal
GI
Where is the money? CXR!
Primary TB
Ranke
Ghon
Tuburculoma
Milliary
Post Primary TB
All that cavitates...
Treatment!
PIRES
Questions?