pneumonia in adults.2013

8/20/2019 Pneumonia in Adults.2013

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How Do I Think AboutPneumonia?

Resident’s Thursday School

07!"!0#$

% Rush Pierce %r& 'D& 'PH

Di(ision o) Hos*ital 'edicine&+,'


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-utline

• Re(iew resources

• .ase based discussion that will

co(er – Dia/nosis

– Treatment

• ased on – IDSAATS .AP 1!0072 /uidelines

– H.AP3APHAP 1!00"2 /uidelinesHow Do I Think About Pneumonia?07!"!0#$ !


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Resources

• 4uidelines a(ailable

– +,'H site 1htt*s5hos*itals6health6unm6eduintranetInde6c)m 2

– IDSA website 8 /uidelines a(ailable )or download toPalm or iPhone 1htt*5www6idsociety6or/.ontent6as*?id9:0;; 2

• +*


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07!"!0#$ >How Do I Think About Pneumonia?


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.ase #

• " yo male smoker has ! days o) chills&dys*nea& and *urulent s*utum6 He has no risk)actors )or HI3& donates blood $year 1mostrecently one month a/o2 and does not take any

medications6 T 9 $;6#& P 9 ##00& HR 9 :"&RR 9 !0& Sa-! 9 ;:@ RA6 amination showsno abnormalities6 .BR is read as Cminimalstreakin/ at lun/ bases& atelectasis (s6 early

*neumonia• Should I treat with antibiotics?

07!"!0#$ How Do I Think About Pneumonia? "


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07!"!0#$ How Do I Think About Pneumonia?


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Does this *atient ha(e*neumonia?

• H5

• P5 3S most use)ul in *redictin/ se(erity• .BR is /old standard < may be normal in u*

to 7@ on admissionE assume *neumonia*resent i) con(incin/ h and )ocal P

• Sus*ected *neumonia with ne/ .BR 8consider )u .BR or .T 1more sensiti(e2

How Do I Think About Pneumonia?07!"!0#$ 7

Sensitivity Specifcity

Fe(erchills ;"@

Dys*nea 70@

Purulents*utum

"0@

Any o) abo(e 70 8 :0@ >0 8 "0@


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Thinkin/ about *neumonia5 >ste*s

#6 Put into initial clinical classiGcation

!6 Decide site o) care$6 Tests )or etiolo/y

>6 Initial em*iric thera*y

How Do I Think About Pneumonia?07!"!0#$ ;


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Ste* #5Initial clinical classiGcation

#6 'aor immunodeGciency

!6 Tuberculosis 1sus*ected or established2

$6 Relati(ely normal hosts without T1location at time o) in)ection2

• .ommunity


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.ase !

• "" yo homeless man )rom 'eico has !days o) chills& ni/ht sweats& dys*nea& and*urulent s*utum without hemo*tysis6 He

has not lost wei/ht6 He has no risk)actors )or HI3& takes no medications& andis not diabetic6 am re(eals T 9 $;6#& P9 ##00& HR 9 :"& RR 9 !0& Sa-! 9

;:@ RA& crackles at the ri/ht base6

• Should I order airborne isolation?

07!"!0#$ How Do I Think About Pneumonia? #0


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07!"!0#$ ##How Do I Think About Pneumonia?


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hen to sus*ect T1Intern Sur(i(al 4uide2

• I) two or more ss

– Hemo*tysis

– .ou/h J ! weeks

– ,i/ht sweats

– t loss J #0 K in $ mos

• I) sus*icious .BR 1anyo) these2

– +**er lobe inGltrates

– 'iliary *attern

– .a(itary lesions

– ,odular inGltrate

Res*onse to sus*ected T

-rder airborn isolation and.BR

-rder AF smears& cultures1does not ha(e to be =A'L2

How Do I Think About Pneumonia?07!"!0#$ #!


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• .ommunity


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.AP (s H.AP3APH.AP

• Healthcare


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.ase !

• The *atient has ne(er beenhos*italiOed& resides at home& doesnot take dialysi& has not recei(ed

chemothera*y& and his s*ouse hasnot been sick

07!"!0#$ How Do I Think About Pneumonia? #"


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• .ommunity


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How Do I Think About Pneumonia?07!"!0#$ #7


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.ase $

• " yo male smoker has ! days o) chills&dys*nea& N *urulent s*utum6 ,osi/niGcant P'H6 He has )elt and eaten*oorly6 T 9 $;6#& P 9 ##00& HR 9 :"&RR 9 !0& Sa-! 9 ;:@ RA& crackles at theri/ht a*e6 He is not con)used6 . 9#"& HH 9 #>6">!& ,a 9 #!;& 9 $6"& .l

9 #0"& .-! 9 !06 +,creat 9 $!#6>6.BR shows R+M inGltrate6

• .an I send this *atient home?

07!"!0#$ How Do I Think About Pneumonia? #;


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www6meddean6luc6edu07!"!0#$ #:How Do I Think About Pneumonia?


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07!"!0#$ !0How Do I Think About Pneumonia?


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Pneumonia Se(erity Inde1PSI2

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.+R


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I.+ admission 9 one maor or $ minor

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How Do I Think About Pneumonia?07!"!0#$ !>


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.ase $ < continued

• " yo male smoker has ! days o) chills&dys*nea& N *urulent s*utum6 ,osi/niGcant P'H6 He drinks alcohole(eryday6 T 9 $;6#& P 9 ##00& HR 9 :"&RR 9 !0& Sa-! 9 ;:@ RA& crackles at theri/ht base6 He is not con)used6 . 9#"& HH 9 #>6">!& ,a 9 #!;& 9 $6"& .l

9 #0"& .-! 9 !06 +,creat 9 $!#6>6.BR shows R+M inGltrate6

• hat etiolo/ic tests do I order?

07!"!0#$ How Do I Think About Pneumonia? !"


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07!"!0#$ !How Do I Think About Pneumonia?


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Dia/nostic tests )or etiolo/y

• hy not etiolo/ic tests )or e(eryone?

• -ut*t 8 4et Sa-!E Routine tests )oretiolo/y are o*tional

• In*t < lood and s*utum culturesrecommended )or most 1but not all2

• I.+ < blood and s*utum cultures& andMe/ionella and *neumococcal +AT

How Do I Think About Pneumonia?07!"!0#$ !7


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How Do I Think About Pneumonia?07!"!0#$ !;


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How Do I Think About Pneumonia?07!"!0#$ !:


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How Do I Think About Pneumonia?07!"!0#$ $0


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.ase >

• !> yo *re(iously healthy )emale has! days o) chills& dys*nea& N *urulents*utum6 ,o si/niGcant P'H6 T 9

$;6#& P 9 ##00& HR 9 :"& RR 9!0& Sa-! 9 :!@ RA& crackles at theri/ht base6 .,. and .hem 7

normal6 .BR 9 early RMM *neumonia• hat antibiotics should I order?

07!"!0#$ How Do I Think About Pneumonia? $#


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07!"!0#$ $!How Do I Think About Pneumonia?


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m*iric R o) out*atient.AP

• Healthy and no antibiotics in *ast $ months – 'acrolide -R doycycline

• I) cardio*ulmonary dO& eta


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-ut*atient RB o) .AP

• .andidates )or out*t thera*y

– Mow PSI or .+R


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.ase $ < continued

• " yo male smoker has ! days o) chills&dys*nea& N *urulent s*utum6 ,osi/niGcant P'H6 He has )elt and eaten*oorly6 T 9 $;6#& P 9 ##00& HR 9 :"&RR 9 !0& Sa-! 9 ;:@ RA& crackles at theri/ht base6 He is not con)used6 . 9#"& HH 9 #>6">!& ,a 9 #!;& 9 $6"& .l

9 #0"& .-! 9 !06 +,creat 9 $!#6>6.BR shows R+M inGltrate

• hat antibiotics do you order?

07!"!0#$ How Do I Think About Pneumonia? $"


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07!"!0#$ $How Do I Think About Pneumonia?


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m*iric R o) in*atient .AP 8 nos*ecial considerations

• In*atient 8 ward5

– res*iratory =uinolone

-R

– 1ce)triaone or ce)taOidime2 1aOithro ordoy2

• I.+ 8

– 1ce)triaone or ce)taOidime2 1I3 aOithro orres*iratory =uinolone2

– I) P., aller/ic use aOtreonam res*iratory=uinolone

How Do I Think About Pneumonia?07!"!0#$ $7


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m*iric in*atient R o) .AP 8s*ecial considerations

• Pseudomonas – su//esti(e /ram stain& bronchiectasis& )re= eacs o)

.-PD *rior antibiotic r

– Re/imens5

– 1osyn or mere*enam2 ci*ro-R

– 1osyn or mere*enam or aOtreonam2 amino/lycoside res*iratory =uinolone

• 'RSA

– su//esti(e /ram stain& SRD& I3D+& *rior inuenOa&*rior antibiotics es* =uinolones& or much 'RSA incommunity

– Re/imen5 Add lineOolid -R (ancomycin

How Do I Think About Pneumonia?07!"!0#$ $;


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.ase $ < continued

• " yo male ! days a/o with R+M*neumonia and treated with ce)triaoneand aOithromycin6 -n rounds is )eelin/

better& eatin/& not con)used6 T 9 $76:&HR 9 #0!& P 9 #0"7"& RR 9 #!& Sa-!9 ;;@ on room air

• hen I can I switch to an oral re/imen

and what re/imen?

• hen can the *t /o home?

07!"!0#$ How Do I Think About Pneumonia? $:


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07!"!0#$ >0How Do I Think About Pneumonia?


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Switchin/ to oral

• I) s*eciGc *atho/en identiGed& switch tonarrow s*ectrum thera*y

• hen clinically im*ro(in/&

hemodynamically stable& able to take orals&switch to oral r 8 i) no *atho/en& o)tenaOithro alone

• Duration 9 at least " days& and until

a)ebrile )or two days& and ha(e only onesi/n o) clinical instability6 I) *atho/en isPseudomonas treat at least #> days

How Do I Think About Pneumonia?07!"!0#$ >#


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Timin/ o) dischar/e

Readmission rate or death: no instability = 10%; 1 instability = 14%; 2+ instabilities = 46%

How Do I Think About Pneumonia?07!"!0#$ >!

P i b ) th


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Pneumonia 8 be)ore they /ohome

• Smokin/ cessation

• 3accination

How Do I Think About Pneumonia?07!"!0#$ >$


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.AP 8 hat’s ,ew

• Increasin/ reco/nition o) (iral *atho/ens

• .onsideration o) en(ironmentale*osures as risk )actor )or .AP

• +se o) P.R 1and other tests2 to /uideinitial antibiotic choice

• +se o) inammatory markers to hel*

with dia/nosis and /uide thera*y• 3accine eUcacy

How Do I Think About Pneumonia?07!"!0#$ >>


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Vuestions?

07!"!0#$ How Do I Think About Pneumonia? >"

m* r c t era*y o


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m* r c t era*y oH.APHAP3AP with 'DR

risk )actorsce)e*ime& ce)taOadime& imi*enam& or osyn

PM+S

ci*rooacin& le(ooacin& or amino/lycoside

• I) 'RSA concerns add lineOolid or(ancomicin

How Do I Think About Pneumonia?07!"!0#$ >

S it hi t l th )


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Switchin/ to oral thera*y )orH.APHAP3AP

Pseudo: if sens

i!ro + "u#$doy$linda

&R'":

sensiti(ities

i!ro + "u#$doy$linda )R moi

How Do I Think About Pneumonia?07!"!0#$ >7


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As*iration

• hen to use5 obser(edsus*ectedas*iration )e(er or leucocytosis orinGltrate

• Re/imens5

– +nasyn 1doy -R aOithro2

Au/mentin or clinda – Res*iratory =uinolone

How Do I Think About Pneumonia?07!"!0#$ >;

, di i


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,on


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.linical res*onse to non<res*ondin/ *neumonia

• Ree(aluate initial microbiolo/ic results 8 consider +AT

• Reassess risk )actors )or in)ection with unusualor/anism

• Re*eat blood cultures )or worsenin/ *neumonia orclinical deterioration

• Mook )or secondary in)ections 1catheter& urinary& skin2

• 4et .T to R- PT& thoracentesis to R- em*yema&bronchosco*y to R- unusual *atho/ens

pneumonia in adults.2013

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