HACK. these are a few of my favourite respiratory infections
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Transcript of HACK. these are a few of my favourite respiratory infections
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HACK.these are a few of my favourite respiratory infections
Brendan MunnEmergency Residents’ Academic DayAugust 13 2009
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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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
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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Respiratory Tract Infections
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Respiratory Tract Infections
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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?
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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case 1
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HPI : 64F with cough, fever x 1 week
O/E : febrile, RR 32
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
“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
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Special Populations
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Special Populations
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CAP
VAP
HAP
HCAP
HIV
TB
ASPIRATION
AECOPD
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case 2
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HPI : 64F with cough, fever x 1 week
O/E : febrile, RR 32, LLL crackles
PMHx : nil
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Sputum Cultures - Evidence
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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
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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Disposition - Evidence
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(1) Pneumonia Severity Index (PSI)
online calculators available
limitations - 20 factors, CAP
Fine, MJ. NEJM, 1997 Jan
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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curb 65
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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
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case 3
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HPI : 64F with L THA
O/E : febrile, RR 32, LLL crackles
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Blood Cultures - Evidence
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<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
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case 4
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HPI : 64F diabetic receiving daily foot
wound care at home with cough,
fever x1 week
O/E : febrile, RR 32, LLL crackles
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HCAP RF
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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
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MDR RF
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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
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case 5
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HPI : 28M with cough x 6 weeks,
worsening SOB
O/E : febrile, RR 32
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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case 7
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HPI : 64F alcoholic w cough, fever
x 1 week
O/E : febrile, RR 32, RLL opacity
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case 8
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
References1. Tintinalli
2. Up To Date
3. EMRAP
4. ATS CAP and HAP Guidelines 2007