Tuesday ConferenceTuesday ConferenceApproach to Community Approach to Community

Acquired PneumoniaAcquired Pneumonia

Selim Krim, MDSelim Krim, MD

Assistant ProfessorAssistant Professor

TTUHSCTTUHSC

Case 1Case 1

A 62-year-old white male presents complaining of cough, fever, A 62-year-old white male presents complaining of cough, fever, and difficulty breathing, which developed during the night. He and difficulty breathing, which developed during the night. He has no symptoms of rhinorrhea, sore throat, or earache. He is has no symptoms of rhinorrhea, sore throat, or earache. He is not a smoker and has no history of asthma or recent antibiotic not a smoker and has no history of asthma or recent antibiotic use. He is a business executive who travels extensively and just use. He is a business executive who travels extensively and just returned from California.returned from California.

Case 1Case 1

On physical examination, he appears flushed but otherwise alert On physical examination, he appears flushed but otherwise alert and oriented. He is 5-11, 180 lbs and has a blood pressure of and oriented. He is 5-11, 180 lbs and has a blood pressure of 110/70 mmHg, a heart rate of 90 beats per minute, a respiratory 110/70 mmHg, a heart rate of 90 beats per minute, a respiratory rate of 24 breaths per minute, and a body temperature of 39 ºC. rate of 24 breaths per minute, and a body temperature of 39 ºC.

Lung sounds reveal a mild dullness in right base, no increased Lung sounds reveal a mild dullness in right base, no increased

tympany, and coarse breath sounds with mild rales in right tympany, and coarse breath sounds with mild rales in right posterior lung base. He is not wheezing. The rest of his exam is posterior lung base. He is not wheezing. The rest of his exam is normal. normal.

Based on your history and Based on your history and physical exam what is your physical exam what is your

diagnosis?diagnosis?

Diagnosis of Diagnosis of PneumoniaPneumonia

Signs and symptoms Signs and symptoms

• Fever Fever or hypothermia, or hypothermia, coughcough with or without sputum, with or without sputum, dyspneadyspnea, , chest discomfort, sweats, or rigorschest discomfort, sweats, or rigors

• Atypical pneumonia associated with headaches, diarrhea, Atypical pneumonia associated with headaches, diarrhea, nonexudative pharyngitis, bullous myringitis, slow onset, nonexudative pharyngitis, bullous myringitis, slow onset, myalgiasmyalgias

• Physical exam may reveal fever, tachypnea, Physical exam may reveal fever, tachypnea, tachycardiatachycardia..

• Lung exam; increased tactile fremitus, Lung exam; increased tactile fremitus, dullness to percussiondullness to percussion, , decreased breath sounds, decreased breath sounds, presence of rales or cracklespresence of rales or crackles

MCQ 3MCQ 3

• What is the next most important step in this patient's care?

• Empiric therapy with a fluoroquinolone• Chest x-ray• Sputum culture• Hospitalization • CBC, glucose, BUN, Na tests

Diagnostic testsDiagnostic tests

• Chest x-ray essential (AP and Lateral)Chest x-ray essential (AP and Lateral)• Patchy airspace infiltrates (Mycoplasma)Patchy airspace infiltrates (Mycoplasma)• Lobar or segmental consolidation (w/air bronchogram) Lobar or segmental consolidation (w/air bronchogram)

(Pneumococcal)(Pneumococcal)• Diffuse alveolar or interstitial infiltrates (viral or Mycoplasma Diffuse alveolar or interstitial infiltrates (viral or Mycoplasma

and other)and other)

EpidemiologyEpidemiology

MCQ 1MCQ 1• Which of the following statements is not true about community-

acquired pneumonia?

• More than 4 million cases of community-acquired pneumonia (CAP) occur each year

• Less than 10% of patients with CAP need hospitalization• No causative agent is identified in 30% to 50%of cases• Streptococcus pneumoniae is the most commonly identified

organism • Nursing home-acquired pneumonias are usually caused by the

same organisms as community acquired pneumonias but with increased numbers of S aureus and gram-negative organisms

MCQ 2MCQ 2• Streptococcus pneumoniae is identified in up to what Streptococcus pneumoniae is identified in up to what

percentage of community-acquired pneumonia cases? percentage of community-acquired pneumonia cases?

• 40% 40% • 50% 50% • 60% 60% • 70% 70% • 80%80%

Identified Pathogens in Community-acquired Pneumonia

Pathogen Percentage

• Streptococcus pneumoniae 20-60%• Haemophilus influenzae 3-10%• Staphylococcus aureus 3-5%• Gram-negative bacilli 3-10%• Legionella species 2-8%• Mycoplasma pneumoniae 1-6%• Chlamydia pneumoniae 4-6%• Viruses 2-15%• Aspiration 6-10%• Others 3-5%

MCQ 4MCQ 4

• What is the most likely pathogenic mechanism in this patient's pneumonia?

• Direct inoculation • Aspiration of oropharyngeal contents • Hematogenous deposition• Reactivation• Inhalation of infectious particles

Pathogenetic mechanisms in Pneumonia

• Inhalation of infectious particles Common• Aspiration of oropharyngeal or gastric content Common• Hematogenous deposition Uncommon• Invasion from infection in contiguous structures Rare • Direct inoculation Less common • Reactivation More common in

Immunocompromised hosts

Case 1Case 1

A 62-year-old white male presents complaining of cough, fever, A 62-year-old white male presents complaining of cough, fever, and difficulty breathing, which developed during the night. He and difficulty breathing, which developed during the night. He has no symptoms of rhinorrhea, sore throat, or earache. He is has no symptoms of rhinorrhea, sore throat, or earache. He is not a smoker and has no history of asthma or recent antibiotic not a smoker and has no history of asthma or recent antibiotic use. He is a business executive who travels extensively and just use. He is a business executive who travels extensively and just returned from California.returned from California.

Case 1Case 1

On physical examination, he appears flushed but otherwise alert On physical examination, he appears flushed but otherwise alert and oriented. He is 5-11, 180 lbs and has a blood pressure of and oriented. He is 5-11, 180 lbs and has a blood pressure of 110/70 mmHg, a heart rate of 90 beats per minute, a respiratory 110/70 mmHg, a heart rate of 90 beats per minute, a respiratory rate of 24 breaths per minute, and a body temperature of 39 ºC. rate of 24 breaths per minute, and a body temperature of 39 ºC.

Lung sounds reveal a mild dullness in right base, no increased Lung sounds reveal a mild dullness in right base, no increased

tympany, and coarse breath sounds with mild rales in right tympany, and coarse breath sounds with mild rales in right posterior lung base. He is not wheezing. The rest of his exam is posterior lung base. He is not wheezing. The rest of his exam is normal. normal.

Should this patient be Should this patient be admitted?admitted?

RISK STRATIFICATIONRISK STRATIFICATION

Pneumonia Severity Index Calculator

Risk of 30 d Mortality By Risk of 30 d Mortality By Point TotalPoint Total

Risk Class Point score Mortality%Risk Class Point score Mortality%

• I   0.1I   0.1• II < 70 0.6II < 70 0.6• III 71-90 2.8III 71-90 2.8• IV 91-130 8.2IV 91-130 8.2• V > 130 29.2V > 130 29.2

Case 1 (Part 2)Case 1 (Part 2)

Empiric therapy with an oral macrolide was prescribed, and theEmpiric therapy with an oral macrolide was prescribed, and the patient was sent home. Two days later, he presents at the patient was sent home. Two days later, he presents at the

emergency room with shaking chills and fever, increasingly emergency room with shaking chills and fever, increasingly productive cough, and difficulty breathing.productive cough, and difficulty breathing.

His vital signs are as follow: BP 110/60 mmHg, body His vital signs are as follow: BP 110/60 mmHg, body temperature 40.5° C, pulse rate 126 beats/min, and respiration temperature 40.5° C, pulse rate 126 beats/min, and respiration rate 28 breaths/min. He is alert and oriented. His exam again rate 28 breaths/min. He is alert and oriented. His exam again reveals rales and dullness in the right lower posterior lung fields reveals rales and dullness in the right lower posterior lung fields without wheezing. Chest x-ray shows a focal infiltrate in the right without wheezing. Chest x-ray shows a focal infiltrate in the right lower lung and a small pleural effusion.lower lung and a small pleural effusion.

MCQ 5MCQ 5

• After recalculating your PSI , what is this patient's 30-day After recalculating your PSI , what is this patient's 30-day mortality risk factor classification and should he be admitted? mortality risk factor classification and should he be admitted?

• II• II II • III III • IV IV • VV

RISK STRATIFICATIONRISK STRATIFICATION

Pneumonia Severity Index Calculator

Risk of 30 d Mortality By Risk of 30 d Mortality By Point TotalPoint Total

Risk Class Point score Mortality%Risk Class Point score Mortality%

• I   0.1I   0.1• II < 70 0.6II < 70 0.6• III 71-90 2.8III 71-90 2.8• IV 91-130 8.2IV 91-130 8.2• V > 130 29.2V > 130 29.2

MCQ 6MCQ 6

• Which of the following findings would NOT further raise his risk factor score (and increase his 30-day mortality risk)?

• Serum urea nitrogen > 30 mg/dL• Confusion• Arterial blood pH below 7.35• Elevated white blood cell count (>15,000) • Na below 130 mEq/L

MCQ 7MCQ 7• Which statement is NOT correct concerning this patient?

• Because initial empiric outpatient therapy failed, the possibility of pulmonary emboli or malignancy constitutes a majority

• He should be hospitalized and given empiric intravenous antibiotic therapy with fluoroquinolone alone

• Extensive serology testing should be conducted for HIV,

Mycoplasma and Chlamydia species, SARS, and influenza A and B on specimens obtained by bronchoscopy

• Sputum gram-stain and cultures as well as blood cultures need

to be obtained after hospital admission

Which test to order?Which test to order?

MCQ 8MCQ 8

• Pathogen-specific treatment with a macrolide or doxycycline in community-acquired pneumonia is recommended with which organism?

• Staphylococcus aureus • Mycoplasma pneumoniae• Pseudomonas aeruginosa • Influenza A• Streptococcus pneumoniae

How would you treat this How would you treat this patient?patient?

Case 1 (Part 3)Case 1 (Part 3)

• Patient is admitted to the hospital and treated with IV Patient is admitted to the hospital and treated with IV ciprofloxacin. After 3 days, he is still febrile and in need of ciprofloxacin. After 3 days, he is still febrile and in need of oxygen supplementation, but he is alert and eating on his own. oxygen supplementation, but he is alert and eating on his own. Blood and sputum cultures are negative.Blood and sputum cultures are negative.

MCQ 9MCQ 9

• Which of the following would be the next best step?Which of the following would be the next best step?

• Change to oral antibiotics based on presumed Change to oral antibiotics based on presumed S pneumoniaeS pneumoniae • Add zanamivir for possible influenza A or BAdd zanamivir for possible influenza A or B• Direct fluorescent antibody staining by nasal swab for viruses or Direct fluorescent antibody staining by nasal swab for viruses or

sputum for sputum for LegionellaLegionella• Fiberoptic bronchoscopy with lavage and transbronchial biopsyFiberoptic bronchoscopy with lavage and transbronchial biopsy• Add vancomycin with or without rifampin Add vancomycin with or without rifampin

Would you consider dischargingWould you consider discharging

your patient at this point?your patient at this point?

Discharge Criteria

• Candidates for discharge should have no more than one of the following poor prognostic indicators:

• Temperature > 37.8 degrees Celsius • Pulse > 100 beats per minute • Respiratory rate > 24 per minute • Systolic blood pressure < 90 mmHg • Oxygen saturation < 90 percent• Inability to maintain oral intake

Key PointsKey Points• Community-acquired pneumonia can be treated empirically

with oral antibiotics in the outpatient setting in patients with class I or II PORT category risk factor stratification.

• Patients younger than age 50 who have no comorbid health problems and who present with minimal signs and symptoms of possible pneumonia can safely be treated without the need for further testing.

• A macrolide or doxycycline is the treatment of choice for healthy patients younger than age 60 who have presumed pneumonia. Fluoroquinolones are not recommended in these patients because of increasing problems with antibiotic resistance.

Key PointsKey Points• In all patients in whom pneumonia is suspected, a chest x-ray In all patients in whom pneumonia is suspected, a chest x-ray

should be ordered to provide diagnostic evidence with which to should be ordered to provide diagnostic evidence with which to distinguish different patterns of infiltrates. distinguish different patterns of infiltrates.

• The need for in-patient care can be determined by professional The need for in-patient care can be determined by professional judgment, based on the patient's signs and symptoms; however, judgment, based on the patient's signs and symptoms; however, a risk factor calculation can be helpful in determining those with a risk factor calculation can be helpful in determining those with high predicted mortality. high predicted mortality.

• Obtaining blood cultures within 24 hours of admission and Obtaining blood cultures within 24 hours of admission and starting antibiotics within 4 hours of admission have been starting antibiotics within 4 hours of admission have been shown to reduce 30-day mortality and are considered quality shown to reduce 30-day mortality and are considered quality indicators. indicators.

Key PointsKey Points

• Because 30% to 50% of patients with community-acquired Because 30% to 50% of patients with community-acquired pneumonia never have a pathogen identified, it is recommended pneumonia never have a pathogen identified, it is recommended that empiric therapy selection be based on presumed organisms that empiric therapy selection be based on presumed organisms and their sensitivities, history of exposure, other comorbid and their sensitivities, history of exposure, other comorbid health conditions, and x-ray findings. health conditions, and x-ray findings.

• Aggressive testing including cultures, serology testing, and Aggressive testing including cultures, serology testing, and other rapid assays to determine the causative pathogen are other rapid assays to determine the causative pathogen are appropriate for most inpatients. More invasive testing, including appropriate for most inpatients. More invasive testing, including bronchoscopy, should be reserved for deteriorating patients in bronchoscopy, should be reserved for deteriorating patients in whom no etiology has been determined.whom no etiology has been determined.

Thank YouThank You