7. Mr. SM
๏ฎ 69 years
๏ฎ Does not smoke (anymore since two years)
๏ฎ No co-morbids
๏ฎ Cough since five days
๏ฎ Coughs up some green phlegm
๏ฎ Looks unwell
8. Mr. SM
๏ฎ Pulse 92 reg
๏ฎ BP 130/90mm Hg
๏ฎ RR 20/min
๏ฎ Temp 38.5 C
๏ฎ Percussion: normal
๏ฎ Auscultation: some scattered rhonchi
9. Mr. SM
๏ฎ Diagnosis?
๏ฎ Acute bronchitis
๏ฎ Pneumonia
๏ฎ Exacerbation COPD
14. Diagnostic models
โข Hopstaken et al
โขDry cough, diarrhoea, temp > 38 C
โขIf all three present: 76% CAP, if none present: 6%
โข Diehr et al
โขAbsence of rhinorrhoea and sore throat, presence of night sweats,
myalgia, sputum all day, resp rate > 25, fever
โข Score 1: 9% CAP, score 4, 27%, score 6 100%
โข Khalil et al
โขCough, chest pain, shortness of breath, temp>38, heart rate>100,
Not Of help
Resp rate>20, pulse oximetry<95%
โขPos pred value 30%, neg pred value 99%
โข Gonzales Ortiz et al
โข pathologic auscultation, neutrophilia, pleural pain, dyspnoea
โข pos pred value 23%, neg pred value 88%
โข Melbye et al
โข Absence of coryza and sore throat, presence of dyspnoea, chest pain, crackles
โขPos pred value 17%, neg pred value 79%
15. Additional tests
๏ฎ Radiological investigations
๏ฎ Tests to detect bacterial pathogens
๏ฎ Gram stain, sputum c/s, blood c/s
๏ฎ Urine test for Streptococcus pneumoniae
sen>70%,specificity>95%,
๏ฎ Legionella antigen
๏ฎ Tests to detect viral pathogens
๏ฎ Test for influenza
๏ฎ Biomarkers
๏ฎ CRP
๏ฎ Procalcitonine/adrenomodulin
17. AD, 50 ys
๏ฎ Hello doctor, โฆ Iโve got fever and dry cough since two
days
๏ฎ BP 120/70 HR 88r RR 18โ TEMP 39.0ยฐC
๏ฎ Breath sound diminished on right base
HOSPITAL ADMISSION?
18. Hospital admission?
1. No, mild clinical syndrome
2. Yes, high fever
3. What about history?
Otherwise healthy man
19. Hospital admission?
1. No, mild clinical syndrome in otherwise healthy man
Pneumonia = 4 ๏ medium risk = 10%
20. DFE, 34
โข Fever (38.5ยฐC) 2days
โข Dry cough 3days
โข Physical examination:
Chest x-ray
โข non-ill; BP 130/80 HR 96r RR 20โ
โข rales right lung base
You - his physician โ
decide โฆ
22. History is lacking:
the patient underwent splenectomy 2 years before
He is immunocompromised
at risk for development of severe fulminant sepsis
(especially by S. pneumoniae and H. influenzae)
23. FP, 81 ys
โข Fever (37.7ยฐC) started one day before
โข non-productive cough
โข Non-ill; BP 120/85 HR 90 RR 20โ
โข Co-morbids-DM, CHF;
What would you do?
24. FP, 81 ys
1. admit to hospital
2. treat him as outpatient
admit to hospital: patient at risk for adverse outcome
27. DA, 63 ys
โขFever (37.9ยฐC) started two days before
โข non-productive cough
You - his physician - decide that your patient
is a candidate for hospital admission
Why?
28. DA, 63 ys, otherwise healthy
โข Fever (37.9ยฐC) started two days before
โข non-productive cough
The speech is interrupted by frequent breaths
Hello doctor Iโve got fever and dry cough since two days
breath breath breath breath breath
29. CRB-65 predicts death from community-acquired pneumonia
โขAnalysis performed on 1343 patients (208 out-patients and 1135 hospitalized)
with all data sets completed for the calculation of CURB, CRB and CRB-65
โขValidated in 1967 patients (482 out-patients and 1485 hospitalized)
Bauer TT et al. J Intern Med. 2006; 260:93-101
30. CURBโ65 score
Score one point for presence of each Clinical feature (0 โ
5)
1. Confusion
2. Urea > 7 mmol/l
3. Respiratory rate ๏ณ 30/min
4. Blood pressure (SBP <90 or DBP ๏ฃ 60mmHg)
5. Age ๏ณ 65yrs
(Albumin < 30 g/dl had an OR 4.7 [2.5-8.7] <0.001)
Lim et al Thorax 2003;58:377-382
32. RESULTS: Overall 30-day mortality was 4.3% (0.6% in out-patients and 5.5% in hospitalized patients,
p<0.0001). Overall, the CURB, CRB and CRB-65 scores provided comparable predictions for death from CAP
CONCLUSIONS: Both the CURB and CRB-65 scores can be used in the hospital and
out-patients setting to assess pneumonia severity and the risk of death
Given that the CRB-65 is easier to handle, we favor the use of CRB-65 where blood
urea nitrogen is unavailable
Bauer TT et al. J Intern Med. 2006; 260:93-101
33. SCAP score
Major Minor
๏ฎ RR >30 breaths/min โ 9
points
๏ฎ PaO2/FIO2 <250 mmHg โ 6
๏ฎ Arterial pH <7.30 โ 13 points
points
๏ฎ Systolic blood pressure <90
๏ฎ BUN >30 mg/dL (10.7 mmol/L)
mmHg โ 11 points
โ 5 points
๏ฎ Altered mental status โ 5
points
๏ฎ Age โฅ80 years โ 5 points
๏ฎ Multilobar/bilateral infiltrates
on x-ray โ 5 points
>=10 severe CAP
34. EMPIRIC TREATMENT?
YES !!!
Based on knowledgeโฆ.
โฆ..You need to know
๏ฎ Epidemiology in YOUR area
๏ฎ Rate of antibiotic resistance in YOUR area
Please do not forget Microbiology work
upโฆโฆ
EVEN IF IT COSTSโฆ.
35. Factors in empirical antibiotic choice for CAP
GEOGRAPHY
Spectrum of causative pathogen
Acquired antibiotic resistance
THE PATIENT
Illness severity
Other characteristics (eg age, vomiting)
THE ANTIBIOTIC
Randomised controlled trial
Drug side effects
Cost
36. GEOGRAPHICAL VARIATION IN
(32 prospective studies; n = 8211)
CAP %
0 10 20 30 40
S pneumoniae
H influenzae
Legionella
Staph aureus
GNEB
UK Europe AUS + NZ N America
37. GEOGRAPHICAL VARIATION IN
(32 prospective studies; n = 8211)
CAP %
0 5 10 15 20
M pneumoniae
C pneumoniae
C psittaci
C burnetii
Viruses
UK Europe AUS + NZ N America
38. ANTIBIOTIC THERAPY
S pneumoniae
H influenzae B-lactam
Macrolide
Mycoplasma Tetracycline
Chlamydia Fluoroquinolone
Legionella
Gram-negative
bacteria Cephalosporin
39. ATS/IDSA
INPATIENT โ NON-ICU
Fluoroquinolone (strong recommendation; level I evidence)
๏ข-lactam + macrolide
(strong recommendation; level I evidence)
Mandell et al Clin Infect Dis 2007;44(Suppl 2):S27-S72
40. ATS/IDSA GUIDELINES
INPATIENT โ ICU
๏ข-lactam +
Either Azithromycin (level II evidence)
or Fluoroquinolone (strong recommendation; level I evidence)
For Pseudomonas
Anti-pseudomonal ๏ข-lactam +
Either cipro or levo (level II evidence)
or above ๏ข-lactam + gentamicin + azithromycin
or above ๏ข-lactam + antipneumococcal fluoroquinolone
(weak recommendation; level III evidence)
Mandell et al Clin Infect Dis 2007;44(Suppl 2):S27-S72
46. Conclusion
๏ฎ Clinical assessment
๏ฎ Know your local epidemiology
๏ฎ Be aware of national and international
outbreaks
๏ฎ Never forget Mycobacterium tuberculosis