Diagnosis & Mangement of Community-Acquired Pneumonia, Hospital Acquired Pneumonia & Aspiration Pneumonia
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Clinical overview of Community Acquired Pneumonia, Hospital Acquired Pneumonia, Aspiration Pneumonia. Covers pathophysiology, clinical management, prevention, risk stratification (pneumonia severity index), prognostic factors, complications. Includes case studies, comprehension questions. Given at Jackson Park Medical Center on 12/1/2013. Includes references.
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Diagnosis & Mangement of Community-Acquired Pneumonia, Hospital Acquired Pneumonia & Aspiration Pneumonia
- 1. Pneumonia Riaz Rahman Destiny Univ. student presentation:
- 2. Question 1 An HIV+ patient with a CD-4+ count of 802 is found to be hypoxic on room air. Chest X-ray shows multi-lobular consolidation. What is the most likely causative organism? A. Moraxella catarrhalis B. Klebsiella pneumoniae C. Staphylococcus aureus D. Streptococcus pneumoniae E. Mycobacterium tuberculosis Pre-Test
- 3. Question 2 A 47 year old homeless alcoholic male presents to your clinic complaining of insidious onset dry cough. He describes his sputum as “red jelly.” Chest x-ray shows a bulging fissure. What is the most likely diagnosis? A. Aspiration Pneumonia B. Acute Bronchitis C. Ventilator Associated Pneumonia D. Hospital Acquired Pneumonia E. Adult Respiratory Distress Syndrome Pre-Test
- 4. Question 3 A 62 year old male presents with a non-productive cough of 2 weeks duration. Physical exam reveals wheezing, rhonchi, crackles. The patient has a normal pulse in but a high fever. What type of pneumonia is most likely? A. Typical Community Acquired Pneumonia B. Hospital Acquired Pneumonia C. Atypical Community Acquired Pneumonia D. Ventilator Associated Pneumonia Pre-Test
- 5. Question 4 An HIV+ patient who has a CD-4+ count of 52 presents with acute onset cough and fever. He does not take antiretroviral meds or TMP-SMX, is hypoxic on room air, and has a diffuse bilateral infiltrate on chest film. What is the most likely causative organism? A. Streptococcus pneumoniae B. Pneumocystis carinii C. Aspergillis fumigatus D. Coccidiodes E. Mucormycosis Pre-Test
- 6. Question 5 An elderly man presents w/ pneumonia, GI disturbance, bradycardia, and hyponatremia. What is the most likely causative organism? A. Streptococcus pneumoniae B. Staphlococcus aureus C. Legionella pneumophilia D. Coxiella burnetti Pre-Test
- 7. Case Study 58 yo male presents to walk-in clinic c/o 24-hour history of fever, chills, productive cough, and episode of rigors last night. PMH: COPD, diabetes, smoking 2 packs/day (75 pack years lifetime). Meds: combination steroid/long-acting beta agonist inhaler, tiotropium bromide and albuterol, as needed. Physical exam: tactile fremitus, expiratory wheezes and rhonchi. Vitals: BP 168/92, HR 128, RR 32, T 101.3°F pulse oximetry 87% (RA). Patient is placed on 4 liters O2, and albuterol via nebulizer. His O2 sat increases to 94%, his RR decreases to 24, and pulse decreases to 112. As the patient is still mildly hypoxic, tachypneic, tachycardic) and requiring supplemental oxygen, he is admitted to a local hospital. Chest x-ray reveals right lower lobe infiltrate and a white blood cell count of 17,000/mm3. Sputum culture reveals S. pneumoniae. The patient is placed on moxifloxacin 400 mg daily for 7 days and is started on prednisone and albuterol via small-volume nebulizer. He rapidly improves and is discharged 3 days later with instructions to finish antibiotics/steroids and to follow-up with PCP. Pre-Test
- 8. Pneumonia Lower respiratory tract infection: Inflammatory condition of the lung which primarily affects alveoli. It is usually caused by infection Typical symptoms include a cough, chest pain, fever, and difficulty breathing D/dx: URI, Acute Bronchitis, Lung Abscess Epidemiology: 8th leading cause of death in the U.S. Affects ~450 million people globally per year (seven percent of the world population) Results in ~4 million deaths worldwide, mostly in third- world countries Introduction
- 9. Classification Community Acquired Pneumonia (CAP) Occurs in the community or within the first 72 hours of hospitalization; Can be typical or atypical Most common bacterial pathogen is S. Pneumoniae (60%) Hospital Acquired Pneumonia (HAP) Occurs during hospitalization after first 72 hours Gram-negative bacilli (Pseudomonas, Klebsiella, E. coli, Enterobacter, Serratia, Acinetobacter, & S. aureus, including MRSA) Acid suppression (PPI use) may increase risk Ventilator Associated Pneumonia Aspiration Pneumonia Chemical pneumonitis due to aspiration of gastric contents Bacterial pneumonia ≥24–72 h later, due to aspiration of oropharyngeal microbes Outpatients: typical oral flora (Strep, S. aureus, anaerobes) Inpatients or chronically ill: GNR and S. aureus Introduction
- 10. Other Common Etiologies Introduction Presentation Cause Young, Healthy Patients Mycoplasma, Chlamydia, Viral Recent Viral Syndrome Staphylococcus Aureus Alcoholics; Aspirators Klebsiella; other GNR COPD H. influenzae, M. catarrhalis Gastrointestinal Symptoms; Confusion; Elderly; Smokers Legionella Persons present at the birth of an animal Coxiella burnetii Arizona construction workers Coccidoidomycosis HIV with <200 CD4+ cells Pneumocystis (PCP) Nursing Home Resident Pseudomonas
- 11. Clinical Symptoms “Typical” CAP Acute onset of fever, productive cough w/ purulent sputum, dyspnea, pleuritic pain “Atypical” CAP: originally described as culture (-) Insidious onset of dry (nonproductive) cough Extrapulmonary sx: Nausea, Vomiting, diarrhea, headache, myalgias, sore throat) Ventilator Associated Pneumonia Fever, Hypoxia Increasing secretions Work-Up
- 12. Clinical Signs “Typical” CAP Tachycardia, tachypnea Late inspiratory crackles, bronchial breath sounds, increased tactile and vocal fremitus, dullness on percussion Pleural friction rub: associated with pleural effusion “Atypical” CAP Pulse–temperature dissociation: normal pulse in the setting of high fever is suggestive of atypical CAP. Wheezing, rhonchi, crackles Work-Up
- 13. Diagnosis Best initial diagnostic test: Chest x-ray Most accurate test: Sputum Gram stain and Sputum Bacterial culture Initial workup 1. All cases of respiratory disease (fever, cough, sputum) should have a chest x-ray (PA & Lateral) and oximeter ordered with the first screen. 2. If there is shortness of breath, also order oxygen with the first screen. 3. If there is shortness of breath and/or hypoxia, order an ABG. 4. CBC w/ diff, Electrolytes, BUN/Cr, glc, LFTs Work-Up
- 14. Imaging Typical CAP – Lobar Consolidation on CXR Atypical CAP - Patchy interstitial pattern on CXR Work-Up (From Erkonen WE, Smith WL. Radiology 101: The Basics and Fundamentals of Imaging. Philadelphia, PA: Lippincott Williams & Wilkins, 1998:110, Figure 6-54A and B.)
- 15. Other Considerations Additional microbiologic studies Mycoplasma: PCR of throat or sputum/BAL before first abx Legionella: urine Ag S. pneumoniae: urinary Ag MTb: induced sputum for AFB stain and mycobact. Cx PCP: Induced sputum for PCP if HIV+ or known T cell- mediated immunity; HIV test if 15–54 y Bronchoscopy: consider if pt is immunosuppressed, critically ill, failing to respond, or has chronic pneumonia. Decision to Admit Outpatient versus inpatient monitoring; ICU or no ICU. The pneumonia severity index (PSI) is used to risk-stratify In general elderly, hypoxic patients with or without a fever should be admitted. Consider the ICU, depending on severity of hypoxia. Work-Up
- 16. Risk Factor PORT Score Sex Men +Age (yrs) Women +(Age-10) Comorbidities Nursing Home +10 Neoplasm +30 Liver Disease +20 CHF +10 CVA +10 Renal Disease +10 Exam ∆Mental Status +20 RR > 30 +20 SBP < 90 +20 T<35 or >40 +15 HR > 125 +10 Management Risk Factor PSI Score Labs pH<7.35 +30 BUN>30 +20 Na<130 +20 Glucose>250 +10 Hct <30 +10 PaO2 <60 +10 SaO2<90 +10 Pleural Effusion +10 Risk Stratification Pneumonia Severity Index (PSI)
- 17. Prognosis Clas s Total PSI Score Risk Mortality Suggested triage I <70 (Age 50, no comorbidities) Low 1% Outpatient II <70 Low 1% Outpatient III 71–90 Low 2.8% Brief inpatient IV 91–130 Moderate 8.2% Inpatient V >130 High 29.2% ICU Management
- 18. Clinical scenario Empiric treatment guidelines Outpatient No recent abx: macrolide OR doxycycline Recent abx: [macrolide AND (high-dose amox /clav or 2nd-gen. ceph.)] OR [respiratory FQ] Community-acquired, Hospitalized [3rd-gen. ceph. AND macrolide] OR [respiratory FQ] Community-acquired, hospitalized, ICU [3rd-gen. ceph. or amp-sulbactam] AND [macrolide or FQ] (assuming no risk for Pseudomonas) Hosp-acquired & risk for MDR pathogens [Antipseudomonal PCN or ceph. or carbapenem] AND [FQ or (gentamicin azithromycin)] AND [vancomycin or linezolid] Immunosuppressed [As above] ± [TMP-SMX ] ± [steroids to cover PCP] Aspiration (3rd-gen. ceph. or FQ) ± [clindamycin or metronidazole] Treatment
- 19. Prevention Pneumococcal Vaccine: Persons >65 years of age High-Risk medical illness (heart disease, sickle cell disease, pulmonary disease, diabetes, or alcoholic cirrhosis, or asplenic individuals) Influenza Vaccine: give yearly to people at increased risk for complications and health care workers VAP precautions: HOB 30, chlorhexidine rinse; aspiration precautions in high-risk Pts Maintenance
- 20. Pleural effusion “parapneumonic effusions" Can be seen in more than 50% of patients with CAP on routine CXR. Empyema is infrequent in these patients. Most of these effusions have an uncomplicated course and resolve with treatment of the pneumonia with antibiotics. Thoracentesis should be performed if the effusion is significant (>1 cm on lateral decubitus film). Send fluid for Gram stain, culture, pH, cell count, determination of glucose, protein, and LDH levels. Pleural empyema occurs in 1% to 2% of all cases of CAP (up to 7% of hospitalized patients with CAP). See Chapter 2. Acute respiratory failure may occur if the pneumonia is severe. Complications
- 21. Question 6 A 37 year old female presents with tachycardia, tachypnea, late inspiratory crackles, bronchial breath sounds, increased tactile and vocal fremitus, dullness on percussion. What is the best initial test? A. Arterial Blood Gas B. Sputum Culture C. Sputum Gram Stain D. Chest X-ray E. Spiral CT Post-Test
- 22. Question 7 An otherwise healthy 29 year old male is diagnosed with Community Acquired Pneumonia on an outpatient basis. His PSI score is <50. He states he has not recently been on any antibiotics. What is the best first- line therapy? A. Ampicillin-Sulbactam B. Ceftriaxone C. Ceftriaxone and Ciprofloxacin D. Doxycycline E. Moxifloxacin Post-Test
- 23. Question 8 A 34 year old male presents with pesistent dry cough, weakness and malaise. Pulmonary infiltrates are visualized on CXR. 3mL of patient’s blood is added to anticoagulated tube and placed into ice water. Several minutes later, clumping is detected inside the tube. What is the most likely causative organism? A. Mycoplasma B. Ureaplasma C. Streptococcus pneumoniae D. Pneumocystis carinii Post-Test
- 24. Question 9 A 72 year old nursing home resident is admitted for community-acquired pneumonia. The patient is found to have a PSI Score of 140. What is the patient’s relative mortality risk? A. No Risk B. Low Risk C. Intermediate Risk D. High Risk Post-Test
- 25. Question 10 A 54 year old male smoker is admitted for inpatient treatment of typical community- acquired pneumonia. Excess fluid is visualized between the visceral and parietal pleura on CXR. What is the most likely complication? A. Pleural Empyema B. Pleural Emphysema C. Pleural Effusion D. Pleural Confusion Post-Test
- 26. References Arnold FW, Summersgill JT, Lajoie AS, et al. A worldwide perspective of atypical pathogens in community-acquired pneumonia. Am J Respir Crit Care Med 2007; 175:1086. File TM. Community-acquired pneumonia. Lancet 2003; 362:1991. File TM Jr, Niederman MS. Antimicrobial therapy of community-acquired pneumonia. Infect Dis Clin North Am 2004; 18:993. Johnstone J, Mandell L. Guidelines and quality measures: do they improve outcomes of patients with community-acquired pneumonia? Infect Dis Clin North Am 2013; 27:71. Lim WS, Macfarlane JT, Boswell TC, et al. Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines. Thorax 2001; 56:296. Malcolm C, Marrie TJ. Antibiotic therapy for ambulatory patients with community-acquired pneumonia in an emergency department setting. Arch Intern Med 2003; 163:797. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27. Marrie TJ, Shariatzadeh MR. Community-acquired pneumonia requiring admission to an intensive care unit: a descriptive study. Medicine (Baltimore) 2007; 86:103. Marrie TJ, Poulin-Costello M, Beecroft MD, Herman-Gnjidic Z. Etiology of community-acquired pneumonia treated in an ambulatory setting. Respir Med 2005; 99:60. Read RC. Evidence-based medicine: empiric antibiotic therapy in community-acquired pneumonia. J Infect 1999; 39:171. Thank You!
Editor's Notes
- D/dx If nasal discharge, sore throat, or ear pain predominates, upper respiratory infection is likely. clinical features (cough, sputum, fever, dyspnea) are not reliable in differentiating between pneumonia and acute bronchitis. CXR is the only reasonable method of differentiating between pneumonia and acute bronchitis.
- VAP - Patients on mechanical ventilation are at risk of developing pneumonia because the normal mucociliary clearance of the respiratory tract is impaired (cannot cough). Also, positive pressure impairs the ability to clear colonization. Most cases of CAP result from aspiration of oropharyngeal secretions because the majority of organisms that cause CAP are normal inhabitants of the pharynx.
- Influenza A & B et al. (see “Viral Respiratory Infections”) (no organism identified in 40–60% cases) Radiographic changes and clinical findings do not help in identifying the causative pathogen in CAP.
- “Atypical” pneumonia refers to organisms not visible on Gram stain and not culturable on standard blood agar. S/s & imaging do not reliably distinguish between “typical” (S. pneumo, H. flu) and “atypical” (Mycoplasma, Chlamydia, Legionella, viral) Pleuritic chest pain (suggests pleural effusion)
- Studies have shown that if vital signs are entirely normal, the probability of pneumonia in outpatients is less than 1%.
- The following steps are appropriate in patients admitted to the hospital with suspected pneumonia: • CXR (PA and lateral) Considered sensitive—If CXR findings are not suggestive of pneumonia, do not treat the patient with antibiotics. • Gram stain and culture of sputum (confirmatory) The value of routine sputum collection for Gram stain and culture is controversial (low sens/spec). The Infectious Disease Society of America has recently advocated performing sputum Gram stain and culture in all patients hospitalized with CAP. A good sputum specimen has >25 PMNs and <10 epithelial cells per lowpower field. A positive sputum culture is not pneumonia. • Laboratory tests—CBC and differential, BUN, creatinine, glucose, electrolytes • O2 saturation • Two pretreatment blood cultures • Antibiotic therapy
- Typical: Changes include interstitial infiltrates, lobar consolidation, and/or cavitation. Multilobar consolidation indicates very serious illness. Atypical: Diffuse reticulonodular infiltrates, Absent or minimal consolidation VAP: New infiltrates on CXR Chest PA (A) and lateral (B) radiographs: Right lower lobe pneumonia (straight arrows). On the PA radiograph, the right cardiac border is clearly visible, and the right hemidiaphragm is partially silhouetted (double straight arrows). These findings indicate that the infiltrate is posterior or in the right lower lobe as confirmed on the lateral radiograph (straight arrows). CXR resolves in most by 6 wks; After treatment, changes evident on CXR usually lag behind the clinical response (up to 6 weeks). consider f/u to r/o underlying malignancy or other dx False-negative chest radiographs occur with neutropenia, dehydration, infection with PCP (Pneumocystis carinii pneumonia), and early disease (<24 hours)
- Legionella: urine Ag very sensitive, antigen persists for weeks (detects L. pneumophila L1 serotype, 60–70% of clinical disease), Elevated transaminases & decr. Na w/ Legionella S. pneumoniae urinary Ag (Se 50–80%, Sp >90%) MTb: induced sputum for AFB stain and mycobact. cx (empiric respiratory isolation while pending); avoid quinolones if considering TB; request rapid DNA probe if stain EB PCP: silver stain, can also detect fungi
- The decision to hospitalize or treat as an outpatient is probably the most important decision to be made and is based on severity of disease Patients are stratified into five classes based on severity (see Table 10-1). The Pneumonia Severity Index can serve as a general guideline, but clinical judgment is critical in making this decision. The decision to admit the patient is not based on a specific organism (one does not have this information when making this decision).
- Treat outpatient pneumonia with: (continued for 5 days. Do not stop treatment until patient has been afebrile for 48 hours) Macrolide (azithromycin, doxycycline, or clarithromycin) Respiratory fluoroquinolone (levofloxacin, moxifloxacin) Treat inpatient pneumonia with: Ceftriaxone and azithromycin Fluoroquinolone as a single agent Treat ventilator-associated pneumonia (VAP) with: lmipenem or meropenem, piperacillin/tazobactam or cefepime; Gentamicin; and Vancomycin or linezolid Route of therapy InPts should initially be treated w/ IV abx to PO when clinically responding and able to take Pos For low-risk Pts, can discharge immediately after switching to PO abx *When possible, organism-directed therapy, guided by in vitro susceptibilities or local patterns of drug resistance should be used. For ventilator-associated pneumonia, 8 15 d of Rx, except for Pseudomonas and other non-fermenting GNR
- Influenza vaccine—give yearly to people at increased risk for complications and to health care workers b. Pneumococcal vaccine—for patients >65 years and for younger people at high risk (e.g., those with heart disease, sickle cell disease, pulmonary disease, diabetes, or alcoholic cirrhosis, or asplenic individuals)
- No recent abx: macrolide OR doxycycline Recent abx: [macrolide AND (high-dose amox /clav or 2nd-gen. ceph.)] OR [respiratory FQ] [3rd-gen. ceph. AND macrolide] OR [respiratory FQ] [3rd-gen. ceph. or amp-sulbactam] AND [macrolide or FQ] (assuming no risk for Pseudomonas)