Pneumonia

Sanjay Kalra, MD, FRCPAssociate Professor of Medicine

Division of Pulmonary & Critical Care Medicine

Mayo Clinic

Rochester, MN

Disclosures

NONE

Learning Objectives

• Define the subtypes of pneumonias• Identify when to suspect and how to

diagnose pneumonia • Severity Staging• Recognize empiric treatment decisions• Discuss parapneumonic effusions/

empyema

Definitions

• Suspected community-acquired pneumonia is defined by acute symptoms and presence of signs of lower respiratory tract infection (LRTI) without other obvious cause

• New pulmonary infiltrate on chest radiograph is needed for definite diagnosis.

Definitions Hospital-acquired and Ventilator-associated Pneumonias

• HAP, or nosocomial pneumonia, arises 48 hours or more after hospital admission in the absence of signs or symptoms of pneumonia at the time of admission

• VAP is a subtype of HAP that develops after endotracheal intubation

• (Because only about 10% of patients with HAP are not mechanically ventilated, the terms HAP and VAP are often used interchangeably)

Ottosen SCNA 2014

Definitions Health Care Associated Pneumonia

American Thoracic Society (ATS) guidelines (2005):

New category of infections to encompass recent inpatient or on ongoing treatment in a long-term or outpatient health care facility

HCAP New pneumonia in:

• Any patient who was hospitalized in an acute care hospital for 2 or more days within 90 days of the infection

• Resided in a nursing home or long-term care facility

• Received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection

• Or attended a hospital or hemodialysis clinic

Ottosen SCNA 2014

Other Definition Issues

Ottosen SCNA 2014

When should you think of pneumonia?

• Temperature > 37.8 C• Pulse > 100/min• Rales/Crackles• Decreased breath

sounds• Absence of asthma

Respiratory Symptoms plus

Ann Intern Med 1990;113:664

The Cough + 1 RuleSuspect if

New focal chest signs on examinationAt least one systemic featureNo other explanation for the illness

Chest imaging is necessary for a definite diagnosis

And helps• to detect associated lung diseases• to gain insight into causative agent (in some

cases)• to assess severity• as baseline to assess response

IDSA 1998 & BTS 2001

Other Diagnostic TestsProcalcitonin

Alba Am J Med 2015

Alba Am J Med 2015

Inpatient vs Outpatient Treatment

• Medical Risk Assessment• Psychosocioeconomic

considerations• Patient preference

StratificationMedical Risk

• OutpatientOtherwise healthy adults

• Outpatient Cardiorespiratory or other comorbidity

• Inpatient Floor Unit• Intensive Care Unit

Index of SeverityThe Original BTS CAP Index

R.U.B. Predicts Death

• Respiratory Rate > 30/min• BUN > 20 mg/dL• Diastolic blood pressure < 60

mm HgQ J Med 1987:62;195-220

RISK ASSESSMENTDefining low risk patients

PSIPneumonia Severity Index

The Pneumonia Severity Index

• PSI relies on 2 pre-existing patient features• Age over 50• Co-existing chronic illnesses

• 5 Adverse clinical features• Mental status*• Respiratory Rate*• SBP*• Pulse Rate• Temperature

PSI Pre-existing Condition:Scoring System for Risk Classes II-V

AgeMale No. of years of ageFemale No. of years of age - 10Nursing home Add 10 points

Add the patient's age in years (age -10, for females)

Risk Class Mortality Rates

Risk Class Mortality Site of CareI (none) 0.1% OutpatientII (< 70 pts) 0.6% OutpatientIII (71 – 90 pts) 2.8% Inpatient

IV (91 – 130 pts) 8.2% InpatientV (> 130 pts) 29.2% Inpatient

NEJM 1997;336:243

Risk Stratification ScoresCURB65

Ottosen SCNA 2014

Assessment of Severity/Disposition

Prina, Lancet 2015

Microbiological Testing

Prina Lancet 2015

Empirical Therapy

Prina, Lancet 2015

Bacteremia in CAP

• 5% False-positive culture leading to increased length of hospital stay

Metersky AJRCCM 2004

Antibiotic Timing in CAP

Clinical Course/Timeline

Prina, Lancet 2015

Ottosen SCNA 2014

Ottosen SCNA 2014

Presumptive PathogensEarly

Presumptive PathogensLate

Ottosen SCNA 2014

Zilberberg CID 2010, Ottosen SCNA 2014

VAP Diagnostic SurrogateCPIS

When things don’t go as expected..

Ottosen SCNA 2014

Non-resolving Pneumonias

• Granulomatous Infection - TB, Fungal,• Exotic Infection - Brucellosis, Tularemia,

Ricketsial• Drug Resistant Organisms• Post-obstructive Pneumonia• Non-infectious Causes

• Pulmonary embolism• Alveolar hemorrhage• Vasculitis• CVD• Sarcoidosis

Seven Degrees of Suppuration

MIST1

• N=454 (427 randomized) with pH <7.2 or proven intrapleural infection

• SK 250000 IU bid x 3 days vs placebo• No difference in deaths or surgical

drainage rate at 3 months - 31% vs 27%• No difference in in LOS, radiographic

outcome• Side effects 7% vs 3% (p=0.08)

Current Management of Parapneumonic Empyema in the High(er) Risk Patient

Piccolo An Am Thor Soc 2014

Piccolo An Am Thor Soc 2014

Piccolo An Am Thor Soc 2014

Novel Strategies

Transmission ControlViruses

Transmission ControlBacteria