Pneumonia

Dr Swati Das

Consultant Pulmonologist

Radiological Clinical

Is It Pnemonia?

Pneumonia is an acute infection of lung parenchyma

Can be subdivided into different types according to epidemiological criteria

Epidemiological classification of Pneumonia

CAP: Community Acquired Pneumonia

HCAP: Health Care Associated Pneumonia

HAP or NP: Hospital Acquired Pneumonia

VAP: Ventilator Associated Pneumonia

Unknown in the most of countries

5-11/1000 adults in US & UK*

*Eur Respir Mon, 2009, 43, 111–132

Incidence of CAP

Pneumonia: a difficult diagnosis ?

Mr. SM

69 years

Does not smoke (anymore since two years)

No co-morbids

Cough since five days

Coughs up some green phlegm

Looks unwell

Pulse 92 reg

BP 130/90mm Hg

RR 20/min

Temp 38.5 C

Percussion: normal

Auscultation: some scattered rhonchi

Mr. SM

Diagnosis?

Acute bronchitis

Pneumonia

Exacerbation COPD

Mr. SM

Aetiology Bacterial

Viral

Tumor

Cardiac

Signs & symptoms Cough

Fever

Crackles

Rales

Diagnosis Bronchitis

COPD

Heart failure

Pneumonia

Lung cancer

Nothing specific

Searching for the correct diagnosis

Questions on diagnosis

How to detect pneumonia?

Diagnostic value of signs and symptoms ???

Additional value of tests?

Most important tests

Diagnostic models

• Hopstaken et al

•Dry cough, diarrhoea, temp > 38 C

•If all three present: 76% CAP, if none present: 6%

• Diehr et al

•Absence of rhinorrhoea and sore throat, presence of night sweats,

myalgia, sputum all day, resp rate > 25, fever

• Score 1: 9% CAP, score 4, 27%, score 6 100%

• Khalil et al

•Cough, chest pain, shortness of breath, temp>38, heart rate>100,

Resp rate>20, pulse oximetry<95%

•Pos pred value 30%, neg pred value 99%

• Gonzales Ortiz et al

• pathologic auscultation, neutrophilia, pleural pain, dyspnoea

• pos pred value 23%, neg pred value 88%

• Melbye et al

• Absence of coryza and sore throat, presence of dyspnoea, chest pain, crackles

•Pos pred value 17%, neg pred value 79%

Not Of help

Additional tests

Radiological investigations

Tests to detect bacterial pathogens

Gram stain, sputum c/s, blood c/s

Urine test for Streptococcus pneumoniae

sen>70%,specificity>95%,

Legionella antigen

Tests to detect viral pathogens

Test for influenza

Biomarkers

CRP

Procalcitonine/adrenomodulin

Site of care ?

AD, 50 ys

Hello doctor, … I’ve got fever and dry cough since two

days

BP 120/70 HR 88r RR 18’ TEMP 39.0°C

Breath sound diminished on right base

HOSPITAL ADMISSION?

1. No, mild clinical syndrome

2. Yes, high fever

3. What about history?

Hospital admission?

Otherwise healthy man

1. No, mild clinical syndrome in otherwise healthy man

Hospital admission?

Pneumonia = 4 medium risk = 10%

• Fever (38.5°C) 2days

• Dry cough 3days

• Physical examination:

• non-ill; BP 130/80 HR 96r RR 20’

• rales right lung base

DFE, 34

Chest x-ray

You - his physician –

decide …

… to hospitalise him

WHY?

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)

• Fever (37.7°C) started one day before

• non-productive cough

• Non-ill; BP 120/85 HR 90 RR 20’

• Co-morbids-DM, CHF;

FP, 81 ys

What would you do?

1. admit to hospital

2. treat him as outpatient

FP, 81 ys

admit to hospital: patient at risk for adverse outcome

Pneumonia + age + CHF + DM = 9 complications risk = 31%

•Fever (37.9°C) started two days before

• non-productive cough

DA, 63 ys

You - his physician - decide that your patient

is a candidate for hospital admission

Why?

• Fever (37.9°C) started two days before

• non-productive cough

DA, 63 ys, otherwise healthy

The speech is interrupted by frequent breaths

Hello doctor I’ve got fever and dry cough since two days

breath breath breath breath breath

•Analysis performed on 1343 patients (208 out-patients and 1135 hospitalized)

with all data sets completed for the calculation of CURB, CRB and CRB-65

•Validated in 1967 patients (482 out-patients and 1485 hospitalized)

Bauer TT et al. J Intern Med. 2006; 260:93-101

CRB-65 predicts death from community-acquired pneumonia

CURB–65 score

Score one point for presence of each Clinical feature (0 –

5)

1. Confusion

2. Urea > 7 mmol/l

3. Respiratory rate 30/min

4. Blood pressure (SBP <90 or DBP 60mmHg)

5. Age 65yrs

(Albumin < 30 g/dl had an OR 4.7 [2.5-8.7] <0.001)

Lim et al Thorax 2003;58:377-382

CURB 65

0-1=Outpatient

2=Hospital

>=3 HDU/ICU

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

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

SCAP score

Major

Arterial pH <7.30 — 13 points

Systolic blood pressure <90 mmHg — 11 points

Minor

RR >30 breaths/min — 9 points

PaO2/FIO2 <250 mmHg — 6 points

BUN >30 mg/dL (10.7 mmol/L) — 5 points

Altered mental status — 5 points

Age ≥80 years — 5 points

Multilobar/bilateral infiltrates on x-ray — 5 points

>=10 severe CAP

EMPIRIC TREATMENT?

YES !!! Based on knowledge….

…..You need to know

Epidemiology in YOUR area

Rate of antibiotic resistance in YOUR area

Please do not forget Microbiology work

up……

EVEN IF IT COSTS….

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

0 10 20 30 40

S pneumoniae

H influenzae

Legionella

Staph aureus

GNEB

%

UK Europe AUS + NZ N America

GEOGRAPHICAL VARIATION IN

CAP (32 prospective studies; n = 8211)

0 5 10 15 20

M pneumoniae

C pneumoniae

C psittaci

C burnetii

Viruses

%

UK Europe AUS + NZ N America

GEOGRAPHICAL VARIATION IN

CAP (32 prospective studies; n = 8211)

S pneumoniae

H influenzae

Mycoplasma

Chlamydia

Legionella

Gram-negative

bacteria

B-lactam

Macrolide

Tetracycline

Fluoroquinolone

Cephalosporin

ANTIBIOTIC THERAPY

Mandell et al Clin Infect Dis 2007;44(Suppl 2):S27-S72

ATS/IDSA

INPATIENT – NON-ICU

Fluoroquinolone (strong recommendation; level I evidence)

-lactam + macrolide

(strong recommendation; level I evidence)

Mandell et al Clin Infect Dis 2007;44(Suppl 2):S27-S72

ATS/IDSA GUIDELINES

INPATIENT – ICU

-lactam +

Either Azithromycin (level II evidence)

or Fluoroquinolone (strong recommendation; level I evidence)

For Pseudomonas

Anti-pseudomonal -lactam +

Either cipro or levo (level II evidence)

or above -lactam + gentamicin + azithromycin

or above -lactam + antipneumococcal fluoroquinolone

(weak recommendation; level III evidence)

34 yrs, Chinese; ER visit for fever and blood-tinged sputum

Risk factors for TB

Yes/No

IF YES NO QUINOLONES

Antibiotic within 6 hours and oxygen therapy

Conclusion

Clinical assessment

Know your local epidemiology

Be aware of national and international outbreaks

Never forget Mycobacterium tuberculosis