Community acquired pneumonia

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CAP BASIC

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Community acquired pneumonia

  1. 1. COMMUNITY ACQUIRED PNEUMONIA DR. ABHAY MANGE
  2. 2.  70 year old female patient  r/o Badegaon district Nagpur was admitted in MICU, on 12/12/2013 with c/o  Dry cough since 1 month  Fever since 1 month  Breathlessness since 15 days, increased since 4days  h/o arthralgia +  No h/o bronchial Asthma, PTB/contact in past  No h/o HTN/DM/IHD past,  No h/o recent hospitalization
  3. 3. 0n examination  Confused  Febrile  Pulse -140/min, ire. irregular  RR-44/min  SpO2 – 78 % in room air, 92 % with O2( 5 L/min)  BP- 120/80 mmHg  Pallor +  JVP- nr  Edema feet absent  No lymphadenopathy  No s/o arthritis  RS – AE decreased on lt side crackles were present Lt.MA, IAA,ISA .  CVS- S I changing, no murmur  PA- Soft, S/L np  CNS – Confused ,no menningeal signs  CRB-65 =4
  4. 4. Investigations  Hb – 9.9 gm%  TLC-14000/cumm  P-88% , L-10%,E-1%,M-1%  BUL-95 mg%, SC-1.9mg%  Na -147 meq/l, K-3.8 meq/l  LFT- WNL,Except S.Alb=2.8gm%  ECG s/o Atrial fibrillation  CXR S/O Consolidation Left Lung with Synpneumonic effusion
  5. 5. Provisional diagnosis  Consolidation Left Lung  Synpneumonic Effusion  Atrial fibrillation
  6. 6. Severity indices  CURB 65 = 4  Confusion +  Urea>19mgm/dl 95mg/dl  Respiratory Rate >30/min 44/min  Blood Pressure SP<90/ DP< 60 120/80  Age>65 years +
  7. 7. Severity indices CURB 30 DAYS SCORE MORTALITY 0-1 1.5% 2 9.2% 3-5 22% Sensitivity - 66% Specificity - 73%
  8. 8. Severity indices PSI SCORE =150 (CLASS-V) CLINICAL PARAMETER SCORE  AGE 70 YR , FEMALE 60  ALTERED SENSORIUM 20  RR >20 20  BUN >30 20  PULSE >125 10  PLEURAL EFFUSION 10  TOTAL 150
  9. 9. Severity indices
  10. 10. Severity indices
  11. 11. Severity indices SMART-COP score =7  Multilobar chest radiography involvement 1 point  Low Albumin level 1 point  High Respiratory rate(25/min) 1 point  Tachycardia (>125) 1point  Confusion 1 point  Poor Oxygenation 2 points
  12. 12. Severity indices SMART-COP  Derived from the Australian CAP Study (ACAPS)  Identifies patients who received invasive respiratory and vasopressor support (IRVS). Interpretation of SMART-COP score  0 to 2 points—low risk of needing IRVS  3 to 4 points—moderate risk (1 in 8) of needing IRVS  5 to 6 points—high risk (1 in 3) of needing IRVS  7 or more points—very high risk (2 in 3) of needing IRVS  Severe CAP = a SMART-COP score of 5 or more points.
  13. 13. PARAMETER AGE <50 AGE >50 POINTS SBP < 90 mmhg <90 mmhg 2 Multilobular CXR involvement + + 1 Albumin <35gm/l <35gm/l 1 Resp.rate >25 /min >25 /min 1 Tachycardia >125/min >125/min 1 Confusion(acute) + + 1 Low Oxygen PaO2 <70 or SpO2<93 or PaO2/FIO2 < 333 PaO2 <60 or SpO2<90 or PaO2/FIO2 < 250 2 PH < 7.35 <7.35 2
  14. 14. Treatment  PUP, O2 5/L min IVF  Inj. Piperacillin + tazobactum 4.5 gm bd  Inj. Azithromycin 500 mg od  Inj . Metrogyl 500 mg tds  Inj . Diltiazem 12.5 mg stat  Tab Diltiazem sr 60 mg od  Nebulisation with duolin
  15. 15. Treatment and course on Day 3 ON EXAM TREATMENT  No Clinical Improvement  Febrile  Pulse – 120/min  RR – 40/min  SpO2 – 95 % with O2  BP 120/70  Crackles persistent Also on right Side (IC)  Inj. Meropenam 1 gm tds  Inj. Vancomycin I gm bd  Inj. Levofloxacin 500 mg od Blood Urea- 103mgm% Serum Creat- 1.3mgm%
  16. 16. Treatment & Course on Day 6 ON EXAM TREATMENT  Febrile  Pulse -98/min,regular  RR – 44/min  SpO2 -91% with o2  BP – 120/70  Crackles persistent  Present all over the right side as well  TLC 13800/cumm  P79%, Platelets 1.10,000/cumm  Tobramycin repsules 300mg (5ml) bd  Cap Tamiflu 75mg bd added
  17. 17. Day 9 – No Improvement in Cl Condt  Inj. Colistin 2 MU bd,  Inj . Linezolid 600 mg bd,  Inj. Lasix 40 mg od, •Sputum AFB- NEG •H1N1 -ve •Pleural fluid •Exudative, •TLC=380/cmm,N-28%,L-70%, •ADA-Neg CT Thorax planned
  18. 18. Day 15  Clinically stable  Inj antibiotics stopped  Tab Cefixime 200 + azithromycin 250 bd
  19. 19. CT -THORAX B/L patchy inter- lobular and intra- lobular septal thicknening with associated ground glass opacities predomintly in sub pleural location Ground glass and reticular opacities in b/l upper lobes FSO- Non specific interstitial pneumonia
  20. 20.  PULMONOLOGIST OPINION-  Non specific Interstitial Pneumonia  ? Collagen Tissue Disorder  RA factor – positive  CRP- Negative  ANA- Negative  LE CELL –Negative  E-NA - Negative
  21. 21. Final diagnosis  Non specific Interstitial Pneumonia with  MDR-Community acquired pneumonia
  22. 22. DISCUSSION
  23. 23. Definition  IDSA define CAP as an acute infection of the pulmonary parenchyma, accompanied by the presence of an acute infiltrate on a chest radiograph (or altered auscultatory findings consistent with pneumonia) in a patient not hospitalized or residing in a long-term care facility for >14 days before onset of symptoms .
  24. 24. Microbial Causes of CAP, by Site of Care  Outpatients Non-ICU ICU  S. pneumoniae S. pneumoniae S.pneumoniae  Mycoplasma pneumoniae M. pneumoniae Staphylococcus aureus  H. influenzae Chlamydia pneumoniae Legionella spp.  C. pneumoniae H. influenzae Gram-negative bacilli  Respiratory virusesa Legionella spp. H. influenzae Respiratory virusesa  a=Influenza A and B, adenovirus, respiratory syncytial virus, and parainfluenza
  25. 25. Clinical Features  Systemic complaints include malaise, and high fever  Pulmonary symptoms include any combination of  Dyspnea  Chest discomfort  Pleuritic pain  Chest splinting  Cough productive of purulent or blood-tinged sputum  Tachypnea  Tachycardia  In advanced cases you may see:  Cyanosis  Confusion  Chest sounds include:  Early on in disease a fine crepitant rales over the involved portion of the lung(s).  Progression to lobar consolidation results in:  Dullness to percussion  Vocal fremitus  Whispered pectoriloquy  Bronchial breathing  Pleural effusions can occur with the following symptoms:  Pleural friction rub  Dullness to percussion  Decreased breathing sounds  Egophony  If necrosis of the lung occurs, cavities in the lung develop resulting in cavernous or amphoric breathing directly over the cavitary lesion..
  26. 26. Site-of-Care Decisions (ATS) Hospital admission decision.  For patients with CURB-65 scores 2, o more-intensive treatment—that is, hospitalization or, where appropriate and available, intensive in-home health care services—is usually warranted.  Objective criteria or scores should always be supplemented with o Physician determination of subjective factors, including the ability to safely and Reliably take oral medication and the availability of outpatient support resources
  27. 27. Site-of-Care Decisions – ATS Guidelines ICU admission decision  Direct admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation.  Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed . Minor criteria  Respiratory rate > 30 breaths/min  PaO2/FiO2 ratio <250  Multilobar infiltrates  Confusion/disorientation  Uremia (BUN >20 mg/dL)  Leukopenia (WBC count, <4000 cells/mm3)  Thrombocytopenia (platelet count, <100,000 cells/mm3)  Hypothermia (core temperature, <36C)  Hypotension Major criteria  Invasive mechanical ventilation  Septic shock with the need for vasopressors
  28. 28. Diagnostic Testing Recommended diagnostic tests for etiology Patients with CAP should be investigated for specific pathogens  That would significantly alter standard (empirical) management decisions,  When presence of such pathogens is suspected on the basis of clinical and epidemiologic clues
  29. 29. Diagnostic Testing  Routine diagnostic tests to identify etiologic diagnosis are optional for outpatients with CAP.  Pretreatment blood samples for culture and an expectorated sputum sample for stain and culture should be obtained from hospitalized patients with the clinical indications listed below but are  optional for patients without these conditions.  Intensive care unit admission  Failure of outpatient antibiotic therapy  Cavitary infiltrates  Leukopenia  Active alcohol abuse  Chronic severe liver diseas  Severe obstructive/structural lung disease  Asplenia (anatomic or functional)  Recent travel (within past 2 weeks)  Positive Legionella UAT  Positive pneumococcal UAT result  Pleural effusion
  30. 30. Diagnostic Testing  Pretreatment Gram stain and culture of expectorated sputum should be performed only if,  a good-quality specimen can be obtained and  quality performance measures for collection, transport, and processing of samples can be met.  Patients with severe CAP, should at least have blood samples drawn for culture, urinary antigen tests for Legionella pneumophila and Streptococcus pneumoniae performed, and expectorated sputum samples collected for culture.  For intubated patients, an endotracheal aspirate sample should be obtained
  31. 31. Empirical antimicrobial therapy Outpatient treatment  Previously healthy and no antibiotics in past 3 months  A macrolide Clarithromycin (500 mg PO bid) or Azithromycin (500 mg PO once, then 250 mg qd) or  Doxycycline (100 mg PO bid)  Comorbidities or antibiotics in past 3 months:  select an alternative from a different class A respiratory fluoroquinolone Moxifloxacin (400 mg PO qd), Gemifloxacin (320 mg PO qd), Levofloxacin (750 mg PO qd)] or  A -lactam [preferred: high- dose amoxicillin (1 g tid) or amoxicillin/clavulanate (2 g bid); or  ceftriaxone (1–2 g IV qd), cefpodoxime (200 mg PO bid), cefuroxime (500 mg PO bid)] plus  a macrolide
  32. 32. Empirical antimicrobial therapy Inpatients, Non-ICU  A respiratory fluoroquinolone moxifloxacin (400 mg PO or IV qd), gemifloxacin (320 mg PO qd), levofloxacin (750 mg PO or IV qd) or  A -lactam [cefotaxime (1–2 g IV q8h), ceftriaxone (1–2 g IV qd), ampicillin (1–2 g IV q4–6h), ertapenem (1 g IV qd in selected patients)] plus  A macrolide [oral clarithromycin or azithromycin (as listed above for previously healthy patients) or IV azithromycin (1 g once, then 500 mg qd)] Inpatients, ICU  A -lactam [cefotaxime (1–2 g IV q8h), ceftriaxone (2 g IV qd), ampicillin-sulbactam (2 g IV q8h)] plus  Azithromycin or a fluoroquinolone (as listed above for inpatients, non-ICU
  33. 33. Empirical antimicrobial therapy Special Concerns If Pseudomonas is a consideration  An antipneumococcal, antipseudomonal –lactam [piperacillin/tazobactam (4.5 g IV q6h), cefepime (1–2 g IV q12h), imipenem (500 mg IV q6h), meropenem (1 g IV q8h)] plus either ciprofloxacin (400 mg IV q12h) or levofloxacin (750 mg IV qd)  The above –lactams plus an aminoglycoside [amikacin (15 mg/kg qd) or tobramycin (1.7 mg/kg qd) and azithromycin]  The above –lactams plus an aminoglycoside plus an antipneumococcal fluoroquinolone If CA-MRSA is a consideration  Add linezolid (600 mg IV q12h) or vancomycin (1 g IV q12h).
  34. 34. Empirical antimicrobial therapy Duration of antibiotic therapy  Patients with CAP should be treated for a minimum of 5 days ,  should be afebrile for 48–72 h, and should have no more than 1 CAP-associated sign of clinical instability before discontinuation of therapy  A longer duration of therapy may be needed  if initial therapy was not active against the identified pathogen or  if it was complicated by extrapulmonary infection, such as meningitis or endocarditis.
  35. 35. Multidrug-Resistant CAP COMMON PATHOGENS  Pseudomonas Aeruginosa  Acinetobacter baumanii  Staphylococcus aureus  Klebsiella pneumoniae  Streptococcus pneumoniae
  36. 36. Multidrug-Resistant CAP Pseudomonas Aeruginosa  Most worrisome characteristics of P. aeruginosa is its low antibiotic susceptibility, which is attributable to a concerted action of multidrug efflux pumps and the low permeability of the bacterial cellular envelopes.  Adjunctive antibiotic therapy with inhaled antibiotics has been proposed in the management of MDR Pseudomonas; however, there is no clear evidence for its use.  The intrinsic susceptibility of P. aeruginosa is already limited to only several antimicrobial classes, but  Emergence of multidrug resistance compromises most of the antipseudomonals except colistin and polymyxin B therapies.
  37. 37. Multidrug-Resistant CAP Acinetobacter  Acinetobacter baumanii is a Gram-negative coccobacillus that is normally a commensal pathogen but can be a nosocomial pathogen.  In 2004, the CDC reported an increasing number of Acinetobacter baumannii infections in military ‘Operation Iraqi Freedom’ and in Afghanistan during ‘Operation Enduring Freedom’.  Most of these showed multidrug resistance , with a few isolates resistant to all drugs tested  Treatment options for MDR Acinetobacter include carbapenems, polymyxins [polymyxin B and polymyxin E (colistin)], tigecycline, and combination therapy with sulbactam or rifampicin, or combination of carbapenem with colistin.
  38. 38. Multidrug-Resistant CAP Acinetobacter  Colistin is as safe and as efficacious as the standard antibiotics for the treatment . Although the recommended dose of colistin is 2 MU intravenously thrice a day, some studies suggest using higher doses of colistin (9 MU/day) .  Sulbactam is a relatively new agent for the treatment of MDR Acinetobacter. The recommended dose for sulbactam is 40-80 mg/kg (at least 6 g/day in divided doses).  Rifampicin in combination with colistin has also been shown to be beneficial in observational studies.  Tigecycline is approved by the FDA for treatment of complicated CAP
  39. 39. Multidrug-Resistant CAP Staphylococcus aureus  Community-acquired MRSA (CA-MRSA) has now emerged as an epidemic that is responsible for rapidly progressive, fatal diseases, including necrotizing pneumonia, severe sepsis.  The first documented strain with complete (>16 μg/ml) resistance to vancomycin, termed vancomycin-resistant Staphylococcus aureus(VRSA) appeared in the United States in 2002.  Linezolid-resistance in S. aureus was reported in 2001.  Drugs approved for the treatment of MRSA pneumonia include vancomycin, teicoplanin, and linezolid.  Newer investigational drugs include lipoglycopeptides (telavancin, dalbavancin), cephalosporins (ceftobiprole and ceftaroline), and dihydrofolate reductase inhibitors (iclaprim)
  40. 40. Multidrug-Resistant CAP Streptococcus pneumoniae  Antibacterial resistance in Streptococcus pneumoniae is increasing worldwide, affecting principally beta-lactams and macrolides (prevalence ranging between 1% and 90% depending on the geographical area).  The major mechanism - mutations in genes encoding penicillin- binding proteins.  A large number of drugs with activity against these multi-drug resistant strains (cephalosporins, carbapenems, glycopeptides, ketolides, lincosamides, oxazolidinones, quinolones, deformylase inhibitors).
  41. 41. Multidrug-Resistant CAP Klebsiella pneumoniae  Klebsiella pneumoniae is a facultative anaerobic, Gram-negative, rod-shaped bacterium in the Enterobacteriaceae family.  Klebsiella pneumoniae carbapenemase (KPC)-producing bacteria are a group of emerging highly in a variety of clinical settings around the world.  Parenteral therapeutic options for infections with ESBLproducing and carbapenem-resistant isolatesTigecycline, Colistin, Fosfomycin.
  42. 42. THANKS !

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