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, Not Of help 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%
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
DA, 63 ys•Fever (37.9°C) started two days before• non-productive cough You - his physician - decide that your patient is a candidate for hospital admission Why?
DA, 63 ys, otherwise healthy• Fever (37.9°C) started two days before• non-productive cough The speech is interrupted by frequent breaths Hello doctor I’ve got fever and dry cough since two daysbreath breath breath breath breath
CRB-65 predicts death from community-acquired pneumonia•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
CURB–65 scoreScore 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
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 CAPCONCLUSIONS: Both the CURB and CRB-65 scores can be used in the hospital andout-patients setting to assess pneumonia severity and the risk of deathGiven that the CRB-65 is easier to handle, we favor the use of CRB-65 where bloodurea nitrogen is unavailable Bauer TT et al. J Intern Med. 2006; 260:93-101
SCAP score Major Minor RR >30 breaths/min — 9 points PaO2/FIO2 <250 mmHg — 6 Arterial pH <7.30 — 13 points points Systolic blood pressure <90 BUN >30 mg/dL (10.7 mmol/L) mmHg — 11 points — 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
GEOGRAPHICAL VARIATION IN (32 prospective studies; n = 8211)CAP % 0 10 20 30 40S pneumoniae H influenzae LegionellaStaph aureus GNEB UK Europe AUS + NZ N America
GEOGRAPHICAL VARIATION IN (32 prospective studies; n = 8211)CAP % 0 5 10 15 20M pneumoniaeC pneumoniae C psittaci C burnetii Viruses UK Europe AUS + NZ N America
ATS/IDSAINPATIENT – NON-ICUFluoroquinolone (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) Mandell et al Clin Infect Dis 2007;44(Suppl 2):S27-S72
34 yrs, Chinese; ER visit for fever and blood-tinged sputum
Risk factors for TB Yes/NoIF YES NO QUINOLONES