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Community-acquired respiratory tract infections
The document discusses community-acquired respiratory tract infections and provides guidance on appropriate treatment. It emphasizes that the majority of respiratory infections are viral and do not require antibiotics. For suspected bacterial pneumonia, it recommends using clinical assessment and diagnostic tests to determine the correct empiric antibiotic regimen based on severity and likely pathogens. It also stresses the importance of re-evaluating the patient and adjusting or stopping antibiotics based on diagnostic results and clinical response.
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Community-acquired respiratory tract infections
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- 3. “ We havereached a critical point and must act now on a global scale to slow down antimicrobial resistance”Professor Dame Sally Davies, UK Chief Medical Officer 3
- 4. Core competencies for antimicrobialprescribing C1: Understands the patient and the patient’s clinical needs C2: Understands treatment options and how they support the patient’s clinical needs C3: Works in partnership with the patient and other healthcare professionals to develop and implement a treatment plan C4: Communicates the treatment plan and its rationale clearly to the patient and other health professionals C5: Monitors and reviews the patient’s response to treatment 4 Core Competencies
- 5. Objectives • Effectively useinitial assessment to differentiate between viral and bacterial respiratory tract infections determine appropriate empiric antimicrobial therapy highlighting the importance of establishing the correct diagnosis • Utilize patient specific clinical and microbiologic data to reassess the appropriateness of antimicrobial therapy • Emphasize the role of vaccination and hand hygiene in the prevention of lower respiratory tract infections and the role of the clinician in educating patients about these interventions 5
- 6. Lower respiratory tractinfections Bacterial infection Viral infection Antibiotics = INappropriate Antibiotics = appropriate 6
- 7. Community acquired pneumonia(CAP) • a leading cause of morbidity & mortality, especially in elderly & children Community-acquired respiratory tract infections WHO/S Nahrgang 7
- 8. Majority of these infectionsare due to viral infections and are self-limited Community-acquired respiratory tract infections 8 WHO/S Nahrgang
- 9. Lower respiratory tractinfections Bacterial infection Viral infection Antibiotics = INappropriate Antibiotics = appropriate 9
- 10. Clinical case 1 SubsequentevaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 10
- 11. 45 year-old femalewith 2 day history: fever, cough, pleuritic chest pain rusty brown sputum vaccines NOT up to date fever to 39C, HR 105, RR 35bpm oxygen saturation is 91% on room air bilateral rales and egophony 11
- 12. Clinical assessment Past medical history Current symptoms Systematic approach CoreCompetencies 1 & 2 • Fever • Chills • Cough • Sputum production • Sputum characteristics • Shortness of breath • Chest pain 12
- 13. Clinical assessment Past medical history Current symptoms Physical examination Systematic approach CoreCompetencies 1 & 2 • Rales/crackles • Rhonchi • Wheezing • Egophony • Dullness 13
- 14. A clear differentialdiagnosis Infectious S. Pneumoniae TypicalAtypical Mycoplasma H. influenzae C. pneumoniae Legionella Parainfluenza RSV Adenovirus Influenza Human metapneumovirus Rhinovirus Bacterial Viral 14
- 15. Clinical case 1 SubsequentevaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 15 You suspect bacterial community acquired pneumonia. Now what?
- 16. Diagnostic work-up 2007 IDSAGuidelines • Chest x-ray for confirmation of all cases of suspected pneumonia American College of Chest Physicians • Chest x-ray unless – Afebrile – No tachycardia – No tachypnea AND – Chest examination without evidence of consolidation Core Competency 2 16
- 17. Diagnostic work-up 2007 IDSAGuidelines • Chest x-ray for confirmation of all cases of suspected pneumonia NICE guidance • Consider C-reactive protein – < 20mg/L = no antibiotics – 20 – 100 mg/L = delayed antibiotics – >100mg/L = antibiotics • If hospitalized, chest x-ray Core Competency 2 17
- 18. Clinical case 1 SubsequentevaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 18 Chest x-ray confirms left lower lobe consolidation
- 19. An informed choice SeveritySource Drug resistance Patient factors Cultures Core Competencies 1, 2 & 3 19
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- 21. CURB-65 Confusion present Urea >7 mmol/L or blood urea nitrogen (BUN) > 20 mg/dL Respiratory rate > 30 breaths/minute Blood pressure SBP < 90 mmHg or DBP < 60 mmHg Age > 65 years 21
- 22. CURB-65 Confusion present Urea >7 mmol/L (or BUN > 20 mg/dL) Respiratory rate > 30 breaths/minute Blood pressure SBP < 90 mmHg or DBP < 60 mmHg Age > 65 years Scores > 2 consider hospitalization 22
- 23. Severity Source Drug resistance Patient factors Cultures An informedchoice 23 • CURB-65 = 2 • Admit to hospital
- 24. Severity Source Drug resistance Patient factors Cultures An informedchoice 24 • CAP • Streptococcus pneumoniae
- 25. Severity Source Drug resistance Patient factors Cultures An informedchoice 25 • Recent antimicrobial use? No • Local cumulative susceptibility data?
- 26. Empiric regimen perguidelines 2007 IDSA Guidelines Community acquired pneumonia Inpatient • Beta-lactam plus macrolide • Respiratory fluoroquinolone 26
- 27. Empiric regimen perguidelines 2014 National Institute for Health and Care Excellence (NICE) guidelines https://www.nice.org.uk/guidance/cg191 MODERATE (CURB-65 = 2) amoxicillin OR penicillin G plus macrolide SEVERE (CURB-65 = >3) beta-lactam plus macrolide 27
- 28. Severity Source Drug resistance Patient factors Cultures Other considerations 28 •Allergies? NO • Renal or liver dysfunction? NO • Pregnant? NO
- 29. Severity Source Drug resistance Patient factors Cultures An informedchoice 29 • Blood culture • Sputum culture • Urine pneumococcal antigen
- 30. An informed choice SeveritySource Drug resistance Patient factors Cultures Ceftriaxone + Azithromycin 30
- 31. Clinical Case 1 SubsequentevaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 31 Clinically Improved
- 32. Clinical Case 1 SubsequentevaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 32 Sputum cx: S. pneumoniae WHO/O.Karatuna
- 33. Clinical Case 1 SubsequentevaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 33 Amoxicillin
- 34. Clinical Case 1 SubsequentevaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 34 Prevention
- 35. Clinical Case 2 SubsequentevaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 35
- 36. 25-yo female witha week of cough: Denies fever, chills, night sweats +rhinorrhea Intermittently productive cough hypotension NOT tachycardia or tachypneic bilateral rhonchi and scattered wheeze 36 How would you manage this patient?
- 37. Acute bronchitis Productive cough doesnot differentiate between URTI Acute bronchitis CAP 37
- 38. Diagnostic work-up Acute bronchitis= often no need for diagnostic work-up ✕ 38
- 39. A clear differentialdiagnosis Infectious S. Pneumoniae TypicalAtypical Mycoplasma H. influenzae C. pneumoniae Legionella Parainfluenza RSV Adenovirus Influenza Human metapneumovirus Rhinovirus Bacterial Viral 39
- 40. Clinical Case 2 SubsequentevaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 40 No antibiotics Reassurance & Follow-up Plan
- 41. Review: Community-acquired RTIs Bacterial infectionViral infection 41 Drug Dose Duration Route prescription ............. ............. .............
- 42. Review: Community-acquired RTIs CAP •Use guidelines to make empiric antibiotic choices • Adjust antibiotics with microbiologic data • Typical duration of therapy is <7 days 42 Drug Dose Duration Route prescription ............. ............. .............
- 43. Review: Community-acquired RTIs Acutebronchitis • Do not prescribe antibiotics • Patient education is key! 43 Drug Dose Duration Route prescription ............. ............. .............
- 44. Quiz time! Please click “Next”to proceed.