Community-acquired Respiratory Infection Treatment
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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 Infection Treatment
- 2. Course content Courseroadmap Basic concepts Common infections 2
- 3. “ We have reached 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 antimicrobial prescribing 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 use initial 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 tract infections 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 infections are due to viral infections and are self-limited Community-acquired respiratory tract infections 8 WHO/S Nahrgang
- 9. Lower respiratory tract infections Bacterial infection Viral infection Antibiotics = INappropriate Antibiotics = appropriate 9
- 10. Clinical case 1 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 10
- 11. 45 year-old female with 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 Core Competencies 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 Core Competencies 1 & 2 • Rales/crackles • Rhonchi • Wheezing • Egophony • Dullness 13
- 14. A clear differential diagnosis Infectious S. Pneumoniae TypicalAtypical Mycoplasma H. influenzae C. pneumoniae Legionella Parainfluenza RSV Adenovirus Influenza Human metapneumovirus Rhinovirus Bacterial Viral 14
- 15. Clinical case 1 Subsequent evaluationInitial 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 IDSA Guidelines • 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 IDSA Guidelines • 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 Subsequent evaluationInitial 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 Severity Source Drug resistance Patient factors Cultures Core Competencies 1, 2 & 3 19
- 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 informed choice 23 • CURB-65 = 2 • Admit to hospital
- 24. Severity Source Drug resistance Patient factors Cultures An informed choice 24 • CAP • Streptococcus pneumoniae
- 25. Severity Source Drug resistance Patient factors Cultures An informed choice 25 • Recent antimicrobial use? No • Local cumulative susceptibility data?
- 26. Empiric regimen per guidelines 2007 IDSA Guidelines Community acquired pneumonia Inpatient • Beta-lactam plus macrolide • Respiratory fluoroquinolone 26
- 27. Empiric regimen per guidelines 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 informed choice 29 • Blood culture • Sputum culture • Urine pneumococcal antigen
- 30. An informed choice Severity Source Drug resistance Patient factors Cultures Ceftriaxone + Azithromycin 30
- 31. Clinical Case 1 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 31 Clinically Improved
- 32. Clinical Case 1 Subsequent evaluationInitial 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 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 33 Amoxicillin
- 34. Clinical Case 1 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 34 Prevention
- 35. Clinical Case 2 Subsequent evaluationInitial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 35
- 36. 25-yo female with a 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 does not differentiate between URTI Acute bronchitis CAP 37
- 38. Diagnostic work-up Acute bronchitis = often no need for diagnostic work-up ✕ 38
- 39. A clear differential diagnosis Infectious S. Pneumoniae TypicalAtypical Mycoplasma H. influenzae C. pneumoniae Legionella Parainfluenza RSV Adenovirus Influenza Human metapneumovirus Rhinovirus Bacterial Viral 39
- 40. Clinical Case 2 Subsequent evaluationInitial 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 infection Viral 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 Acute bronchitis • Do not prescribe antibiotics • Patient education is key! 43 Drug Dose Duration Route prescription ............. ............. .............
- 44. Quiz time! Please click “Next” to proceed.