CLAIRE NOWLAN & SAM SEARLE. Pneumonia in the nursing home

Transcription

1 CLAIRE NOWLAN & SAM SEARLE Pneumonia in the nursing home

2 No disclosures or conflicts of interest

3 PMHX: A. FIB. GERD MIXED DEMENTIA MMSE 16/30 HTN Mr. Hack 86 years old

4 RAMIPRIL 4 MG OD PARIET 20MG OD DONEPEZIL 10MG OD WARFARIN 5MG OD Text Current medications

5 TEXT Mr Hack Nursing staff call: last 3 days more confused new cough fall last night You see patient who is: tired more distractible than usual

6 PHYSICAL EXAM HR 96, O2 88%, T 37.8, BP 110/60, RR 25 Chest: Clear, breath sounds only heard at apices

7 Questions Is this pneumonia? If pneumonia - what type? Do you need any investigations? Which antibiotic will you use to treat? For how long? Are you worried about any drug interactions? Could the pneumonia have been prevented? What is Mr. Hack s prognosis?

8 Importance of Pneumonia 9 th Leading cause of death (overall) 23% mortality in 14 days Risk Factors for Pneumonia in LTC: Age, male sex, dysphagia, unable to take oral meds, profound disability, bedridden, urinary incontinence [Pneumonia is] the captain of the men of death. Sir William Osler

9 Differential Pneumonia (viral/ bacterial) Aspiration/ pneumonitis/ pneumonia Acute Bronchitis Exacerbation of Chronic Obstructive Pulmonary disease

10 Is it Acute Bronchitis? Acute Bronchitis Inflammation large and mid airways No signs of pneumonia Principles and Practice of Infectious Diseases 2014 Most commonly viruses Rhinovirus Influenza RSV Metapneumovirus Coronaviruses Adenovirus <10% M. pneumoniae, C. pneumoniae, B. pertussis No antibiotics 60-80% of patients receive abx Pt reassurance, Vaccinations, smoking cessation

11 Antibiotics for bronchitis Endpoint Clinical improvement at follow-up adverse effects in the antibiotic group RR (95% CI) 1.07 ( ) 1.20 (1.05 to 1.36) Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD DOI: / CD000245

12 GOLD STANDARD TO DIAGNOSE PNEUMONIA IS CXR Do you have easy access??

13 A ~Minimum Criteria to Diagnose Pneumonia Any of: 1. Fever 38.9 o C and one of a) RR>24/ Productive Cough 2. Fever o C and one of a) RR>24/ pulse>100/ Rigors/ New Delirium 3. COPD and New or Increased cough with purulent sputum 4. New/ Increased cough and one of a) RR>24/ new delirium

14 afebrile for 48 hours no more than one clinical instability factor defined as HR >100 beats/min RR >24 breaths/min SBP 90 mmhg Sats < 90% on room air Success at 30 days was 92.6% (long) and 94.4% (short)

15 Within hours Mr. Hack is better!! Maybe this was just a aspiration or aspiration pneumonitis? STOP ANTIBIOTICS

16 Minimizing collateral damage Re-evaluate medical status Focus on Personalized Care Use as short a course as necessary Evidence supports azithromycin for 3 days Evidence supports levofloxacin 750 mg for 5 days

17 PEER REVIEWED GUIDELINE APP MUMS Health

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19 Another Good Resource rxfiles.ca\abx

20 Concern with aspiration? Appears ~40-60% in LTC

21 Consider using.. ASPIRATION PNEUMONIA GUIDELINES

22 Local Antibiotic Resistance Rates Unclear 4% of pneumonoccal illnesses have resistance to fluroquinolones MUMS nation wide

23 DON T FORGET ABOUT DRUG INTERACTIONS! Mr. Hack is taking Warfarin Warfarin + Abx = Bleeding

24 DOCTOR S STRIKE

25 Preventative what is out there? Dental Care dental care professionals > nurses Vaccinations influenza Tamiflu only when public health involved Aspiration Chin tuck technique Careful hand feeding Increase risk: Proton pump inhibitors Protective: ACE inhibitors

26 Prognosis Level of evidence is poor (23% mortality in 14 days) Multiple tools available: frailty, CURB-65, PSI and ED- MEWS. This is a good time to review advanced directives, especially for aspiration pneumonia in dementia.

27 CRB-65 High Risk Pneumnonia Confusion (MMSE<9, new disorientation) RR >30 breaths/min SBP <90mmHg or DBP <60mmHG Age >= 65 Three or four high risk mortality (30 days)

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29 Answers Is this pneumonia? Yes - RR more than 24, T 37.8, new cough, new delirium If pneumonia - what type? Is he at risk for aspiration? Do you need any investigations? Ideally CXR - but likely not available Which antibiotic will you use to treat? For how long? Are you worried about any drug interactions? Yes - Warfarin Could the pneumonia have been prevented? Could you have stopped the PPI? Good dental hygiene? What is Mr. Hack s prognosis? He is not severely ill, scored 2 on MEWS scale. Fraily score unknown.

30 Take home points Use a minimal criteria set (RR, temp, confusion, sputum) Treat pneumonia as community acquired pneumonia, but be on the lookout for early improvement (stop Abx) Shorter courses are favoured Don t forget about interactions such as Abx with Warfarin Use Caution in individuals who aspirate

31 Patient care goals should be created and documented as clearly/ early as possible Get flu shot Optimize dysphagia/ medications

32 EALTH.CA EANV.CA

33 Much thanks to Dr. Glen Patriquin Dr. Paul Bonnar Dr. Ian Davis

34 Questions?