PNEUMONIA REVIEW. Objectives. Pneumonia. CAPA 2015 Annual Conference

Transcription

1 PNEUMONIA REVIEW Tracey DelNero, MSPAS, PA-C Director of Clinical Education Touro University California Objectives Differentiate etiologies of pneumonia Differentiate pneumonias by transmission mechanism Identify SIRS criteria Recognize inpatient admission criteria Differentiate treatment choices based on etiology, age, healthcare setting and comorbidities Identify current immunization recommendations Pneumonia Pneumonia is a constellation of s/sx (fever, chills, cough, pleuritic CP, sputum production, hyper- or hypothermia, increased respiratory rate, dullness to percussion, crackles, wheezing, egophony, pleural friction rub) in combination with at least one opacity of CXR. 1

2 PREVENTION Pneumonia Prevention Influenza Vaccine yearly Egg Allergy Hives only reaction Eligible for standard Inactivated vaccine Recombinent vaccine (RIV) [FluBlok] = no egg protein Pneumococcal Vaccine Pneumococcal (conjugate) 13-valent (PCV13) Pneumococcal (polysaccharide) 23-valent (PPSV 23) Co-Administration of Vaccines Inactive Influenza + PCV13 = no current recommendation Data show efficacy of PCV13 and systemic sx with co-administration Inactive Influenza + PPBV23 = OK If not co-administered, separate by 1 month PPBV23 + PCV13 = NEVER 2

3 ACIP Recommended Intervals Age Group 24-71mo Underlying conditions Immunocompetent with underlying chronic conditions Asplenia immuncompromised 6-18 yr High-risk immunocompetent (cochlear implant, CSF leak) Asplenia immunocompromised 19yr High-risk immunocompetent (cochlear implant, CSF leak) Asplenia immunocompromised PCV13 PPSV23 8 weeks 8 weeks 8 weeks PPSV23 PCV13 8 weeks 8 weeks 1 year 65yr NA 1 year* 1 year preferred sequence *adopted June 2015 Current ACIP Guidelines Pts 65+ Previously Vaccinated before 65 y/o who are now 65+ Administer PCV13-1 year after most PPSV vaccination; then 1 year later Revaccinate with PPBV23 (or when >5 years since last PPSV23 vaccination) IS IT PNEUMONIA? IF SO, WHAT KIND? 3

4 To R/o Pneumonia Clear CXR OR Clinically = absence of the SIRS criteria SIRS criteria T <98.6 or > 100.4, R>20, P>90, WBC <4K or > 12K Tachypnea criteria = >50 for <12month old, > 40 for 1-5 y/o, > 30 for >5 y/o Transmission Routes Microaspiration inhalation of bacterial from nasopharynx Pneumococcal, H.influenzae Aerosolization - inhalation of airborne spores/droplets Fungal, TB, Viral, Legionella Hematogenous Disseminated TB or Fungal Multi-organism d/t sepsis, endocarditis, IVSA Gross aspiration Anaerobic, gram (-) bacilli Types of Pneumonia Lobar involves entire lung lobe Pneumococcal, Mycoplasma, Legionella, Gram (-) Bronchopneumonia patchy consolidation Bacterial, viral, fungal Interstitial pneumonia interstitial inflammation Mycoplasma most common, but possible with all bacteria, virus, fungus Irritants Asbestos, coal dust, talc dust Miliary pneumonia discrete lesions from hematogenous (disseminated) spread Fungal, TB 4

5 PNA Categories Community Acquired (CAP) Hospital Acquired (HAP) Occurs 48 hours after admission No endotracheal intubation Ventilator Associated (VAP) hours after endotracheal intubation Healthcare Associated (HCAP) H/o hospitalization >2 days in last 90 days Recent IV abx, chemotherapy, wound care, hemodialysis Resides in LTC facility CAP Organisms Outpatient Tx S. pneumoniae Mycoplasma Viral Chlamydiophilia H. influenzae Legionella Inpatient Tx S. pneumoniae Viral Mycoplasma Staphylococcus aureus HAP, HCAP & VAP Organisms HAP/HCAP Staphylococcus (MRSA) Gram negative bacteria Pseudomonas; E. coli; Klebsiella Anaerobic (aspiration associated) Polymicrobial VAP Similar to HAP Less MRSA Increased pseudomonas 5

6 BACTERIAL PNEUMONIA CAP S/Sx History (sx = insidious or sudden) Common sx = Fever, cough (+/-productive), SOB/DOE,Chest pain/pressure/tightness Occasional sx = Headache, GI c/o, myalgias, fatigue Elderly sx = falls, confusion Physical Tachypnea* (>25), dullness to percussion, fremitus, egophony, rales/crackles, friction rub, tachycardia*(>100), Lungs can be CTAB w/lobar! CAP- Diagnosis CXR standard not 100% sensitive CT more sensitive RUL infiltrate R/o TB too Always obtain imaging if T>101.3 or (+)Friction rub CBC Blood cultures All hospitalized patients Outpatient hypothermic, homeless, ETOH Pulse Oximetry 6

7 I MADE THE DIAGNOSIS BUT WHERE SHOULD I TREAT? CURB-65 A-Drop SCAP CURB -65 British Thoracic Society Criteria Confusion Urea (BUN>7mmol) RR> 30 BP (systolic <90 OR diastolic <60) Age 65 Admit 2, Consider ICU 3 Limitation not well studies in diverse populations A-Drop Japanese Respiratory Society Criteria Age (M>70; F> 70) Dehydration status (BUN >210 mg/l) Respiratory status (SaO2<90) Orientation disturbance (confusion) Pressure (Systolic <90) 7

8 Severity Community-Acquired Pneumonia (SCAP) American Thoracic Society/Infectious Disease Society of America Major Criteria Mechanical Ventilation Septic shock Other factors Alcohol withdrawal Hypoglycemia Hyponatremia Elevated lactate level Cirrhosis Asplenia Minor Criteria RR>30 PaO2/FiO2 ratio <250 Multilobar infiltrates Confusion Uremia Leukopenia Thrombocytopenia Hypothermia Hypotension ICU if 1major or 3minor criteria Non-Scored Admission Criteria Exacerbations of co-morbidities Unable to take PO medications Unable to receive appropriate OP care Cognitive impairment, substance abuse Your Clinical Judgment! AKA Your GUT! TREATMENT OPTIONS 8

9 Outpatient Antibiotic Choices OP uncomplicated Macrolide Doxycycline pt at risk for QT prolongation or Abx resistance OP high risk (Abx use w/3mo or comorbidities) Respiratory Fluoroquinolone high dose ß Lactam + macrolide or doxycycline Tx Duration = 5 days or 48 afebrile QT Prolongation Oh Crap! Metabolic low K, Mg, Ca, Hypothyroidis m Anorexia AV block Medications Macrolides Anti-arrhythmics Methadone Oxycodone Psych meds Zofran IP - Non ICU- Antibiotic Choices Respiratory fluoroquinolone ß Lactam + either macrolide (azithromycin) IV Or Doxycycline Aztreonam (β lactam allergic) Tx Duration days Early onset of treatment with good response, can decrease tx to 7 days 9

10 ICU Antibiotic Choices No suspected Pseudomonas ß Lactam + Either macrolide IV or fluoroquinolone Suspected Pseudomonas Antipneumococcal ß lactam(rocephin) + Respiratory Fluroquinolone IV OR ß lactam + aminoglycoside + Either azithromycin OR fluoroquinolone Criteria for Verification of Resolution Pt age 50 year old Smokers Complicated treatment course Reoccurrence of sx Suspicious x-ray findings Immunocompromised ASPIRATION PNEUMONIA 10

11 Procedural General Anesthesia Nasogastric (NG) Tube Endotracheal (ET) Tube EGD Bronchoscopy Non-procedural Most Common Alcohol intoxication Stroke Seizure LOC Other causes: Overdose Brain lesion Dysphagia Neuromsk (Parkinsons, MS) Etiology Aspiration Syndromes Acute onset Tachypnea, SOB, bronchospasm, cyanosis CXR opacities Posterior Upper lobes = aspiration in supine position (RUL-most common) Posterior Lower Lobes = aspiration in semirecumbent or upright position Tx Piperacillin/tazobactam; Ampicillin/sulbactam; Clindamycin; Moxifloxacin FUNGAL PNEUMONIA 11

12 Disease Fungus Common epidemic Coccidiomycosis* Histoplasmosis* Opportunistic diseases Pneumocystis Aspergillosis Cryptococcosis Coccidioides immitis Histoplasmosis capsulatum Pneumocystis carinii Aspergillus fumigatus Cryptococcus neoformans FUNGAL CAUSES Coccidioidomycosis Valley Fever Central California, Arizona, New Mexico, Western Texas, Mexico Soil dwelling fungi grows as fluffy mold lives as non-budding spherical in the host Inhalation from windborne spore(s) 40% of cases are primary pulmonary days after exposure Coccidioidomycosis cont. S/Sx: fever, CP, cough-dry, malaise, HA, myalgias (traveling) Hypersensitivity reactions erythema nodosum, erythema mulitforme, arthralgias, conjunctivitis, episcleritis Diagnostics: Serology Culture* (bld, urine) CBC WBC +/- mild lymphocytosis, and/or eosinophila ESR elevated CXR = hilar adenopathy, infiltrates, Pleural effusion 12

13 Hypersensitivity Skin Reactions Erythema Nodosum Photo obtained from Medicinenet.com Coccidioidomycosis - cont Mild respiratory system disease Symptomatic treatment only Treatment Indications: Persistent sx, extensive inflitrates, co-morbidities, dissemination Tx choices: ketaconazole (Nizoral) {only FDA approved}; fluconazole (Diflucan) 400mg/day for 3-6mo Amphotericin B severe cases Disseminated risk factors African American, Filipinos, Native American, Hispanics, pregnant, Immunocompromised Histoplasmosis South East, Mid-Atlantic, Central states Think Ohio River and Mississippi River areas Latin America, Africa, Asia Acute infection 5-18 days after exposure Soil contaminated w/ bird/bat feces Spores airborne after soil disruption Construction, spelunking, excavation, cleaning chicken coops/ attics/ barns Inhalation of the spores results in granuloma development in the alveoli 13

14 S/Sx: Histoplasmosis cont. fever, CP, cough-dry, malaise, HA, myalgias Usually mild cold Diagnostics: Culture* (sputum) Variable results with Blood/urine CXR = 1 lobe nodular infiltrates, hilar adenopathy, +/- pneumonitis Tx: Mild disease Symptomatic treatment only, self limiting 4-10d Disseminated: Mild/Moderate = Itraconazole (12-18 wk) Severe =Amphotericin B x2wk, then Itraconazole (12-18wks) VIRAL PNEUMONIA Influenza Adenovirus Parainfluenza RSV - Kids In Summary CAP Tx Macrolide or Respiratory FQ Chronic illness (ie. DM = Resp FQ) CURB65 and SCAP Tx location tools Don t forget travel hx for fungal PNA Early Abx treatment increases survival and decreases length of tx Prevention is KEY 14

15 Resources Lim et al. Defining community-acquired pneumonia severity on presentation on hospital: an international derivation and validation study. Thorax;2003;58: Fine et al. A prediction rule to identify low risk patients with CAP, N Engl J Med; 1997;89: Restrepo et al. Late admission to ICU in patients with CAP is associated with higher mortality. Chest; 2010;137:552. Harrison s Principles of Internal Medicine. New York:McGraw-Hill Current Medical Diagnosis and Treatment. New York:Lange; Syyjala et al. High resolution computed tomography for diagnosis of community acquired pneumonia. Clinical Infectious Disease. 1998:27: Shindo, Y et al. Comparison of Severity scoring systems A-Drop and CURB- 65 for community acquired pneumonia. Respirology Sep;13(5): Scalera NM and File TM. How long should we treat community-acquired pneumonia? Curr Opin Infect Dis. 2007;20: