Pneumonia 2017 OMAR PIRZADA

Transcription

1 Pneumonia 2017 OMAR PIRZADA

2 Pneumonia Pneumonia is common 0.5-1% of adults per year, 5-12% presenting to GP with LRTi 22-42% will be admitted to hospital

3 Symptoms and signs Case 1 26 year old man Sudden onset symptoms, recent foreign travel Haemoptysis, pleuritic chest pain, O2 dependent, Looks clinically very unwell High fever T40, BP 80/40, SPO2 88%, RR30

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5 Question 1 The most likely diagnosis is: A. Standard Community acquired pneumonia B. This is more like an atypical pneumonia C. Neither, another diagnosis should be considered

6 Atypical Pneumonia Misleading term; Walking pneumonia Difficult to distinguish typical and atypical pneumonia Definition of atypical pneumonia varies between authorities Mycoplasma, Chlamydia pneu. and Legionella sp

7 Pneumonia-- Causes Bacterial--- Commonest cause is bacterial Commonest organism by far is Streptococcus pneumoniae Viral traditional understanding children and the young get virals 15% of Pneumonia is Viral in children Yet, In adults, 30% of pneumonia is viral

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9 Signs and symptoms Fever 80%, cough 97%, SOB, crackles O/E 80% Huijskens EG et al J Med Microbiol Do not distinguish between typical and atypical pneumonias

10 Case 2 21 year old lady, student Sudden onset cough, fever, haemoptysis Prior cardiac surgery repair, not on warfarin/noac T40 C

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12 Pneumonia The most likely diagnosis is: A. Standard community acquired pneumonia B. An atypical pneumonia C. Neither, another diagnosis should be considered

13 This lady has TB Upper lobe predominant disease, presence of cavitation Essential to consider infection control, public health This lady had smear +ve disease, was proven MTB Not only that this was confirmed MDRTB Numerous ward contacts, nursed in an open bay for 36 hours 178 further screening contacts

14 TB 94% of consolidation in CAP is mid and lower zone Remember TB upper lobe predominant disease Presence of cavitation NICE TB Quality standards Jan 17 CXR features recognise and see next working day Remember HIV

15 Diagnosis of pneumonia -CXR Imaging CXR good test but a surrogate marker of pneumonia 17% hospitalised for CAP won t have CAP Musher et al 2013 CAP- CXR may be ve in around 5% of cases Elderly Early disease Dehydrated If suspicion strong e.g. sepsis, repeat CXR, PA if possible

16 Imaging of pneumonia CT is not a recommended test for pneumonia Where CT is useful Immunocompromised Underlying lung cancer suspected Lung USS is a new modality for CAP diagnosis Pregnancy, Operator dependent

17 Chest x-ray Other diseases can look exactly the same Manifest as consolidation

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19 Lung cancer

20 PE--- with pulmonary infarction

21 Cryptogenic Organising Pneumonia

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23 Granulomatosis with Polyangitis

24 Case 3 36 year old lady Known asthma, never admitted Cough, SOB, wheeze 4 days PEFR 280 l/min, predicted 480 l/min Eosinophils 1.64 O/E 40% O2, spo2 91%

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26 Pneumonia The most likely diagnosis is: A. Standard community acquired pneumonia B. An atypical pneumonia C. Neither, another diagnosis should be considered

27 A. Asthma is common, 5-10% general population Pneumonia is common C. Asthma, major eosinophilia, bilateral pulmonary infiltrates Churg-Strauss syndrome Diagnosis not to miss

28 Pneumonia in the elderly Pneumonia x4 incidence in elderly Elderly have fewer symptoms, less fever Brown and Lerner 1998 in old age pneumonia may be latent coming on without chill. Of fever there may be none. Osler S Pneumoniae is the majority causative organism 58% Mortality is 10-30% >65; 40% at 1 year; Tipping and de Villiers 2014 Kothe et al 3-5 years

29 Diagnosis of pneumonia Empiric therapy vs pathogen directed therapy Recent development of diagnostics and biomarkers

30 Biomarkers for Pneumonia New biomarkers available for CAP management Aid early distinction of CAP from CCF Allow differentiation of LRTi from URTi Guide antibiotic therapy-- initiation Procalcitonin

31 Procalcitonin Procalcitonin is a precursor of calcitonin, elevates with bacterial infection; blood test Increases in CAP, more specifically than in any other disease A PCT level <0.25 discourages antibiotic use, >0.25 promotes Antibiotics can be withheld and stopped with no increase in mortality Trials show PCT reduces ab use from 8 4 days

32 PCR diagnosis Rapid development of PCR for pneumonia diagnosis Viral PCRs--- up to 1/3 CAP is confirmed viral Influenzae A+B, Rhinovirus, Coronavirus, RSV Near point testing Mycoplasma, Chlamydia, Legionella multiplex PCR Nasopharyngeal swab Much faster results than serology

33 Severity of pneumonia Multiple scoring systems CURB 65 PSI CURB 65, v good- validated scoring system NICE guidance Pneumonia emphasises use Comment check score, rely on its utility

34 Expanded CURB 65 Liu JL, Xu F, Hui Zhou, Wu XJ, Shi LX, Lu RQ, et al. Expanded CURB-65: a new score system predicts severity of community-acquired pneumonia with superior efficiency. Sci Rep Add LDH, platelets, serum albumin More accurate severity and mortality predictor

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36 Treatment of pneumonia Initial treatment principles: Treatment is empiric to avoid delay and reduce mortality Treatment is directed against S pneumoniae

37 Treatment of pneumonia Antibiotics empiric -- S pneumoniae 105 pneumonia NHS trials currently underway Latest on ab Tazocin, ceftaroline: 5 th gen, solithromycin Recent studies show beta-lactam monotherapy is non inferior to beta lactam and macrolide Postma et al NEJM 2015 Lower mortality, length of stay, fewer cardiac events

38 Treatment of pneumonia Monitoring Use CRP, Procalcitonin Optimise oxygenation Spo % BTS guidelines June 17 Consider ventilatory support for a failing po2 Avoid NIV, avoid RSU CPAP/intubation in an HDU/ ICU Don t forget role of ECMO

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42 Vaccination Recommend pneumonia vaccination for pneumonia prevention Pneumovax 23 valent polysacceride vaccine Poor effectiveness after 65 years Suzuki et al, Lancet 2017 Newer 13 valent conjugate vaccine Prevenar Superior immunologic response. PCV 13 response much greater than PPV23 Jackson et al 2013 Licensed over 50s

43 Summary Pneumonia- common Diagnosis pitfalls and DDx Advances in biomarkers- Procalcitonin Imaging of pneumonia CURB 65 effective, new scoring systems Pneumonia treatment- abs, O2, ECMO

44 Thank you

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46 Oxygenation BTS guidelines 94-98% O2 by saturations Prescribe Increase O2 increase FiO2 15 lo2 60% O2 reservoir O2, 80-85% O2

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48 Follow up CXR For pneumonia make sure you arrange a follow up x-ray especially for higher risk groups Underlying malignancy 1-2%, Lung cancer Complications Abscess, Broncheictasis, TB >50 years of age, Smoker

49 Complications of pneumonia Empyema Bronchiectasis Lung abscess Latest understanding CAP associated with longer term risk 30 day mortality is 10-12% for hospitalised CAP Substantial mortality rise for 1 year Remains 3-5 years elevated mortality

50 69 year old man, smoker until 2 weeks ago 6 weeks ago, pneumonia episode, unresolved symptoms Cough, sputum, fever Sputum culture confirms, H influenzae

51 Lung abscess 6 weeks of intravenous antibiotics as an OP Repeat CT Abscess better, reveals underlying Lung cancer 36% of abscesses harbour underlying Lung cancer

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53 Urinary tests Rapid, 15 minutes to process, ELISA assays 2 tests Urinary Legionella, Pneumococcal ag Legionella --- serotype 1 only, 90% Sens 74%, Spec 99% Pneumococcal ag Sens 74%, Spec 97% 2 RCTs no outcome differences

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55 Switching to oral therapy Jama 2016, 315,

56 Bacterial vs Viral

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60 COP