URIs and Pneumonia. Elena Bissell, MD 10/16/2013

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1 URIs and Pneumonia Elena Bissell, MD 10/16/2013

2 Objectives Recognize and treat community acquired PNA in children/adults Discern between inpatient and outpatient treatment of PNA Recognize special populations/cases of PNA

3 Case 1 3 yo female who attends daycare comes to clinic with mother. Mother states pt has had 3 days of runny nose, slight cough, fever to and sounding like she is breathing hard. On exam her temp is 38.0, HR is 115, BP 93/57, RR is 31. Oxygen sat is 95%. Her capillary refill is 1-2 seconds. She is well appearing other than runny nose. TMs nml. Lungs CTAB.

4 Viral URI Virus Proportion of cases Predominant months of circulation* Other clinical syndromes Rhinoviruses (more than 100 serotypes) 30 to 50 percent Present year round with a peak in September and a smaller peak in March and April Respiratory syncytial virus 5 percent November to March Bronchiolitis Influenza viruses 5 to 15 percent Winter months, with peak in February Influenza Croup Pneumonia Parainfluenza viruses 5 percent September to January with peak in October and November Croup Adenoviruses <5 percent September to May Pharyngoconjunctival fever Enteroviruses (echoviruses and coxsackieviruses) <5 percent Present year round, with a peak during the summer Aseptic meningitis (nonpolio enteroviruses) Herpangina (cocksackievirus type A) Coronaviruses 10 to 15 percent November to February Pneumonia Croup Human metapneumovirus Unknown Late winter and early spring Pneumonia Bronchitis

5 Bronchiolitis: RSV, HMV. Children are hypoxic, wheezing, increased WOB and cough/runny nose. CXR nonspecific and takes time to fully recover. Croup: Caused by Parainfluenza/Influenza/Corona virus. Pts progress from nasal irritation, congestion and coryza to febrile, hoarseness, barking cough and stridor in hours. Symptoms typically persist for three to seven days with a gradual return to normal.

6 5 days later she is brought back by her mother. She appeared to be getting better but now mom is worried.. T 38.2, RR 45, HR 150, O2 sat 85% She is tachypnic, ill appearing, cap refill is 4sec. HEENT exam unchanged, lung exam CTAB

7 Community Acquired PNA in children: TABLE Age-Based Etiologies of Childhood Community-Acquired Pneumonia Age Common etiologies Less common etiologies 2 to 24 months Respiratory syncytial virus Human metapneumovirus Parainfluenza viruses Influenza A and B Rhinovirus Adenovirus Enterovirus Streptococcus pneumoniae Chlamydia trachomatis Mycoplasma pneumoniae Haemophilus influenzae (type B and nontypable) Chlamydophila pneumoniae 2 to 5 years Respiratory syncytial virus Human metapneumovirus Parainfluenza viruses Influenza A and B Rhinovirus Adenovirus Enterovirus S. pneumoniae M. pneumoniae H. influenzae (B and nontypable) C. pneumoniae Staphylococcus aureus (including methicillin-resistant S. aureus) Group A streptococcus Older than 5 years M. pneumoniae C. pneumoniae S. pneumoniae Rhinovirus Adenovirus Influenza A and B H. influenzae (B and nontypable) S. aureus (including methicillinresistant S. aureus) Group A streptococcus Respiratory syncytial virus Parainfluenza viruses Human metapneumovirus Enterovirus

8 Treatment 2 months to 5 years-most likely Strep pneumo or Mycoplasma pneumo. What antibiotic would you choose? 5 to 18-most likely M. Pneumo, C. Pneumo. What antibiotic would you choose?

9 Case 2 83 yo female with DM and HTN who lives at home comes into clinic complaining of cough, pain in left side with breathing and fever. On exam she is oriented, febrile to 38.2, HR 103, BP 160/87, RR 25 and O2 sat is 89%. Her lungs are CTAB and she does not have crackles or egophany/tactile fremitus. WBC 15000, Na 129, BUN 26

10 CAP Dx: What are Objective findings of PNA Decision to treat outpatient vs. inpatient: CURB 65 or Pneumonia Severity Index Treatment

11 Case 3 74 yo male with dementia BIBA from Nursing Home with fever, hypoxia and cough. Healthcare Associated PNA: defined as pneumonia that occurs in a non-hospitalized patient with extensive healthcare contact, as defined by one or more of the following: Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days Residence in a nursing home or other long-term care facility Hospitalization in an acute care hospital for two or more days within the prior 90 days Attendance at a hospital or hemodialysis clinic within the prior 30 days

12 Other special cases: Hospital Acquired PNA- developed after 48 hours inpatient. Vanc/Zosyn, additional antispsuedamonal if indicated Aspiration PNA-Alcoholics or patients with LOC. Treat with fluoroquinolone with or without clindamycin, metronidazole (Flagyl), or a beta-lactam Legionella-High fever (greater than 104 F [40 C]), male sex, multilobar involvement, and gastrointestinal and neurologic abnormalities have been associated with CAP caused by Legionella infection. PNA with Pleural effusion

13 References: Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD DOI: / CD pub3. Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, Johnson DW, Klassen TP, Hartling L. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD DOI: / CD pub4. File, T. Treatment of hospital-acquired, ventilator-associated, and healthcare-associated pneumonia in adults. Up to Date Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD DOI: / CD pub3. Haider BA, Lassi ZS, Bhutta ZA. Short-course versus long-course antibiotic therapy for non-severe community-acquired pneumonia in children aged 2 months to 59 months. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD DOI: / CD pub2. Hendley, J., Pappas, D. The common cold in children: Clinical features and diagnosis. Up to Date STUCKEY-SCHROCK, K., Hayes, B., GEORGE, C., Community-Acquired Pneumonia in Children. Am Fam Physician Oct 1;86(7): THIBODEAU, K., Atypical Pathogens and Challenges in Community-Acquired Pneumonia. Am Fam Physician Apr 1;69(7): WATKINS, R., LEMONOVICH, T., Diagnosis and Management of Community-Acquired Pneumonia in Adults. Am Fam Physician Jun 1;83(11):