PNEUMONIA

1
PNEUMONIA

• Tasbirul Islam MD, FCCP, MRCP (UK)
• Division of Pulmonary Critical care
• IU Arnett hospital
• Adjunct Clinical Assistant Professor
• Indiana University School of Medicine

2
Objectives

• Diagnosis and assessment of pneumonia.
• Discuss the different scoring system for
  assessing severe pneumonia.
• Discuss the therapy principles.

3
Epidemiology and Impact

• Approximately 4 million adults develop CAP
  annually in the USA.
• 1.1 Million hospitalizations per year
• Cost 21 billion
• Mortality from severe CAP is high worldwide, with
  pneumonia/influenza as the eighth leading cause
  of death in the USA, accounting for 0.3 of
  deaths in 2004.
• National Center for Health Statistics. Health
  Statistics, 2006. www.cdc.gov/nchs/fastats
• File and Tan Curr Opin Pul Med 389-97,
  1997

4
Fine et. al., JAMA 1996 275134
5
Community Acquired Pneumonia
Mortality
in 1000s
6
Case 1

• 65 y/o male smoker has 2 days of chills, dyspnea,
  and purulent sputum. He has no risk factors for
  HIV, donates blood 3x/year (most recently one
  month ago) and does not take any medications. T
  38.1, BP 110/60, HR 95, RR 20, SaO2 89
  RA. Examination shows no abnormalities. CXR is
  read as minimal streaking at lung bases,
  atelectasis vs. early pneumonia
• Does he have pneumonia?
• Should I treat with antibiotics?

7
Does this patient have pneumonia?
Sensitivity Specificity
Fever/chills 85
Dyspnea 70
Purulent sputum 50
Any of above 70 90 40 50

• Hx
• PE VS most useful in predicting severity
• CXR is gold standard - may be normal in up to 7
  on admission assume pneumonia present if
  convincing hx and focal PE
• Suspected pneumonia with neg CXR consider f/u
  CXR or CT (more sensitive)

8
Case 1

• 65 y/o male smoker has 2 days of chills, dyspnea,
  and purulent sputum. He has no risk factors for
  HIV, donates blood 3x/year (most recently one
  month ago) and does not take any medications. T
  38.1, BP 110/60, HR 95, RR 20, SaO2 89
  RA. Examination shows no abnormalities. CXR is
  read as minimal streaking at lung bases,
  atelectasis vs. early pneumonia
• Does he have pneumonia? Probably
• Should I treat with antibiotics?
  Probably

9
Thinking about pneumonia 4 steps

• Put into initial clinical classification
• Decide site of care
• Tests for etiology
• Initial empiric therapy

10
Step 1Initial clinical classification

• Major immunodeficiency
• Tuberculosis (suspected or established)
• Relatively normal hosts without TB (location at
  time of infection)
• Community-acquired (CAP)
• Healthcare-associated (HCAP)
• Hospital acquired (HAP)
• ventilator-acquired (VAP)

11
Pneumonia

• HAP Hospital-acquired pneumonia
• 48 h from admission (early within 4 days of
  admission and late after 4 days of admission).
• VAP Ventilator-associated pneumonia
• 48 h from endotracheal intubation
• HCAP Healthcare-associated pneumonia
• Long-term care facility (NH), hemodialysis,
  outpatient chemo, wound care, etc.
• CAP Community-acquired pneumonia
• Outside of hospital or extended-care facility

12
Case 1

• The patient has never been hospitalized, resides
  at home, does not take dialysis, has not received
  chemotherapy.
• He has CAP

13
Case 2

• 55 y/o homeless man from Mexico has 2 days of
  chills, night sweats, dyspnea, and purulent
  sputum without hemoptysis. He has not lost
  weight. He has no risk factors for HIV, takes no
  medications, and is not diabetic. Exam reveals T
  38.1, BP 110/60, HR 95, RR 20, SaO2 89
  RA, crackles at the right base.
• Should I order airborne isolation?

14
When to suspect TB

• If two or more sxs
• Hemoptysis
• Cough gt 2 weeks
• Night sweats
• Wt loss gt 10 in 3 mos
• If suspicious CXR (any of these)
• Upper lobe infiltrates
• Miliary pattern
• Cavitary lesions
• Nodular infiltrate

• Response to suspected TB
• Order airborn isolation and CXR
• Order AFB smears, cultures (does not have to be
  qAM!)

15
Case 2

• 55 y/o homeless man from Mexico has 2 days of
  chills, night sweats, dyspnea, and purulent
  sputum without hemoptysis. He has not lost
  weight. He has no risk factors for HIV, takes no
  medications, and is not diabetic. Exam reveals T
  38.1, BP 110/60, HR 95, RR 20, SaO2 89
  RA, crackles at the right base.
• Order isolation, get CXR and AFB smear.

16
Thinking about pneumonia 4 steps

• Put into initial clinical classification
• Decide site of care
• Tests for etiology
• Initial empiric therapy

17
Case 3

• 65 y/o male smoker has 2 days of chills, dyspnea,
  purulent sputum. No significant PMHx. He has
  felt and eaten poorly. T 38.1, BP 110/60, HR
  95, RR 20, SaO2 89 RA, crackles at the
  right apex. He is not confused. WBC 15K, H/H
  14.5/42, Na 128, K 3.5, Cl 105, CO2 20.
  BUN/creat 32/1.4. CXR shows RUL infiltrate.
• Can I send this patient home?

18
Hospitalize or outpatient?

• Has a direct bearing on location and
• intensity of lab evaluation, antibiotic
• therapy and costs.
• Single episode CAP TX inpatient 7500
• gt20 fold higher than cost of outpatient
• 20 patients with pneumonia hospitalized.

19
Who should be considered for hospitaladmission?

• Pneumonia Severity Index (PSI)
• The British Thoracic Society CURB-65
• SMART-COP
• PIRO score
• Modified ATS criteria
• IDS / ATS guidelines

20
Pneumonia Severity Index PSI
Pneumonia Severity Index (PSI)
Fine et al N Engl J Med 1997336243-250
21
CURB-65
22
CURB 65
23
CRB-65

• CRB-65 was more sensitive (1.00 vs. 0.80) and had
  better LR- (0.00 vs. 0.41), and NPV (1.00 vs.
  0.92).
• CURB-65 had better specificity (0.48 vs. 0.21),
  LR (1.54 vs. 1.26), and PPV (0.23 vs. 0.20).
• Crit Care. 2013 17(Suppl 3) P39.

24
CURB-65 vs CRB-65
25
SMART-COP

• Low Systolic blood pressure 2 points
• Multilobar chest radiography involvement 1
  point,
• Low Albumin level 1 point,
• High Respiratory rate 1 point,
• Tachycardia 1 point,
• Confusion 1 point,
• Poor Oxygenation 2 points, and
• Low arterial pH 2 points

26
42/50 (84) patients who died had SMART-COP scores
3 points
27
SMART-COP score

• A SMART-COP score of gtor3 points identified 92
  of patients who received IRVS, Sensitivities of
  PSI and CURB-65 for identifying the need for IRVS
  were 74 and 39, respectively.
• Charles PG, et al Australian
  Community-AcqGrayson ML SMART-COP a tool for
  predicting the need for intensive respiratory or
  vasopressor support in community-acquired
  pneumonia. Clin Infect Dis 2008, 47375-384.
  uired Pneumonia Study Collaboration,

28
PIRO system

• The elements of the PIRO concept
• Predisposition (chronic illness, age, and
  comorbidities)
• Insult (injury, bacteremia, endotoxin)
• Response (neutropenia, hypoxemia, hypotension)
• Organ dysfunction

29
(No Transcript)
30
Length of stay in the ICU and mechanical
ventilation days , increased significantly Accordi
ng to level of risk defined by the PIRO score
31
Considering the observed mortality for each PIRO
score the patients were stratified in four levels
of risk a) Low, 02 points b) Mild, 3
points c) high, 4 points d) Very high, 58
points
When the patients were distributed according PIRO
scoring, the mortality rate increased
significantly (p 0.001)
32
Who should be considered for admission tothe
intensive care unit?
Infectious Diseases Society of America/American
Thoracic Society guidelines for intensive care
unit admission

• Major criteria
• Invasive mechanical ventilation
• Septic shock with the need for vasopressors

• Minor criteria
• Respiratory rate 30 breaths/minute
• PaO2/FiO2 ratio 250
• Multilobar infiltrates
• New onset confusion/disorientation
• Uremia (BUN level 20 mg/dl)
• Leukopenia (WBC count lt4,000 cells/mm3)
• Thrombocytopenia (platelets lt100,000 cells/mm3)
• Hypothermia (core temperature lt36C)
• Hypotension requiring aggressive fluid
  resuscitation

1 major or 3 minor criteria for ICU admission.
33
Modified ATS Criteria For Severe CAP

• Major Criteria
• --Need For Mechanical Ventilation
• --Presence of Severe Sepsis
• Minor Criteria
• --Systolic Blood Pressu ure lt 90 mmHg
• --PaO2/FIO2 lt 250
• --Multilobar Disease
• 1 Major or 2 Minor Treatment in an ICU
• Ewig et al Am J Respir Crit Care Med
  19981581102-1108

34
Risk factors for Severe Pneumonia

• Alcoholism
• COPD
• Immunosuppression
• Heart Disease
• Institutionalization
• Age gt 70 Yrs
• Elderly ? Likelihood Of Co Morbid Diseases
• Inhaled Steroids / PPI Use

35
Physical findings associated with increase
mortality

• Respiratory rate gt 30
• Diastolic blood pressure lt 60 mm Hg or systolic
  blood pressure lt 90 mm Hg
• Pulse gt125
• Temp lt35 or gt40 C (lt95F or gt104F)
• Confusion or decreased LOC

36
Lab and X-ray associated withincreased mortality

• WBC lt4 or gt30 x 10 (9)
• PaO² lt60 or PaCO² gt50 room air
• BUN gt20
• Chest x-ray multi lobular, pleural effusion,
• presence of a cavity.
• HCT lt30 or Hgb lt9
• Arterial ph lt7.35
• Evidence of sepsis
• ARRD 19931481418 NEJM 1997336243 Clin
  Infect Dis 200744S27

37
When is the ICU Used in CAP?

• National database in UK of 172 ICUs with 17,869
  CAP cases (5.9 of all ICU admits)
• 59 admitted within first 2 days, 21.5 days 2-7,
  19.5 gt 7 days.
• 54.6 mechanically ventilated on admission to ICU
• Mortality rate in ICU 34.9, 49.4 in hospital
• 46.3 mortality if admit in first 2 days
• 50.4 if admit day 2-7, 57.6 if after day 7 (
  plt0.001)

• Woodhead et al. Critical Care 2006 10 S1

38
Case 3

• 65 y/o male smoker has 2 days of chills, dyspnea,
  purulent sputum. No significant PMHx. He has
  felt and eaten poorly. T 38.1, BP 110/60, HR
  95, RR 20, SaO2 89 RA, crackles at the
  right apex. He is not confused. WBC 15K, H/H
  14.5/42, Na 128, K 3.5, Cl 105, CO2 20.
  BUN/creat 32/1.4. CXR shows RUL infiltrate.
• CURB 653
• Can I send this patient home?
  NO

39
Thinking about pneumonia 4 steps

• Put into initial clinical classification
• Decide site of care
• Tests for etiology
• Initial empiric therapy

40
Pathogenesis

• Inhalation, aspiration and hematogenous spread
  are the 3 main mechanisms by which bacteria
  reaches the lungs

41
Diagnosis of Pneumonia

• Chest radiograph is the most important diagnostic
  tool.
• Clinical presentation is not diagnostic of an
  etiology.
• Yield of pathogens from gram stain of adequate
  expectorated sputum, blood culture, sputum
  culture from patients with CAP 30-40.
• Immunologic/serologic tests.

42
Diagnostic Testing

• Chest X-Ray
• Careful Assessment of Disease Severity Risk
  Factors
• Hospitalized Patients
• Assessment of Oxygenation/Gas Exchange
• CBC, Chemistry, Blood Cultures
• If resistant or unusual organism
  suspected
• Sputum Gram Stain
• ? Serologic Studies
• Am J Respir Crit Care Med 20011631730-1754

43
Diagnostic tests for etiology

• Why not etiologic tests for everyone?
• Outpt Get SaO2 Routine tests for etiology are
  optional.
• Inpt - Blood and sputum cultures recommended for
  most (but not all)
• ICU - blood and sputum cultures, and Legionella
  and pneumococcal UAT

44
(No Transcript)
45
Community Acquired Pneumonia
Microbiology

• S. pneumoniae 20-60
• H. influenzae 3-10
• Chlamydia pneumoniae 4-6
• Mycoplasma pneumonaie 1-6

• Legionella spp. 2-8
• S. aureus 3-5
• Gram negative bacilli 3-5
• Viruses 2-13

40-60 - NO CAUSE IDENTIFIED 2-5 - TWO OR MORE
CAUSES
Bartlett. NEJM 19953331618-24
46
Bacteriology of Severe CAP

• 89 patients with severe CAP 1996- 1998 , compared
  to severe CAP 1984-1987

Legionel
PA
Ruiz et. al., Am J Respir Crit Care Med 1999
160923-929
47
(No Transcript)
48
Sputum for diagnosis in CAP

• Sputum exam--good specimen available only
  30 off time, 30 of patient on antibx
• before spec obtained and 25 may have
• agents not identified from routine culture
• Criteria for good specimen is lt 10
• squamous cells and gt 25 WBC per low
• powered field--low sensitivity and
  specificity
• Murray PR, Mayo Clin Proc 197550339
  Clin Infec Dis 199418501

49
Review of Lung Anatomy
RUL
LUL
RML
LLL
Lingula
RLL
http//www.meddean.luc.edulumenMedEdGrossAnatomyth
orax0thor_lecthorax1.jpg
50
RUL Pneumonia
51
RML Pneumonia
52
RLL Pneumonia
53
LUL Pneumonia
54
Lingular Pneumonia
55
LLL Pneumonia
56
Recently
(PCT) levels appears to be useful in order to
minimize this problem. The sensitivity and
specificity of PCT in bacterial infections were
found to be 92.6 and 97.5
Cantürk et al., Turk J Med Sci 2008 38 (2)
139-144
57
Invasion by pathogenic bacteria
Bacterial toxins and cytokines
Stimulate PCT production in all paraynchymal cells
Adapted from Christ-Crain et al. 2005
58
IFN-g
Decreases PCT production
Viral infection
59
Diagnostic accuracy of PCT compared to other
biomarkers used in sepsis
Sensitivity 89 Specificity 94 NPV 90 PPV
94

• PCT levels accurately differentiate
  sepsis from noninfectious inflammation
• PCT has been demonstrated to be the best
  marker for differentiating patients with sepsis
  from those with systemic inflammatory reaction
  not related to infectious cause

Simon L. et al. Clin Infect Dis. 2004
39206-217.
60
PCT guidance in antibiotic usage Effects on
length of stay

• Effect of PCT-guided management in patients with
  sepsis on ICU length of stay

Nobre V. et alAM Resp Crit Care Med 2008
177498-505
61
PCT guidance in antibiotic usage has been shown
to significantly shorten the time patients need
to be on antibiotics

• KEY TAKEAWAY
• Tailoring of AB treatment using PCT to the
  individual patient needs safely led to a
  reduction of average treatment duration from 12
  to 5 days with same outcome

Nobre V. et al AM Resp Crit Care Med 2008
177498-505
62
Antibiotic Exposure in Patients Receiving
Antibiotic Therapy
PCTControl
All Patients (n 1359)
Community-acquired Pneumonia (n 925)
100
80
60
Patients Receiving Antibiotic Therapy,
40
20
0
0 1 2 5 7 9
11 gt13
0 1 2 5 7 9
11 gt13
Time After Study Inclusion, d
Time After Study Inclusion, d
No. of Patients PCT 506 484
410 306 207 138 72 46 Control
603 589 562 516 420 324 157
100
417 410 359 272 161 126 64
41461 453 444 428 361 292 146
91
Schuetz P et al. J Am Med Assoc.
2009302(10)1059-66.
63
(No Transcript)
64

• Antibiotics were started/ stopped based on a
  predefined cut-off ranges of PCT value
• Primary end point
• 28 and 60 days mortality
• No. of days without antibiotics

65

• Recent reanalysis of the Community-Acquired
  Pneumonia Intensive Care Unit (CAPUCI) study, in
  which patients with severe CAP requiring ICU
  admission were assessed, has suggested that
  radiologic progression of pulmonary infiltrates
  is a significant adverse prognostic feature. In
  contrast, bacteremia levels appeared not to
  affect patient outcomes.
• Lisboa T, et al Community-Acquired
  Pneumonia Intensive Care Units (CAPUCI) Study
  Investigators Radiological progression of
  pulmonary infiltrates predicts a worse prognosis
  in severe community-acquired pneumonia than
  bacteremia. Chest 2008

66

• 3 patients with bronchiogenic
• carcinoma initially present with
• pneumonia.
• All patients over 40, all smokers or
• former smokers need follow up chest x-ray in
  4-6 week.

67
Thinking about pneumonia 4 steps

• Put into initial clinical classification
• Decide site of care
• Tests for etiology
• Initial empiric therapy

68
Case 4

• 24 y/o previously healthy female has 2 days of
  chills, dyspnea, purulent sputum. No
  significant PMHx. T 38.1, BP 110/60, HR 95,
  RR 20, SaO2 92 RA, crackles at the right
  base. CBNC and Chem 7 normal. CXR early RLL
  pneumonia
• What antibiotics should I order?

69
CAP management issues

• Causative pathogen frequently not found.
• Pneumococcal and atypical pathogen coverage
  important CaMRSA
• Treatment predominantly empiric.
• Give treatment quickly (lt4-8 hours).
• Increasing antibiotic resistance.
• Decision to hospitalize/discharge.
• Bartlett Clin Infect Dis 26811, 1998

70
THERAPY PRINCIPLES

• Appropriate Matching antibiotic sensitivities of
  the organism to the antibiotic used.
• Alternative from a different class should be
  selected.
• Adequate includes appropriate PLUS correct dose,
  penetration to site of infection, correct route
  and combination therapy (if needed)
• Need proper antibiotic dosing (normal renal
  function)
• Ciprofloxacin 400 mg q8h Levofloxacin 750 mg qD
• Imipenem 1 gm q 8H or 500 mg q 6hMeropenem 1 gm
  q 6-8 h
• Piperacillin/Tazobactam 4.5 gm q 6h
• Cefepime 2 gm q 8-12h
• Ceftazidime 2 gm q 8h
• Gentamicin or Tobramycin 7 mg/kg / day or
  Amikacin 20 mg/kg/day
• Linezolid 600 mg q 12 h
• Vancomycin 15 mg/kg q12h

71

• Mortality in patients receiving concordant
  therapy was 14 the excess mortality for
  discordant therapy was 36.
• Discordant therapy, multilobar involvement,
  underlying COPD, and hospitalization during the
  previous 12 weeks were independently associated
  with death.
• Lujan M, et al Prospective observational study
  of bacteremic pneumococcal pneumonia effect of
  discordant therapy on mortality. Crit Care Med
  2004,32625-631.

72
Antibiotic Timing in CAP and Mortality
                                             
                                                  
                                                  
                                                  
           Antibiotic First-Dose Timing and
30-Day Mortality Rates Houck et al Arch Intern
Med 2004 164 637-644
73
Harm from the 4 Hour Rule

• Overdiagnosis and overtreatment may lead to
  unnecessary C. difficile colitis
• 15 cases C. diff. 12 given antibiotics for
  pneumonia (new hospital CAP care plan) and 6 in
  retrospect DID NOT HAVE
• Polgreen et al. ICHE 2007 28 212-214
• 2003 IDSA guideline endorsed 4 hour rule. Compare
  all patients with admit dx of CAP 2005 vs. 2003
  (n510)
• Antibiotics in 4 hours 66 vs. 54 (p0.007)
• Dx CAP with neg CXR 28 vs. 20 (p0.04)
• Final dx of CAP 59 vs. 76 (plt0.001)
• 2005 with more blood cultures, more total
  antibiotics
• Kanwar et al. Chest 2007 131 1865-1869

74
OUTCOMES IN SEVERE CAPADEQUACY OF THERAPY

• Adequate therapy with 7 mortality vs. 60 with
  inadequate therapy. Torres et al ARRD 1991 144
  312
• 286 patients , mortality 28.5, 50 mechanical
  ventilation. 194 effective initial therapy
  (response at 72 hours), 92 ineffective therapy

INEFFECTIVE
LEROY ET AL INTENSIVE CARE MED 199521 24
75
ATS guidelines Modifying Factorsfor penicillin
resistance and drug Resistant Pneumococci

• Age gt 65 yr
• ß Lactam Therapy within past 3 months
• Alcoholism
• Immune-Suppressive Illness
• Multiple Medical Co-morbbidities
• Exposure to Child in a Day Care Center
• Am J Respir Crit Care Med 20011631730-1754

76
Risk for Pseudomonas aeruginosa

• Structural Lung Disease (Bronchiectasis)
• Corticosteroid Therapy (gt10 mg Prednisone/day)
• Broad-Spectrum Antibiotic Therapy for gt 7 days in
  past month
• Malnutrition
• Am J Respir Crit Care Med 20011631730-1754

77
Traditional Treatment Paradigm
Conservative start with workhorse antibiotics
Reserve more potent drugs for non-responders
78
New Treatment Paradigm
Hit hard early with appropriate antibiotic(s)
Short Rx. Duration De-escalate where possible
79
The Effect of the Traditional Approach
Inappropriate therapy ()
45
50
40
34
30
17
20
10
0
CAP
HAP
HAP on CAP
Kollef, et al. Chest 1999115462474
80
New data Dont Wait for Results !
Tumbarello, et al. Antimicrob Agents Chemother
20075119871994
81
New data The Speed of Delay ! (PSI Class 4 5)
Kumar, et al. Crit Care Med 20063415891596
82
Empiric Rx of outpatient CAP

• Healthy and no antibiotics in past 3 months
• Macrolide OR doxycycline
• If cardiopulmonary dz, Beta-lactam rx in past 3
  mos, alcoholism, immunosuppressive rx, or
  exposure to child in day-care
• Respiratory quinolone OR
• beta lactam (high dose amoxicillin or
  Augmentin) macrolide or doxycycline
• Duration of rx 5-7 days.

83
Empiric Rx of inpatient CAP no special
considerations

• Inpatient Floor
• respiratory quinolone
• OR
• (ceftriaxone or ceftazidime) (azithro or doxy)
• ICU
• (ceftriaxone or ceftazidime) (IV azithro or
  respiratory quinolone)
• If PCN allergic use aztreonam respiratory
  quinolone

84
Empiric therapy of HCAP/HAP/VAP with MDR risk
factors

• Cefepime, Ceftazadime, Imipenam, or Zosyn
• PLUS
• Ciprofloxacin, Levofloxacin, or Aminoglycoside
• If MRSA concerns add linezolid or vancomycin.

85
Aspiration

• When to use observed/suspected aspiration
  fever or leucocytosis or infiltrate
• Regimens
• Unasyn or Zosyn
• Augmentin or clindamycin
• Respiratory quinolone

86
Duration of Therapy

• ? ? ? ? ? ?
• 5 -7 days - outpatients
• 7-10 days inpatients, S. pneumoniae
• 10-14 days Mycoplasma, Chlamydia, Legionella
• 14 days - chronic steroid users

Am J Respir Crit Care Med 1631730-54, 2001
87
Case 3

• 65 y/o male smoker has 2 days of chills, dyspnea,
  purulent sputum. No significant PMHx. He has
  felt and eaten poorly. T 38.1, BP 110/60, HR
  95, RR 20, SaO2 89 RA, crackles at the
  right base. He is not confused. WBC 15K, H/H
  14.5/42, Na 128, K 3.5, Cl 105, CO2 20.
  BUN/creat 32/1.4. CXR shows RUL infiltrate
• What antibiotics do you order?
• CURB 653
• As Inpatient floor

88
Case 4

• 24 y/o previously healthy female has 2 days of
  chills, dyspnea, purulent sputum. No
  significant PMHx. T 38.1, BP 110/60, HR 95,
  RR 20, SaO2 92 RA, crackles at the right
  base. CBNC and Chem 7 normal. CXR early RLL
  pneumonia
• What antibiotics should I order?
• CURB 650
• As outpatient (No risk factors)

89
Pneumonia, approach to thenonresponder with CAP

• 6 to 15 of CAP patients may not respond to
  initial treatment
• Reassess diagnosis and therapy
• ? empyema, resistant organism, other complication
• ? noninfectious, i.e. cancer, pulm embolus, CHF,
  vasculitis, drug fever, ARDS, BOOP...
• Consider bronchoscopy, further diagnostic
  testing, escalation or change of therapy.
• Definition varies from no change in 3 days to 4
  weeks.
• Menendez R, Chest 20071321348

90
Case 3

• 65 y/o male 2 days ago with RUL pneumonia and
  treated with ceftriaxone and azithromycin. On
  rounds is feeling better, eating, not confused. T
  37.9, HR 102, BP 105/75, RR 12, SaO2
  88 on room air
• When I can I switch to an oral regimen. and what
  regimen?
• When can the pt go home?

91
When to switch IV to PO?

• Improvement in cough, dyspnea
• Afebrile lt100 F on two occasions 8 hrs
• apart
• WBC decreasing
• Functioning GI tract with adequate oral
• intake

92
Discharge Criteria

• During 24 H before discharge, no more than 1
  following
• Temp gt 37.8
• Pulse gt100
• RRgt24
• Systolic B/P lt90
• O2 sat lt90
• Inability maintain oral intake
• Altered mental status
• Arch Intern Med 19951551273 JAMA
  19982791452 Clin Infect Dis 2004391783

93
Case 3

• 65 y/o male 2 days ago with RUL pneumonia and
  treated with ceftriaxone and azithromycin. On
  rounds is feeling better, eating, not confused. T
  37.9, HR 102, BP 105/75, RR 12, SaO2
  90 on room air.
• Swith to oral med and discharge home.

94
Prevention

• Smoking cessation
• Vaccination per ACIP recommendations
• Influenza
• Inactivated vaccine for people gt50 yo, those at
  risk for influenza compolications, household
  contacts of high-risk persons and healthcare
  workers
• Intranasal live, attenuated vaccine 2-49yo
  without chronic underlying dz
• Pneumococcal (PCV 13 and PPSV 23)
• Immunocompetent 65 yo, chronic illness and
  immunocompromised 64 yo

95
QUIZ 1

• A 64-year-old female presents to the emergency
  department from home with a two day history of
  cough, fever, and dyspnea. She has a past medical
  history of coronary artery disease with normal
  left ventricular function, as well as a history
  of chronic hepatitis C. On physical exam, BP
  92/70, a HR 110, RR 32, and Temp 38.5. She is
  alert and oriented. Laboratory testing reveals
  normal electrolytes, hemoglobin, and arterial
  blood gas, BUN 32, and a serum creatinine of 1.3.
  CXR reveals a right middle lobe infiltrate
  without apparent pleural effusion.

96
What risk startification instrument will help to
decide out patient vs inpatient treatment

• CURB 65
• PSI
• SMART-COP
• PIRO

97
Calculate the CURB 65 and decide about out
patient vs inpatient vs ICU eval

• CURB 6502
• Supervised outpatient or brief inpatient
  treatment.

98
QUIZ2

• 50 yr old male came to ED with cough, fever,
  intermittent exertional chest pain and CXR showed
  LLL infiltrate. CURB 65 0 and SpO2 85 on RA

99

• Out patient antibiotic therapy
• Out patient Abx therapy along with brief home O2
• Consider inpatient therapy.

100
QUIZ3

• 30 years old female came to ED with H/O SOB,
  cough, fever. She is found to be confused and
  vitals showed SBP 85/HR 100/RR 31/Temp 35.6/SpO2
  92. Confusion and SBP improved with 3 L fluid.
  Lab showed BUN 32/WBC 3000/CXR shower RLL/RUL
  infiltrate. Now patient wants to go home.

101

• Send the patient home with oral antibiotics as
  she improved with fluid.
• Admit the patient to the floor and initiate
  macrolide.
• Admit the patient to ICU and initiate IV
  monotherapy.
• Admit the patient to ICU and initiate IV dual
  therapy.

102
Who should be considered for admission tothe
intensive care unit?
Infectious Diseases Society of America/American
Thoracic Society guidelines for intensive care
unit admission

• Major criteria
• Invasive mechanical ventilation
• Septic shock with the need for vasopressors

• Minor criteria
• Respiratory rate 30 breaths/minute
• PaO2/FiO2 ratio 250
• Multilobar infiltrates
• New onset confusion/disorientation
• Uremia (BUN level 20 mg/dl)
• Leukopenia (WBC count lt4,000 cells/mm3)
• Thrombocytopenia (platelets lt100,000 cells/mm3)
• Hypothermia (core temperature lt36C)
• Hypotension requiring aggressive fluid
  resuscitation

1 major or 3 minor criteria for ICU admission.
103
QUIZ4

• 30 years old female came to ED with H/O SOB,
  cough, fever. She is found to be confused and
  vitals showed SBP 85/HR 100/RR 31/Temp 35.6/SpO2
  92. Confusion and SBP improved with 3 L fluid.
  Lab showed BUN 32/WBC 3000/CXR shower RLL/RUL
  infiltrate.

104

• Continue present Abx
• Change to IV macrolides
• Change to IV Ceftriaxone
• Change to IV Quinolones
• Change to IV Ceftriaxone and IV Quinolones.
• Change to IV Ceftriaxone and IV macrolides.

105
QUIZ5

• 73 years old female admitted to medical floor
  with a diagnosis of CAP and treated with IV
  antibiotics.

106
Which of the following would be recommended

• 10-14 days of Abx with dual coverage
• 5-7 days of IV Abx followed by oral ABx for a
  total of 10-14 days.
• Change to oral ABx once the patient is clinically
  improved, afebrile and able to take PO med and
  observe another 48-72 hrs after switch to PO med.
• Minimum 5 days Resp quinolones or combination of
  macrolide and beta lactam ABx and discontinue ABx
  when patient is afebrile for 48-72 hrs.
• Discharge the patient once stable on the same day
  of switching PO med.

107
(No Transcript)