approach to peumonia

CLINICAL APPROACH TO PNEUMONIA

Dr Izham Cheong, FRCPProfessor of Medicine, UNIVERSITI KEBANGSAAN

MALAYSIA

“ The most widespread & fatal of all acute diseases, pneumonia, is now Captain of the Men of Death” : Sir William Osler

Facts about pneumonia in USA• 6th most common cause of

death.• Increased by 59% between

1979 to 1994.• 2-3 million cases of CAP in 10

million visits.• 500,000 hospitalizations (258

per 100,000 pop).• 45,000 deaths (average 14%

hospitalised).• Cost : about $ US 4.5 billion.

JAMA 1996;275:189

MMWR 1997;46:556

Ten leading causes of hospitalization and death in Malaysia (2000)

Hospitalization (Total=1,559 280) Respiratory diseases 6.58%

Deaths (Total=29 447)Heart disease 15.10%Septicaemia 10.98CVA 9.47Accident 8.79Neoplasms 8.75Perinatal diseases 7.28GI diseases 4.69Pneumonia 4.33Renal disease 3.65Ill-defined diseases 3.62

CLINICAL APPROACH TO PNEUMONIA

Key points to remember

KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS PNEUMONIA

CAPTypicalS. pneumoniaeH. influenzaeM. catarrhalis

AtypicalL. pneumophilaM. pneumoniaeC. pneumoniaeC. psittacosiC. burnetti

HAP (VAP)Gram –veP. aeroginosaAcinetobacter spp.Proteus spp.Klebsiella spp.E. cloacaeP. maltophilaLegionella spp.

Gram +veS. aureus (MRSA)S. pneumoniaeOther streptococciS. epidermidis

Polymicrobial

NHAPGram –veKlebsiella spp.P. aeroginosa

Gram +veS. aureus

Anaerobes

1. EPIDEMIOLOGY OF RESPIRATORY PATHOGENS

KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS A PNEUMONIA

2. EARLY EMPIRIC TREATMENT IS ESSENTIAL BECAUSE NO SPECIFIC PATHOGEN CAN BE IDENTIFIED IN 30% to 70% OF PATIENTS.

Relationship of receiving an antibiotic withina time frame and 30-daymortality

Meehan TP, 1997

OR

of

30-d

Su

rviv

al (9

5%

CI)

KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS A PNEUMONIA

3.THE RISE IN ANTIBIOTIC RESISTANCE

Penicillin and macrolide resistantS. pneumoniae

ESBL-producing Klebsiella spp.

MDR pathogens: P. aeroginosa P. maltophila Enterobacter spp. Stenotrophomonas spp.

MRSA + VRSA

VRE

KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS A PNEUMONIA

4. CONTAIN COST WITHOUT NEGATIVELY AFFECTING MORTALITY

Minimize admissions

Oral antibiotics

Shorten hospitalization

CLINICAL APPROACH TO PNEUMONIA

What do I do?

mild severe

Clinical Approach to a Patient with CAP

History

Medicineislearnedbythe bedsideandnot inthe classroom

Sir William Osler (1849-1919)

HISTORY

1. WHICH CATEGORY?

CAP

NHAP

HAP (VAP)

2. CAN THE PATIENT BE IMMUNOCOMPROMISED?

HISTORY

DON’T TRUST ANY ONE NOWADAYS!!!

HISTORY3.ANY UNDERLYING LUNG DAMAGE?

HISTORY4. COMORBIDITY ?

“mimic” pneumoniaimpact on drug treatment

HISTORY6. WHAT IS HIS JOB?

Any andeverything!!

Pulmonary TB

Q feverAnthrax

HISTORY7. CONTACT WITH….

Chlamydia pneumoniae

Francisella tularensis

Yersinia pestis

HISTORY Legionellosis

IS IT SAFE TOTRAVEL??

HISTORY8. HIGH RISK BEHAVIOURS

““Yumm-Seng””

IVDU

smoking

HISTORY9. ASPIRATION ?

stroke

vomiting

unconcious/fits

Ryle’s tube

HISTORY10. WHAT DRUGS ARE YOU TAKING?

Amiodarone

Nitrofurantoin

Bleomycin

Chlorambucil

Procarbazine

BulsulfanCyclophosphamide

Aziathioprine

Methotrexate

Sulphonamides

Lung infiltrates

Heroin

Methadone

Chlorthiaxide

Contrast media

Pulmonary oedema

Clinical Presentation

Clinical Approach to a Patient with CAP

Typical pneumonia acute ill-looking,SOB fever and chills productive cough, leukocytosis pleurisy

Atypical pneumonia as above + extrapulmonary features CNS involvement: ENT involvement: M. pneumoniae

Diarrheas: M. pneumoniae or L. pneumophila Abdominal pain: L. pneumophila

Rash: C. psittacosis M. pneumoniae

Cutaneous findings

Erythema multiforme M. pneumoniaeMaculopapular rash MeaslesErythema nodosum C. pneumoniaeEcthyma gangrenosum M. tuberculosis

P. aeruginosa

Oral findings

Peridontal disease anaerobic pathogens Foul smelling sputum

Clinical Approach to a Patient with CAPPhysical examination

Neurologic disease

Absent gag AspirationAltered conciousnessRecent seizure

Cerebellar ataxia M. pneumoniaeL. pneumophila

Encephalitis M. pneumoniaeC. burnetti

Clinical Approach to a Patient with CAP

Physical examination

Differential Diagnosis of Common Radiographic Patterns in Patients with Pneumonia

Focal opacity Interstitial

S. pneumoniaeM. pneumoniaeL. pneumophilaC. pneumoniaeM. tuberculosisAspiration

Viral M. pneumoniaeP. cariniiC. psittaci

Differential Diagnosis of Common Radiographic Patterns in Patients with Pneumonia

Interstitial with lymphadenopathy

Cavitation

Epstein Barr virusF. tularensisC. psittasi

Anaerobic abscessS. aureusAerobic gram-neg bacilliM. tuberculosisC. neoformansN. asteroides and A. israelii

Differential Diagnosis of Common Radiographic Patterns in Patients with Pneumonia

Segmental pneumonia withlymphadenopathy

Miliary

M. tuberculosisFungal infection

M. tuberculosisH. capsulatumVaricella zooster

COMMUNITY-ACQUIRED PNEUMONIAWhich patient require hospitalization?

Respiratory rate > 30/min Diastolic hypotension Altered mental status Renal failure Age > 65 years Co-existing disease Leukopenia Severe anaemia Acidosis Hypoxaemia Multilobar involvement Systolic BP < 90mmHg PaO2/FIO < 250

Niederman, 1993; Barlett, 1995; Fine, 1995; Ewig, 1998

INTERNATIONAL GUIDELINES FOR EMPIRICAL ANTIMICROBIAL THERAPY

OF COMMUNITY-ACQUIRED PNEUMONIA

Guidelines Outpatient General ward ICU

European RespiratorySociety (1998)

penicillin or aminopenicillins

Alternatives: macrolodes tetracyclines

cephalosporins quinolones

(2nd or 3rd generation cephalosporin or -lactam/-lactamase inhibitor or IV penicillin) macrolide or 2nd generation quinolones;

2nd or 3rd generation cephalosporin + 2nd generation quinolones rifampicin

Infectious Diseases Societyof America (2000)

doxycycline macrolide

new floroquinolone

-lactam with macrolide

OR

new fluoroquinolone

Extended spectrum cephalosporin or –lactam/-lactamase inhibitor + either IV fluoroquinolone or IV macrolide (if structural lung disease cover P. aeroginosa)

WHAT DO IUSEFORMY PATIENTSWITHACOMMUNITY-ACQUIREDPNEUMONIA ?

HOW DO I EMPIRICALLY TREAT MY PATIENT WITH

COMMUNITY-ACQUIRED PNEUMONIA?

SETTING THERAPEUTIC OPTIONS

Ambulatory, not requiring hospitalization, age under 60 years

Oral macrolide (erythromycin or azithromycin)

Ambulatory, not requiring hospitalization, comorbidity or age over 60 years

Oral -lactam/-lactamase inhibitor + macrolideOROral antipneumococcal fluoroquinolone

Requiring hospitalization -lactam (sulperazone or ceftriaxone) + macrolide or antipneumococcal fluoroquinolone

Aspiration pneumonia requiring hospitalization

-lactam/-lactamase inhibitor alone(ampicillin/sulbactam, pipericillin/tazobactam))

Izham, 2002Empiric therapy (pathogen unknown or awaiting cultures)

MY EMPIRICAL THERAPY OF SEVERE CAP IN COMPROMISED HOST

Compromised host Usual pathogen Empiric therapy

Chronic alcoholics Oral anaerobesand/orKlebsiella spp.

3rd or 4th generation cephalosporinORmeropenam

Postviral influenzae S. aureus CloxacillinORvancomycin

HIV S. pneumoniaeSalmonellaLegionella

new fluoroquinolone

Congenital/acquired asplenia or hyposplenia

S. pneumoniaeN. meningitidisH. influenzae

-lactam/-lactamase inhibitorORmeropenam

Izham,2002

Why is pneumonia still a leading cause of morbidity and mortality ?

• Changing pathogens• Greater diagnostic difficulties• Widespread antibiotic resistance• Survival of patients at both

extremes of ages• Larger population of

compromised hosts• More hospital-acquired

pneumonia

Despite more and better antimicrobials

“Of all the diseases to which man is heir, those known in etiology, possible of cure, capable of prevention, are for the most part caused by infectious agents” -therefore

What shall I do with my next pneumonia?

Choose the right antibiotic.

Choose the right physician!!!!!!!!