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Pneumonia
Sanjay Kalra, MD, FRCPAssociate Professor of Medicine
Division of Pulmonary & Critical Care Medicine
Mayo Clinic
Rochester, MN
Disclosures
NONE
Learning Objectives
• Define the subtypes of pneumonias• Identify when to suspect and how to
diagnose pneumonia • Severity Staging• Recognize empiric treatment decisions• Discuss parapneumonic effusions/
empyema
Definitions
• Suspected community-acquired pneumonia is defined by acute symptoms and presence of signs of lower respiratory tract infection (LRTI) without other obvious cause
• New pulmonary infiltrate on chest radiograph is needed for definite diagnosis.
Definitions Hospital-acquired and Ventilator-associated Pneumonias
• HAP, or nosocomial pneumonia, arises 48 hours or more after hospital admission in the absence of signs or symptoms of pneumonia at the time of admission
• VAP is a subtype of HAP that develops after endotracheal intubation
• (Because only about 10% of patients with HAP are not mechanically ventilated, the terms HAP and VAP are often used interchangeably)
Ottosen SCNA 2014
Definitions Health Care Associated Pneumonia
American Thoracic Society (ATS) guidelines (2005):
New category of infections to encompass recent inpatient or on ongoing treatment in a long-term or outpatient health care facility
HCAP New pneumonia in:
• Any patient who was hospitalized in an acute care hospital for 2 or more days within 90 days of the infection
• Resided in a nursing home or long-term care facility
• Received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection
• Or attended a hospital or hemodialysis clinic
Ottosen SCNA 2014
Other Definition Issues
Ottosen SCNA 2014
When should you think of pneumonia?
• Temperature > 37.8 C• Pulse > 100/min• Rales/Crackles• Decreased breath
sounds• Absence of asthma
Respiratory Symptoms plus
Ann Intern Med 1990;113:664
The Cough + 1 RuleSuspect if
New focal chest signs on examinationAt least one systemic featureNo other explanation for the illness
Chest imaging is necessary for a definite diagnosis
And helps• to detect associated lung diseases• to gain insight into causative agent (in some
cases)• to assess severity• as baseline to assess response
IDSA 1998 & BTS 2001
Other Diagnostic TestsProcalcitonin
Alba Am J Med 2015
Alba Am J Med 2015
Inpatient vs Outpatient Treatment
• Medical Risk Assessment• Psychosocioeconomic
considerations• Patient preference
StratificationMedical Risk
• OutpatientOtherwise healthy adults
• Outpatient Cardiorespiratory or other comorbidity
• Inpatient Floor Unit• Intensive Care Unit
Index of SeverityThe Original BTS CAP Index
R.U.B. Predicts Death
• Respiratory Rate > 30/min• BUN > 20 mg/dL• Diastolic blood pressure < 60
mm HgQ J Med 1987:62;195-220
RISK ASSESSMENTDefining low risk patients
PSIPneumonia Severity Index
The Pneumonia Severity Index
• PSI relies on 2 pre-existing patient features• Age over 50• Co-existing chronic illnesses
• 5 Adverse clinical features• Mental status*• Respiratory Rate*• SBP*• Pulse Rate• Temperature
PSI Pre-existing Condition:Scoring System for Risk Classes II-V
AgeMale No. of years of ageFemale No. of years of age - 10Nursing home Add 10 points
Add the patient's age in years (age -10, for females)
Risk Class Mortality Rates
Risk Class Mortality Site of CareI (none) 0.1% OutpatientII (< 70 pts) 0.6% OutpatientIII (71 – 90 pts) 2.8% Inpatient
IV (91 – 130 pts) 8.2% InpatientV (> 130 pts) 29.2% Inpatient
NEJM 1997;336:243
Risk Stratification ScoresCURB65
Ottosen SCNA 2014
Assessment of Severity/Disposition
Prina, Lancet 2015
Microbiological Testing
Prina Lancet 2015
Empirical Therapy
Prina, Lancet 2015
Bacteremia in CAP
• 5% False-positive culture leading to increased length of hospital stay
Metersky AJRCCM 2004
Antibiotic Timing in CAP
Clinical Course/Timeline
Prina, Lancet 2015
Ottosen SCNA 2014
Ottosen SCNA 2014
Presumptive PathogensEarly
Presumptive PathogensLate
Ottosen SCNA 2014
Zilberberg CID 2010, Ottosen SCNA 2014
VAP Diagnostic SurrogateCPIS
When things don’t go as expected..
Ottosen SCNA 2014
Non-resolving Pneumonias
• Granulomatous Infection - TB, Fungal,• Exotic Infection - Brucellosis, Tularemia,
Ricketsial• Drug Resistant Organisms• Post-obstructive Pneumonia• Non-infectious Causes
• Pulmonary embolism• Alveolar hemorrhage• Vasculitis• CVD• Sarcoidosis
Seven Degrees of Suppuration
MIST1
• N=454 (427 randomized) with pH <7.2 or proven intrapleural infection
• SK 250000 IU bid x 3 days vs placebo• No difference in deaths or surgical
drainage rate at 3 months - 31% vs 27%• No difference in in LOS, radiographic
outcome• Side effects 7% vs 3% (p=0.08)
Current Management of Parapneumonic Empyema in the High(er) Risk Patient
Piccolo An Am Thor Soc 2014
Piccolo An Am Thor Soc 2014
Piccolo An Am Thor Soc 2014
Novel Strategies
Transmission ControlViruses
Transmission ControlBacteria