pneumonia sahd
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Pneumonia SAHD. Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists June 2010. Learning objectives. Recognise the Clinical features of pneumonia Demonstrate appropriate use of CURB-65 severity scoring index Know the main causes of Community acquired pneumonia - PowerPoint PPT PresentationTRANSCRIPT
Coventry and Warwickshire Pathology
Pneumonia SAHD
Senior Academic Half Day
Matt Rogers & James Clayton
Consultant Microbiologists
June 2010
Coventry and Warwickshire Pathology
Learning objectives
• Recognise the Clinical features of pneumonia
• Demonstrate appropriate use of CURB-65 severity scoring index
• Know the main causes of Community acquired pneumonia
• Interpret laboratory results and apply to Clinical decisions
• Understand the key principles of antibiotic prescribing
Coventry and Warwickshire Pathology
Are you feeling
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4. Go away and leave me alone
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What is your favouritespeciality?
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Coventry and Warwickshire Pathology
How well do you think you could deal with a patient in ED with a
Chest Infection?
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Coventry and Warwickshire Pathology
Presentation of pneumonia
• Fever/chills/sweats/rigors• Cough• Productive of sputum –
clear/purulent/blood stained etc.
• Dyspnoea• Pleuritic chest pain• Malaise• Anorexia and vomiting• Headache• Myalgia• Diarrhoea
Coventry and Warwickshire Pathology
Chest examination
• Anatomic Landmarks
• The Extrathoracic Examination
• Chest Inspection, Palpation, Percussion
• Chest Auscultation
Coventry and Warwickshire Pathology
Clinical signs of pneumonia
• Pyrexia• Tachypnoea• Cyanosis – rare• Altered mental state• Consolidation
– Dull percussion note– Inspiratory crepitations– Bronchial breathing– Increased vocal resonance and tactile vocal fremitus (voice
vibration felt with the hand greater over areas of consolidation)– Whispering pectoriloquy (increased loudness of voice over
area of consolidation when auscultating)
Coventry and Warwickshire Pathology
Infective exacerbation of COPD
• Please exclude a diagnosis of Infective exacerbation of COPD before treating for Community Acquired Pneumonia (CAP)
• Infective Exacerbation of COPD – past history of COPD
• ↑ dyspnoea
• ↑ sputum volume
• increased sputum purulence
Coventry and Warwickshire Pathology
Classification of pneumonias
• Typical vs Atypical ??IS THIS VALID??• Community acquired (CAP) vs hospital
acquired (HAP)• Lobar vs Bronchopneumonia• Aspiration pneumonia• Immunocompromised host pneumonia• There is often difficulty in placing a
pneumonia into one category or another
Coventry and Warwickshire Pathology
Management of pneumonia
• Depends on severity and co-morbidity (particularly CAP)
• Formally assess severity CURB-65• Supportive treatment essential
– IV fluids– Oxygen– Analgesia– need for ventilation?
• Investigations• Antibiotic therapy
Coventry and Warwickshire Pathology
Complications of pneumonia
• Bacteraemia/Septicaemia……death
• Lung abscess
• Parapneumonic effusion/empyema
Coventry and Warwickshire Pathology
Which criteria are included in CURB-65 severity scoring
Cya
nosis
Ure
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Bas
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65%
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1. Cyanosis
2. Urea
3. Respiratory rate
4. Base excess
5. 65% O2 required0of5
Coventry and Warwickshire Pathology
Severity: CURB-65
• Confusion: new confusion AMT <8• Urea >7mmol/l• Respiratory rate: >=30/min• Blood pressure: sys <90 or dias <60• >65 years old
• Hypoxia Arterial pO2 <8Kpa• Multilobar disease
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CURB-65
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Implications of CURB-65
• Severe pneumonia is CURB-65 >3 • Score of 3 = mortality 17%, • Score of 4 = mortality 41.5%, • Score of 5 = mortality 57%
• Need admission and IV antibiotics
• Non-severe pneumonia CURB-65 0 or 1• Score of 1 = Mortality 3.2%
• O/p treatment with oral antibiotics
• CURB 2 – Needs clinical judgement in hospital• Mortality 13%
Coventry and Warwickshire Pathology
MAU AuditZoe Campbell F2 SHO
• Only those with Severe pneumonia according to CURB criteria should receive IV antibiotics
• 18 out of 25 patients received IV antibiotics
• 18 patients were classified mild/mod (? Oral antibiotics)
• 7 patients were classified severe (? IV antibiotics)
I.V.
Oral
Mild/Moderate
Severe
Coventry and Warwickshire Pathology
Investigations of Pneumonia
• CXR• O2 saturation +/- gases• Microbiology…• Biochemistry
– Urea– LFT– CRP
• Haematology– FBC: WBC, plts, ?clotting
Coventry and Warwickshire Pathology
What microbiology samples would you send on a patient with severe
CAP?
Sputu
m
Nose
swab
Urin
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2. Nose swab
3. Urinary Antigen
4. Serology
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Send appropriate samples
Coventry and Warwickshire Pathology
Sputum: microscopy• Sputum appearance?• Mucoid/Salivary/Blood
stained/Green/Yellow etc• Gram stain??: Sputum/BAL
etc.• Special stains: TB/PCP etc.
Coventry and Warwickshire Pathology
Sputum: culture and sensitivity
Coventry and Warwickshire Pathology
Blood culture
• Blood cultures should be taken from anyone with severe pneumonia
• Sterile technique vital• Inoculate into blood
culture bottles, aerobic and anaerobic
• Automated blood culture machine for 5 days
• Please take before pt on antibiotics!!!
Coventry and Warwickshire Pathology
Others• BAL/Pleural fluid more of a reliable sample
than sputum• Serology-Acute and convalescent phase (0
and 14 days). A useful test for Mycoplasma, Chlamydia, Legionella, Coxiella, Influenza etc.
• Antigen detection: Immunoflourescence (eg RSV from NPAs)
• Urine for legionella/pneumococcal antigen
Coventry and Warwickshire Pathology
BTS guidelines
• All patients admitted with severe CAP should have – Blood cultures – Sputum culture– Legionella antigen
• All patients admitted with non-severe CAP need – Blood cultures – Sputum cultures (unless have had recent course of
antibiotics)
Coventry and Warwickshire Pathology
Which bacteria are common causes of CAP
Esc
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1. Escherichia coli
2. Streptococcus pneumoniae
3. Haemophilus influenzae
4. Coagulase negative staphylococci
5. Moraxella catarrhalis
Coventry and Warwickshire Pathology
Organisms causing Pneumonia
Viruses – Influenza, parainfluenza
Community acquired pneumoniaStreptococcus pneumoniae Mycoplasma
pneumoniaeHaemophilus influenzae Legionella pneumophilaMoraxella catarhalis Chlamydia psittaciStaphylococcus aureus Coxiella burnetti
Hospital acquired PneumoniaEscherichia coli, Klebsiella pneumoniae, Acinetobacter baumanii etc
Coventry and Warwickshire Pathology
CAP causative organisms
Coventry and Warwickshire Pathology
Streptococcus pneumoniae
• Gram positive streptococcus, commensal flora. Need to distinguish infection from colonisation
• Acute pyogenic infection• Rapidly progressing infection
often associated with bacteraemia
• Often fatal in elderly/immunocompromised. Capsule is the most important virulence factor
• Capsular based vaccines available for at risk groups
Coventry and Warwickshire Pathology
Hospital acquired pneumonia
• Often after courses of antibiotics
• At risk patients• Possibly ventilated• Enteric gram negative
bacilli –E.coli, K.pneumoniae etc
• Pseudomonas aeruginosa
• MRSA
Coventry and Warwickshire Pathology
Chest Infection
• Possible choicesAmoxicillin
AugmentinCefuroximeCiprofloxacin
CeftazidimeTazocinMeropenem
• +/- erythromycin/clarithromycin (Atypical cover)
Coventry and Warwickshire Pathology
And Atypicals!
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Coventry and Warwickshire Pathology
Coventry and Warwickshire Treatment Guidelines (Hospital)
Coventry and Warwickshire Pathology
Community acquired pneumonia
– Strep. pneumoniae ~ 30 - 40%– Haemophilus influenzae ~ 5 - 10%– Staph. aureus ~ 0.5 - 5%
• Severity of infection (CURB-65 score)– Determines need for IV or oral treatment– Determines need for broad vs narrow cover
Coventry and Warwickshire Pathology
Don’t forget atypicals in CAP!
– Legionella pneumophila ~ 1 - 5%– Mycoplasma pneumoniae ~ 1 - 10%– Chlamydophila pneumoniae < 10% ?– Chlamydia psittaci, Coxiella < 2%– Viruses including Influenza < 15%
• Addition of – Macrolide e.g. erythromycin or clarithromycin– Tetracycline e.g. doxycycline– (Ciprofloxacin)
Coventry and Warwickshire Pathology
Chest Infection Recommendation
Coventry and Warwickshire Pathology
Chest Infection recommendation
Coventry and Warwickshire Pathology
Mid session interval
You have 5 minutes, the attendance book will be available
for signing on your return
Coventry and Warwickshire Pathology
Which of the following do you do when prescribing antibiotics
Rev
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1. Review pts previous microbiology results
2. Document indication and duration/review date in the patients notes
3. Write indication on drug chart
4. Write review or stop date on drug chart
5. Review antibiotic at 48hrs and change to oral if appropriate
Coventry and Warwickshire Pathology
How well do you think you could deal with a patient in ED with a
Chest Infection?
Super
bly W
ell
Adeq
uatel
y
Poorly
Rat
her n
ot say
0% 0% 0%0%0%
1. Superbly
2. Well
3. Adequately
4. Poorly
5. Rather not say
0of5