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Approach to peumonia
1. CLINICAL APPROACH TO PNEUMONIA Dr Izham Cheong, FRCP Professor 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
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3. 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 10.98 CVA 9.47 Accident 8.79 Neoplasms 8.75 Perinatal diseases 7.28 GI diseases 4.69 Pneumonia 4.33 Renal disease 3.65 Ill-defined diseases 3.62
5. KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS PNEUMONIA 1. EPIDEMIOLOGY OF RESPIRATORY PATHOGENS NHAP Gram –ve Klebsiella spp. P. aeroginosa Gram +ve S. aureus Anaerobes HAP (VAP) Gram –ve P. aeroginosa Acinetobacter spp. Proteus spp. Klebsiella spp. E. cloacae P. maltophila Legionella spp. Gram +ve S. aureus (MRSA) S. pneumoniae Other streptococci S. epidermidis Polymicrobial CAP Typical S. pneumoniae H. influenzae M. catarrhalis Atypical L. pneumophila M. pneumoniae C. pneumoniae C. psittacosi C. burnetti
6. 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 within a time frame and 30-day mortality Meehan TP, 1997 OR of 30-d Survival (95% CI)
7. KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS A PNEUMONIA 3.THE RISE IN ANTIBIOTIC RESISTANCE Penicillin and macrolide resistant S. pneumoniae ESBL-producing Klebsiella spp. MDR pathogens: P. aeroginosa P. maltophila Enterobacter spp. Stenotrophomonas spp. MRSA + VRSA VRE
8. KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS A PNEUMONIA 4. CONTAIN COST WITHOUT NEGATIVELY AFFECTING MORTALITY Minimize admissions Oral antibiotics Shorten hospitalization
20. HISTORY 10. WHAT DRUGS ARE YOU TAKING? Amiodarone Nitrofurantoin Bleomycin Chlorambucil Procarbazine Bulsulfan Cyclophosphamide Aziathioprine Methotrexate Sulphonamides Lung infiltrates Heroin Methadone Chlorthiaxide Contrast media Pulmonary oedema
21. 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
22. Cutaneous findings Erythema multiforme M. pneumoniae Maculopapular rash Measles Erythema nodosum C. pneumoniae Ecthyma gangrenosum M. tuberculosis P. aeruginosa Oral findings Peridontal disease anaerobic pathogens Foul smelling sputum Clinical Approach to a Patient with CAP Physical examination
23. Neurologic disease Absent gag Aspiration Altered conciousness Recent seizure Cerebellar ataxia M. pneumoniae L. pneumophila Encephalitis M. pneumoniae C. burnetti Clinical Approach to a Patient with CAP Physical examination
24. Differential Diagnosis of Common Radiographic Patterns in Patients with Pneumonia Focal opacity Interstitial S. pneumoniae M. pneumoniae L. pneumophila C. pneumoniae M. tuberculosis Aspiration Viral M. pneumoniae P. carinii C. psittaci
25. Differential Diagnosis of Common Radiographic Patterns in Patients with Pneumonia Interstitial with lymphadenopathy Cavitation Epstein Barr virus F. tularensis C. psittasi Anaerobic abscess S. aureus Aerobic gram-neg bacilli M. tuberculosis C. neoformans N. asteroides and A. israelii
26. Differential Diagnosis of Common Radiographic Patterns in Patients with Pneumonia Segmental pneumonia with lymphadenopathy Miliary M. tuberculosis Fungal infection M. tuberculosis H. capsulatum Varicella zooster
27. COMMUNITY-ACQUIRED PNEUMONIA Which 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
28. INTERNATIONAL GUIDELINES FOR EMPIRICAL ANTIMICROBIAL THERAPY OF COMMUNITY-ACQUIRED PNEUMONIA Extended spectrum cephalosporin or –lactam/ -lactamase inhibitor + either IV fluoroquinolone or IV macrolide (if structural lung disease cover P. aeroginosa ) -lactam with macrolide OR new fluoroquinolone doxycycline macrolide new floroquinolone Infectious Diseases Society of America (2000) 2 nd or 3 rd generation cephalosporin + 2 nd generation quinolones rifampicin (2 nd or 3 rd generation cephalosporin or -lactam/ -lactamase inhibitor or IV penicillin) macrolide or 2 nd generation quinolones; penicillin or aminopenicillins Alternatives: macrolodes tetracyclines cephalosporins quinolones European Respiratory Society (1998) ICU General ward Outpatient Guidelines
29. WHAT DO I USE FOR MY PATIENTS WITH A COMMUNITY- ACQUIRED PNEUMONIA ?
30. HOW DO I EMPIRICALLY TREAT MY PATIENT WITH COMMUNITY-ACQUIRED PNEUMONIA? Izham, 2002 Empiric therapy (pathogen unknown or awaiting cultures) -lactam/ -lactamase inhibitor alone (ampicillin/sulbactam, pipericillin/tazobactam)) Aspiration pneumonia requiring hospitalization -lactam (sulperazone or ceftriaxone) + macrolide or antipneumococcal fluoroquinolone Requiring hospitalization Oral -lactam/ -lactamase inhibitor + macrolide OR Oral antipneumococcal fluoroquinolone Ambulatory, not requiring hospitalization, comorbidity or age over 60 years Oral macrolide (erythromycin or azithromycin) Ambulatory, not requiring hospitalization, age under 60 years THERAPEUTIC OPTIONS SETTING
31. MY EMPIRICAL THERAPY OF SEVERE CAP IN COMPROMISED HOST Izham,2002 -lactam/ -lactamase inhibitor OR meropenam S. pneumoniae N. meningitidis H. influenzae Congenital/acquired asplenia or hyposplenia new fluoroquinolone S. pneumoniae Salmonella Legionella HIV Cloxacillin OR vancomycin S. aureus Postviral influenzae 3 rd or 4 th generation cephalosporin OR meropenam Oral anaerobes and/or Klebsiella spp . Chronic alcoholics Empiric therapy Usual pathogen Compromised host
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33. “ 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!!!!!!!!
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