MED2_PULMO 28 April 2016

COMMUNITY-ACQUIRED PNEUMONIA Are there other diagnostic tests needed?

Sources: lecture, pulmo workbook, side notes
 Investigate for specific pathogens only when the etiology would
 Does the patient have pneumonia? significantly alter standard empirical management decisions:
 Will we admit him/her? o ICU admissions
 Where will we admit?  These are the ones who are critically ill; you really
 What antibiotic should we give? wanna know what specific organism is present.
 When should we start antibiotics? Request sputum culture or blood culture
 When do we expect clinical response?  (+) bacteria in blood from 2 different sites – suggest
 When should we switch? bacteremia  severe infection
 When should we send the patient home? o Failure of previous antibiotic therapy
 If he took antibiotics in the past 3 months, then you
Epidemiology cannot give this same antibiotic now because you
Top 20 illnesses or causes of hospitalizations in the Phil in the first have an increased risk of the bacteria being resistant
quarter of 2011, based on the number of health insurance claims paid by  If the patient took antibiotics 6 months ago, you can
Philhealth give the same antibiotic to this patient
Rank Illness Claims o Cavitary infiltrates
1 Pneumonia 79,631  TB
2 Chronic renal failure 68,739 o Leukopenia
3 Single NSD of child 55,519  immunocompromised
4 Diarrhea and gastroenteritis 53,282 o Active alcohol abuse
5 Liveborn infant care 36,565 o Chronic severe liver disease
6 Other disorders of urinary system 33,057 o Severe obstructive/structural lung disease
7 Dengue hemorrhagic fever 31,101 o Asplenia
8 Dengue fever (classic dengue) 21,716 o Recent travel
9 Primary HTN 21,212 o (+) Legionella UAT result
10 Acute URTI 18,553 o (+) pneumococcal UAT result
o Pleural effusion
CASE:  Need to identify specific organism present; request
D.Makabrid, 26 yo call center agent, previously diagnosed to have for thoracentesis
bronchial asthma, consulted for dyspnea
2 wks cough with yellowish phlegm WILL WE ADMIT HIM?
1 wk fever Philippine Clinical Practice Guidelines on the Dx, Empiric
3 days exertional dyspnea
Management, and Prevention of CAP in Immunocompetent Adults
Nausea and vomiting
2010 update (see last page for a clearer? picture :D)
PE:
Alert, aware
Preferred semi-upright position, 100/70, RR 29, T 38C
Chest I – symmetrical expansion
P – increased tactile fremiti L lower lung field
P – dullness T7 down L
A – increased BS T7 down, wheezes over the rest of the LF

DIAGNOSIS OF PNEUMONIA
Does he have pneumonia?
 Clinical features
o Symptoms
 Fever, cough, dyspnea (TRIAD)
 In most instances, symptoms alone can give us a
clue that it is pneumonia
o Physical examination
 Tachypnea, rales, evidence of consolidation
 Symptoms + evidence of consolidation on PE
(increased tactile fremiti, dullness, increased BS)
strongly suggests pneumonia
 Diagnostic testing
o Demonstrable infiltrate by chest x-ray
 Philhealth will look for xray results
 Air bronchograms
 Hazy infiltrates

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 MED2_PULMO 28 April 2016

Using the algorithm above, the patient is LOW RISK and should NOT be
admitted. But, let us further assess…

PNEUMONIA SEVERITY INDEX (PSI)

(scoring was not mentioned by Dra but you can check the pulmo workbook.
No need to memorize daw, there is already a mobile app for this)
 Age  PE  Labs
 Sex o Altered o pH < 7.35
 Nursing Home mental o Na <130
resident status o BUN >30 Using CRB 65, our patient’s score is still 0  no need for hospitalization
 Co-morbid o Temp o pO2 <60 Score of 3 or 4, you may also consider ICU admission
diseases <35 or ≥ or sat
o Renal 40 <90 Even though the CURB 65 and CRB 65 of our patient is 0, I will still admit
disease o SBP <90 o Hct <30 him. Why?
o CVD o RR ≥ 30 o Pleural
For LOW RISK, admit when:
o Liver o HR ≥ 125 effusion
o Gluc  Complications of pneumonia
disease
o Neoplasia >250  Exacerbation of underlying disease
o CHF o He had exacerbation of asthma (wheezing)
 Inability to take oral meds or receive outpatient care
Severity classification (PSI) o Nausea and vomiting
Risk Class Score Mortality  Multiple risk factors
Low I <51 0.1%  PLUS
Low II 51-70 0.6% o Hypoxemia O2 sat <90% or pAO2 <60mmHg
Low III 71-90 0.9% o Shock
Medium IV 90-130 9.5% o Decompensated co-existing disease
High V >130 26.7% o Pleural effusion
Higher score, higher risk of mortality o Inability to take oral meds
Medium and high-risk  admit o Social problems
o Lack of response to previous antibiotic tx
CURB 65
WHAT IS THE MOST COMMON ORGANISM IN CAP?
MOST COMMON – S.pneumoniae
Outpatient Inpatient (non ICU) Inpatient (ICU)
S. pneumoniae S. pneumoniae S. pnemoniae
M. pneumoniae M. pneumoniae Staph aureus
H. influenza H. influenza Legionella spp
C. pneumoniae C. pneumoniae Gram (-) bacilli
Respiratory viruses Legionella spp H. influenzae
Aspiration
Respiratory viruses

WHAT ANTIBIOTIC WILL WE GIVE?

Risk stratification Potential pathogen Empiric therapy
Low-risk CAP S. pneumoniae Previously healthy:
M. pneumoniae Amoxicillin OR
H. influenza Extended macrolides (if
C. pneumoniae suspected atypical
Moraxella catarrhalis pathogen)
From American College of Chest Physicians Enteric gram (-) bacilli
Using CURB 65, our patient’s score is 0  low risk, outpatient (among those with co- With stable comorbid
morbid illness) illness (ex: pneumonia
CRB 65 + asthma not in
British classification; BUN was omitted because oftentimes you don’t have exacerbation):
BUN data right away B-lactam/B-lactamase
inhibitor combination
Clinical factor Points
(BLIC)
Confusion 1
Respiratory rate ≥ 30 breaths/min 1 OR
Systolic BP <90 mmHg 1
Or Second-gen oral
Diastolic BP ≤ 60 mmHg cephalosporins (ex.
Age ≥ 65 1 cefuroxime) ±
Extended macrolides

Alternative:
Third-gen oral
cephalosporin
±
Extended macrolide

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Moderate-risk CAP S. pneumoniae IV non-antipseudomonal

M. pneumoniae B-lactam (BLIC,
H. influenza cephalosporin or
C. pneumoniae carbapenem)
Moraxella catarrhalis +
Enteric gram (-) bacilli Extended macrolide
Legionella pneumophila
Anaerobes (among OR
those with risk of
aspiration) IV non-antipseudomonal
B-lactam (BLIC,
cephalosporin, or
carbapenem)
+
respiratory FQ
High-risk CAP S. pneumoniae No risk for P.
M. pneumoniae aeruginosa:
H. influenza IV non-antipseudomonal
C. pneumoniae B-lactam (BLIC,
Moraxella catarrhalis cephalosporin, or
Enteric gram (-) bacilli carbapenem)
Legionella pneumophila +
Anaerobes (among IV extended macrolide *Less and less resistance to Penicillin, therefore in our setting we can still
those with risk of or IV respiratory FQ give this drug for pneumonia caused by S.pneumoniae
aspiration) *Ampicillin (for H. influenza), increasing resistance.
Staph aureus With risk for P.
Pseudomonas aeruginosa:
aeruginosa IV antipneumococcal
antipseudomonal B-
lactam (BLIC,
cephalosporin or
carbapenem)
+
IV extended macrolide
+
Aminoglycoside

OR

IV antipneumococcal
antipseudomonal B-
lactam (BLIC,
cephalosporin or
carbapenem)
+
IV
ciprofloxacin/levofloxacin
(high-dose)

So for our patient, since he is moderate risk, we will give him IV non-
antipseudomonal B-lactam (BLIC, cephalosporin or carbapenem) +
Extended macrolide
or
IV non-antipseudomonal B-lactam (BLIC, cephalosporin, or carbapenem) +
respiratory FQ

VERY IMPORTANT CONSIDERATIONS

 Local resistance patterns are of UTMOST IMPORTANCE in
choosing antibiotic coverage
 If MTB is also a possibility, frequent FQ use may lead to resistance
of MTB to this antibiotic and may limit its use in drug resistant TB
o Penicillin – for typical organisms
o Macrolide – for atypical organisms
o FQ – both typical and atypical  that’s why it is so easy to
prescribe pero we have to lessen the use of FQ so that we will
not limit its use for TB

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WHEN SHOULD WE START ANTIBIOTICS?

 Start within 4 hours from diagnosis
o Lower mortality rate noted in some but not all studies
o Once you diagnose, give antibiotics!

HOW LONG SHOULD WE GIVE ANTIBIOTICS?

 Depends on the drug (ex. azithromycin – one dose lang)
 Most instances, 5-7 days for low risk
 Remember that when you prescribe antibiotics, give detailed
instructions
o Ex. do not just put TID; include “every 8 hours” or “6 AM, 2 PM,
10 PM”

WHEN DO WE EXPECT CLINICAL RESPONSE?

 Clinical improvement within 72 hours
o Not necessarily complete resolution of symptoms
 Decrease WBC count
o (esp if initial WBC is high; some patients kasi present with low
WBC count kahit may infection na)
Need to stepdown to reduce hospital stay
 Functioning GI tract (*see last page for streamline/step-down guidelines)
o Decreased nausea and vomiting
 Radiographic lag
o Takes a longer time for the xray to become normal (usually
after 4 wks pa; in the elderly or immunocompromised, 6-8 wks)
 If delayed response:
o Complications of pneumonia
 Pleural effusion
 Lung abscess
o Resistant organisms
o Wrong diagnosis
 For these patients, do complete hx and PE, and labs
again; you may also ask for a repeat chest xray
 Get sputum exam, blood cultures etc Functioning GI tract – so we can prescribe him oral meds

HOW CAN WE PREVENT CAP?

Smoking – impairs local lung defenses (mucociliary apparatus)

Influenza does not cause pneumonia directly but it can impair the immune
system  risk for pneumonia; for patients who present with pneumonia,
look for history of a viral infection

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Suspected aspiration –
bedridden patients,
stroke patients

Choices of
oral step-
down therapy
for our case

PLEASE ALSO READ PP 30-35 OF THE PULMO WORKBOOK

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