PULMO LECTURE

JI Monitor’s Hour
April 15, 2020
 CASE # 1
• 75 year old female known hypertensive, diabetic, coming in for cough. History started 4 days
prior when Patient had nonproductive cough, along with easy fatigability and pleuritic chest
pain. 3 days prior, noted undocumented fever. Sought consult, CXR done outside showed
streaky and hazy densities in RLL. Patient was then advised admission but opted transfer in
our institution
• ROS: (-) headache, chest pain, PND, orthopnea, abdominal pain
• PMHx: (+) HTN>20 years, UBP 120/80 HBP 140 on Amlodipine 5mg OD, Losartan 50mg OD
(+) DM > 20 years SMBG 120-130 on Minidiab 10mg BID and Janumet 50/500mg BID
(+) arterial insufficiency on cilostazol 50mg OD
s/p appendectomy (2016)
• FHx: (+) DM (-) HTN, stroke, cancer
• PSHx: nonsmoker, nondrinker of alcoholic beverages
 CASE # 1

• Physical examination
BP 120/80 PR 72 RR 18 TP 37
pink palpebral conjunctiva
(+) Bilateral coarse crackles with decreased breath sounds, R base
Normal rate regular rhythm
Abdomen soft nontender
(+) hyperpigmentation on both lower extremities
gr 2 equal pulses, no edema
 GUIDE QUESTIONS

• What is the most likely diagnosis

• What is the risk stratification?
• What is the best initial diagnostic test?
• What is the most likely causative organism?
• What is the mainstay of treatment?
• What other lab tests you would need to request?
 GUIDE QUESTIONS

• What is the most likely diagnosis CAP r/o pleural effusion, right
• What is the risk stratification? Moderate
• What is the best initial diagnostic test? Chest x-ray
• What is the most likely causative organism? Streptococcus pneumoniae
• What is the mainstay of treatment? Antibiotics
• What other lab tests you would need to request?
 CASE # 1

• Diagnostic tests done outside

CBC 11.6/3.98/34/11600/N67 L23 M7 E2/adequate
BUN 14 Crea 0.7
Na 137 K 3.4 Mg 1.6
FBS 13.11 HbA1c 11.7
Cholesterol 164.86 TG 117 HDL 29 LDL 112 VLDL 23 C/D 5.7
Uric Acid 5.15 ALT 23
UA Y/sl. turbid/glucose 1+/blood 3+/leu 3+/1.01/5.0/R 6-8 W 51-75 epi many bacteria moderate
ECG SR 1st degree AV block, left axis deviation, T wave inversion leads V2-V6
CASE # 1
 PNEUMONIA

• Infection of pulmonary parenchyma

• Classifications:
• CAP
• VAP
• HAP
• HCAP: meant to encompass cases of CAP that were caused by multi-drug pathogens
associated with HAP
• Rather than relying on a predefined subset, it is better to assess individually on the
basis of risk factors for infection with an MDR organism

Multi-drug Resistant Gram-
negative bacteria and MRSA
Hospitalization ≥ 2 days in the
previous 90 days
Use of antibiotics in previous 90
days
Immunosuppression
Non-ambulatory status
Tube feedings
Gastric acid suppression
Severe COPD or bronchiectasis
MRSA RISK FACTORS
Nosocomial MRSA
Hospitalization ≥ 2 days in the
previous 90 days
Use of antibiotics in previous 90
days
Chronic hemodialysis in previous
30 days
Documented prior MRSA
colonization
Congestive heart failure
Gastric acid suppression
Community-acquired MRSA
Cavitary infiltrate or necrosis
Gross hemoptysis
Neutropenia
Erythematous rash
Concurrent influenza
Young, previously healthy status
Summer-month onset
 PATHOPHYSIOLOGY
• Routes of infection
• Aspiration from oropharynx: most common mechanism
• Hematogenous spread: e.g., from infective endocarditis
• Contiguous extension: from infected pleural or mediastinal space
• Defenses in respiratory tract
• Mechanical factors: eg, gag and cough reflexes
• Resident alveolar macrophages: have intrinsic antibacterial/antiviral activity
• Only when capacity of alveolar macrophages to ingest/ kill microorganisms is exceeded does
clinical pneumonia become manifest
• Adaptive immune response
 PHYSICAL EXAM AND LAB FINDINGS

• Fever: release of inflammatory mediators such as IL-1 and TNF

• Hemoptysis: when erythrocytes cross the alveolar-capillary membrane
• Radiographic infiltrate and rales: capillary leak
• Hypoxemia: alveolar filling
• Respiratory alkalosis: increase in respiratory drive in systemic inflammatory response
syndrome
• Dyspnea: decreased compliance due to capillary leak, hypoxemia, increased respiratory drive,
increased secretions, and occasionally infection-related bronchospasm
 PATHOLOGY: 4 STAGES

• Edema: with proteinaceous exudate; rarely evident in clinical/ autopsy specimen

• Red hepatization: Presence of RBC in intra-alveolar exudate
• Neutrophil influx
• Gray hepatization: No new RBCs are extravasating
• Neutrophil is the predominant cell
• Abundant fibrin deposition
• Corresponds with containment of infection and improvement in gas exchange
• Resolution: Macrophage reappears as the dominant cell
• Debris of neutrophils, bacteria, and fibrin has been cleared
 PATHOLOGY

• Bronchopneumonia: most common in nosocomial pneumonia

• Lobar pneumonia: more common in bacterial CAP
 MICROBIAL CAUSES OF CAP BY SITE OF CARE

OUTPATIENTS
Streptococcus pneumoniae
Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydia pneumoniae
Respiratory viruses
HOSPITALIZED PATIENTS
NON-ICU ICU
Streptococcus pneumoniae Streptococcus pneumoniae
Mycoplasma pneumoniae Staphylococcus aureus
Chlamydia pneumoniae Legionella spp.
Haemophilus influenzae Gram-negative bacilli
Legionella spp. Haemophilus influenzae
Respiratory viruses Respiratory viruses

• Atypical organisms: intrinsically resistant to β-lactam agents

• Mycoplasma pneumoniae
• Chlamydia pneumoniae
• Legionella spp.
 EPIDEMIOLOGIC FACTORS SUGGESTING CAUSES OF PNEUMONIA
Factor Possible Pathogen Factor Possible Pathogen
Alcoholism Streptococcus pneumoniae, oral anaerobes, Travel to Ohio or St. Histoplasma capsulatum
Klebsiella pneumoniae, Acinetobacter spp, Lawrence river valley;
Mycobacterium tuberculosis exposure to bats
COPD or smoking Haemophilus influenzae, Pseudomonas Travel to SW US Hantavirus, Coccidioides spp.
aeruginosa, Streptococcus pneumoniae, Travel to Southeast Burkholderia pseudomallei, avian
Moraxella catarrhalis, Chlamydia Asia influenza virus
pneumoniae
Stay in hotel or on Legionella spp.
Structural lung P. aeruginosa, Burkholderia cepacia, S. cruise ship in 2 wks
disease (eg, aureus
Local influenza activity Influenza virus, S. pneumonia, S. aureus
bronchiectasis)
Exposure to birds Chlamydia psittacci
Dementia, stroke, Oral anaerobes, gram-negative enteric
altered LOC bacteria Exposure to rabbits Francisella tularensis
Lung abscess CA MRSA, oral anaerobes, endemic fungi, M. Exposure to sheep, Coxiella burnetti
tuberculosis, atypical mycobacteria goats, parturient cats
 EPIDEMIOLOGIC FACTORS SUGGESTING CAUSES OF PNEUMONIA

CLINICAL PEARLS
• Atypical pathogens:
• Stay in hotel or cruise ship in previous 2 weeks:
• Stroke, dementia, decreased consciousness:
• Recent antibiotic use, malnutrition, steroid use,
bronchiectasis:
• Structural lung disease:
• Significant gingivitis:
 EPIDEMIOLOGIC FACTORS SUGGESTING CAUSES OF PNEUMONIA

CLINICAL PEARLS
• Atypical pathogens: Mycoplasma, chlamydia, legionella
• Stay in hotel or cruise ship in previous 2 weeks: Legionella
• Stroke, dementia, decreased consciousness: Anaerobes, gram negative bacteria
• Recent antibiotic use, malnutrition, steroid use, Pseudomonas aeruginosa
bronchiectasis:
• Structural lung disease: Pseudomonas aeruginosa
• Significant gingivitis: Anaerobes
 DIAGNOSTICS

• Physical examination alone: Sensitivity 58%, specificity 67%

• Elderly may initially present with confusion alone
• Chest radiography: necessary to differentiate CAP from other conditions
• Pneumatocele: S. aureus
• Upper-lobe cavitating lesion: Tuberculosis
• Chest CT scan: may done for those with suspected postobstructive pneumonia caused
by tumor or foreign body or suspected cavitary disease
 QUESTION

• Sputum GS/CS

Which characteristic of sputum sample is considered adequate for culture?

A. > 25 neutrophils and > 10 squamous epithelial cells per LPF
B. > 25 neutrophils and < 10 squamous epithelial cells per LPF
C. < 25 neutrophils and > 10 squamous epithelial cells per LPF
D. > 25 neutrophils and < 10 squamous epithelial cells per HPF
 QUESTION

• Sputum GS/CS
Which characteristic of sputum sample is considered adequate for culture?
A. > 25 neutrophils and > 10 squamous epithelial cells per LPF
B. > 25 neutrophils and < 10 squamous epithelial cells per LPF
C. < 25 neutrophils and > 10 squamous epithelial cells per LPF
D. > 25 neutrophils and < 10 squamous epithelial cells per HPF
 DIAGNOSTICS
• Sputum GS/CS
• Main purpose of Gram’s stain is to ensure that a sample is suitable for culture
• Sputum sample must have > 25 neutrophils and < 10 squamous epithelial cells per
LPF to be adequate for culture
• Yield of positive cultures from sputum samples is ≤50%
• ATS guideline 2019: Sputum GS/CS is recommended for patients with/who are
o Severe CAP, especially if intubated
o Being empirically treated for MRSA or P. aeruginosa
o Previously infected with MRSA or P. aeruginosa
o Hospitalized and received IV antibiotics in the last 90 days
 DIAGNOSTICS
• Blood CS
• Only 5-14% of cultures of blood from patients hospitalized with CAP are positive
• Most frequently isolated pathogen: S. pneumoniae
• Indications for blood CS:
• Harrisons: neutropenia, asplenia, complement deficiencies, chronic liver disease, severe
CAP
• ATS guideline 2019: Blood CS is recommended for patients with/who are
o Severe CAP, especially if intubated
o Being empirically treated for MRSA or P. aeruginosa
o Previously infected with MRSA or P. aeruginosa
o Hospitalized and received IV antibiotics in the last 90 days
 DIAGNOSTICS
• Procalcitonin
• Procalcitonin levels of <0.1 mg/L indicate a high likelihood of viral infection, whereas
levels >0.25 mg/L indicate a high likelihood of bacterial pneumonia
• ATS 2019 guideline: Empiric antibiotic therapy should be initiated in adults with
clinically suspected and radiographically confirmed CAP regardless of initial serum
procalcitonin level
 RISK STRATIFICATION
ATS guideline for severe CAP CPG 2016 for severe CAP
(1 major, ≥3 minor) (Moderate CAP plus any of the ff)
Minor criteria Moderate CAP
Respiratory rate ≥ 30 breaths/min Respiratory rate ≥ 30 breaths/min
PaO2/FiO2 ratio ≤ 250 Pulse rate ≥ 125bpm
Multilobar infiltrates Temp ≤ 36 or ≥40 C
Confusion/ disorientation SBP ≤ 90mmHg, DBP ≤ 60mmHg
BUN ≥ 20mg/dL Altered mental state of acute onset
Leukopenia< 4000 cells/μl Suspected aspiration
Thrombocytopenia < 100,000/μl Unstable/ decompensated comorbid: DM, cancer,
Hypothermia <36C neurologic disease in evolution, CHF II-IV, unstable
CAD, renal failure on dialysis, uncompensated COPD,
Hypotension requiring aggressive fluid resuscitation decompensated liver disease
Major criteria Plus
Septic shock requiring vasopressors Severe sepsis and septic shock
Respiratory failure requiring mechanical ventilation Need for mechanical ventilation
 QUESTION
• Treatment
A 35-year-old man with no clinically relevant medical history came in the ER for a 3- day history
of productive cough and fever.
He was dyspneic tachypneic and was intubated, what will you start as empiric antibiotics?
A. Ceftriaxone 2 gm OD + Azithromycin dihydrate 500 mg OD IV
B. Piperacillin Tazobactam 4.5 grams q6 + Levofloxacin 750mg OD IV
C. Meropenem 1 gm q8h + Azithromycin dihydrate 500 mg OD IV + Amikacin 15 mg/kg OD
D. Cefepime 2 gms q8-12h + Ciprofloxacin 400 mg q8-12h IV + Linezolid 600 mg q12h IV
 QUESTION
• Treatment
A 35-year-old man with no clinically relevant medical history came in the ER for a 3- day history
of productive cough and fever.
He was dyspneic tachypneic and was intubated, what will you start as empiric antibiotics?
A. Ceftriaxone 2 gm OD + Azithromycin dihydrate 500 mg OD IV
B. Piperacillin Tazobactam 4.5 grams q6 + Levofloxacin 750mg OD IV
C. Meropenem 1 gm q8h + Azithromycin dihydrate 500 mg OD IV + Amikacin 15 mg/kg OD
D. Cefepime 2 gms q8-12h + Ciprofloxacin 400 mg q8-12h IV + Linezolid 600 mg q12h IV
 TREATMENT
ATS guideline 2019 CPG 2016
Low Risk
No comorbidities Amoxicillin 1 g TID Amoxicillin 1g TID
OR Doxycycline 100 mg BID OR Azithromycin 500mg OD, Clarithromycin 500mg
OR Macrolide BID
With co-morbidities Co-amoxiclav/cephalosporin AND macrolide/doxycycline Co-amoxiclav 1g BID
OR Respiratory fluoroquinolone OR Cefuroxime 500mg BID
• Levofloxacin 750mg OD, moxifloxacin 400mg OD ± macrolide
Moderate Risk
β-lactam + macrolide IV antipseudomonal β-lactam
• Ampicillin-sulbactam 1.5g IV q6 • Ampicillin-sulbactam 1.5g IV q6
• Ceftriaxone 2g IV OD/ cefotaxime 1-2g IV q8h • Cefuroxime 1.5g IV q8/ ceftriaxone 2g IV OD
OR Respiratory quinolone AND Oral macrolide OR respiratory quinolone
High Risk/ Severe
*β-lactam + macrolide *β-lactam + macrolide
OR β-lactam + fluoroquinolone β-lactam + fluoroquinolone
P. aeruginosa coverage *Piperacillin-tazobactam/ cefepime/ ceftazidime 2g q8/ *Piperacillin-tazobactam 4.5 q6/ cefepime 2g q8/
imipenem 500mg q6/ meropenem/aztreonam meropenem 1g q8 + macrolide + aminoglycoside
MRSA coverage vancomycin 15 mg/kg q12 or linezolid 600mg q12 Vancomycin/ Linezolid/ Clindamycin
SIMPLIFIED DIAGRAM OF ANTIBIOTIC COVERAGE
 QUESTION
• Treatment
A 35-year-old man with no clinically relevant medical history came in the ER for a 3- day history
of productive cough and fever.
He was dyspneic tachypneic and was intubated, what will you start as empiric antibiotics?
A. Ceftriaxone 2 gm OD + Azithromycin dihydrate 500 mg OD IV
B. Piperacillin Tazobactam 4.5 grams q6 + Levofloxacin 750mg OD IV
C. Meropenem 1 gm q8h + Azithromycin dihydrate 500 mg OD IV + Amikacin 15 mg/kg OD
D. Cefepime 2 gms q8-12h + Ciprofloxacin 400 mg q8-12h IV + Linezolid 600 mg q12h IV
 CASE # 1
• 75 year old female known hypertensive, diabetic, coming in for cough. History started 4 days
prior when Patient had nonproductive cough, along with easy fatigability and pleuritic chest
pain. 3 days prior, noted undocumented fever. Sought consult, CXR done outside showed
streaky and hazy densities in RLL. Patient was then advised admission but opted transfer in
our institution
• ROS: (-) headache, chest pain, PND, orthopnea, abdominal pain
• PMHx: (+) HTN>20 years, UBP 120/80 HBP 140 on Amlodipine 5mg OD, Losartan 50mg OD
(+) DM > 20 years SMBG 120-130 on Minidiab 10mg BID and Janumet 50/500mg BID
(+) arterial insufficiency on cilostazol 50mg OD
s/p appendectomy (2016)
• FHx: (+) DM (-) HTN, stroke, cancer
• PSHx: nonsmoker, nondrinker of alcoholic beverages
 ADMITTING ORDERS
Admit to REGULAR room
Monitor vital signs every 4 hours, I and O every shift, CBG 3x/day premeals
Diet: Diabetic diet 1600kcal 60g protein divided into 3 meals, 2 snacks; no simple sugars
IVF: PNSS 40cc/hr
Diagnostics: CBC, CXR, Crea, BUN, Na, K, Mg, urinalysis
Therapeutics:
1. Ceftriaxone 2g IV OD
2. Azithromycin 500mg PO OD
3. Amlodipine 5mg OD
4. Losartan 50mg OD
5. Kalium durule 1 tab TID x 6 doses
6. Magnesium oxide 250mg 1 tab TID x 6 doses
7. Hold OHAS for now
8. Start Apidra sliding scale