HACK.these are a few of my favourite respiratory infections
Brendan MunnEmergency Residents’ Academic DayAugust 13 2009
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Objectives
1. review common respiratory infections
2. myths and just enough EBM
3. provide an approach to the above
4. discuss some cases
5. minimize powerpoint
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Respiratory Tract Infections
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Respiratory Tract Infections
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Approach
1. is this pneumonia?
2. what tests should i order?
3. is this pneumonia special?
4. what f*ing antibiotic(s?) should i start?
5. should this patient be admitted?
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case 1
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HPI : 64F with cough, fever x 1 week
O/E : febrile, RR 32
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“Does this patient have Community Acquired Pneumonia? Diagnosing Pneumonia by History and Physical Examination”
Metlay JP, Kapoor WN, Fine MJ.
JAMA. 1997 Nov 5;278(17):1440-5.
NO specific symptoms for dx pneumonia
NO fever, tachypnea, tachycardia is Sn
Special Populations
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Special Populations
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CAP
VAP
HAP
HCAP
HIV
TB
ASPIRATION
AECOPD
case 2
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HPI : 64F with cough, fever x 1 week
O/E : febrile, RR 32, LLL crackles
PMHx : nil
Sputum Cultures - Evidence
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only 20% yield
no correlation C&S with gram or with BC
misses atypicals
nosocomial risk
does not change antibiotics or outcome
ATS07 guidelines : for all “complicated”Roson B, Clin Infect Dis
2000
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Disposition - Evidence
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(1) Pneumonia Severity Index (PSI)
online calculators available
limitations - 20 factors, CAP
Fine, MJ. NEJM, 1997 Jan
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curb 65
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C Confusion
U Uremia >7mmol/L
R Respiratory Rate > 30
B BP > 90 (S) or >60 (D)
65 Age >65
Lim, WS. Thorax, 2003 May
case 3
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HPI : 64F with L THA
O/E : febrile, RR 32, LLL crackles
Blood Cultures - Evidence
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<10% yield in CAP
50% false positive in ED
only 2% positive once antibiotics
limited data for inpatient if immune N
ATS07 guidelines : for all “complicated”
Corbo J, BMJ 2004
case 4
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HPI : 64F diabetic receiving daily foot
wound care at home with cough,
fever x1 week
O/E : febrile, RR 32, LLL crackles
HCAP RF
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hospitalization >2d in preceding 90 days
long-term care facilit resident
home infusion or wound care therapy
chronic dialysis
family member with drug resistant bug
MDR RF
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Antibiotics within the preceding 90 days
Current hospitalization of ≥ 5 days
High frequency of antibiotic resistance in the community or in the specific hospital unit
Immunosuppressive disease and/or therapy
Presence of risk factors for HCAP
case 5
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HPI : 28M with cough x 6 weeks,
worsening SOB
O/E : febrile, RR 32
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case 7
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HPI : 64F alcoholic w cough, fever
x 1 week
O/E : febrile, RR 32, RLL opacity
case 8
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Review1. is this pneumonia?
hx/phys poor, gestalt and a monkey, CXR
2. what tests should i order?good empiric abx > sputum and blood cx
3. is this pneumonia special?know your categories and risk factors
if VAP/HCAP/HAP evaluate MDR risk
always consider HIV, TB
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Review
4. what f*ing antibiotic(s?) should i start?empiric coverage of common organisms
5. should this patient be admitted?use the PSI
or at worst use CURB65 and feces
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References1. Tintinalli
2. Up To Date
3. EMRAP
4. ATS CAP and HAP Guidelines 2007