Respiratory InfectionsRespiratory Infections

Caroline KowalCaroline KowalPreceptor: Dr. Rhonda NessPreceptor: Dr. Rhonda Ness

Core Rounds Core Rounds Dec 11, 2003Dec 11, 2003

ObjectivesObjectives

Alberta Clinical Practice GuidelinesAlberta Clinical Practice Guidelines Community Acquired Pneumonia Community Acquired Pneumonia

Adult/ChildAdult/Child Nursing home acquired PneumoniaNursing home acquired Pneumonia

ImmunocompromisedImmunocompromised AlcoholicsAlcoholics

Guidelines not prospectively Guidelines not prospectively validatedvalidated

Prior studies of pneumonia guidelines Prior studies of pneumonia guidelines have reported:have reported: decreased lengths of stay, admission decreased lengths of stay, admission

rates, and costsrates, and costs no change in clinical outcomes.no change in clinical outcomes.

DefinitionsDefinitions

Community Acquired Pneumonia Community Acquired Pneumonia (CAP)(CAP) – –

Pneumonia in pt not hospitalized last Pneumonia in pt not hospitalized last 14d, OR hospitalized <4d prior to 14d, OR hospitalized <4d prior to onset sxonset sx

Adult - >16 y ageAdult - >16 y age

Community Acquired Community Acquired PneumoniaPneumonia

AdultsAdultsIncidence:Incidence: #1 cause of infectious related deaths#1 cause of infectious related deaths #6 cause of death overall#6 cause of death overall 12/1000 adults (US stats)12/1000 adults (US stats) 80% outpt tx80% outpt tx Mortality <1% for outpt, 14% for Mortality <1% for outpt, 14% for

admitted admitted 50% pneumonia cases and 90% 50% pneumonia cases and 90%

mortality in pt >65 years agemortality in pt >65 years age

2-27% (50% APG) CAP is S.pneumoniae2-27% (50% APG) CAP is S.pneumoniae Risk factors for resistant S.pneumo:Risk factors for resistant S.pneumo:

Beta-lactam/quinolone i.e.cipro/macrolide use in last 3 Beta-lactam/quinolone i.e.cipro/macrolide use in last 3 monthsmonths

EToHEToH >65 y.o.>65 y.o. ImmunosupressedImmunosupressed Exposure to children in childcare facilityExposure to children in childcare facility Resident of long term care facilityResident of long term care facility

Worry if it is a highly resistant S.pneumo (invasive) Worry if it is a highly resistant S.pneumo (invasive) 7% or 27% pt 7% or 27% pt

Outpt DO NOT need antimircobial activity against Outpt DO NOT need antimircobial activity against highly resistant S.pneumo. Use macrolides or B highly resistant S.pneumo. Use macrolides or B lactam monotxlactam monotx

Mycoplasma pneumonia 20% CAP (esp Mycoplasma pneumonia 20% CAP (esp younger)younger)

Chlamydia pneumoniae 10% CAP and Chlamydia pneumoniae 10% CAP and may be co-pathogen in elderlymay be co-pathogen in elderly

Influenza A and B, parainfluenza, Influenza A and B, parainfluenza, adenovirus in 2-15% CAPadenovirus in 2-15% CAP

20% cases TB in residents of long term 20% cases TB in residents of long term care facilities (20-30X increased risk TB)care facilities (20-30X increased risk TB)

PresentationPresentation

In elderly, may not have classic S&S, In elderly, may not have classic S&S, may be afebrile. May present with may be afebrile. May present with delerium/confusion (44.5% delerium/confusion (44.5% pneumonia pt)pneumonia pt)

RR> 25 has sensitivity 90% and RR> 25 has sensitivity 90% and specificity of 95% for dx pneumoniaspecificity of 95% for dx pneumonia

Single temp 38.3 C has sens 40% Single temp 38.3 C has sens 40% (37.8C has sens 70%)(37.8C has sens 70%)

InvestigationsInvestigations

Blood culture only if pt has hx of Blood culture only if pt has hx of chills/rigorschills/rigors Blood culture within 24h presentation associated Blood culture within 24h presentation associated

with a decreased 30d mortality in CAPwith a decreased 30d mortality in CAP(Meehan, TP, et al. Quality of care, process, and outcomes in (Meehan, TP, et al. Quality of care, process, and outcomes in

elderly patients with pneumonia elderly patients with pneumonia JAMA JAMA 1997;278:2080-2084)1997;278:2080-2084)

Do 3 sets:Do 3 sets: 1aerobic/1 anaerobic1aerobic/1 anaerobic 1 aerobic from 21 aerobic from 2ndnd site at same time site at same time

Blood culture evidence?Blood culture evidence?

Mortality rate from bacteremic Mortality rate from bacteremic pneumococcal CAP has shown little pneumococcal CAP has shown little improvement in the past three improvement in the past three decades, remaining between 19% decades, remaining between 19% and 28%, (depending on the and 28%, (depending on the population and institution studied)population and institution studied)

Helpful in 15% ptHelpful in 15% pt

Blood gasesBlood gases

SaO2 <90% or pt has COPD take SaO2 <90% or pt has COPD take ABG on room air or baseline 02 level ABG on room air or baseline 02 level if on chronic O2 therapyif on chronic O2 therapy

Thoracentesis if effusion >10mm on Thoracentesis if effusion >10mm on lateral XRlateral XR

Recurrent pneumonia – need w/u for Recurrent pneumonia – need w/u for immunosupression or structural abNimmunosupression or structural abN

Gram stainGram stain

Adequate if < 25 epithelial cells per low-Adequate if < 25 epithelial cells per low-powered fieldpowered field

>10 gram-positive, lancet-shape >10 gram-positive, lancet-shape diplococci in a hpf is a sensitive and diplococci in a hpf is a sensitive and specific predictor of pneumococcal specific predictor of pneumococcal pneumoniapneumonia

Gram stain not helpful for other types Gram stain not helpful for other types pneumoniapneumonia

NPV 80%NPV 80%

Fine et al. Prediction Rule to identify Fine et al. Prediction Rule to identify low risk pt with CAP. NEJM low risk pt with CAP. NEJM

1997;336:2431997;336:243 14, 199 adult in pt with CAP14, 199 adult in pt with CAP 5 classes of risk of death in 30d5 classes of risk of death in 30d Validated with 38.039 in ptValidated with 38.039 in pt

PORT cohort 2287 in and outptPORT cohort 2287 in and outpt Detemined 20 factors independently related to Detemined 20 factors independently related to

mortality in an additive fashionmortality in an additive fashion Limits:Limits:

Medical/psychosocial C/IMedical/psychosocial C/I ImmunosuppressedImmunosuppressed May oversimplify, clinical judgement NBMay oversimplify, clinical judgement NB No SaO2 in class INo SaO2 in class I

PORT ScorePORT Score

Risk classes 1 (lowest) to 5 (highest)Risk classes 1 (lowest) to 5 (highest) Class 1 -2 younger pt (35 – 59y)Class 1 -2 younger pt (35 – 59y) Class 3 -5 older pt (72- 79y)Class 3 -5 older pt (72- 79y) Based also on comorbidities, abnormal Based also on comorbidities, abnormal

physical findings, lab valuesphysical findings, lab values Outpt mx for class 1 and 2Outpt mx for class 1 and 2 Brief in pt observation class 3Brief in pt observation class 3 Admission class 4 and 5Admission class 4 and 5

Who to admit?Who to admit?

PORT scorePORT score Hypotension (SBP Hypotension (SBP

< 90, DBP < 60)< 90, DBP < 60) Tachypnea Tachypnea Low satsLow sats Elevated BUN Elevated BUN

(>20) or Cr > 120(>20) or Cr > 120 Altered LOCAltered LOC

WBC <4 or >30WBC <4 or >30 ANC <1ANC <1 Elevated PT or Elevated PT or

PTTPTT Low pltsLow plts Multilobar Multilobar

involvementinvolvement CavitationCavitation Rapid spreadingRapid spreading

Who goes to ICU?Who goes to ICU?American Thoracic Society GuidelinesAmerican Thoracic Society Guidelines

RR > 30RR > 30 Severe Respiratory Failure (PaO2/FiO2 Severe Respiratory Failure (PaO2/FiO2

<250)<250) VentilatedVentilated Bilateral infiltrates or multilobarBilateral infiltrates or multilobar ShockShock VasopressorsVasopressors Oliguria (<20cc/h)Oliguria (<20cc/h) Presence of one factor 98% sens, 32% Presence of one factor 98% sens, 32%

specificspecific

Management CAPManagement CAP

HydrationHydration Wt loss >5-10% associated w increased Wt loss >5-10% associated w increased

mortalitymortality Abx to cover S.pneumo, M.pneumo, C.pneumoAbx to cover S.pneumo, M.pneumo, C.pneumo

11stst choice macrolide or doxycycline choice macrolide or doxycycline Macrolide resistance for S.pneumo ~10% and Macrolide resistance for S.pneumo ~10% and

may have suboptimal coverage for H. may have suboptimal coverage for H. influenzae . . . Avoid in pt with chills/rigorsinfluenzae . . . Avoid in pt with chills/rigors

Floroquinolones – use for failed first line tx or Floroquinolones – use for failed first line tx or for elderly with significant comorbidityfor elderly with significant comorbidity

BIPAP (Dean et al. Chest 2000)BIPAP (Dean et al. Chest 2000)

Which antibiotics and why?Which antibiotics and why? To“Risk stratify” and “Drug stratify”To“Risk stratify” and “Drug stratify”

Increasing evidence that Increasing evidence that pneumococcus needs double coveragepneumococcus needs double coverage

BASICS TO COVER FOR ALL CAP:BASICS TO COVER FOR ALL CAP: S.pneumo, H.flu, M.catarrhalisS.pneumo, H.flu, M.catarrhalis are are

principal bugs (B LACTAM)principal bugs (B LACTAM) Atypicals include Atypicals include Mycoplasma, Mycoplasma,

Legionella, Legionella, and and C. pneumoniae C. pneumoniae (MACROLIDE)(MACROLIDE)

Inpatient MxInpatient Mx

Cephalosporin iv (i.e., ceftriaxone, Cephalosporin iv (i.e., ceftriaxone, cefotaxime, etc.) with significant cefotaxime, etc.) with significant activity againstactivity against S. pneumoniaeS. pneumoniae, , H. H. influenzaeinfluenzae, and , and M. catarrhalisM. catarrhalis PLUS PLUS

Macrolide iv to provide activity Macrolide iv to provide activity against atypical organismsagainst atypical organisms

Cipro Cipro NOT for CAPNOT for CAP

Inadequate coverage S.pneumoInadequate coverage S.pneumo Hydrophilic molecule as opposed to hydophobic molecules Hydrophilic molecule as opposed to hydophobic molecules

of other quinolonesof other quinolones Activates efflux pumps which may be initial step in quinolone Activates efflux pumps which may be initial step in quinolone

resistanceresistance Chen et al found that the prevalence of ciprofloxacin-resistant Chen et al found that the prevalence of ciprofloxacin-resistant

pneumococci (MIC ≥ 4 mcg/mL) increased from 0% in 1993 to pneumococci (MIC ≥ 4 mcg/mL) increased from 0% in 1993 to 3.7% in 19983.7% in 1998

Combination of reduced susceptibility and increased Combination of reduced susceptibility and increased resistance!resistance!

Floroquinolones (levo) monotx in critically ill has not been Floroquinolones (levo) monotx in critically ill has not been established (but likely would work as covers gm +, gm - , established (but likely would work as covers gm +, gm - , atypicals and some anaerobes)atypicals and some anaerobes)

Chen D, McGeer A, de Azavedo JC, et al and The Canadian Bacterial SurveillanceNetwork. Decreased susceptibility of Streptococcus pneumoniae tofluoroquinolones in Canada. N Engl J Med 1999;341:233-239.

When to use “Vitamin L”When to use “Vitamin L”

Floroquinolones (levofloxacin, Floroquinolones (levofloxacin, gatifloxacin, moxifloxacin)gatifloxacin, moxifloxacin)

Reserved for selected pts with: Reserved for selected pts with: (CDC-(CDC-DRSPWG)DRSPWG)

Inpt who failed ceftriaxone + macrolideInpt who failed ceftriaxone + macrolide Allergic 1Allergic 1stst line agents line agents DocumentedDocumented infection with highly infection with highly

resistant S.Pneumo (penicillin MIC 4 resistant S.Pneumo (penicillin MIC 4 mcg/ml)mcg/ml)

Abx coverageAbx coverage

11stst gen cephalosporins – gm (+) gen cephalosporins – gm (+) 22ndnd gen cephalosporing - Cefoxitin, cefotetan, and gen cephalosporing - Cefoxitin, cefotetan, and

cefmetazole, provide coverage against cefmetazole, provide coverage against BacteroidesBacteroides 33rdrd gen cephalosporins – more gm (–) rod coverage gen cephalosporins – more gm (–) rod coverage

Ceftazidime for Ceftazidime for Pseudomonas Pseudomonas Imipenem has broad coverage against aerobic and Imipenem has broad coverage against aerobic and

anaerobic organisms.anaerobic organisms. Aztreonam good for gm (-) bacilli such asAztreonam good for gm (-) bacilli such as

PseudomonasPseudomonas Clindamycin, Metronidazole - anaerobes, e.g. Clindamycin, Metronidazole - anaerobes, e.g. B. B.

fragilisfragilis..

S.Pneumo Resistance S.Pneumo Resistance Capital Health RegionCapital Health Region

Penicillin Penicillin 15.8%15.8% Amoxicillin Amoxicillin 4.7%4.7% Cefuroxime Cefuroxime 9.8%9.8% Cefotaxime/ceftriaxone Cefotaxime/ceftriaxone 3.9% 3.9% Macrolide Macrolide 13%13% TMP-SMX TMP-SMX 21%21% Levofloxacin Levofloxacin <1%<1% Vancomycin Vancomycin 0%0%

S.Pneumo % Sensitivity Antibiotogram S.Pneumo % Sensitivity Antibiotogram CalgaryCalgary

Community vs Nursing Home vs PLC vs FMCCommunity vs Nursing Home vs PLC vs FMC vs RVGvs RVG

Penicillin 87%, 100%, 73%, 95%, 85%Penicillin 87%, 100%, 73%, 95%, 85% Amoxil 100%,100%,100%,100%,100%Amoxil 100%,100%,100%,100%,100% Ceftiaxone Ceftiaxone 100%,100%,100%,100%,94%100%,100%,100%,100%,94% Erythro 60%, 100%, 60%, 84%, 66% Erythro 60%, 100%, 60%, 84%, 66% SXT 60%, 100%, 60%, 75%, 51% SXT 60%, 100%, 60%, 75%, 51%

July 1, 2001 – June 30, 2002

S. pneumoniae S. pneumoniae with penicillinwith penicillin resistanceresistance also has resistance to also has resistance to (all on same gene):(all on same gene): MacrolidesMacrolides AugementinAugementin TMP-SMXTMP-SMX 22ndnd and 3 and 3rdrd generation cephalosporins generation cephalosporins No resistance to vancomycin or No resistance to vancomycin or

quinolonesquinolones Various levels of resistance (minimal with Various levels of resistance (minimal with

cephalosporins, may be intermediate with cephalosporins, may be intermediate with macrolides)macrolides)

BUT . . . Greatest growth in resistance is to BUT . . . Greatest growth in resistance is to floroquinolonesfloroquinolones Greatest risk for emergent resistance during tx Greatest risk for emergent resistance during tx

and resultant tx failures so also has largest and resultant tx failures so also has largest increased tx duration because of resistance and increased tx duration because of resistance and big decrease clinical response to emerging big decrease clinical response to emerging infectionsinfections

Risk factors for resistance to floroquinolones:Risk factors for resistance to floroquinolones: >64y.o>64y.o COPDCOPD Past fluoroquinolone usePast fluoroquinolone use

Is Resistant S.pneumo clincially Is Resistant S.pneumo clincially significant?significant?

Tx failures reported with AOM and meningitisTx failures reported with AOM and meningitis Relationship with resistance and pneumococcal pneumonia unclearRelationship with resistance and pneumococcal pneumonia unclear

*Ceftriaxone (1 g/day iv) or cefotaxime (1.5-2 g/8 h iv) work well in *Ceftriaxone (1 g/day iv) or cefotaxime (1.5-2 g/8 h iv) work well in adult patients with systemic nonmeningeal pneumococcal infections adult patients with systemic nonmeningeal pneumococcal infections caused by strains with ceftriaxone/cefotaxime MIC up to 1 mcg/mL (or caused by strains with ceftriaxone/cefotaxime MIC up to 1 mcg/mL (or even 2mcg/ml)even 2mcg/ml)

429 episodes CAP 429 episodes CAP correlated the ceftriaxone/cefotaxime MICs and correlated the ceftriaxone/cefotaxime MICs and antibiotic therapy with 30 d mortality rateantibiotic therapy with 30 d mortality rate

In 185 episodes treated with 1 g/d of ceftriaxone (n = 171) or 1.5-2 In 185 episodes treated with 1 g/d of ceftriaxone (n = 171) or 1.5-2 g/8 h of cefotaxime (n = 14)g/8 h of cefotaxime (n = 14)

18% (26/148) sensitive strain mortality rate18% (26/148) sensitive strain mortality rate 13% (3/24) intermediate resistant strain mortatlity rate13% (3/24) intermediate resistant strain mortatlity rate 15% (2/13) resistant strain mortality rate15% (2/13) resistant strain mortality rate respectively (P = 0.81)respectively (P = 0.81)

* Pallares R, Capdevila O, Liñares J, et al. Hospital Bellvitge, University of Barcelona, Spain; Clinical Relevance of Current NCCLS Ceftriaxone/Cefotaxime Resistance Breakpoints in non-Meningeal Pneumococcal Infections. Abstract

Poster, 2001.

Elderly and CAPElderly and CAP

Susceptible gm (-) enteric organisms Susceptible gm (-) enteric organisms such as:such as: KlebsiellaKlebsiella Escherichia coliEscherichia coli PseudomonasPseudomonas

Increased risk infection with DRSPIncreased risk infection with DRSP Need macrolide + cephalosporin or Need macrolide + cephalosporin or

fluoroquinolonefluoroquinolone

Risk Factors for DRSP or Risk Factors for DRSP or atypical pathogens in the atypical pathogens in the

ElderlyElderly1) Increasing fragility (> 85 years of age, comorbid conditions, 1) Increasing fragility (> 85 years of age, comorbid conditions,

previous infection, etc.) of the patientprevious infection, etc.) of the patient2) Acquisition of the pneumonia in a skilled nursing facility2) Acquisition of the pneumonia in a skilled nursing facility3) Presence of an aspiration pneumonia, suggesting gram (-) or 3) Presence of an aspiration pneumonia, suggesting gram (-) or

anaerobics anaerobics 4) Chronic alcoholism (4) Chronic alcoholism (Klebsiella pneumoniae)Klebsiella pneumoniae)5) Pneumococcal pneumonia in pt with comorbidities and no 5) Pneumococcal pneumonia in pt with comorbidities and no

Pneumovax vaccinePneumovax vaccine6) Hx of infection with gram (-), anaerobic, or resistant6) Hx of infection with gram (-), anaerobic, or resistant species of species of S. pneumoniaeS. pneumoniae7) Hx of treatment failure7) Hx of treatment failure8) Previous hospitalizations for pneumonia8) Previous hospitalizations for pneumonia9) Previous ICU hospitalization for pneumonia9) Previous ICU hospitalization for pneumonia10) Caught pneumonia in area with known DRSP10) Caught pneumonia in area with known DRSP11) Immunodeficiency and/or severe underlying disease.11) Immunodeficiency and/or severe underlying disease.

Admission CriteriaAdmission Criteria

Pneumonia Severity of Illness scorePneumonia Severity of Illness score Give abx within 8 hours of arrival to Give abx within 8 hours of arrival to

hospital (decreases mortality)hospital (decreases mortality)

Poor Outcome Risk FactorsPoor Outcome Risk Factors

RR > 30RR > 30 SBP <90, DBP <60SBP <90, DBP <60 ARFARF Malnourished or >5% wt loss in past Malnourished or >5% wt loss in past

monthmonth Functional impairmentFunctional impairment Age/comorbid conditionsAge/comorbid conditions

..

Numerous studies showing that Numerous studies showing that pneumonia guidelines can reduce pneumonia guidelines can reduce mortality and reduce unnecessary mortality and reduce unnecessary use of resourcesuse of resources

Case AJ: 11yo maleCase AJ: 11yo male

N/V/D x 1 dayN/V/D x 1 day 6x vomitting, 2x diarrhea6x vomitting, 2x diarrhea Periumbilical abdo painPeriumbilical abdo pain ““Dizzy”Dizzy” Rhinitis, coughRhinitis, cough 38C, HR 117, RR 28, 105/75, 96% RA38C, HR 117, RR 28, 105/75, 96% RA

AJ’s ExamAJ’s Exam

PalePale Small cervical nodesSmall cervical nodes Abdo exam nontenderAbdo exam nontender No indrawingNo indrawing Decreased breath sounds RLL, Decreased breath sounds RLL,

cracklescrackles

Pediatric CAPPediatric CAP

Bronchopneumonia – acute inflammation Bronchopneumonia – acute inflammation smaller bronchial tubes and smaller bronchial tubes and peribronchiolar alveoliperibronchiolar alveoli

Pneumonitis Syndrome – Infants 1 – 3 Pneumonitis Syndrome – Infants 1 – 3 months old, afebrile with cough, tachypnea months old, afebrile with cough, tachypnea and progressive respiratory distress. and progressive respiratory distress. CXR shows diffuse pulmonary infiltrates and air CXR shows diffuse pulmonary infiltrates and air

trappingtrapping Single or mutlipathogens involvedSingle or mutlipathogens involved

IncidenceIncidence

35-45/1000 kids <5 y.o.35-45/1000 kids <5 y.o. 16-20/1000 in 5 - 9 y.o.16-20/1000 in 5 - 9 y.o. 6-12/1000 >9 y.o.6-12/1000 >9 y.o.

No specific cause of pneumonia No specific cause of pneumonia identified in 40-60% casesidentified in 40-60% cases

Age best predictor for the Age best predictor for the offending BUGoffending BUG

As we all know, VIRUSES #1 age As we all know, VIRUSES #1 age 1month to 2 years1month to 2 years

RSV 50%RSV 50% Parainfluenza 25% Parainfluenza 25% Small number influenza A, B and Small number influenza A, B and

adenovirusadenovirus

Neonatal PeriodNeonatal Period GBSGBS ListeriaListeria E.coliE.coli

Infants 1 – 3 monthsInfants 1 – 3 months Usu have pneumonitis Usu have pneumonitis

syndromesyndrome Chlamydia trachomatisChlamydia trachomatis Bordetella pertussisBordetella pertussis RSVRSV

3 months – 2 years3 months – 2 years Usu viralUsu viral S.pneumoS.pneumo Non typable H.fluNon typable H.flu M.catarrhalisM.catarrhalis Mycoplasma pneumoniaMycoplasma pneumonia C.pneumonia C.pneumonia Increasing incidence Increasing incidence

C.Pneumonia (1-15%)C.Pneumonia (1-15%)

**Hib vacccine offers no protection against NTHI**

2-5 yr2-5 yr ViralViral S.pneumoS.pneumo H.flu (Hib)H.flu (Hib) Nontypable H.fluNontypable H.flu M.pneumoniaeM.pneumoniae C.pneumoniaeC.pneumoniae

6-18 yr6-18 yr M.pneumoniaeM.pneumoniae S.pneumoS.pneumo C.pneumoC.pneumo NTHINTHI Influenza A and BInfluenza A and B AdenovirusAdenovirus

Bugs that get you into the Bugs that get you into the ICUICU

All ages:All ages: S.pneumoS.pneumo StaphStaph GASGAS HibHib M.pneumoniaeM.pneumoniae AdenovirusAdenovirus RSVRSV

C & M pneumoniaeC & M pneumoniae

C.pneumo 15-18% PCAP aged 3-12C.pneumo 15-18% PCAP aged 3-12 Most asxMost asx Only 10% cases result in clinically Only 10% cases result in clinically

apparent pneumoniaapparent pneumonia Fever, malaise, headache, pharyngitisFever, malaise, headache, pharyngitis Some authors state wheezing more Some authors state wheezing more

common with viral and C & M pneumoniaecommon with viral and C & M pneumoniae ? Increased incidence conjunctivitis? Increased incidence conjunctivitis

Risk FactorsRisk Factors

Recent URTIRecent URTI Exposure to cigarette smokeExposure to cigarette smoke DaycareDaycare Prematurity (up to 1 year)Prematurity (up to 1 year) MalnutritionMalnutrition Recent hospitalization (last 3 months)Recent hospitalization (last 3 months) Immunocompromised, cardiopulm or neurologic Immunocompromised, cardiopulm or neurologic

disordersdisorders Low socioeconomic statusLow socioeconomic status Cystic fibrosisCystic fibrosis

2 classic presentations2 classic presentations

TypicalTypical: fever, chills, pleuritic chest : fever, chills, pleuritic chest pain, productive coughpain, productive cough

AtypicalAtypical: gradual onset over days to : gradual onset over days to weeks, domination of sx of h/a and weeks, domination of sx of h/a and malaise, nonproductive cough, low malaise, nonproductive cough, low grade fevergrade fever

Fever, rigors, pleuritic chest/abdominal Fever, rigors, pleuritic chest/abdominal pain suggest pneumococcal pneumoniapain suggest pneumococcal pneumonia

Temp >38.5CTemp >38.5C RR >50/min in <11 monthsRR >50/min in <11 months RR >40/min in >11 monthsRR >40/min in >11 months RR >28 in 5 -16 yearsRR >28 in 5 -16 years

What makes you suspicious of What makes you suspicious of pneumonia vs the good ol’ pneumonia vs the good ol’

virus?virus? Absence of sx cluster of: Absence of sx cluster of:

Resp distressResp distress TachypneaTachypnea CracklesCrackles Decreased breath sounds excludes Decreased breath sounds excludes

pneumonia pneumonia 100% specificity (level II)100% specificity (level II)

Based on Lethenthal’s paper: 133 pt aged 3 mo – 15y

(26+ pneumonia)

Sn and Sp of Sx to IC PCAPSn and Sp of Sx to IC PCAPLeventhal. Clinical predictors of pneumonia as a guide to ordering Leventhal. Clinical predictors of pneumonia as a guide to ordering

chest roetgenograms. Clin Pediatr 1982; 21:730-734.chest roetgenograms. Clin Pediatr 1982; 21:730-734.

Symptom Symptom TachypneaTachypnea CoughCough ToxicToxic CracklesCrackles RetractionsRetractions FlaringFlaring PallorPallor GruntingGrunting

Sn SpSn Sp 92%92% 15% 15% 92%92% 19% 19% 81%81% 60% 60% 44% 80%44% 80% 35% 82%35% 82% 35% 35% 82%82% 35% 35% 87%87% 19% 19% 94%94%

Findings most sens for predicting infiltrates – tachypnea, cough, toxic look

Findings most spec for + infiltrate – flaring, pallor, grunting

CXR SummaryCXR Summary

In combination with physical exam, In combination with physical exam, do a CXR when:do a CXR when: Questionable dxQuestionable dx Admitting ptAdmitting pt <3y with fever >39C and WBC >15<3y with fever >39C and WBC >15 Complicated pneumonia suspectedComplicated pneumonia suspected

Investigations Pediatric CAPInvestigations Pediatric CAP

CXR gold standard for all pneumoniasCXR gold standard for all pneumonias CBC, diff, blood culturesCBC, diff, blood cultures

Usu WBC consists of polymorphsUsu WBC consists of polymorphs Can get leukocytosis with adeno, influenze or Can get leukocytosis with adeno, influenze or

MycoplasmaMycoplasma Viral infections can cause leukopenia OR it is a sign of Viral infections can cause leukopenia OR it is a sign of

overwhelming bacterial infectionoverwhelming bacterial infection Gram stain/culture if older childGram stain/culture if older child >2 y.o. consider Mycoplasma IgM ELISA(cold >2 y.o. consider Mycoplasma IgM ELISA(cold

agglutinins are of no help)agglutinins are of no help) RSV testing not routinely recommendedRSV testing not routinely recommended

Testing for MycoplasmaTesting for Mycoplasma

Jadavji suggests serologic testing for Jadavji suggests serologic testing for mycoplasma for inpts only, not in outpt or mycoplasma for inpts only, not in outpt or ED settingED setting

Cold agglutinins titire >1:128Cold agglutinins titire >1:128 IgM antibody in serum late in acute phase IgM antibody in serum late in acute phase

or early convalescenceor early convalescence PCR assay from throat or nasopharynxPCR assay from throat or nasopharynx OR quadrupling of acute vs convalescent OR quadrupling of acute vs convalescent

serologyserology

CXR FindingsCXR Findings

VIRALVIRAL

Peribronchial thickeningPeribronchial thickening

Diffuse interstitial infiltratesDiffuse interstitial infiltrates

HyperinflationHyperinflation

BACTERIALBACTERIAL

Subsegmental, segmental or lobar Subsegmental, segmental or lobar infiltratesinfiltrates

Air bronchogramsAir bronchograms

Round pneumonia in early Round pneumonia in early S.pneumoS.pneumo

M.pneumo diffuse infiltrates out of M.pneumo diffuse infiltrates out of proportion to clinical findings (or proportion to clinical findings (or bronchopneumonia infiltrates in bronchopneumonia infiltrates in lower lobes)lower lobes)

Bilateral reticulonodular Bilateral reticulonodular interstitial infitratesinterstitial infitrates

50% bacterial pneumonia will have 50% bacterial pneumonia will have lobar infiltratelobar infiltrate

Can also see alveolar infiltratesCan also see alveolar infiltrates Round pneumonia seen with Round pneumonia seen with

S.pneumoS.pneumo

When to admit pediatric When to admit pediatric CAP?CAP?

Toxic appearanceToxic appearance Age <6 monthsAge <6 months Severe respiratory distress and O2 Severe respiratory distress and O2

requirementsrequirements Dehydration/vomittingDehydration/vomitting No response to oral abxNo response to oral abx ImmunocompromisedImmunocompromised Noncompliant patient/Noncompliant patient/parentparent

ManagementManagement

HydrateHydrate Antipyretics, pain controlAntipyretics, pain control Refer pleural effusionsRefer pleural effusions Drain empyemaDrain empyema Repeat CXR in 2-3 wks if: pleural Repeat CXR in 2-3 wks if: pleural

effusion, pneumatocele, pulmonary effusion, pneumatocele, pulmonary abcessabcess

Recurrent pneumonia in a Recurrent pneumonia in a childchild

Consider:Consider: Aspiration foreign bodyAspiration foreign body Congenital malformationCongenital malformation AsthmaAsthma

Pt with recurrent atelectasis in different Pt with recurrent atelectasis in different areas lungareas lung CFCF ImmunosuppressedImmunosuppressed AspirationAspiration

Oral treatment adequateOral treatment adequate IV abx reserved for neonates and pt IV abx reserved for neonates and pt

with severe pneumoniawith severe pneumonia

Viral vs bacterial?Viral vs bacterial?

Mycoplasma and Chlamydia Mycoplasma and Chlamydia pneumonia more common than we pneumonia more common than we think (may be misdx as a viral think (may be misdx as a viral pneumonia)pneumonia)

Clinically indistinguishableClinically indistinguishable Tx erythromycin (no advantage to Tx erythromycin (no advantage to

use azithro because azithro is to use azithro because azithro is to cover H.influenzae)cover H.influenzae)

RSVRSV

Nasal swabs 90% sens (need good swab)Nasal swabs 90% sens (need good swab) < 3 months at risk for apneic spells 2y to < 3 months at risk for apneic spells 2y to

RSV (wheezing, retractions)RSV (wheezing, retractions) Albuterol vs epinephrine – “nothing works Albuterol vs epinephrine – “nothing works

for bronchiolitis”for bronchiolitis” If severe (hypoxic, indrawing) – use 3 epi’sIf severe (hypoxic, indrawing) – use 3 epi’s

3ml in 1:1000 epinephrine (not racemic)3ml in 1:1000 epinephrine (not racemic) If moderate distress – epi no helpIf moderate distress – epi no help Can try albuterol, if it helps greatCan try albuterol, if it helps great

PCAP - Ceftriaxone, cefotaxime PCAP - Ceftriaxone, cefotaxime and cefuroxime effective in MIC and cefuroxime effective in MIC

>2.0mcg/l>2.0mcg/l Goals Goals clinical outcomes of pt tx with beta-lactam antibiotics clinical outcomes of pt tx with beta-lactam antibiotics

for a systemic infection outside of the CNS (for a systemic infection outside of the CNS (S. pneumoniae S. pneumoniae nonsusceptible to ceftriaxone) (MIC ≥ 1.0 mcg/mL)nonsusceptible to ceftriaxone) (MIC ≥ 1.0 mcg/mL)

Retrospective review of children prospectively identified Retrospective review of children prospectively identified 1993- 991993- 99

100 pt (71 bacteremic, 14 bacteremic + pneumonia, 3 100 pt (71 bacteremic, 14 bacteremic + pneumonia, 3 septic arthritis, 1 cellulitis)septic arthritis, 1 cellulitis) 5 and 6 kids had bacteremia with MIC >2.0mcg/ml)5 and 6 kids had bacteremia with MIC >2.0mcg/ml)

IV ceftriaxone, cefotaxime, or cefuroxime for one or more IV ceftriaxone, cefotaxime, or cefuroxime for one or more doses followed by po abxdoses followed by po abx

One failure in pt with severe combined immune deficiency One failure in pt with severe combined immune deficiency and bacteremiaand bacteremia

Kaplan SL, Mason EO Jr, Barson WJ, et al. Outcome of invasive infections outside the central nervous system caused by Streptococcus pneumoniae isolates nonsusceptible to ceftriazone in children treated with beta-lactam antibiotics. Pediatr Infect Dis J 2001;20:392-396

Immunocompromised/Immunocompromised/ElderlyElderly

Atypical presentation (insidious onset Atypical presentation (insidious onset or may be confused with CHR or or may be confused with CHR or respiratory compromise from lung respiratory compromise from lung dz)dz)

Atypical organisms/opportunistic Atypical organisms/opportunistic infections may be subtleinfections may be subtle

Nursing Home Acquired Nursing Home Acquired PneumoniaPneumonia

Prevalence 1.1-2.5% in chronic care Prevalence 1.1-2.5% in chronic care facilities, incidence 13 - 48%facilities, incidence 13 - 48%

In Calgary single most common In Calgary single most common reason for T/F to hospital (18.5% of reason for T/F to hospital (18.5% of all admissions)all admissions)

Mortality as high as 44%Mortality as high as 44% Exclusions: aspiration pneumonia, Exclusions: aspiration pneumonia,

hospital acquired, CF, bronchiectasis, hospital acquired, CF, bronchiectasis, TBTB

NHAP S&SNHAP S&S

Tachypnea: RR >25 associated with Tachypnea: RR >25 associated with increased morbidity and mortality increased morbidity and mortality (sens 90%, spec 99%)(sens 90%, spec 99%)

RR> 40 transfer to hospitalRR> 40 transfer to hospital Temp >37.8C Sens 70%, spec 90% Temp >37.8C Sens 70%, spec 90%

PPV 55% (absence of fever does PPV 55% (absence of fever does not R/O infection)not R/O infection)

Cough, pleuritic CP, auscultory Cough, pleuritic CP, auscultory findingsfindings

New onset delerium (44% pts)New onset delerium (44% pts)

NHAP BUGSNHAP BUGS

S.pneumo #1S.pneumo #1 H.influenzaeH.influenzae M.catarrhalisM.catarrhalis Legionella Legionella C.pneumoniaeC.pneumoniae Unknown incidence atypicalsUnknown incidence atypicals Gm (-)Gm (-) Anaerobes not important in NHAPAnaerobes not important in NHAP

Cover anaerobes if severe periodontal disease, Cover anaerobes if severe periodontal disease, putrid sputum, necrotizing pneumonia or lung putrid sputum, necrotizing pneumonia or lung abcessabcess

Wt loss in elderlyWt loss in elderly

Wt loss >5-10% associated w Wt loss >5-10% associated w increased mortalityincreased mortality >5% in 30 days or 10% in 6 months>5% in 30 days or 10% in 6 months

NHAP TxNHAP Tx

Amoxil first line if still in homeAmoxil first line if still in home Add macrolide if severe pneumonia or Add macrolide if severe pneumonia or

underlying lung dz underlying lung dz (keep in mind 10% S.pneumo (keep in mind 10% S.pneumo resistance to macrolides, may not cover H.flu)resistance to macrolides, may not cover H.flu)

Cefuroxime if worried about StaphCefuroxime if worried about Staph Doxy is an excellent choice, low RDoxy is an excellent choice, low R Fluoroquinolones if failed intial therapy or Fluoroquinolones if failed intial therapy or

multiple comorbidities. Try to avoid to multiple comorbidities. Try to avoid to decrease resistance formation. (levo decrease resistance formation. (levo overused in NH in particular)overused in NH in particular)

PseudomonasPseudomonas

Not seen in CAPNot seen in CAP Risks:Risks:

Chronic or prolonged use broad Chronic or prolonged use broad spectrum abx (>7D)spectrum abx (>7D)

BronchiectasisBronchiectasis MalnutritionMalnutrition Neutrophil dysfxn (e.g. >10mg Neutrophil dysfxn (e.g. >10mg

prednisone/d)prednisone/d) HIV (can get Pseudomonal CAP)HIV (can get Pseudomonal CAP)

Pseudomonas TxPseudomonas Tx

B lactams Pip/tazoB lactams Pip/tazo ImipenemImipenem MeropenemMeropenem

33rdrd and 4 and 4thth generation cephalosporins generation cephalosporins Cefepime, ceftazidimeCefepime, ceftazidime

CiproCipro AminoglycosidesAminoglycosides

Aspiration PneumoniaAspiration Pneumonia

EtoH, IVDU, neurologically impaired, EtoH, IVDU, neurologically impaired, poor oral hygienepoor oral hygiene

Correlate with gram stain (Correlate with gram stain (multiple multiple bacterial morphotypes phagocytosed in bacterial morphotypes phagocytosed in WBC’s)WBC’s)

Aspiration Pneumonia TxAspiration Pneumonia Tx

Cover anaerobes (B.fragilis 15%), Cover anaerobes (B.fragilis 15%), peptostreptococcuspeptostreptococcus ClindamycinClindamycin CefoxitinCefoxitin Pip/TazoPip/Tazo Metronidazole (not as good if abcess Metronidazole (not as good if abcess

present)present)