Community-Acquired community-acquired pneumonia as: Pneumonia The - PowerPoint PPT Presentation

1. In 1898, William Osler described Community-Acquired community-acquired pneumonia as: Pneumonia The Latest A. An ailment that often leads to suffocation and death. 55% B. A friend of the aged. 33% Brad Sharpe, M.D. C. A common and mortal disease Professor of Clinical Medicine which can be diagnosed by simple Department of Medicine 12% observation and percussion of the UCSF 0% chest. sharpeb@medicine.ucsf.edu A friend of the aged. Bad. Really bad. An ailment that often lea.. A common and mortal di... D. Bad. Really bad. I have no relevant financial relationships to disclose. CAP: A Practical Approach "Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old man escapes those “Brad, pneumonia sucks.” ‘cold gradations of decay’ so distressing of -- Mary R. Sharpe himself and to his friends.“ November 2011 -- William Osler, M.D., 1898 CAP: A Practical Approach CAP: A Practical Approach 1

Update in CAP Roadmap • Background • Etiology • Diagnosis • Treatment • Prevention CAP: A Practical Approach CAP: A Practical Approach Specific Goals: Caveats • Describe the most common causes of • Will not talk about healthcare-associated community-acquired pneumonia in the pneumonia (HCAP) outpatient setting • Order appropriate diagnostic tests for CAP • Will not discuss admission decision (complex) • Initiate appropriate antibiotics in the treatment of community-acquired pneumonia (CAP) • Syllabus or specific questions: • State the optimal duration of therapy in CAP (sharpeb@medicine.ucsf.edu) • State the benefits and need for preventative measures for CAP Community-Acquired Pneumonia CAP: Current & Future 2

Roadmap CAP: Background • Background • 5 million cases/year in the U.S. • Etiology • 80% of CAP is treated outpatient • Diagnosis • Sixth leading cause of death • Treatment • Prevention • Inpatient mortality 10-35% • Outpatient mortality < 1% CAP: A Practical Approach CAP: A Practical Approach CAP: Background CAP: Background • Some evidence that quality of care for Cough 90%* African-Americans with CAP is worse Dyspnea 66% • Higher mortality among Caucasians Sputum 66% Pleuritic chest pain 50% * Yet, only 4% of all visits for cough are pneumonia Halm EA, Teirstein AS. N Engl J Med 2002;347(25):2039. Mortensen EM, et al. BMC Health Serv Res . 2004;4:20. CAP: A Practical Approach CAP: A Practical Approach Mayr FB, et al. Crit Care Med . 2010;38:759. 3

Clinical Presentation: Geriatrics Roadmap • Less “classic” presentations • Background • 10% have NONE of the classic signs or symptoms • Etiology • Up to 35% will not have fever • Diagnosis • Up to 50% will have altered mental status • Treatment • Up to 50% will have “asthenia” • Prevention Mehr DR, et al. J Fam Prac 2001;50(11):1101. Riquelme R, et al. Am J Respir Crit Care Med 1997;156:1908. Sund-Levander M, et al. Scand J Inf Dis . 2003;35:306. Simoneti AF, et al . Ther Adv ID . 2014;2:3. Community-Acquired Pneumonia CAP: A Practical Approach “Typical” vs. “Atypical” “Typical” vs. “Atypical” • Typical organisms • Atypical organisms ♦ S. pneumoniae, H. influenzae, M. catarrhalis, etc . ♦ M. pneumoniae, C. pneumoniae, Legionella spp, etc. CAP: A Practical Approach CAP: A Practical Approach 4

“Typical” vs. “Atypical” “Typical” vs. “Atypical” • Classic teaching is not supported by the • Classic teaching is not supported by the literature literature • Some general trends • Some general trends • S. pneumoniae in older pts, co-morbidities • Mycoplasma in patients < 50 years old • But - no history, exam, laboratory, or • Bilateral hazy opacities more likely to be radiographic features predict organism atypical (but not always) • “Walking pneumonia” • “Classic lobar pneumonia” CAP: A Practical Approach CAP: A Practical Approach Etiology of CAP Microbiology of CAP Outpatients (mild) Non-ICU inpatients ICU inpatient Jain S, et al. NEJM. 2015. CAP: A Practical Approach Community-Acquired Pneumonia File TM. Lancet 2003;362:1991. 5

Microbiology of CAP Microbiology of CAP • Prospective study of 2320 patients with CAP admitted to 5 hospitals • All extensive diagnostic evaluation • Blood cultures, sputum cultures • Urine antigen for S. pneumoniae & Legionella • Nasopharyngeal PCR for viruses, Chlamydophila , Mycoplasma • Some serologic testing Jain S, et al. NEJM. 2015. Jain S, et al. NEJM. 2015. Community-Acquired Pneumonia Community-Acquired Pneumonia Microbiology of CAP Microbiology of CAP 1) Rhinovirus 2) Influenza 3) Streptococcus pneumoniae Jain S, et al. NEJM. 2015. Jain S, et al. NEJM. 2015. Community-Acquired Pneumonia Community-Acquired Pneumonia 6

Microbiology of CAP Etiology of CAP Outpatients (mild) Non-ICU inpatients ICU inpatient • No pathogen detected in > 60% of patients • Real-world ~ 80-90% • Many possible explanations • Mainly viruses? • Inadequate diagnostic testing Jain S, et al. NEJM. 2015. Community-Acquired Pneumonia CAP: A Practical Approach File TM. Lancet 2003;362:1991. Etiology of CAP Take Home Points Outpatients (mild) Non-ICU inpatients ICU inpatient 1) 2) • Resp. viruses • S pneumoniae • Resp. viruses • S pneumoniae • Legionella • S pneumoniae 3) • M pneumoniae • H influenzae • M pneumoniae • C pneumoniae • GNRs 4) • C pneumoniae • H influenzae • S aureus • H influenzae 5) • Resp. viruses (?) • Legionella spp File TM. Lancet 2003;362:1991. CAP: Current & Future Community-Acquired Pneumonia Metlay JP, et al. JAMA 1997;278(17):1440. 7

Take Home Points Roadmap 1) Cover typical and atypical bacteria • Background 2) • Etiology 3) • Diagnosis 4) • Treatment 5) • Prevention Community-Acquired Pneumonia CAP: A Practical Approach 2. A 65-year old man presents to urgent care complaining 2. A 65-year old man presents to urgent care complaining of subjective fever, chills, and productive cough x 3 days. He of subjective fever, chills, and productive cough x 3 days. He reports mild shortness of breath. His temperature is 38.6 o C, reports mild shortness of breath. His temperature is 38.6 o C, RR 20, O 2 saturation 95% on RA. He has crackles at the RR 26, O 2 saturation 95% on RA. He has crackles at the right base on lung exam. You should: right base on lung exam. You should: a. Treat for community-acquired pneumonia. A. Treat for community-acquired pneumonia. 43% b. Send him for a PA and lateral CXR. B. Send him for a PA and lateral CXR. c. Send him for blood and sputum cultures. 33% C. Send him for blood and sputum cultures. d. Prescribe sudafed and robitussin and send him 23% D. Prescribe sudafed and robitussin and send him home. home. e. Perform trans-tracheal aspiration E. Perform trans-tracheal aspiration 0% 0% 0% f. B and C F. B and C C . . . . . . . d . . . . . q a . . . o s n c r a a a l d d n d a l B - n n y a e t a d a h n i A c o d u P o e a m f r a b l a t d - m r r s o o u n o f s a c f r m m e t r b o i i m f h h i c r r t d d o a n s f e n e r r e e r e T S S CAP: A Practical Approach P CAP: A Practical Approach P 8

Diagnosis of CAP Chest Radiograph – Gold Standard • All expert guidelines state should have 1) Select clinical features positive CXR to make diagnosis (e.g. cough, fever, sputum, pleuritic chest pain) ● History & exam not good enough (50% sensitive) • In outpt setting, should see an infiltrate. AND ● Order CXR if you are concerned about CAP ● If CXR negative, likely should not treat for CAP 2) Infiltrate by CXR or other imaging • In the inpatient setting, can see pneumonia with a negative CXR (~30%) IDSA/ATS Guidelines. CID . 2007;44:S27-72. Metlay J. Ann Intern Med . 2003. CAP: A Practical Approach Community-Acquired Pneumonia 2. A 65-year old man presents to urgent care complaining Chest Radiograph – Gold Standard? of subjective fever, chills, and productive cough x 3 days. He reports mild shortness of breath. His temperature is 38.6 o C, RR 26, O 2 saturation 95% on RA. He has crackles at the right base on lung exam. You should: • Should (generally) order CXR in all patients with suspected pneumonia. a. Treat for community-acquired pneumonia. • In the hospital, a positive CXR is not b. Send him for a PA and lateral CXR. necessary to treat as CAP (but consider other c. Send him for blood and sputum cultures. diagnoses) . d. Prescribe sudafed and robitussin and send him home. e. Perform trans-tracheal aspiration f. B and C Community-Acquired Pneumonia CAP: A Practical Approach 9