Pneumonia Sanjay Kalra, MD, FRCP

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1 Pneumonia Sanjay Kalra, MD, FRCP Associate Professor of Medicine Division of Pulmonary & Critical Care Medicine Mayo Clinic Rochester, MN

2 Disclosures NONE

3 Learning Objectives Define the subtypes of pneumonias Identify when to suspect and how to diagnose pneumonia Severity Staging Recognize empiric treatment decisions Discuss parapneumonic effusions/ empyema

4 Definitions Suspected community-acquired pneumonia is defined by acute symptoms and presence of signs of lower respiratory tract infection (LRTI) without other obvious cause New pulmonary infiltrate on chest radiograph is needed for definite diagnosis.

5 Definitions Hospital-acquired and Ventilator-associated Pneumonias HAP, or nosocomial pneumonia, arises 48 hours or more after hospital admission in the absence of signs or symptoms of pneumonia at the time of admission VAP is a subtype of HAP that develops after endotracheal intubation (Because only about 10% of patients with HAP are not mechanically ventilated, the terms HAP and VAP are often used interchangeably) Ottosen SCNA 2014

6 Definitions Health Care Associated Pneumonia American Thoracic Society (ATS) guidelines (2005): New category of infections to encompass recent inpatient or on ongoing treatment in a long-term or outpatient health care facility HCAP New pneumonia in: Any patient who was hospitalized in an acute care hospital for 2 or more days within 90 days of the infection Resided in a nursing home or long-term care facility Received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection Or attended a hospital or hemodialysis clinic Ottosen SCNA 2014

7 Other Definition Issues Ottosen SCNA 2014

8 When should you think of pneumonia? Respiratory Symptoms plus Temperature > 37.8 C Pulse > 100/min Rales/Crackles Decreased breath sounds Absence of asthma Ann Intern Med 1990;113:664

9 The Cough + 1 Rule Suspect if New focal chest signs on examination At least one systemic feature No other explanation for the illness

10 Chest imaging is necessary for a definite diagnosis And helps to detect associated lung diseases to gain insight into causative agent (in some cases) to assess severity as baseline to assess response IDSA 1998 & BTS 2001

11

12

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15 Other Diagnostic Tests Procalcitonin Alba Am J Med 2015

16 Alba Am J Med 2015

17 Inpatient vs Outpatient Treatment Medical Risk Assessment Psychosocioeconomic considerations Patient preference

18 Outpatient Stratification Medical Risk Outpatient Otherwise healthy adults Cardiorespiratory or other comorbidity Inpatient Floor Unit Intensive Care Unit

19 Index of Severity The Original BTS CAP Index R.U.B. Predicts Death Respiratory Rate > 30/min BUN > 20 mg/dl Diastolic blood pressure < 60 mm Hg Q J Med 1987:62;

20 RISK ASSESSMENT Defining low risk patients PSI Pneumonia Severity Index

21 The Pneumonia Severity Index PSI relies on 2 pre-existing patient features Age over 50 Co-existing chronic illnesses 5 Adverse clinical features Mental status* Respiratory Rate* SBP* Pulse Rate Temperature

22 PSI Pre-existing Condition: Scoring System for Risk Classes II-V Age Male No. of years of age Female No. of years of age - 10 Nursing home Add 10 points Add the patient's age in years (age -10, for females)

23 Risk Class Mortality Rates Risk Class Mortality Site of Care I (none) 0.1% Outpatient II (< 70 pts) 0.6% Outpatient III (71 90 pts) 2.8% Inpatient IV ( pts) 8.2% Inpatient V (> 130 pts) 29.2% Inpatient NEJM 1997;336:243

24 Risk Stratification Scores CURB65 Ottosen SCNA 2014

25 Assessment of Severity/Disposition Prina, Lancet 2015

26 Microbiological Testing Prina Lancet 2015

27 Empirical Therapy Prina, Lancet 2015

28 Bacteremia in CAP 5% False-positive culture leading to increased length of hospital stay Metersky AJRCCM 2004

29 Antibiotic Timing in CAP

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31

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34 Clinical Course/Timeline Prina, Lancet 2015

35 Ottosen SCNA 2014

36 Presumptive Pathogens Early Ottosen SCNA 2014

37 Presumptive Pathogens Late Ottosen SCNA 2014

38 VAP Diagnostic Surrogate CPIS Zilberberg CID 2010, Ottosen SCNA 2014

39 When things don t go as expected.. Ottosen SCNA 2014

40 Non-resolving Pneumonias Granulomatous Infection - TB, Fungal, Exotic Infection - Brucellosis, Tularemia, Ricketsial Drug Resistant Organisms Post-obstructive Pneumonia Non-infectious Causes Pulmonary embolism Alveolar hemorrhage Vasculitis CVD Sarcoidosis

41 Seven Degrees of Suppuration

42

43 MIST1 N=454 (427 randomized) with ph <7.2 or proven intrapleural infection SK IU bid x 3 days vs placebo No difference in deaths or surgical drainage rate at 3 months - 31% vs 27% No difference in in LOS, radiographic outcome Side effects 7% vs 3% (p=0.08)

44 Current Management of Parapneumonic Empyema in the High(er) Risk Patient Piccolo An Am Thor Soc 2014

45 Piccolo An Am Thor Soc 2014

46 Piccolo An Am Thor Soc 2014

47 Novel Strategies

48 Transmission Control Viruses

49 Transmission Control Bacteria

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