Academic Day Seminar #11: Pneumonia

How do you treat pneumonia?:

  • CURB-65
    (confusion, urea, RR > 30 bpm, BP)

    • If hypotensive → sign of sepsis…if vasodilating → on the way to developing septic shock
    • <1% of CRB-65 < 1 need to seek further health care as out-patient

Things to consider:

  • What are you treating? → PMHx
    • Cardiac conditions
      • HF → pulmonary edema (sign: pink, frothy sputum)
        • ↑ HR could also be due to CHF
          (CRB-65 helps to determine how aggressive to be)
      • IHD
      • Angina
    • COPD (sign: white sputum, can be yellow, green or brown)
      • colour does not predict type of organism
    • How to differentiate from the above:
      • s/s of infection (e.g. fever)
      • changes in sputum (e.g. change in volume, pernicity, characteristics)
    • Stroke, dysphagia, chronic alcohol use  and/or seizures → increase the risk of aspiration!
    • History of recurrent pneumonias
    • History of TB, MRSA, Pseudomonas, Immunocompromised (e.g. cancer, bone marrow transplant, HIV)
      • CF patients are colonized with pseudomonas
  •  How sick is my patient? What spectra of activity do I need?
    • CRB-65 → help dictate if require PO/IV (also need to ensure that GI tract is functioning)
    • Pulse oximetry
  • Risk
    • Location of my patient
    • Abx within past 3 months
    • Recent travel history
    • Health care associated (e.g. three timess weekly dialysis)
      • doesn’t apply to employees of health care
  • Potential contraindications
    • Organ dysfunction
    • Current medications
    • Contraindications
    • QTc
  • Patient specific factors
    • allergies
    • GI abnormalities
    • Weight

Laboratory values:

  • 2016 guidelines state that data for CRPH is weak → do not base decision to initiate antibiotics on CRP
  • WBC can be lower than normal in a severe infection (since using more than can make)
  • Surgical procedure will ↑ stress which will ↑ WBC even if no s/s of infection

Diagnostics:

  • CXR → consolidation (alveoli in one area fill up with pus to fight infection → becomes solid)
    • a lot of areas of whitness in area of lungs where bacteria cause infection
  • Pulse oximetry is not validated like CRB-65 but tells us severity

Clinical Pearls:

  • Meropenem and pip/tazo does not cover atypicals
    • getting everything else in the system → setting them up for opportunistic infections!
  • Linezolid: great activity with g+ but not g- or atypicals
  • No advantage over clarithromycin over azithromycin
    • Clarithormycin: more DIs with CYP enzymes and have a shorter half life when stop = clear quickly (potentially ↓ risk of resistance)
  • Short courses of Azithromycin – likely get extra 48 hours of activity after discontinuation → handy if limited compliance
  • Cefotaxime: similar susceptibility to ceftriaxone susceptibility
    • Cefotaxime: every 8 hours
    • Ceftriaxone: every 24 hours
      • don’t want to use in smal children as 50% hepatic and 50% renal → can cause biliary sludge, develop obstruction and cause jaundice
        → not concerning in adults as have large biliary tree
  • If aspirate during surgery…how would you know whether to put patients on antibiotics?
    • Lungs are sterile → if food enters, lungs will develop inflammatory response (e.g. fever, cough)…but some people get very sick as they already have so much in their lungs and are at risk of respiratory failure
    • Would consider starting abs if patent is worsening over next 24 hours
  • Suspecting signs of aypical bacteria: slowly progressing symptoms, malaise, muscle aches, sore throat, and low-grade fever with nonproductive cough
  • Ventilation is not a requirement to start antibiotics
  • If have prophylactic antibiotics before OR for surgery
    • single dose of prophylactic antibiotics should NOT bias you against what to select (concerned with antibiotics that patients have been on for a relatively long time)
  • If going into shock from inflammation and/or infection, would want to start BROAD!
  • If get series of patients receiving same antibiotics consistently → see trend of g- organisms that are resistant
  • Sputum Cxs are not reliable and may not always provide the pathogen
    → ask yourself what are the pathogens consistent with causing this condition
  • VAP: worst extreme of HAP = need to be the most aggressive!
    • bypassed te patient’s defense mechanism = high risk of infection from anythig in the environment
    • patients who require ventilation tend to already be very sick

Approach:

  1. Confirm infection
    – What are their microbiology results?
    – CXR?
  2. What is the site? What are the likely pathogens?
    – How does the surgical site look like? Pus? Redness? Spillage?
    – aspiration during surgery
    – chronicity of surgery
    – timeline of surgery
  3. How sick are they? How aggressive should I be?
    – duration of stay in hospital
    (e.g. HAP – new onset >48 hours stay)
    – previous infection history in hospital
    – time course of symptoms
  4. Patient-specifi factors/Antibiotic contraindication
  5. Evaluate regularly for de-escalation of treatment
    – CAP likely requires 5 days of tx but if it looks like it will need several days to improve → can extend to 7 days

 

 

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