Lectures Bronchitis and Community acquired pneumonia introduce acute bronchitis, bronchitis and management, community pneumonia, pneumonia diagnosis & sputum Gram stain, cause of pneumonia in the community, the guidance of DSA / ATS antibiotics for pneumonia in adults in the community,...
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Nội dung Text: Lectures Bronchitis and Community acquired pneumonia - Lisa A. Cosimi. M.D
- Bronchitis and Community
Acquired Pneumonia
Lisa A. Cosimi. M.D.
Brigham and Women’s Hospital
Beth Israel Deaconess Medical Center
Harvard Medical School
- Case 1
• Mrs. Thuy is a 63 year old previously
healthy woman who presents to your
office for the second time in one week
with a cough productive of yellow sputum
and rhinorrea that won’t go away. She’s
requesting antibiotics because her
neighbor told her this would help her to
feel better. She has no fever, O2
saturation is normal and her lungs are
clear.
- What do you recommend?
a) Azithromycin
b) Doxycycline
c) Levofloxacin
d) Erythromycin
e) Reassurance that she will begin to feel
better soon
- Acute bronchitis
• Definition: Upper respiratory infection
associated with cough, lasting less than 2-3
weeks.
• Patients may also have symptoms of
rhinorrhea, sinus or nasal congestion though
not always present
- Acute bronchitis
• Very common
• In U.S., 70% of cough presentations
• Viral etiology is most common (adenovirus,
influenza, rhinovirus, parainfluenza, RSV)
• Generally, self limited (1-2 weeks)
- Bronchitis - Management
• Supportive
• Seven large randomized, controlled trials and 3
metanalyses showed no benefit of antimicrobial
treatment in general populations
• Overuse of antibiotics leads to increases in
resistance and increased health care costs
• Recent reports of association with cardiovascular
death with macrolide use
– Average risk: 4.7 extra deaths/100,000 treated (Azithro)
– Known HTN/CHF/DM: 24.5/100,000
Ray et al, NEJM; 2012;366:1881-90
Smith et al, “Acute Bronchitis” Cochrane Database 2012
- Who/when would you treat?
• During documented pertussis outbreaks
• Patients with chronic bronchitis
• Patients with underlying lung disease
(asthma, COPD, heavy tobacco use)
- Case 2
• Mrs. Thuy’s friend, Mrs. Phuong, is obese
with diabetes. She comes to see you one
month later complaining of 5 days of
productive cough with fever, dyspnea and left
sided pleuritic chest pain.
• On exam she is sitting comfortably.
Temperature is 39.7 C, Blood pressure:
122/70, Respirations: 22, Sa02: 96% on room
air.
• She has crackles at the left base.
- What do you recommend?
a) Azithromycin
b) Doxycycline
c) Levofloxacin
d) Erythromycin
e) Reassurance that she will begin to feel
better soon
- Should this woman be admitted to a
hospital?
A. Yes
B. No
C. Depends on CXR result
D. Depends on the arterial blood gas result
E. Need more information
- CXR
- Community Acquired Pneumonia
• Top infectious cause of mortality in both the U.S. and
in Vietnam
• Vietnam – 4% of reported deaths
• In the U.S.
– 4.8 million cases per year
– 50,097 deaths
http://www.cdc.gov/globalhealth/countries/vietnam/
http://www.cdc.gov/nchs/fastats/lcod.htm
- Diagnosis
• Clinical
– Fever, cough, dyspnea with or without pleuritic pain
– Symptoms in elderly may be unusual: fever, confusion,
abdominal pain.
• CXR: Useful to establish diagnosis when uncertain.
Useful in excluding associated findings, especially in the
elderly. Routine for all hospitalized patients and most
ambulatory patients with suspected pneumonia.
• Blood cultures: 13% sensitivity, a marker for high risk
patients.
- Pneumonia Diagnosis
Gram Stain & Sputum Culture
• Can be useful to direct therapy, but:
– 30% pneumonia, non-productive
– 14% adequate sputum sample G.S.
– 15-30% prior antibiotic therapy
– 40-60% “negative” culture results
Etiology can be established
- Sputum Gram Stain and Culture
Recommendation
• Collect sputum sample if feasible, and
especially in hospitalized or
immunocompromised patients, but do not
delay treatment.
• A properly collected specimen should have <
10 epithelial cells per low powered field
- How an I.D. doc views pneumonia:
From Mandell, et al. , Principle and Practice of Infectious Diseases, 7th edition., c/o Joel Katz, M.D.
- How the rest of the world views
Pneumonia:
- Which antibiotic should you choose?
Etiology of CAP (%)
Outpatient Inpatient
(n=547) (n=6152) ICU(n=1415)
Unknown 64.4 48.3 39.7
S. pneumonia 4 20.3 22.5
H. influenza 4 6 5.3
M. pneumonia 15.3 3.9 1.9
C. pneumonia 4.5
Legionella spp. 0.9 3.4 5.9
S. aureus 1.8 2.5
GNR 3.2 10
P. carinii 1.3 1.6
Influenza 3.5 2.8
Polymicrobial 1.5 8.6 5.4
Webster et.al. AFC 2004;8;3-6
c/o Joel Katz, M.D.
- Additional considerations for
Vietnam
• Similar organisms in published literature
• Additional organisms including:
– Tuberculosis
– Burkholderia pseudomallei (melioidosis)
– Avian influenza
• Ongoing study by Oxford University
Tran et al, Pediatr Infect Dis J. 1998 Sep;17(9 Suppl):S192-4
- Etiology of CAP (%)
Beta-lactam
OP(n=547) IP (n=6152) ICU(n=1415)
Unknown 64.4 48.3 39.7
S. pneumonia 4 20.3 22.5
H. influenza 4 6 5.3
M. pneumonia 15.3 3.9 1.9
C. pneumonia 4.5
Legionella spp. 0.9 3.4 5.9
S. aureus 1.8 2.5
GNR 3.2 10
P. carinii 1.3 1.6
Influenza 3.5 2.8
Polymicrobial 1.5 8.6 5.4
Webster et.al. AFC 2004;8;3-6
c/o Joel Katz, M.D.
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