Lectures Bronchitis and Community acquired pneumonia

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.

Temperature is 39.7 C, Blood pressure: 122/70, Respirations: 22, Sa02: 96% on room air.

• On exam she is sitting comfortably.

• 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

– 30% pneumonia, non-productive – 14% adequate sputum sample G.S. – 15-30% prior antibiotic therapy – 40-60% “negative” culture results

• Can be useful to direct therapy, but:

Etiology can be established <50% of cases, and Etiologic dx does NOT reduce mortality, LOS,

cost

PL Ho. Clin Inf Dis. 2001;32:701-707; E Garcia-Vazquez. Archives Int Med. 2004;164:1907-11; Bartlett, et al. Clin. Infectious Disease. 1998; 26:811; Skerrett, et al. Sem in Resp Infect. 1997; 12:308.

Testing can delay treatment

Sputum Gram Stain and Culture Recommendation

• Collect sputum sample if feasible, and

especially in hospitalized or immunocompromised patients, but do not delay treatment.

10 epithelial cells per low powered field

• A properly collected specimen should have <

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 (n=547)

Inpatient (n=6152)

ICU(n=1415) 39.7 22.5 5.3 1.9

48.3 20.3 6 3.9

64.4 4 4 15.3 4.5 0.9

5.9 2.5 10 1.6

Unknown S. pneumonia H. influenza M. pneumonia C. pneumonia Legionella spp. S. aureus GNR P. carinii Influenza Polymicrobial

3.5 1.5

3.4 1.8 3.2 1.3 2.8 8.6

5.4

Webster et.al. AFC 2004;8;3-6 c/o Joel Katz, M.D.

Additional considerations for Vietnam

– Tuberculosis – Burkholderia pseudomallei (melioidosis) – Avian influenza

• Similar organisms in published literature • Additional organisms including:

Tran et al, Pediatr Infect Dis J. 1998 Sep;17(9 Suppl):S192-4

• Ongoing study by Oxford University

Etiology of CAP (%) Beta-lactam

IP (n=6152) ICU(n=1415) 39.7 22.5 5.3 1.9

48.3 20.3 6 3.9

OP(n=547) 64.4 4 4 15.3 4.5 0.9

5.9 2.5 10 1.6

Unknown S. pneumonia H. influenza M. pneumonia C. pneumonia Legionella spp. S. aureus GNR P. carinii Influenza Polymicrobial

3.5 1.5

3.4 1.8 3.2 1.3 2.8 8.6

5.4

Webster et.al. AFC 2004;8;3-6 c/o Joel Katz, M.D.

IP (n=6152) ICU(n=1415) 39.7 22.5 5.3 1.9

48.3 20.3 6 3.9

Etiology of CAP (%) Macrolide OP(n=547) 64.4 4 4 15.3 4.5 0.9

5.9 2.5 10 1.6

3.4 1.8 3.2 1.3 2.8 8.6

5.4 3.5 1.5

Unknown S. pneumonia H. influenza M. pneumonia C. pneumonia Legionella spp. S. aureus GNR P. carinii Influenza Polymicrobial

Webster et.al. AFC 2004;8;3-6 c/o Joel Katz, M.D.

Etiology of CAP (%) Tetracyclines

IP (n=6152) ICU(n=1415) 39.7 22.5 5.3 1.9

48.3 20.3 6 3.9

OP(n=547) 64.4 4 4 15.3 4.5 0.9

5.9 2.5 10 1.6

Unknown S. pneumonia H. influenza M. pneumonia C. pneumonia Legionella spp. S. aureus GNR P. carinii Influenza Polymicrobial

3.5 1.5

3.4 1.8 3.2 1.3 2.8 8.6

5.4

Webster et.al. AFC 2004;8;3-6 c/o Joel Katz, M.D.

Etiology of CAP (%)

Quinolones

IP (n=6152) ICU(n=1415) 39.7 22.5 5.3 1.9

48.3 20.3 6 3.9

OP(n=547) 64.4 4 4 15.3 4.5 0.9

5.9 2.5 10 1.6

Unknown S. pneumonia H. influenza M. pneumonia C. pneumonia Legionella spp. S. aureus GNR P. carinii Influenza Polymicrobial

3.5 1.5

3.4 1.8 3.2 1.3 2.8 8.6

5.4

Webster et.al. AFC 2004;8;3-6 c/o Joel Katz, M.D.

IDSA/ATS guidelines: Antibiotics for community acquired pneumonia in adults

• Previously healthy and no use of

antimicrobials within the previous 3 months: – Macrolide (azithromycin, clarithromycin, or

erythromycin)

OR – Doxycyline

If comormidities present

• Respiratory fluoroquinolone (moxifloxacin, gemifloxacin,

or levofloxacin [750 mg])

OR • Beta‐lactam (high‐dose amoxicillin,

amoxicillin‐clavulanate; alternative agents: ceftriaxone, cefpodoxime, or cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)

Comorbidities: chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; or use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected):

Other considerations in treatment

Ask about travel, exposures, other illnesses

History/Scenario

Treatment

Suspected aspiration pneumonia

Amoxacillin-clavulanate or clindamycin

Influenza with bacterial super- infection

Beta-lactam or fluoroquinolone (consider MRSA as below)

Admitted to ICU

Fluoroquinolone or Beta lactam + Macrolide.

History of HIV

Consider TB, PCP

Concern for TB

Avoid quinolone

Consider MRSA

Acquired in hospital, recent antibiotics, sicker than expected, not getting better

Length of treatment

• Treat community acquired pneumonia for at

least 5 days. • Prior to stopping:

– Afrebrile for 48‐ 72 hours and – No more than one abnormality in: vital

signs, oral intake, mental status.

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

Pneumonia guidelines for admission

• Admit and stabilize those patients most at risk

• Avoid admission for low risk patients to

for mortality.

decrease – Thromboembolic events – Nosocomial infections – Costs

Community Acquired pneumonia – Risk stratification

• CURB-65 • Pneumonia severity index (PSI)

CURB-65 Risk Score

•Confusion •Urea > 30 •Respiratory rate > 30 •Blood pressure < 90 systolic or <60 diastolic •age 65 or older

CURB-65 Risk Score

Risk of death or ICU admission: • 0—0.7% • 1—3.2% • 2—13.0% • 3—17.0% • 4—41.5% • 5—57.0%

Lim WS, et al. Thorax. 2003; 58:377-382.

PORT Study Prediction Rule (PSI)

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

Yes/No Yes/No Yes/No Yes/No Yes/No

Step 1: Stratify to Risk Class I vs. Risk Classes II-V Presence of: Over 50 years of age Altered mental status Pulse ≥125/minute Respiratory rate >30/minute Systolic blood pressure <90 mm Hg Temperature <35°C or ≥40°C History of: Neoplastic disease Congestive heart failure Cerebrovascular disease Renal disease Liver disease If answer to all is no, patient is Class I. If Yes to any, then proceed to point scoring system

Step 2: Stratify risk

Demographics

30-day Mortality

If Male If Female Nursing home resident

Points Assigned +Age (yr) +Age (yr) - 10 +10

0.1%

Comorbidity

Neoplastic disease Liver disease Congestive heart failure Cerebrovascular disease Renal disease

+30 +20 +10 +10 +10

0.9%

Physical Exam Findings

Altered mental status Pulse ≥125/minute Respiratory rate >30/minute

+20 +10 +20

Systolic blood pressure <90 mm Hg Temperature <35°C or ≥40°C

+20 +15

Lab and Radiographic Findings

Class I Class II (<70 pts) 0.6% Class III (71-90) Class IV (91-130) 9.3% Class V (>130 pts) 27%

Arterial pH <7.35

+30

Blood urea nitrogen ≥30 mg/dl (9 mmol/liter) +20 Sodium <130 mmol/liter +20

Glucose ≥250 mg/dl (14 mmol/liter) Hematocrit <30%

+10 +10

Partial pressure of arterial O2 <60mmHg Pleural effusion

+10 +10

http://pda.ahrq.gov/clinic/psi/psicalc.asp Fine, MJ, "N Engl J Med 336 (4): 243–250. Chalmers JD, Thorax 65 (10): 878–83. Aujesky D (2005). Am. J. Med. 118 (4): 384–92.

Case 2

63 year-old woman with diabetes and obesity presents with productive cough for 6 days, fever, dyspnea, and right pleuritic CP. • No extremis. T=103.5°; BP 118/60; RR 26. Crackles are noted at the right lung base. SaO2 96% on room air.

CURB65 = 0

63-10=53 points –> Class II

Should this woman be admitted to a hospital? A. Yes B. No C. Depends on CXR result D. Depends on the ABG result E. Need more information

Pneumonia Prevention

• Vaccination: – Pertussis – Pneumococcal vaccination – Influenza

• Tobacco cessation • HIV testing

Pertussis (whooping cough) Vaccine

• Bordetella pertussis • 2012: 139,382 cases worldwide • DTP: > 3 doses (WHO), DTaP: 5 doses • Vietnam historically with high rates of

vaccination, but recent deaths with Quinvaxem a whole cell vaccine

use of acellular vaccines

• Recent epidemics in U.S. in setting of increasing

Pneumococcus in children

• WHO estimates: In 2008 of 8.8 million global annual deaths amongst children <5 years of age, 476 000 caused by pneumococcal infectons

serious pneumococcal disease

• Children with HIV are at increased risk of

Pneumococcal vaccine

children

• Safe and effective in children and adults • Worldwide, priority for vaccination is in

• PCV efficacy:

– 71-93% for invasive pneumococcal disease (bacteremia, meningitis)

– 24% for pneumonia

Influenza (Seasonal)

• Spreads easily from person to person • Affects all age groups: Age <2 and > 65 most at risk as well as those with chronic medical conditions

temperate regions

• Annual epidemics that peak in winter in

• Three types: A, B, C (C is rare) • Signs and symptoms: high fever, cough (dry), headache, myalgia, severe malaise, sore throat, rhinnorhea

Influenza – Vietnam (2012-2013)

Data source: FluNet ( www.who.int/flunet ), GISRS

Influenza prevention – every day

http://www.who.int/mediacentre/factsheets/fs211/en/index.html

• Cover your cough • Stay home if sick • Avoid touching eyes, nose, face • Hand washing (sanitizer) • Disinfect surfaces

Influenza prevention - vaccination

• Healthy adults: Prevents 70% - 90% of

• Composition of vaccine chosen by WHO after monitoring of worldwide circulating strains

influenza specific illness

• Elderly:

– Reduces severe illness and complications

– Reduces deaths by 80%.

by up to 60%.

Influenza – Who should be vaccinated

• Elderly • People with chronic medical conditions • Pregnant women • Health care workers • Those with essential function in society • Children 6 months – 2 years • Nursing home residents