Upload
waidid
View
413
Download
1
Embed Size (px)
Citation preview
Diagnosis and Management of Acute Community Acquired Pneumonia
Dr. Ivan Hung
MBChB (Bristol), MD (HK), FRCP (Lon, Edin), PDipID (HK) Clinical Associate Professor
Honorary Consultant Department of Medicine, QMH The University of Hong Kong
Causes of febrile respiratory illness
• Streptococcus pneumoniae • Staphylococcus aureus • Haemophilus influenzae
• Enterobacteriaceae (ill health, >65) • Oral aerobes/Anaerobes (AspiraBon)
• Acinetobacter baumannii • Pseudomonas aeruginosa • Burkholderia pseudomallei(sputum)
• Legionella pneumophilia (sputum, urinary anBgen EIA)
• Mycoplasma pneumoniae • Chlamydophila pneumoniae/psiKaci • Coxiella burneBi (Q fever) • Mycobacterium tuberculosis (sputum)
• Influenza A H3N2, H1N1, H5N1, H9N2, H7N9) • Influenza B • Influenza C • Adenovirus • RSV • Parainfluenza 1, 2, 3, 4 • Rhinovirus Clade A, B, C • Metapneumovirus • MERS-‐CoV • Coronavirus SARS SARS • Coronavirus OC43 OC43 • Coronavirus HKU1 HKU1 • Coronavirus 229E 229E • Enterovirus • Bocavirus
• PROLONGED shedding in children and immunosuppressed hosts
BACTERIA
*BLOOD, PLEURAL FLUID,BAL(Bronchoalveolar lavage)
VIRUSES
Causes of febrile respiratory illness
• Cryptococcus • Aspergillus • Dimorphic fungi:
Penicillium, Histoplasma, Coccidioides,
• Zygomycetes • PneumocysBs • *usually in
immunosuppressed host
• Paragonimus westermanii • Ascaris lumbricoides • Strongyloides stercoralis • Many others • * usually eosinophilia in
blood
PARASITES FUNGI
Overview of URTI
• Acute infection of URT
• Nose, sinuses, pharynx or larynx
• Common causes: – Influenza – Adenovirus – RSV – Parainfluenza – Rhinovirus – Metapneumovirus – Coronavirus – Enterovirus
• Symptoms: – Fever – Malaise, myalgia – Headache – Nasal discharge – Sore-throat – Itchy eyes
• Treatment: – Antiviral: Influenza: neuraminidase
inhibitors or adamantanes; RSV: ribavirin
– Analgesics: paracetamol, NSAID
National Institute for Health and Clinical Excellence: Guidance; 2008 Jul
Antibiotics ….when?
Key laboratory tests for diagnosis of acute community acquired pneumonia • 1. Blood culture • 2. Sputum/ETA/BAL for gram stain, bacterial culture (fungal &
AFB smear & culture, PCP smear, parasiBc ova) • 3. Pleural fluid for gram stain, bacterial culture (fungal/AFB
smear & culture) • 4. NPA or T/S (sputum, ETA, BAL) for respiratory virus
anBgens (animal -‐ camel / poultry exposure in endemic areas: RT-‐PCR for MERS-‐CoV / H7N9)
• 5. Urine for pneumococcal anBgenuria • 6. Urine for legionella pneumophila serogroup 1 anBgenuria
No. of infected cells: determining test sensitivity Swabs inserted: sampling posterior pharyngeal wall / level of ear lobes
Specimens with high viral load Timing of specimen taking: viral load usually highest within the first 48 hours after onset of disease
Aspirate and swab in Viral transport medium, Stored at 4 (<24hr) or -70(>24hr) degree Celsius
Epidemic curve of staff with influenza like illness in AE department
Clinical attack rate: 46% (17 infected / 37 staff) M:F = 9:6 Infected doctor = 9 (50%, 9/18) Infected frontline nurse = 5 (45%, 5/11) Infected senior nurse = 2 (33%, 2/6) Infected supporting staff = 1 (50%, 1/2)
Clinical symptoms: Sneeze: 9 Nasal drip: 6 Fever: 3 Cough: 11 Sputum: 8 Sore-throat: 11 Headache: 3 Lethargy: 6 Risk factor for infection:
Lack of vaccination (p=0.051) Infected case: none received vaccine Non-infected case: 4 (25%)received vaccine
Case 1 • F/27; Japanese • History of pepBc ulcer disease and leh
ovarian cyst
• Fever & cough for 2 days – Given oral cefuroxime by private pracBBoner.
No improvement
• TOCC – Came back from Japan ~2 weeks before
symptom onset – Works in office buildings – No contact with paBents with influenza-‐like-‐
illness – No clustering
• A&E (day 2 aher symptom onset) – Temp 39.5°C – BP 107/65 – Pulse 130
Day 2 a&er symptom onset (A&E)
Case 1 • Diagnosis (A&E):
– community acquired pneumonia
• AnBbioBcs: – AugmenBn 1g bd po – Azithromycin 500mg daily po
• Persistent fever
• AdmiKed 5 days aher symptom onset
• Switched to – IV AugmenBn 1.2g q8h – oral Azithromycin 500mg daily
Day 5 a&er symptom onset (admission)
Case 1 • Sputum culture:
– WBC: 3+, commensals
• NPA: – negaBve for respiratory
viruses by direct immunofluorescence
• Blood culture: – no growth (taken aher 3 days of
AugmenBn / Azithromycin)
Day 7 a&er symptom onset (hospitalized)
• Persistent fever without clinical/radiological improvement despite 6 days of AugmenBn & Azithromycin
• OpBons? 1. Start Meropenem
2. Start Doxycycline 3. Start TB treatment (HREZ) 4. Start oseltamivir 5. ConBnue with current
treatment
Oral AugmenBn/ IV AugmenBn
Oral Azithromycin
0 1 2 3 4 5 6 7 8
• Persistent fever without clinical/radiological improvement despite 6 days of AugmenBn & Azithromycin
• OpBons? 1. Start Meropenem
2. Start Doxycycline 3. Start TB treatment (HREZ) 4. Start oseltamivir 5. ConBnue with current
treatment
• Given piperacillin-‐tazobactam & doxyccycline – Rapid resoluBon of symptoms
• Ix: – NPA PCR for Mycoplasma
pneumoniae: posiBve – Mycoplasma pneumoniae serology
• <10 (D5) à 1280 (D21) • Macrolide resistance marker found:
A2063G mutaBon
Oral AugmenBn/ IV AugmenBn
Oral Azithromycin
0 1 2 3 4 5 6 7 8
Case 1
Doxycyline
Azithromycin
AugmenBn
J Infect Chemother. 2010 Apr;16(2):78-‐86.
The problem of MRMP
J Infect Chemother. 2010 Apr;16(2):78-‐86
MRMP rate in the world • China: 70%-‐90% • Taiwan: 23% • Japan: 87.1% (children) • US: up to 18% • Europe: up to 26%
Clin Infect Dis. 2012; 55(12):1642–9 Pediatr Pulmonol. 2012 Nov 20. doi: 10.1002/ppul.22706.
MMWR Morb Mortal Wkly Rep. 2012 Oct 19;61:834-‐8 J AnBmicrob Chemother. 2011 Apr;66(4):734-‐7.
Hong Kong Lung DC et al. Hong Kong Med J. 2011 Oct;17(5):407-‐9.
Clinical implications:
• Longer Bme to resoluBon of fever • More persistent symptoms/signs • Longer duraBon of anBbioBcs • Higher bacterial load
Rapid effecBveness of tetracyclines
Tetracyclines be>er than quinolone
Clin Infect Dis. 2012; 55(12):1642–9
Case 2 • M/30 months • Good past health • All vaccinaBons up-‐to-‐date, received
a dose of pneumococcal conjugate vaccine (private pracBBoner)
• Travelled to Singapore 31/3 – 8/4, – Transit at Vietnam on 31/3 (3h
at departure hall) – Mosquito bite on 5/4
• 6/4: Fever to 40℃ with occasional dry cough
• 8/4: Given ventolin for symptom at HKSH outpaBent
• 10/4: persistent fever, no symptom improvement à AdmiKed to HKSH – started on AugmenBn
9/4 13/4
WCC 11.87 2.66
ANC 5.54 0.48
Lym 4.08 1.38
Aty Lym -‐ 5%
Plt 285 183
9/4, 13/4 Blood culture: sterile 13/4 Throat Swab: normal flora 14/4 -‐ Mycoplasma IgM: neg -‐ Dengue virus IgM/IgG: negaBve
13/4 CXR: Right pleural effusion � US-guided pleural aspiration
� Turbid fluid: c/st negative � Wcc 5346, Rbc 3000, ADA 71.5 � Protein 34.9, pH 8.0
� Augmentin à Cefepime
Transferred to QMH 18/4 18/4 CT thorax at HKSH
– ConsolidaBve changes at RML and RLL with associated loss of volume.
– Early change of necroBzing pneumonia has to be considered
– Moderate right pleural effusion with no mediasBnal shih
– Prominent pre-‐carinal LN up to 0.6x1.3cm
9/4 13/4 18/4 WCC 11.87 2.66 11.68 ANC 5.54 0.48 3.62 Lym 4.08 1.38 7.48 Atyp lym 5% Plt 285 183 566
Day 13 a&er symptom onset (Day 2 a&er admission to QMH)
18/4: Blood culture: sterile MSU: no growth NPA x respiratory virus IF: negative ASOT <100 Legionella antigen: negative Melioidosis serology: T/F EMU, Gastric aspirate: AFB smear negative US-guided pleural drainage: Right pleural effusion with internal echoes and incomplete septation, measuring <1cm in thickness, with thickest part 1.4cm Fluid appearance: Turbid pH 7.0, fluid protein 56.0 LDH 606, TCC 6925, neutrophil 70% AFB smear negative, TB-PCR Gram stain: no organisms seen Bacterial culture: sterile
Antibiotics: Augmentin 10-13/4, Cefepime 13-18/4 Fortum, Vancomycin, Azithromycin 18/4
Case 3 What further investigations could be done?
Pleural fluid Urine
…confirmed with PCR of pleural fluid!
Diagnosis: S pneumoniae pneumonia with parapneumonic effusion
• Complicated Pneumococcal pneumonia: – Sputum culture: non-‐specific – Blood culture posiBvity: <10-‐
20% – Pleural effusion
• Direct examinaBon: sensiBvity 70-‐74%
• Low culture sensiBvity • previous anBbioBc use (>90% in paBents with parapneumonic effusion)
Detects C-polysaccharide wall antigen of S. pneumoniae
CSF Urine Sensitivity 95.4% 57.1% Specificity 100% 86.3% PPV 100% 15% NPV 99.7% 97.9%
• Cross-‐reacBvity reported in: – Streptococcus viridans,
Enterococcus faecalis (PF) Porcel et al. Chest. 2007;131:1442-‐1447
– Streptococcus oralis (CSF) Alonso-‐Tarrés C et al. Lancet. (2001)13;358(9289):1273-‐4.
– Streptococcus sanguis, S miNs (PF) Flores et al, Eur J Pediatr (2010) 169:581-‐584
– Streptococcus oralis – Streptococcus salivarius (PF) Ploton
et al. Pathol Biol.(2006)54:498-‐501
Pros Easy to perform Less affected by antibiotics treatment Bedside test Rapid
Cons Antibiotics susceptibility cannot be done Serotyping not possible Cost ($1500 for 12) Cross-reactivity
Case 3 • Elderly male, NS/social drinker, • PH: hypertension X 30yr, DM for
15 yr now on insulin, mild coronary artery disease (LAD), hyperlipidemia, gout
• Chronic renal failure on CAPD • Acute onset of fever and
shortness of breath for 1 day, given two doses of ciproxfloxacin 250mg q12h by family physician. He had no bowel moBon for one day.
• Referred to QMH with worsening of symptoms
• Drug list: – Cadura 1mg bd – Adalat GITS 90mg bd – Betaloc 75mg bd
– Hydralazine 75mg tds – Lipitor 20mg nocte – CaCO3 2000/1000mg bd with meals – Renagel 1200mg bd – Lanthanum carbonate 500mg bd – Mircera 50 micrograms q10days – Lasix 120mg daily – Natrilix SR 1 tab daily – NaHCO3 900mg daily – CarBa 100mg daily – ForBfer 1 tab daily
Case 3 • PaBent given IV AugmenBn 1.2
gm q12h aher blood culture by nephrologist
• Though no coffee ground or melena, upper endoscopy by gastroenterologist because Hb dropped from 11 (last blood checking at OPD) to 7
• Endoscopy aborted because of desaturaBon to 70%; RR 30/min. Admit to ICU by intensivist;
• Had diarrhea 7X watery in 24hr aher admission
• Consulted microbiologist/ID Day 4 after symptom onset
(admission)
Case 3 • Microbiology & ID:
– Temp: 39 C, p – BP 160/90, RR 25/min – P: 120/min, irregular (80 regular aher
digoxin/amiodarone) – SaO2: 70% on room air; 95% while on CPAP – Slow mentaBon, pallor+, facial puffiness,
bilateral ankle edema, scratch mark+ – No exit site erythema or tunnel tract /
abdominal tenderness, PD fluid clear; – Decreased air entry to leh posterior chest;
coarse inspiratory crepitus • Hb 7.5, WBC 8.6, N 7.4, L 0.65, Plt 160, • Urea 36.2, Cr 1299, Na 135, K 5.1, A/G
28/33, ALP 34, ALT 13, AST 28, Ca 2.1, PO4: 1.68
• LDH 405(221), troponin 0.21 (N<0.5 AMI), CPK 131 (355)
• RetrospecBve quesBoning: history of travel to a Hotel and zoo for 1 day(9 Dec) in Guangzhou 6 days before admission(18 Dec)
Day 5 after symptom onset
Case 3 • RecommendaBons:
1. Microbiological workup for causes of acute community acquired typical & atypical pneumonia with history of zoonoBc contact in a uraemic paBent on CAPD
2. Empirical IV levofloxacin 0.5 gm q48h, meropenem0.5gm q24h, one dose zanamivir 0.6 gm Bll anBgenuria & viral PCR back
3. Acute leh heart failure: draw fluid out by increased PD Day 6 after symptom onset
(LLZ consolidation despite dialysis)
InvesBgaBons & what to do next? • Blood culture: negaBve • Cold aggluBnin: negaBve
• Sputum not produced Bll day 4 aher admission (21 Dec) • NPA viral anBgen by IF: negaBve (19 Dec) • Resplex II RT-‐PCR for 10(16) viruses: influenza A(M, pH1, H3), and B, adenovirus,
parainfluenza 1-‐3, respiratory syncyBal virus A and B, human metapneumovirus, human rhinovirus. coronavirus (229E, OC43, NL63, HKU1), coxsackie/echo virus, bocavirus and adenoviruses (B, E): negaBve
• Urine anBgen EIA(Binax) for legionella pneumophila serogroup1 & streptococcus pneumoniae C polyssacharide: negaBve (20 Dec)
• Urinalysis: proteinuria 100mg/dL; glucose: 250mg/dL; occult blood: small; RBC: <30/ul
• Stool culture & clostridium difficile cytotoxin: negaBve • PD fluid: normal cell count & culture negaBve
Recent travel, acute CAP, diarrhea: Real-‐Bme PCR for legionella pnemophila 22 Dec 2011
NPA on Day 1 & Sputum sample on Day 4 are posiBve; Stop meropenem & zanamivir; ConBnue levofloxacin alone; NoBfy epidemiologists of CHP
Legionella antigenuria EIA: negative 2X; Early use of ciprofloxacin? Renal failure & inability to concentrate bacterial antigen?
No response to Beta-‐lactams; Respond to Fluoroquinolones Marcolides Tetracyclines by 2 to 3 days;
*
*
Legionellosis in what host
• Risk factors for Legionnaires‘ disease include 1. increasing age, 2. smoking, 3. male sex, 4. chronic lung disease, 5. hematologic malignancies, 6. end-‐stage renal disease, 7. lung cancer, 8. immunosuppression, 9. diabetes and 10. HIV/AIDS
• Health advice to paBents with immunosuppressed condiBons: 1. eat and drink boiled items, 2. use sterile or off-‐boiled water for nebulizers, 3. rinse mouth with off-‐boiled water, 4. flush iniBal stream and avoid nebulizaBon 5. consider inline bacterial filter in very immunosuppressed
hosts