How Do I Think About

Pneumonia?
Residents Thursday School
07/25/2013
J Rush Pierce Jr, MD, MPH
Division of Hospital Medicine,
UNM

Outline
Review resources
Case based discussion that will
cover
Diagnosis
Treatment

Based on
IDSA/ATS CAP (2007) guidelines
HCAP/VAP/HAP
(2005) guidelines
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Resources
Guidelines available
UNMH site (
https://hospitals.health.unm.edu/intranet/Index.cfm )
IDSA website guidelines available for download to
Palm or iPhone (
http://www.idsociety.org/Content.aspx?id=9088 )
Up-to-Date (varies some from guidelines)
Sanford Guide generally follows guidelines
Adult Community-Acquired Pneumonia Order Set
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How Do I Think About Pneumonia?

Case 1
65 y/o male smoker has 2 days of chills,
dyspnea, and purulent sputum. He has no risk
factors for HIV, donates blood 3x/year (most
recently one month ago) and does not take any
medications. T = 38.1, BP = 110/60, HR = 95,
RR = 20, SaO2 = 89% RA. Examination shows
no abnormalities. CXR is read as minimal
streaking at lung bases, atelectasis vs. early
pneumonia
Should I treat with antibiotics?

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How Do I Think About Pneumonia?

Does this patient have

pneumonia?
Sensitivity
Specificity

Hx:

Fever/chills

85%

Dyspnea

70%

Purulent
sputum

50%

of above
70 in
90%
40 50%
PE: VSAny
most
useful
predicting
severity
CXR is gold standard - may be normal in up
to 7% on admission; assume pneumonia
present if convincing hx and focal PE
Suspected pneumonia with neg CXR
consider f/u CXR or CT (more sensitive)

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Thinking about pneumonia: 4

steps
1.
2.
3.
4.

Put into initial clinical classification

Decide site of care
Tests for etiology
Initial empiric therapy

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Step 1:
Initial clinical classification
1. Major immunodeficiency
2. Tuberculosis (suspected or established)
3. Relatively normal hosts without TB
(location at time of infection)
Community-acquired (CAP)
Healthcare-associated (HCAP) or Hospital acquired
(HAP) includes ventilator-acquired (VAP)

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Case 2
55 y/o homeless man from Mexico has 2
days of chills, night sweats, dyspnea, and
purulent sputum without hemoptysis. He
has not lost weight. He has no risk
factors for HIV, takes no medications, and
is not diabetic. Exam reveals T = 38.1, BP
= 110/60, HR = 95, RR = 20, SaO2 =
89% RA, crackles at the right base.
Should I order airborne isolation?
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When to suspect TB
(Intern Survival Guide)
If two or more sxs

Hemoptysis
Cough > 2 weeks
Night sweats
Wt loss > 10 # in 3 mos

If suspicious CXR (any

of these)

Upper lobe infiltrates

Miliary pattern
Cavitary lesions
Nodular infiltrate

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Response to suspected TB
Order airborn isolation and
CXR

Order AFB smears, cultures

(does not have to be qAM!)

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Step 1:
Initial clinical classification
1. Major immunodeficiency
2. Tuberculosis (suspected or established)
3. Relatively normal hosts without TB
(location at time of infection)
Community-acquired (CAP)
Healthcare-associated (HCAP) or Hospital acquired
(HAP) includes ventilator-acquired (VAP)

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CAP vs HCAP/VAP/HCAP
Healthcare-associated pneumonia (HCAP)

In hospital > 1 day within past 90 days

Nursing home/SNF/LTAC
Dialysis or outpt hosp within past 30 days
IV antibiotics or chemo, wound care within 30
days
(Family member with MDRO)

HAP occurs > 48 hrs after admission & not

incubating at time of admission
VAP occurs more than 48 72 hrs after
intubation
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Case 2
The patient has never been
hospitalized, resides at home, does
not take dialysi, has not received
chemotherapy, and his spouse has
not been sick

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Step 1:
Initial clinical classification
1. Major immunodeficiency
2. Tuberculosis (suspected or established)
3. Relatively normal hosts without TB
(location at time of infection)
Community-acquired pneumonia (CAP)
Healthcare-associated pneumonia (HCAP) or
Hospital acquired pneumonia (HAP) includes
ventilator-acquired (VAP)

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Thinking about pneumonia: 4

steps
1.
2.
3.
4.

Put into initial clinical classification

Decide site of care
Tests for etiology
Initial empiric therapy

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Case 3
65 y/o male smoker has 2 days of chills,
dyspnea, & purulent sputum. No
significant PMHx. He has felt and eaten
poorly. T = 38.1, BP = 110/60, HR = 95,
RR = 20, SaO2 = 89% RA, crackles at the
right apex. He is not confused. WBC =
15K, H/H = 14.5/42, Na = 128, K = 3.5, Cl
= 105, CO2 = 20. BUN/creat = 32/1.4.
CXR shows RUL infiltrate.
Can I send this patient home?
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07/25/2013

www.meddean.luc.edu
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Pneumonia Severity Index

(PSI)

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CURB-65
Developed by British Thoracic Society
Confusion, BUN >20, Respiratory rate
>30, BP <90 syst or <60 diast, age >64
Score = 0 1 OUTPT
Score = 2 WARD
Score = 3 ICU
Other subjective factors = safely and
reliably take oral meds, availability of
support services
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ICU admission = one major or 3 minor

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Thinking about pneumonia: 4

steps
1.
2.
3.
4.

Put into initial clinical classification

Decide site of care
Tests for etiology
Initial empiric therapy

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Case 3 - continued
65 y/o male smoker has 2 days of chills,
dyspnea, & purulent sputum. No
significant PMHx. He drinks alcohol
everyday. T = 38.1, BP = 110/60, HR = 95,
RR = 20, SaO2 = 89% RA, crackles at the
right base. He is not confused. WBC =
15K, H/H = 14.5/42, Na = 128, K = 3.5, Cl
= 105, CO2 = 20. BUN/creat = 32/1.4.
CXR shows RUL infiltrate.
What etiologic tests do I order?
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Diagnostic tests for etiology

Why not etiologic tests for everyone?
Outpt Get SaO2; Routine tests for
etiology are optional
Inpt - Blood and sputum cultures
recommended for most (but not all)
ICU - blood and sputum cultures, and
Legionella and pneumococcal UAT

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Thinking about pneumonia: 4

steps
1.
2.
3.
4.

Put into initial clinical classification

Decide site of care
Tests for etiology
Initial empiric therapy

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Case 4
24 y/o previously healthy female has
2 days of chills, dyspnea, & purulent
sputum. No significant PMHx. T =
38.1, BP = 110/60, HR = 95, RR =
20, SaO2 = 92% RA, crackles at the
right base. CBNC and Chem 7
normal. CXR = early RLL pneumonia
What antibiotics should I order?
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Empiric Rx of outpatient
CAP
Healthy and no antibiotics in past 3 months
Macrolide OR doxycycline

If cardiopulmonary dz, Beta-lactam rx in

past 3 mos, alcoholism,
immunosuppressive rx, or exposure to child
in day-care
Respiratory quinolone OR
beta lactam (high dose amoxicillin or
Augmentin) + macrolide or doxycycline

Duration of rx = 7 days (may be less with

good response or if use azithro)
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Outpatient RX of CAP
Candidates for outpt therapy
Low PSI or CURB-65
Not crazy
Likely to be compliant, can get meds and F/U

Follow-up
Return if T > 101 or fail to resolve fever in 48
hours
Outpatient visit in 10 14 days
CXR in 1 2 months
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Case 3 - continued
65 y/o male smoker has 2 days of chills,
dyspnea, & purulent sputum. No
significant PMHx. He has felt and eaten
poorly. T = 38.1, BP = 110/60, HR = 95,
RR = 20, SaO2 = 89% RA, crackles at the
right base. He is not confused. WBC =
15K, H/H = 14.5/42, Na = 128, K = 3.5, Cl
= 105, CO2 = 20. BUN/creat = 32/1.4.
CXR shows RUL infiltrate
What antibiotics do you order?
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Empiric Rx of inpatient CAP no

special considerations
Inpatient ward:
respiratory quinolone
OR
(ceftriaxone or ceftazidime) + (azithro or
doxy)

ICU
(ceftriaxone or ceftazidime) + (IV azithro or
respiratory quinolone)
If PCN allergic use aztreonam + respiratory
quinolone
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Empiric inpatient Rx of CAP

special considerations
Pseudomonas
suggestive gram stain, bronchiectasis, freq exacs of
COPD + prior antibiotic rx
Regimens:
(Zosyn or merepenam) + cipro
OR
(Zosyn or merepenam or aztreonam) + aminoglycoside +
respiratory quinolone

MRSA
suggestive gram stain, ESRD, IVDU, prior influenza,
prior antibiotics esp quinolones, or much MRSA in
community
Regimen: Add linezolid OR vancomycin
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Case 3 - continued
65 y/o male 2 days ago with RUL
pneumonia and treated with ceftriaxone
and azithromycin. On rounds is feeling
better, eating, not confused. T = 37.9,
HR = 102, BP = 105/75, RR = 12, SaO2
= 88% on room air
When I can I switch to an oral regimen
and what regimen?
When can the pt go home?
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Switching to oral
If specific pathogen identified, switch to
narrow spectrum therapy
When clinically improving,
hemodynamically stable, able to take orals,
switch to oral rx if no pathogen, often
azithro alone
Duration = at least 5 days, and until
afebrile for two days, and have only one
sign of clinical instability. If pathogen is
Pseudomonas treat at least 14 days
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Timing of discharge

Readmission rate or death: no instability = 10%; 1 instability = 14%; 2+ instabilities = 46%

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Pneumonia before they go

home
Smoking cessation
Vaccination

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CAP Whats New

Increasing recognition of viral pathogens
Consideration of environmental
exposures as risk factor for CAP
Use of PCR (and other tests) to guide
initial antibiotic choice
Use of inflammatory markers to help
with diagnosis and guide therapy
Vaccine efficacy
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Questions?

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Empiric therapy of
HCAP/HAP/VAP with MDR
risk factors
cefepime, ceftazadime, imipenam, or Zosyn
PLUS
ciprofloxacin, levofloxacin, or aminoglycoside

If MRSA concerns add linezolid or

vancomicin

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Switching to oral therapy for

HCAP/HAP/VAP

Pseudo: if sens
cipro +
Aug/doxy/clinda
MRSA:
sensitivities

cipro + Aug/doxy/clinda OR moxi

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Aspiration
When to use: observed/suspected
aspiration + fever or leucocytosis or
infiltrate
Regimens:
Unasyn + (doxy OR azithro)
Augmentin or clinda
Respiratory quinolone
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Non-responding pneumonia
definition (15%)
Progressive pneumonia on CXR with
clinical deterioration, acute respiratory
failure and/or shock occurring in first 72
hours
Delay in achieving clinical stability
Median time = 3 days
require > 5 days

Non-resolution of infiltrate > 30 days

after hospitalization [different problem]
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Clinical response to nonresponding pneumonia

Reevaluate initial microbiologic results consider UAT
Reassess risk factors for infection with unusual
organism
Repeat blood cultures for worsening pneumonia or
clinical deterioration
Look for secondary infections (catheter, urinary, skin)
Get CT to R/O PTE, thoracentesis to R/O empyema,
bronchoscopy to R/O unusual pathogens

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