Objectives for Community Acquired Pneumonia Discussion

Learner Version

Module #18 Created by Wendy Gerstein 11/13

Objectives :

See facilitator version

References:

See facilitator version CASE HPI: Patient is a 75 yo male with history of COPD (FEV 1 70%, not on home oxygen) and hypertension who presents to the ER with a 3-4 day history of worsening cough with some production of greenish phlegm. He also complains of lack of energy and appetite with decreased oral intake, and has had some chills but no obvious fever. Denies CP, but has some SOB with exertion. He denies GI or GU symptoms, and has no headache or neurological complaints. He denies significant weight changes or leg swelling. He is not up to date on immunizations. He denies sick contacts, but did travel recently to southern California to see his brother. In the ED bp 104/54, p 108, RR 20, T 37, 85% RA, 96% on 2 liters. Exam notable for crackles LLL with egophony, mild prolonged expiratory phase bilaterally; rest of exam unremarkable. Labs significant for wbc 13,400, Na 132, K 3.8, Cl 98, HCO3 25, Bun 20, creatinine 1.1, glucose 96. LFT’s normal, UA normal.

What is your initial assessment?

Possible sources of infection?

What is your initial management step?

CXR shows a dense LLL infiltrate with air bronchograms.

What is your initial treatment plan? How would you determine the patient’s severity of illness as well as the appropriate disposition?

What possible outpatient medications can you use for treatment of CAP on discharge from hospital?

After 2 days patient is discharged to home on oral antibiotics and oxygen and is doing better but then 5 days after discharge he develops severe cough with purulent sputum, high fevers, and pleuritic CP. In the ED he is noted to have fever to 38.5, p 120s, bp 90/60. 90% 5 liters, RR 25; CXR shows persistent LLL infiltrate with small effusion and new RUL infiltrate.

What clinical syndrome would be highest on your differential? Can you list 3 or more risk factors for HCAP/HAP?

What organisms are typically implicated in HCAP/HAP?

What is your treatment plan now including antibiotic coverage?

Antibiotic options include:

Do you need to “double cover” for possible resistant GNRs?

MKSAP questions:

ID Question 30;

ID Question 47;

ID Question 50;

ID Question 103; Predictors of morbidity and mortality in pneumonia: CURB-65 and PSI

CURB-65:

 Confusion (based upon a specific mental test or new disorientation to person, place, or time)  BUN > 19 mg/dL  Respiratory rate >30 breaths/minute  Blood pressure <90/60 mmHg  Age >65 years  30-day mortality was 0.7, 2.1, 9.2, 14.5, and 40 percent for 0, 1, 2, 3, or 4 factors.  Patients with a CURB-65 score of 0 to 1 can probably be treated as outpatients; those with a score of 2 should be admitted to the hospital, and those with a score of 3 or more should be assessed for ICU care, particularly if the score is 4 or 5. c. Regardless of predictors, early treatment with antibiotics is associated with improved clinical outcomes. Goal is administration of appropriate antibiotics within 4 hours of triage in ER.

Pneumonia Severity Index (PSI)

Characteristic Points Score Pneumonia Severity Index (PSI) is used to determine a patient's risk of death. The total score is obtained Demographic Factors by adding to the patient's age (in years for men or in years minus 10 for women) the points assigned for Age each additional applicable characteristic. Men: Age in years Women: Age in years - 10 (Data adapted from Fine et al. N Engl J Med 1997; 336; 243-50) Nursing home resident + 10 Coexisting Illnesses Neoplastic disease + 30 Liver disease + 20 Congestive Heart Failure + 10 Cerebrovascular disease + 10 Recommendations Based on total PSI Score Risk Risk Mortality Disposition Renal disease + 10 Score Class Findings on Physical ≤ 50 I Low 0.1% Consider outpatient or Examination observation status Altered mental status + 20 ≤ 70 II Low 0.6% Consider observation or Respiratory rate ≥ 30/min + 20 admit 71-90 III Low 0.9% Consider observation or Systolic blood pressure < 90 mm + 20 admit Hg 91-130 IV Mod 9.3% Admit, consider MICU Temperature < 35° C or ≥ 40° C + 15 > 130 V High 27.0% Admit, consider MICU Pulse ≥ 125 beats/min + 10 Laboratory and Radiographic Findings Admission is recommended for Class I, II and III Arterial pH < 7.35 + 30 patients who are hypoxemic (RA 02 sat of <90%), and patients who have important medical or Blood urea nitrogen ≥ 30 mg/dl + 20 psycho/social contraindications to outpatient care. (11 mmol/1) Sodium < 130 mmol/liter + 20 Glucose ≥ 250 mg/dl (14 + 10 mmol/liter) Hematocrit < 30% + 10 Sa02 < 90%* or Pa02 < 60 mm + 10 Hg Pleural effusion + 10 Total PSI

Post Module Evaluation

Please place completed evaluation in an interdepartmental mail envelope and address to Dr. Wendy Gerstein, Department of Medicine, VAMC (111), or give to Dr. Patrick Rendon, UNM Hospital.

1) Topic of module:______

2) On a scale of 1-5, how effective was this module for learning this topic? ______(1= not effective at all, 5 = extremely effective)

3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:

______

4) Was the attending involved in the teaching of this module? Yes/no (please circle).

5) Please provide any further comments/feedback about this module, or the inpatient curriculum in general:

6) Please circle one:

Attending Resident (R2/R3) Intern Medical student