pneumonia, empyema , and tb

Pneumonia, Empyema, and TB

Meira LouisMargriet Greidanus

Format for Today

• Group work x 30 minutes (3 groups)• Cases as a large group– Case I: Community Acquired Pneumonia– Case II: Health Care Associated Pneumonia– Case III: Para-pneumonic effusion– Case IV: TB

• Questions

Pneumonia

Case I

43 year old male, previously healthy- Cough x 6 days, productive of green sputum- Febrile x 4 days- Now feeling progressively more SOB- No home meds, no allergies

38.0 115 18 130/75 94% ORA

In-patient vs Out-Patient?

PORT score

http://www.mdcalc.com/

CURB-65

Do they work?

What tests?

Which bugs?

Which drugs? outpatient

Which drugs? inpatient

Same as outpatient with

comorbidities!

Which drugs? ICU

Same as outpatient with

comorbidities!

Drugs and special populations

So, when do I worry about the extra coverage?

Time to antibiotics

5Length of antibiotics?

Other things to think about...

Case II

63 yo male, history of COPD, DM, HTN, CHF- Cough x 3 days, productive of yellow sputum- Febrile x 4 days- Now feeling progressively more SOB- Meds: Lasix, ASA, ramipril, insulin- Hospitalized x 5 days for COPD (6 weeks ago)

38.2 83 26 105/64 93% ORA

VS

What’s different about HCAP?

What makes a patient riskier?

• An antipseudomonal cephalosporin or β-lactam (cefepime, ceftazidime, pip-tazo)

• Plus a fluoroquinolone (ciprofloxacin, levofloxacin) • Plus an agent active against MRSA (linezolid or vancomycin)

Empiric Antibiotics for HCAP?

=fluoroquinolone or azithromycin

Para-Pneumonic Effusions

Case III

45yo female, mild HTN, hyperlipidemia- Unwell x few weeks, episodic fevers, cough- Sent in by GP to r/o PE as completed full

course of Azithromycin with no improvement.- Progressive SOB and chest pain

36.5 105 20 145/82 91% ORA

What is it?

When should it be suspected?

How to image?

To treat or not to treat?

So, I poked it, does that help?

When does the pH lie?

If I need to drain, does tube size matter?

TB

Case IV

29yo male, previously healthy- Recently returned from India after 6 month

visit (immigrated several years ago)- Unwell x few weeks, episodic fevers, weight

loss- Completed course of Levofloxacin, no change

37.5 115 22 120/82 92% ORA

Primary TB vs Reactivated TB

10

So, what am I looking for?

Complications of TB

Extra Pulmonary Complications

Neuro

GU

MSK

Cardiac

Renal

GI

Where is the money? CXR!

Primary TB

Ranke

Ghon

Tuburculoma

Milliary

Post Primary TB

All that cavitates...

Treatment!

PIRES

Questions?