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ELEANOR PAGLIA, MD Pneumonia

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Page 1: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

ELEANOR PAGLIA, MD

Pneumonia

Page 2: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

NO DISCLOSURES

Page 3: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Medical Case

75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted to have worsening shortness of breath with ambulation as well as cough (nonproductive). Today fever to 101.4.

PMHx:HTNHLPParkinson’s Disease

Page 4: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Goals

Review MD approach to pneumonia diagnosis

Understand the gap between MD thought process and CDS thought process

Review the most common types of in-hospital pneumonia

Hints on when to query for more specific terminology

Page 5: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Medical Case

Page 6: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Medical Case

Recently admitted to an outside hospital two months ago for a fall and ankle fracture. He spent 2 weeks in STR before returning home. Has been doing well at home with PT/OT and VNA.

Page 7: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Medical Case

Assessment and Plan:(1) Pneumonia – History, exam and

imaging point to this diagnosis. We must consider his recent admission as well as his Parkinson’s Disease in deciding which antibiotics to choose. Will treat with broad spectrum antibiotics in order to cover for HCAP. Will also need to cover anaerobes in addition to the community organisms. Plan to send blood cultures, sputum cultures and follow WBC and temperature curve closely.

Page 8: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Medical Case

Assessment and Plan:(1) Pneumonia – History, exam and

imaging point to this diagnosis. We must consider his recent admission as well as his Parkinson’s Disease in deciding which antibiotics to choose. Will treat with broad spectrum antibiotics in order to cover for HCAP. Will also need to cover anaerobes in addition to the community organisms. Plan to send blood cultures, sputum cultures and follow WBC and temperature curve closely.

Page 9: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Translation Please….

Assessment and Plan:(1) Pneumonia – History, exam and

imaging point to this diagnosis. We must consider his recent admission as well as his Parkinson’s Disease in deciding which antibiotics to choose. Will treat with broad spectrum antibiotics in order to cover for HCAP. Will also need to cover anaerobes in addition to the community organisms. Plan to send blood cultures, sputum cultures and follow WBC and temperature curve closely.

Page 10: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Translation Please….

“consider his recent admission”→ Possible pseudomonas pneumonia→ Possible MRSA pneumonia

“Parkinson’s Disease” “anaerobes” → Possible aspiration pneumonia

“community organisms”→ Possible community acquired pneumonia

Page 11: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Medical Case

DDX (all of these are possible):(1) Community Acquired Pneumonia(2) HealthCare Associated Pneumonia

(HCAP)

Pseudomonas MRSA

(3) Aspiration Pneumonia

Medical Team elects to use Vancomycin, Piperacillin/Tazobactam, Azithromycin.

This combination will treat all possibilities.

Page 12: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Community acquired pneumonia (CAP)

Pneumonia acquired outside of hospitals and extended-care facilities. Patients who have not had exposure to health care system.

Page 13: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Community Acquired Pneumonia (CAP)

PATHOGENSStreptococcus pneumoniaeHaemophilus influenzaeLegionella spp.Moraxella catarrhalisChlamydia pneumoniaeMycoplasmaInfluenza/RSV/Parainfluenza

Page 14: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Streptococcus Pneumoniae

Page 15: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Haemophilus influenzae

Page 16: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Moraxella catarrhalis

Page 17: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Community Acquired Pneumonia(NOT MRSA or pseudomonas)

Fluoroquinolone based regimen: Moxifloxacin Levofloxacin

-OR-

Cephalosporin + Macrolide Ceftriaxone + azithromycin

Page 18: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Healthcare Associated Pneumonia (HCAP)

Identify possible multi-drug resistant pathogens:

Hospitalization for ≥ 2 days in the preceding 90 days

Residence in a nursing home or extended care facility

Home infusion therapy (including antibiotics) Chronic dialysis within 30 days Home wound care Family member with multidrug-resistant pathogen

Page 19: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Healthcare Associated Pneumonia (HCAP)

PATHOGENS Staph aureus: MRSA > MSSA Gram negative bacilli: 

Klebsiella, Enterobacter, Pseudomonas, E.Coli

Similar to HAP (Hospital) and VAP (Ventilator)

Page 20: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Healthcare Associated Pneumonia (HCAP)

PATHOGENS Staph aureus: MRSA > MSSA Gram negative bacilli: 

Klebsiella, Enterobacter, Pseudomonas, E.Coli

Similar to HAP (Hospital) and VAP (Ventilator)

Page 21: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Ventilator-associated Hospital-acquired

Pneumonia that occurs more than 48 hours after endotracheal intubation

Pneumonia that occurs more than 48 hours after admission

Ventilator (VAP) and Hospital (HAP) Pneumonia

Page 22: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Healthcare Associated Pneumonia (HCAP)

PATHOGENS Staph aureus: MRSA > MSSA Gram negative bacilli: 

Klebsiella, Enterobacter, Pseudomonas, E.Coli

Similar to HAP (Hospital) and VAP (Ventilator)

Page 23: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Staphylococcus Aureus

Page 24: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Pseudomonas aeruginosa

Page 25: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Healthcare Associated Pneumonia

MRSA coverage: Vancomycin 15 mg/kg IV q12h (trough >15-20 ug/mL) Linezolid 600 mg IV q12h

http://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540578/all/Vancomycin
http://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540316/all/Linezolid
Page 26: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Healthcare Associated Pneumonia

PLUS Antipseudomonal beta-lactams (IV): Ceftazidime (94%) Piperacillin/Tazopactam (Zosyn)  (96%) Cefepime (91%) Imipenem (95%) Meropenem (95%) Fluroquinolones (Cipro/Levoflox) - (80%)

Page 27: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Antipseudomonal: Anti-MRSA:

Cefepime Ceftazidime Imipenem Meropenem Piperacillin/

Tazobactam

Vancomycin Linezolid

Healthcare Associated Pneumonia

+

Page 28: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Aspiration Pneumonia

Pathogens:Caused by bacteria that normally reside in

the upper airways or stomach.  Community-acquired: mainly anaerobes and

streptococci, consider GNR. Healthcare-associated: anticipate Gram negatives,

Staph aureus +/- anaerobes.

Page 29: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted
Page 30: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Aspiration Pneumonia

Treatment:Clindamycin – covers strep and anaerobesPiperacillin-tazobactam – covers strep and

anaerobes and adds GNR, if need to be covered.

Carbapenem – “big guns”, anaerobes, GPC and GNR

Page 31: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Back to our case…

Page 32: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

CDS Considerations

MDs will often NOT use CDI terms.MD focus is on risk of MDRs.If more than one possible, will treat for

all. Often, sputum is not sent or obtained too

late to be helpful (so treatment is empiric).

Page 33: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

MRSA Pseudomonas

Hospital/STR recently

Vancomycin/Linezolid

GPC on blood CxHCAP/VAP/HAP

Hospital/STRCOPDCystic FibrosisCeftazidimeCefepimePip/Taz (Zosyn)HCAP/VAP/HAP

When to QUERY?

Page 34: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Anaerobic

DementiaNeurologic

ConditionDrugs/ETOHClindamycinPip/Taz (Zosyn)CeftazidimeCefepime

When to QUERY?

Page 35: ELEANOR PAGLIA, MD Pneumonia. NO DISCLOSURES Medical Case 75 yo male presents with fever and shortness of breath. Symptoms began 2 days ago. He was noted

Thank You

Review MD approach to pneumonia diagnosis

Understand the gap between MD thought process and CDS thought process

Review the most common types of in-hospital pneumonia

Hints on when to query for more specific terminology


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