Lectures Bronchitis and Community acquired pneumonia - Lisa A. Cosimi. M.D

Lectures Bronchitis and Community acquired pneumonia introduce acute bronchitis, bronchitis and management, community pneumonia, pneumonia diagnosis & sputum Gram stain, cause of pneumonia in the community, the guidance of DSA / ATS antibiotics for pneumonia in adults in the community,...
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Lectures Bronchitis and Community acquired pneumonia - Lisa A. Cosimi. M.DBronchitis and Community Acquired Pneumonia Lisa A. Cosimi. M.D. Brigham and Women’s HospitalBeth Israel Deaconess Medical Center Harvard Medical School Case 1• Mrs. Thuy is a 63 year old previously healthy woman who presents to your office for the second time in one week with a cough productive of yellow sputum and rhinorrea that won’t go away. She’s requesting antibiotics because her neighbor told her this would help her to feel better. She has no fever, O2 saturation is normal and her lungs are clear. What do you recommend?a) Azithromycinb) Doxycyclinec) Levofloxacind) Erythromycine) Reassurance that she will begin to feel better soon Acute bronchitis• Definition: Upper respiratory infection associated with cough, lasting less than 2-3 weeks.• Patients may also have symptoms of rhinorrhea, sinus or nasal congestion though not always present Acute bronchitis• Very common• In U.S., 70% of cough presentations• Viral etiology is most common (adenovirus, influenza, rhinovirus, parainfluenza, RSV)• Generally, self limited (1-2 weeks) Bronchitis - Management • Supportive • Seven large randomized, controlled trials and 3 metanalyses showed no benefit of antimicrobial treatment in general populations • Overuse of antibiotics leads to increases in resistance and increased health care costs • Recent reports of association with cardiovascular death with macrolide use – Average risk: 4.7 extra deaths/100,000 treated (Azithro) – Known HTN/CHF/DM: 24.5/100,000Ray et al, NEJM; 2012;366:1881-90Smith et al, “Acute Bronchitis” Cochrane Database 2012 Who/when would you treat?• During documented pertussis outbreaks• Patients with chronic bronchitis• Patients with underlying lung disease (asthma, COPD, heavy tobacco use) Case 2• Mrs. Thuy’s friend, Mrs. Phuong, is obese with diabetes. She comes to see you one month later complaining of 5 days of productive cough with fever, dyspnea and left sided pleuritic chest pain.• On exam she is sitting comfortably. Temperature is 39.7 C, Blood pressure: 122/70, Respirations: 22, Sa02: 96% on room air.• She has crackles at the left base. What do you recommend?a) Azithromycinb) Doxycyclinec) Levofloxacind) Erythromycine) Reassurance that she will begin to feel better soon Should this woman be admitted to a hospital?A. YesB. NoC. Depends on CXR resultD. Depends on the arterial blood gas resultE. Need more informationCXRCommunity Acquired Pneumonia• Top infectious cause of mortality in both the U.S. and in Vietnam• Vietnam – 4% of reported deaths• In the U.S. – 4.8 million cases per year – 50,097 deathshttp://www.cdc.gov/globalhealth/countries/vietnam/http://www.cdc.gov/nchs/fastats/lcod.htm Diagnosis• Clinical – Fever, cough, dyspnea with or without pleuritic pain – Symptoms in elderly may be unusual: fever, confusion, abdominal pain.• CXR: Useful to establish diagnosis when uncertain. Useful in excluding associated findings, especially in the elderly. Routine for all hospitalized patients and most ambulatory patients with suspected pneumonia.• Blood cultures: 13% sensitivity, a marker for high risk patients. Pneumonia Diagnosis Gram Stain & Sputum Culture • Can be useful to direct therapy, but: – 30% pneumonia, non-productive – 14% adequate sputum sample G.S. – 15-30% prior antibiotic therapy – 40-60% “negative” culture results Etiology can be established Sputum Gram Stain and Culture Recommendation• Collect sputum sample if feasible, and especially in hospitalized or immunocompromised patients, but do not delay treatment.• A properly collected specimen should have < 10 epithelial cells per low powered field How an I.D. doc views pneumonia:From Mandell, et al. , Principle and Practice of Infectious Diseases, 7th edition., c/o Joel Katz, M.D.How the rest of the world views Pneumonia: Which antibiotic should you choose? Etiology of CAP (%) Outpatient Inpatient (n=547) (n=6152) ICU(n=1415) Unknown 64.4 48.3 39.7 S. pneumonia 4 20.3 22.5 H. influenza 4 6 5.3 M. pneumonia 15.3 3.9 1.9 C. pneumonia 4.5 Legionella spp. 0.9 3.4 5.9 S. ...