1. Pneumonia Tim Lahey, MD MMSc Associate Professor of Medicine Geisel School of Medicine at Dartmouth

2. Epidemiology Worldwide –5.5M deaths Example: US –64M days of restricted activity yearly –10M physician visits yearly –600K hospitalizations

3. What does the enemy look like?

4. Symptoms of Pneumonia Fatigue98% Cough94% Myalgia85% Fever80% Dyspnea74% Pleurisy is uncommon, but a useful clue if present None are very specific

5. Seeking Epidemiological Clues TB risk factors Travel history Animal exposures Mould risk factors

6. IF symptoms suggestive of pneumonia, focused examination Sx Exam

7. Physical Examination Vitals: Fever, hypotension, tachycardia, tachypnea, hypoxia Lungs: Crackles, dullness to percussion, egophony, whispered pectoriloquy Other:  ’d mentation in elderly. Signs of respiratory compromise. Shock.

8. IF exam suggestive of pneumonia, or patient fragile, chest x-ray Sx Exam CXR

9. IDEALLY No Chest X-ray, No Pneumonia IF CHEST X-RAY UNAVAILABLE Treat immunocompetent or frail patients with highly suggestive history and physical

10. Associated Findings Labs –WBC ↕, left shift –Acidosis if sick –Hypoxia Micro –Sputum culture + plausible pathogen –Blood cultures –Studies for respiratory viruses

11. Sputum Gram Stain Sometimes you see a plausible pathogen + WBC

12. Sputum Gram Stain Sometimes you see a plausible pathogen + WBC

13. Sputum Gram Stain Sometimes you see a plausible pathogen + WBC

14. Approach to Sputum Exam If nothing grows, move on If you see oral flora, move on If you see a plausible pathogen treat it only

15. If at risk for TB (everybody in Haiti), check for TB with sputum AFB smear and (if available) culture especially if persistent, failed routine therapy, upper lobe, or HIV+

16. Chest x-ray

23. Chest X-ray Summary Infiltrate Empyema Abscesses

24. Always be suspicious of TB Upper lobe infiltrate &/or cavitation should intensify that suspicion

25. Always be suspicious of TB Upper lobe infiltrate and cavitation should intensify that suspicion

26. It Takes Judgement Complex presentation Variable manifestations Symptoms ↓ in the most susceptible hosts

27. Pathway to Diagnosis Sx ExamCXRDx Epi Labs Vitals Informs likely causes Inform how quickly to work up and treat

28. Pathway to Diagnosis Sx ExamCXRDx

29. Major Types of Pneumonia to Recognize in Haiti Community-acquired Aspiration HIV-associated TB

30. Community Acquired Pneumonia

31. Bad Community Acquired Pneumonia

32. If pneumonia + shock, cover MRSA (ideally with vancomycin but if unavailable oral options include TMP/SMX and doxycycline)

33. Aspiration Pneumonia Impaired mentation Impaired airway protection Oral anaerobes

34. If you suspect aspiration pneumonia, add coverage for oral anaerobes (options are clindamycin, metronidazole or the use of a beta/lactamase inhibitor e.g. amox/clavulanate)

35. When It’s Not Your Everyday Pneumonia TB Immune compromise Abscess Empyema

36. Pneumonia in Patients with HIV Same culprits as in HIV- negative patients Plus –TB even more likely –CD4<200:  PCP –CD4<100:  cryptococcus –CD4<50: KS, MAC, etc. –BMT: Aspergillus, moulds, Nocardia…

37. PCP Bilateral infiltrates Cystic disease Pneumothorax

38. TB Clues Longer duration symptoms Insidious onset Association with HIV or malnutrition Upper lobe predominance on chest x-ray Poor response to empirical therapy If concern  work up

39. Treatment

40. Bronchitis can present with the same symptoms but no lung infiltrate Don’t offer abx for bronchitis –Education / reassurance –Cough suppression –Albuterol –Delayed rx (?) –Re-evaluation if needed

41. Treatment Tailor treatment to –The kind of pneumonia –The patient Narrow when possible

42. TypeMajor pathogensFirst choiceOther options CAP, mildS. pneumo, atypicals DoxycyclineAzithromycin CAP, admitted to the floor S. pneumo, atypicals Ceftriaxone (CTX)+ doxycycline CTX + azithro OR levofloxacin CAP, severeAs above, S. aureus, GNR Add vancomycin to above AspirationAnaerobesAdd clindamycin or metronidazole or (if sure) treat with amox/clavulanate HIV infectedCAP + PCP, crypto and others depending on CD4 Doxycycline if mild and high CD4 CTX + doxycycline if admitted to floor & high CD4 Add TMP/SMX and look for PCP if CD4<200 especially if bilateral Look farther if sick or CD4 low TB Seek and treat TB

43. TypeMajor pathogensFirst choiceOther options CAP, mildS. pneumo, atypicals DoxycyclineAzithromycin CAP, admitted to the floor S. pneumo, atypicals Ceftriaxone (CTX)+ doxycycline CTX + azithro OR levofloxacin CAP, severeAs above, S. aureus, GNR Add vancomycin to above AspirationAnaerobesAdd clindamycin or metronidazole or (if sure) treat with amox/clavulanate HIV infectedCAP + PCP, crypto and others depending on CD4 Doxycycline if mild and high CD4 CTX + doxycycline if admitted to floor & high CD4 Add TMP/SMX and look for PCP if CD4<200 especially if bilateral Look farther if sick or CD4 low TB Seek and treat TB

44. TypeMajor pathogensFirst choiceOther options CAP, mildS. pneumo, atypicals DoxycyclineAzithromycin CAP, admitted to the floor S. pneumo, atypicals Ceftriaxone (CTX)+ doxycycline CTX + azithro OR levofloxacin CAP, severeAs above, S. aureus, GNR Add vancomycin to above AspirationAnaerobesAdd clindamycin or metronidazole or (if sure) treat with amox/clavulanate HIV infectedCAP + PCP, crypto and others depending on CD4 Doxycycline if mild and high CD4 CTX + doxycycline if admitted to floor & high CD4 Add TMP/SMX and look for PCP if CD4<200 especially if bilateral Look farther if sick or CD4 low TB Seek and treat TB

45. TypeMajor pathogensFirst choiceOther options CAP, mildS. pneumo, atypicals DoxycyclineAzithromycin CAP, admitted to the floor S. pneumo, atypicals Ceftriaxone (CTX)+ doxycycline CTX + azithro OR levofloxacin CAP, severeAs above, S. aureus, GNR Add vancomycin to above AspirationAnaerobesAdd clindamycin or metronidazole or (if sure) treat with amox/clavulanate HIV infectedCAP + PCP, crypto and others depending on CD4 Doxycycline if mild and high CD4 CTX + doxycycline if admitted to floor & high CD4 Add TMP/SMX and look for PCP if CD4<200 especially if bilateral Look farther if sick or CD4 low TB Seek and treat TB

46. TypeMajor pathogensFirst choiceOther options CAP, mildS. pneumo, atypicals DoxycyclineAzithromycin CAP, admitted to the floor S. pneumo, atypicals Ceftriaxone (CTX)+ doxycycline CTX + azithro OR levofloxacin CAP, severeAs above, S. aureus, GNR Add vancomycin to above AspirationAnaerobesAdd clindamycin or metronidazole or (if sure) treat with amox/clavulanate HIV infectedCAP + PCP, crypto and others depending on CD4 Doxycycline if mild and high CD4 CTX + doxycycline if admitted to floor & high CD4 Add TMP/SMX and look for PCP if CD4<200 especially if bilateral Look farther if sick or CD4 low TB Seek and treat TB

47. TypeMajor pathogensFirst choiceOther options CAP, mildS. pneumo, atypicals DoxycyclineAzithromycin CAP, admitted to the floor S. pneumo, atypicals Ceftriaxone (CTX)+ doxycycline CTX + azithro OR levofloxacin CAP, severeAs above, S. aureus, GNR Add vancomycin to above AspirationAnaerobesAdd clindamycin or metronidazole or (if sure) treat with amox/clavulanate HIV infectedCAP + PCP, crypto and others depending on CD4 Doxycycline if mild and high CD4 CTX + doxycycline if admitted to floor & high CD4 Add TMP/SMX and look for PCP if CD4<200 especially if bilateral Look farther if sick or CD4 low TB Seek and treat TB

48. TypeMajor pathogensFirst choiceOther options CAP, mildS. pneumo, atypicals DoxycyclineAzithromycin CAP, admitted to the floor S. pneumo, atypicals Ceftriaxone (CTX)+ doxycycline CTX + azithro OR levofloxacin CAP, severeAs above, S. aureus, GNR Add vancomycin to above AspirationAnaerobesAdd clindamycin or metronidazole or (if sure) treat with amox/clavulanate HIV infectedCAP + PCP, crypto and others depending on CD4 Doxycycline if mild and high CD4 CTX + doxycycline if admitted to floor & high CD4 Add TMP/SMX and look for PCP if CD4<200 especially if bilateral Look farther if sick or CD4 low TB Seek and treat TB

49. * Pneumonia, Simplified

50. What if treatment isn’t working? Signs of failure Fevers, worsening dyspnea, etc. Causes to consider Resistant bug, empyema, metastatic infection, wrong diagnosis

51. Prevention Flu shot Pneumonia vaccination HIV dx and treatment TB infection control and prevention

52. PNEUMONIA SUMMARY SX: cough, dyspnea, fever, pleurisy Ex: crackles, asymmetrical lung exam Dx: chest x-ray, sputum smear/cx (AFB) Tx: if sx + exam + CXR  see table Pr: flu shot, pneumococcal vaccines, TB infection control, HIV treatment

53. TypeMajor pathogensFirst choiceOther options CAP, mildS. pneumo, atypicals DoxycyclineAzithromycin CAP, admitted to the floor S. pneumo, atypicals Ceftriaxone (CTX)+ doxycycline CTX + azithro OR levofloxacin CAP, severeAs above, S. aureus, GNR Add vancomycin to above AspirationAnaerobesAdd clindamycin or metronidazole or (if sure) treat with amox/clavulanate HIV infectedCAP + PCP, crypto and others depending on CD4 Doxycycline if mild and high CD4 CTX + doxycycline if admitted to floor & high CD4 Add TMP/SMX and look for PCP if CD4<200 especially if bilateral Look farther if sick or CD4 low TB Seek and treat TB

54. Questions? Tim Lahey, MD MMSc Associate Professor of Medicine Geisel School of Medicine at Dartmouth Timothy.Lahey@Dartmouth.edu