1. Coventry and Warwickshire Pathology Pneumonia SAHD Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists June 2009

2. Coventry and Warwickshire Pathology Four Cases Case 1:

3. Coventry and Warwickshire Pathology Case 1: 67F, presents to A&E PC: SoB, increasing 3/7. Chest pain. Productive cough. PMH: RA on methotrexate, steroids. SH: Lives at home, ex-smoker. –No allergies o/e: P 100, RR 30, BP 170/70, T 38.5C –Coarse creps L base/mid, reduced AE on L

4. Coventry and Warwickshire Pathology Management Diff Diagnoses? Investigations? Admit? Treatment? Blood samples Imaging Microbiology samples CURB-65 score Supportive Rx Specific Rx ?Infection - pneumonia ?PE?CCF?Ca ?Others

5. Coventry and Warwickshire Pathology Blood tests TestResultUnitRef RangeAbnormal WBC 22.68 x10^9/l 4.00-11.00 H Hb 12.0 g/dl 12.0-15.0 Plt 397 x10^9/l 140-400 Neut 19.98 x10^9/l 2.00-7.00 H Lymp 0.95 x10^9/l 1.00-3.00 L C-Reactive Protein 253 mg/L < 11 H Urea18.8mmol/l2.6-6.6H Creatinine269umol/l50-90H Other markers (LFT, TFT, Glucose, Ca 2+ ) normal

6. Coventry and Warwickshire Pathology CXR

7. Coventry and Warwickshire Pathology

8. CURB-65 >11 mmol/l

9. Coventry and Warwickshire Pathology

12. Case 1: Summary Pneumococcal pneumonia / bacteraemia –Predisposition smoker / RA / steroids / Mtx / age –Investigations –Severity score CURB-65 –Appropriate empirical antibiotics –Appropriate targeted antibiotics –Pneumococcal vaccine

13. Coventry and Warwickshire Pathology Case 2:

14. Coventry and Warwickshire Pathology Case 2: 58 M, presents to A&E PC: Cough, SoB, Headache, Diarrhoea. PMH: Nil History: o/e P 90, BP 95/55, RR 26, T 37.4C –R basal creps. Smokes 40/day Tenerife 10 days ago Pigeon fancier Demolition worker

15. Coventry and Warwickshire Pathology Management Diff Diagnoses? Investigations? Admit? Treatment? Blood samples Imaging Microbiology samples CURB-65 score Supportive Rx Specific Rx ?Infection: (holiday / pigeons) ?Asbestos?Ca ?Others Blood culture Atypical serology Legionella Ag

16. Coventry and Warwickshire Pathology Blood tests TestResultUnitRef RangeAbnormal WBC 12.92 x10^9/l 4.00-11.00 H Hb 15.4 g/dl 12.0-15.0 H Plt 284 x10^9/l 140-400 Neut 8.42 x10^9/l 2.00-7.00 H Lymp 1.74 x10^9/l 1.00-3.00 C-Reactive Protein 123 mg/L < 11 H Na128mmol/l135-143L K4.4mmol/l3.7-5.0 Urea12.4mmol/l2.6-6.6H Creatinine108umol/l50-90H ALT105U/l5-38H Bilirubin19umol/l3-20

17. Coventry and Warwickshire Pathology

20. Case 2: Switch to recommended antibiotics: –Erythromycin 500mg qds AND –Rifampicin 600mg bd –14-21 day course. Don’t forget to inform: –Public Health team

21. Coventry and Warwickshire Pathology Case 2: Summary ‘Atypical’ pneumonia – Legionella –History Travel, occupation, smoking, animals Diarrhoea, hyponatraemia –Investigations –Severity score –Appropriate treatment –Public health

22. Coventry and Warwickshire Pathology Case 3:

23. Coventry and Warwickshire Pathology Case 3: 55F, admitted via A&E PC: SoBoE, worsened over 3/7 PMH: Asthma, Emphysema –80 pack year hx, EtOH ++ –Penicillin allergy > Rash Meds: ‘inhalers – a blue one’ o/e RR 22, T 37.5C, P85, BP 110/75 –Cyanotic, tar stains, accessory muscle use –Chest wheezy, crackles throughout

24. Coventry and Warwickshire Pathology

26. Case 3: Steroids Oxygen, BiPAP Salbutamol / Ipratropium nebs Considered for home Oxygen Discharged home Flu / pneumococcal vaccines

27. Coventry and Warwickshire Pathology Complement Fixation Tests (Atypical serology) AntigenAcuteConvalescent Influenza A<1/16 1/16 Influenza B 1/16 1/16 Adenovirus<1/16 1/256 Coxiella<1/16<1/16 Chlamydia 1/16 1/16 Mycoplasma<1/16<1/16

28. Coventry and Warwickshire Pathology Case 3: Summary Patient with COPD and exacerbation –Often no bacterial infection present. –Pneumonia needs to be excluded CFTs / Atypical serology of some help –Retrospective diagnosis Appropriate antibiotics Vaccines for at-risk patients

29. Coventry and Warwickshire Pathology Case 4:

30. Coventry and Warwickshire Pathology Case 4: 83M, admitted 3 weeks ago Run over on pelican crossing SAH, multiple #s Admitted to GCC, deteriorated –Needing more inotropes –Worse saturations, increasing oxygen req. –T 37.8, BP 100/60, WCC rising. Recently had 10/7 of co-amoxiclav and gentamicin for ?UTI

31. Coventry and Warwickshire Pathology

32. Microbiology samples Blood cultures Respiratory sample

33. Coventry and Warwickshire Pathology Recent antibiotics, so d/w microbiology. Meropenem / gentamicin started

34. Coventry and Warwickshire Pathology

35. May represent line infection / colonisation only

36. Coventry and Warwickshire Pathology

37. Case 4: Central line (10 days old) –Changed for a new line –Single dose of vancomycin 1g Meropenem 1g tds –5/7 Rx –Improved slowly Never able to tolerate weaning off ventilator.

38. Coventry and Warwickshire Pathology Case 4: Summary Severe hospital-acquired pneumonia –Predispositions ITU, ventilator, lying flat, head injury –Complicated antibiotic history Misuse of antibiotics lead to resistant organism –Complicated resistant organisms Discuss with microbiology

39. Coventry and Warwickshire Pathology