Intern Survival Series Lecture #6 Most Common Medical Diagnosis: Pneumonia and CHF Shaping the Future of Healthcare | www.thewrightcenter.org
Objectives – Be familiar with the most common primary and secondary diagnosis encountered in medicine – Be able to appropriately work up and treat various types of pneumonia – Be able to identify and appropriately treat CHF Shaping the Future of Healthcare | www.thewrightcenter.org
A Brief Note • This lecture series is not meant to be all inclusive or totally comprehensive to all of medicine • It is not meant to supersede clinical judgment • It is not meant to replace daily reading or bedside teaching • It is meant to act as a starting point for which to grow from as new primary care physicians • It is a tool to help you survive the your new job Shaping the Future of Healthcare | www.thewrightcenter.org
Most Frequent Primary Care, Inpatient Diagnosis • 1)Pneumonia • 2)Congestive Heart Failure • 3)Osteoarthritis • 4)Coronary Artery Disease • 5)Septicemia • 6)Cardiac Dysrhythmias • 7)Chronic Obstructive Pulmonary Disease Shaping the Future of Healthcare | www.thewrightcenter.org
Fastest Growing Inpatient Diagnosis in Medicine • 1)Acute Renal Failure • 2)Anemia • 3)Diabetes Mellitus • 4)Malaise and Fatigue • 5)Pulmonary Heart Disease Shaping the Future of Healthcare | www.thewrightcenter.org
Most Common Secondary Diagnosis • 1)Hypertension • 2)Hyperlipidemia • 3)Fluid and electrolyte disorders • 4)Coronary Atherosclerosis • 5)Diabetes Mellitus • 6)Anemia • 7)Cardiac Dysrhythmias • 8)Esophageal Disorders Shaping the Future of Healthcare | www.thewrightcenter.org
Pneumonia • 2 Broad Categories – Community Acquired Pneumonia – Health Care Acquired/HA Pneumonia Shaping the Future of Healthcare | www.thewrightcenter.org
Community Acquired Pneumonia • Common and potentially serious illness • associated with considerable morbidity and mortality – particularly in elderly patients and those with significant comorbidities • There is seasonal variation Prevalence is greater during the winter months. • • Rates of pneumonia are higher for men than for women • Bacterial vs Viral • Streptococcus pneumoniae is the most common cause of pneumonia worldwide Shaping the Future of Healthcare | www.thewrightcenter.org
Community Acquired Pneumonia • Diagnostic Approach – clinical evaluation • Cough • Fever • Pleuritic chest pain • Dyspnea • Sputum production – chest radiograph – +/- microbiologic testing Shaping the Future of Healthcare | www.thewrightcenter.org
Community Acquired Pneumonia • RADIOLOGIC EVALUATION – The presence of an infiltrate on plain chest radiograph is considered the gold standard – A chest radiograph should be obtained in patients with suspected pneumonia when possible – demonstrable infiltrate by chest radiograph or other imaging technique is required for the diagnosis of pneumonia Shaping the Future of Healthcare | www.thewrightcenter.org
Community Acquired Pneumonia • Radiologic Evidence Shaping the Future of Healthcare | www.thewrightcenter.org
CAP • If the clinical evaluation does not support pneumonia in a patient with an abnormal chest x-ray, other causes for the radiographic abnormalities must be considered – Malignancy – Hemorrhage – Pulmonary edema – Pulmonary embolism – Inflammation secondary to noninfectious causes Shaping the Future of Healthcare | www.thewrightcenter.org
Community Acquired Pneumonia • Obtaining Microbial Evidence • For outpatients with CAP, routine diagnostic tests are optional • Hospitalized patients with specific indications should have blood cultures and sputum Gram stain and culture • Patients with severe CAP requiring ICU admission should have blood cultures, Legionella/pneumococcus urinary antigen tests, and sputum culture – +/- viral panels (rapid infuenza a&b) Shaping the Future of Healthcare | www.thewrightcenter.org
Community Acquired Pneumonia Initial Treatment of non hospitalized patients with out any significant comorbidities – Empiric treatment is the normal – North American Guidelines Recommend macrolides or doxycylcline • azithromycin 500mg PO x 1 day then 250mg PO x 4 days • clarithromycin 500mg PO BID x 5-10 days • doxycycline 100mg PO BID x 5-10 days Shaping the Future of Healthcare | www.thewrightcenter.org
Community Acquired Pneumonia For non-hospitalized patients with comorbidities or recent antibiotic use – fluoroquinolone as monotherapy – combination therapy with a beta-lactam plus a macrolide or doxycycline Shaping the Future of Healthcare | www.thewrightcenter.org
Community Acquired Pneumonia For hospitalized patients not requiring intensive care unit admission • Monotherapy with a respiratory fluoroquinolone • Levaquin most commonly used • Combination Tx w/ an anti-pneumococcal beta-lactam + macrolide – Cetriaxone, cefotamime, unasyn – PLUS – azithromycin, clarithromycin • Coverage for drug-resistant pathogens, such as Pseudomonas or methicillin-resistant Staphylococcus aureus (MRSA), should be included in patients with risk factors Shaping the Future of Healthcare | www.thewrightcenter.org
Community Acquired Pneumonia Hospitalized patients requiring ICU care – combination therapy with an anti-pneumococcal beta-lactam – plus either IV azithromycin or a respiratory fluoroquinolone – plus , if MRSA is suspected, linezolid or vancomycin Shaping the Future of Healthcare | www.thewrightcenter.org
Healthcare-associated pneumonia (HCAP) • Pneumonia that occurs in a non-hospitalized patient with extensive healthcare contact: – Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days – Residence in a nursing home or other long-term care facility – Hospitalization in an acute care hospital for two or more days within the prior 90 days – Attendance at a hospital or hemodialysis clinic within the prior 30 days Shaping the Future of Healthcare | www.thewrightcenter.org
Hospital Acquired Pneumonia • Pneumonia that occurs 48 hours or more after admission • did not appear to be incubating at the time of admission. Shaping the Future of Healthcare | www.thewrightcenter.org
HCAP/HAP • Workup – Very Similar to CAP • Clinical Picture • Radiographic evidence • Blood Culture • Urinary Antigens – Pneumococcal and legionella • CBC, RFP, virus panels, etc Shaping the Future of Healthcare | www.thewrightcenter.org
HCAP/HAP Treatment • Antimicrobial selection should be based upon risk factors for multidrug-resistant (MDR) pathogens – recent antibiotic therapy (if any) – the resident flora in the hospital – the presence of underlying diseases – available culture data Shaping the Future of Healthcare | www.thewrightcenter.org
HCAP/HAP • For patients with risk factors for multi drug resistant pathogens, empiric broad-spectrum, multidrug therapy is recommended. • Once the results of pre-therapy cultures are available, therapy should be narrowed based upon the susceptibility pattern of the pathogens identified Shaping the Future of Healthcare | www.thewrightcenter.org
HCAP/HAP • Commonly Used Intravenous antibiotic regimens – levofloxacin 750mg IV daily – piperacillin/tazobactam 4.5 g IV q 6 hrs • If severely PCN allergic, Aztreonam often substituted – vancomycin 15-20mg/kg IV q 12 • Can use linezolid in place of vanco if needed Shaping the Future of Healthcare | www.thewrightcenter.org
Duration of therapy • De-escalation of therapy should be considered after 48 to 72 hours • De-escalation should be based upon the results of initial cultures and the clinical response of the patient • A short duration of therapy (7 days) is sufficient for most patients with uncomplicated HAP/HCAP who have had a good clinical response Shaping the Future of Healthcare | www.thewrightcenter.org
CHF: A Brief Overview Shaping the Future of Healthcare | www.thewrightcenter.org
NYHA CHF Classification • The New York Heart Association (NYHA). • This system assigns patients to one of four functional classes Class I — symptoms of HF only at activity levels that would limit normal individuals Class II — symptoms of HF with ordinary exertion Class III — symptoms of HF with less than ordinary exertion Class IV — symptoms of HF at rest Shaping the Future of Healthcare | www.thewrightcenter.org
Evolution of CHF (ACC/AHA) Stages in the development of HF Stage A — High risk for • HF, without structural heart disease or symptoms Stage B — Heart • disease with asymptomatic left ventricular dysfunction Stage C — Prior or • current symptoms of HF Stage D — Refractory • end stage HF Shaping the Future of Healthcare | www.thewrightcenter.org
Etiology • Systolic dysfunction – Most common causes: – coronary (ischemic) heart disease – idiopathic dilated cardiomyopathy (DCM) – hypertension – valvular disease • Diastolic dysfunction – Most common causes: – Hypertension – ischemic heart disease – hypertrophic obstructive cardiomyopathy – restrictive cardiomyopathy Shaping the Future of Healthcare | www.thewrightcenter.org
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