Dr Carol Chong

2019
 Learning Objectives
• The key learning objectives for this presentation are
• :hThe Key Learning objectives for this presentaiton
are:
1. Identify key points in history for pneumonia and
COPD
2. Identify type of pneumonia
3. Guess CXR changes before CXR is done
4. Determine likely organisms responsible
5. Understand antibiotic choices
The Australian Curriculum Framework objectives aligned with are:
1.Clinical Management - pneumonia
2.Clinical Symptoms

The Safety and Quality National Standard Aligned with are:

Standard 4 – Medication Safety Standard
Standard 8 – Recognising and Responding to Acute Deterioration Standard

• The Australian Curriculum Framework objectives aligned with are:

Case 1
Mr IA, 50 year old previously well man presents from
the community with 1/7 cough, fever, rigors, pleuritic
chest pain over 1 day.
Felt cold assoc with rigors then sweats 24 hrs prior to
admission.
Then cough, left sided pleuritic chest pain and SOB
Fevers continued  px to ED
Case 1
0/E Hypotensive, systolic b.p 70 despite iv fluid
resuscitation
Temp 40 degrees
Tachycardic HR 110, RR 30, sats 98% on 6L O2.
Chest – Bilateral bronchial breath sounds in bases
S1 S2 nil else
CXR
Case 1
CXR
 – Bilateral lower lobe consolidation

Ix –
FBE Hb 15.7 WCC 19.4 (Neutrophils 17.5) Plt 222
CRP 233
ABG: ph 7.40 CO2 32 O2 67 HCO3 19 Sats 94%
LFTs, U+Es Unremarkable
Other investigations
Don’t forget
Blood cultures
Sputum
Case 1 - Diagnosis
What type of CAP – typical
pneumonia is this? Streptococcus
What are the likely pneumoniae (classic
organisms? history)
Severity of pneumonia? Other possibilities- H.
Treatment influenza, moraxella

Severity: can calculate

PSI
Pneumococcal pneumonia
Classic Sx: Abrubtly ill,fever, rigors cough, pleuritic
pain.
SUDDEN and dramatic onset is typical.
Consolidation on CXR
Treatment options:
i.v benzylpenicillin 1.2g iv qid or ampicilllin 1g iv qid
i.v ceftriazone 1g iv daily
Oral amoxycillin, amoxycillin +clavulanic acid (if mild),
cefuroxime
Severity Assessment
Guides treatment, predicts prognosis.
Pneumonia Severity Index - developed in a cohort of
14,199 patients, validated in over 38,000 patients.
5 risk groups
Scoring system

Fine et al, NEJM, 1997, 336(4):243-250

Characteristic Points
Age
Men Age (years)
Women Age (years-10)
Nursing home resident 10
Coexisting illness
Neoplastic disease 30
Liver disease 20
Congestive heart failure 10
Cerebrovascular disease 10
Renal disease 10
Physical examination findings
Altered mental status 20
Respiratory rate >30 minute 20
Systolic blood pressure <90mmHg 20
Temperature <35 or >40°C 15
Pulse >125/minute 10
Laboratory and radiographic findings
Arterial pH <7.35 30
Blood urea nitrogen >30mg/dL 20
Serum sodium <130mmol/L 20
Serum glucose >250mg/dL 10
Hematocrit <30% 10
Partial pressure of oxygen< 60mmHg 10
Pleural effusion 10
 PSI Class Mortality
Score
<51 I 0.1%
MILD

51-70 II 0.6%

MODERATE
71-90 III 0.9%

91-130 IV 9.5%

SEVERE >130 V 26.7%

 Severity Assessment
British Thoracic Society
American Thoracic Society
guidelines guidelines
2 core or 1 core +add 1 major or 2 minor
 CURB  Major: Septic shock or
 Core: Confusion, Urea need for ventilation
>7mmol, RR>30, B.p<90sys or  Minor: multilobar disease,
<60dias b.p<90sys or <60 dias
 Add: multilobar disease,  PaO /FiO ratio <250
2 2
PaO2<8kPa or Sats<92%
Nierderman et al, Am J Respir
Crit Care Med, 2001, 163:645-
Guidelines of the British Thoracic 651
Society, Thorax 2001, 56:38-47
Mod-severe CAP
Our patient: Mod-severe CAP
Treated with iv ceftriaxone and iv azithromycin given
severity.
Admitted to ICU for inotropic support.
Improved clinically after 5 days
ID r/v
Changed to oral amoxil 500mg o tds and d/c home
Antibiotics
S. H. G Atypical
pneumon influenza negatives
ia
Benzylpenicillin YES YES No No

Ampicillin YES YES No No

Ceftriaxone YES YES YES No

Azithromycin No No No YES
Case 2
Mrs JA, 60 year old previously well female presents
with 2 weeks of cough, lethargy, loss of appetite, some
shortness of breath and fever.
Case 2 - Diagnosis
What type of pneumonia
is this?
What are the likely
organisms?
Additional Q’s to ask pt?
Any special additional
tests?
Likely CXR findings?
Treatment
Case 2 - Diagnosis
What type of pneumonia CAP – atypical
is this? Mycoplasma, Legionella,
What are the likely chlamydia psittici or
organisms? Strep pneumoniae
Additional Q’s to ask pt? Birds, anyone else unwell?
Any special additional Legionella urinary antigen
tests? (only detects serogroup 1),
Likely CXR findings? atypical serology
Treatment CXR – likely worse than
symptoms
 Diffuse patchy infiltrates
 Often bilateral
Treatment
Depends on severity
Atypical cover is crucial

Antibiotics:
Doxycycline 100mg o b.d or
Roxithromycin 150mg o b.d
If mod-severe give i.v:
Azithromycin 500mg iv daily
( or erythromycin)
Duration of treatment: longer than typical
pneumonia – 2-3 weeks.
Case 3
75 year old smoker with known COPD presents with
3/7 of increasing SOB
What other important pieces of information do you
want to know as the consultant on the post-take ward
round?
Important pieces of information
Severity of COPD – Ex tolerance/ functional status,
RFTS
FEV1 (in litres then percentage)
FER
TLCO
Any ICU admissions, BIPAP before?
On Oxygen at home?
On steroids?
Current symptoms – infective or not. Other causes
eg. CCF, PE?
RFTS (the key to diagnosis)
FEV1 – if less than 1.0 Litre this is severe
Mild 50-75%, mod 35-50%, severe <35%
FVC – helps to determine if obstructive or restrictive
deficit.
FER – ratio if reduced = obstructive
TLCO – helps to diagnose any problems with the gas
exchange barrier eg. emphysema.
You’re the ED intern
Pt brought in by MAS straight into resus 2
Very SOB at rest. MAS tell you about hx of COPD,
worse over the last 3 days.

Management
Stabilise the patient first
Airway
Breathing
Circulation

Pt is breathing, RR 40, using access muscles

Pulse 120 sinus rhythm, sats 80% on RA
What now?
Airway, breathing, Circ
Sats 80% (hx of COPD)

Treat hypoxia first then worry about hypercapnia.

Best way to manage hypoxia in the setting of COPD…
BIPAP
Bilevel positive airway pressure
Settings – usually start at 10 (insp) /5 (exp)
Biphasic/bilevel as a mode of ventilation was first presented in
1988 by Professor Benzer of Innsbruck and his group. His theory
consisted of alternating PEEP levels.[6] This was the first time
the acronym BIPAP was used and was followed in 1989 with the
publication of a new approach to ventilatory technique[7] by
Baum & Benzer which was also the first full year of commercial
introduction of "Biphasic Positive Airway Pressure" as an
integrated mode of ventilation on the Evita ventilator. This
concept was introduced as a positive adjunct to weaning from
ventilator support.
BIPAP
You put the BIPAP on – pt’s sats increase to 88%
What else will you do now…
History
Examination – listen to the chest, rule out other
diagnosis
Investigations
Investigations
CXR
ABG – key

Bloods FBE, U+E, CRP, LFTs

Blood cultures, sputum
Results
CXR – looks clear, hyperinflated lungs
Blood tests – WCC 19.0, Crp 300

ABG
Management of Infective Exac of
COPD
ABC
Steroids – prednisolone versus hydrocortisone
Bronchodilators and preventors
Ventolin 5mg/ Atrovent 500mcg/ N saline 5 mls 4-6/24
or qid
Seretide inhaler
What are the common bacteria involved?
Antibiotics – what will you use and why?
COPD bacteria
The most commonly isolated species are nontypable
Haemophilus influenzae, Streptococcus pneumoniae,
and Moraxella catarrhalis. About half of exacerbations
yield positive sputum cultures, and the isolation rate
may be increased by the selection of purulent
samples.

Am J Respir Crit Care Med Vol 172. pp 147–148, 2005

Haemophilus
Influenza
Gram negative
rod
Wikipedia facts:
 Haemophilus influenzae, formerly called Pfeiffer's bacillus or
Bacillus influenzae, is a Gram-negative, rod-shaped bacterium first
described in 1892 by Richard Pfeiffer during an influenza pandemic. A
member of the Pasteurellaceae family, it is generally aerobic, but can
grow as a facultative anaerobe.[1]
 H. influenzae was mistakenly considered to be the cause of influenza
until 1933, when the viral etiology of the flu became apparent; the
bacterium is colloquially known as bacterial influenza. Still, H.
influenzae is responsible for a wide range of clinical diseases.
 H. influenzae was the first free-living organism to have its entire
genome sequenced. The sequencing project was completed and
published in 1995.
H. influenzae
Moraxella Catarrhalis – gram
negative diplococcus
Antibiotics
S. H. G Atypical
pneumon influenza negatives
ia
Benzylpenicillin YES YES No No

Ampicillin YES YES No No

Ceftriaxone YES YES YES No

Azithromycin No No No YES
Steroid conversions
Dexamethasone mg =
Methylprednisolone mg =
Prednisolone mg =
Hydrocortisone mg =
Cortisone mg
Steroid conversions
Dexamethasone 1mg =
Methylprednisolone 4mg =
Prednisolone 5mg =
Hydrocortisone 20mg =
Cortisone 25mg
Case 4
75 year old man 6/7 post laparotomy with 2/7
worsening hypoxia now requiring high flow oxygen.
Was in ICU post-op with abdominal sepsis.

Type of pneumonia
Organisms to cover …
Case 4
Type of pneumonia HAP
Organisms to cover Bacteria– typical S.
pneumoniae
Gram negatives -
Klebsiella pneumonia,
E.coli, proteus, serratia
G –ve: Pseudomonas
aeuriginosa
Staph Aureus MSSA and
MRSA
Nosocomial pneumonia
Not incubating at time of admission
Develops in patient hospitalised longer than 48 hrs.
Most occur by microaspiration of bacterial colonising
oropharynx or upper GIT
Colonisation of oropharynx with aerobic G- bacilli
and exposure to multiresistant pathogens eg MRSA.
Antibiotic options
Ceftriaxone
G+ and G - cover
Timentin or Tazocin or meropenem
G+ and G- cover + MSSA cover
Worried about MRSA
Add in vancomycin
Worried about pseudomonas – dual G- cover.
Case 5
Beryl, 82 year old lady from nursing home px to ED
with increasing SOB, cough, sputum over 1 week.
PMHx:
COPD – ex-heavy smoker, multiple exac requiring
hospital admission over 10 years. No prev ICU
admissions. No NIV
Stroke
Case 5
Sx: Cognitively intact. Wheelchair bound.
Continent. Supportive children.
0/E Afebrile, Sats 85% R.A, 92% on 3L 02, b.p 140/70,
RR. 40, pulse 100, T 36.
Speaking in words. Alert. Appropriate.
Chest – Bibasal crackles lower right chest. Reduced
airentry.
Case Study 5
Ix:
 WCC 12.6, CRP 210, U+E: NAD, LFTs: Alb 30, rest
NAD.
CXR:
 Patchy consolidation right lower lobe.

Severity - Prognosis
Organisms
Antibiotic options
Characteristic Points
Age
Men Age (years)
Women Age (years-10)
Nursing home resident 10
Coexisting illness
Neoplastic disease 30
Liver disease 20
Congestive heart failure 10
Cerebrovascular disease 10
Renal disease 10
Physical examination findings
Altered mental status 20
Respiratory rate >30 minute 20
Systolic blood pressure <90mmHg 20
Temperature <35 or >40°C 15
Pulse >125/minute 10
Laboratory and radiographic findings
Arterial pH <7.35 30
Blood urea nitrogen >30mg/dL 20
Serum sodium <130mmol/L 20
Serum glucose >250mg/dL 10
Hematocrit <30% 10
Partial pressure of oxygen< 60mmHg 10
Pleural effusion 10
Case 5
Type of pneumonia Treat like CAP + HAP
Organisms Strep
Atypicals
Gram negatives –
Klebsiella pneumonia,
E.coli,
G –ve: Pseudomonas
aeuriginosa
Staph aureus (MSSA)
MRSA
MICROBIOLOGY in the elderly
Organism not identified in 50%
Commonest = Strep pneumoniae
(CAP up to 58%, Nursing home
acquired up to 30%)

Ruiz et al, Am J Respir Crit Care Med, 1999, 160:397-405

Kaplan et al, Am J Respir Crit Care Med, 2002, 165:766-772
Zalacain et al, Clinical Pulmonary Medicine, 2004, 11(4):210-218
Author Year Number of Microbial Agents (%)
patients

Venkatesan et al 1990 73 Streptococcus pneumoniae (30%)

Haemophilus influenzae (7%)
Influenza B virus (7%)

Riquelme et al 1996 101 Streptococcus pneumoniae (36%)

Chlamydia pneumoniae (17%)
Coxiella burnetti (11%)

Garcíá-Ordoñez et 2001 343 Streptococcus pneumoniae (42%)

al Haemophilus influenzae (19%)
Legionella pneumophilia (10%)

Zalacain et al 2003 503 Streptococcus pneumoniae (49%)

Haemophilus influenzae (14%)
Legionella pneumophilia (10%)

Fernández-Sabé et 2003 305 Streptococcus pneumoniae (23%)

al Aspiration (10%)
Haemophilus influenza (5%)
 Case 5
Antibiotic options
Ceftriaxone + azithromycin

S. H. G Atypical
pneumo influenza negatives
nia
Benzylpenicillin YES YES No No
Ampicillin YES YES No No
Ceftriaxone YES YES YES No
Azithromycin No No No YES
Case Study 5
Progress: Next 3 days, reduced oral intake, speech Ax
– thickened fluids, iv therapy commenced
Tachypnoea persisted. Cognition remained intact.
No change in vital signs.
Day 4: CRP increased to 250, WCC 21.
Case Study 5
CXR – Worsening of consolidation. Now right lower
and mid zones.
Maintained sats with 2 L 02, RR 40, afebrile.

What antibiotic options are available?

What bacteria aren’t we covering?
 G+ G- Atypical MSSA MRSA Pseudo
S. E.Coli monas
pneum Klebs
Penicillin YES N N N N N
Ceftriaxone YES YES N N N N
Azithromycin N N YES N N N
Timentin YES YES N YES N YES
Tazocin YES YES N YES N YES
Flucloxacillin N N N YES N N
Vancomycin YES N N YES YES N
Meropenem YES YES N YES N YES
Ciprofloxacin N YES N N N YES
Adding in antibiotics
Staph aureus
-add in flucloxacillin or vancomycin (if MRSA
suspected)
-or timentin or tazocin (cover G+,G-,MSSA)
-or meropenem (G+,G-,MSSA)
Sputum grows pseudomonas:
Dual pseudomonal cover:
Eg. Timentin + ciprofloxacin (or gentamicin) or instead
of timentin use 4th generation cephalosporin (cefepime,
ceftazidine) (beware only oral agent – keep in reserve)
or meropenem
Case Study 5
Ceftriaxone + Azithromycin:
About to be changed to
timentin +azithromycin or
Ceftriaxone + azithromycin +flucloxacillin

But…
Case Study 4
Patient requests withdrawal of medical therapy.
Palliative care provided.
Morphine relieves dyspnoea.
Dies on Day 10
Case 6
Mr RM, 82 year old inpatient for 1 week with right
MCA infarct found to be hypoxic and febrile.

Likely aspiration pneumonia

Antibiotic choices …
Antibiotics
Ceftriaxone is good enough
(even benzylpenicillin would do if aspiration in the
community – now in hospital cover G+ and G-)

Use metronidazole for anaerobic infections below the

diaphragm
Aspiration pneumonia
Commonly due to bacteria that normally reside in
upper airways and stomach
True aspiration pneumonia- caused by less virulent
bacteria (normal flora) in susceptible host prone to
aspiration
Aspiration – usually ANAEROBIC bacteria residing in
gingival crevices
Compared to CAP – slower tempo of disease
Aspiration
CXR –
involvement of dependent segments
Anaerobic bacteria – difficult to isolate esp after
inception of antibiotic treatment
Major pathogens:
Peptostreptococcus, fusobacterium, prevotella,
bacteroides, G-
Aspiration in hospitalised patients
Often a mixture of anaerobes and gram negative
bacilli or staph aureus.
Higher frequency of aerobic pathogens colonising
upper airway.
Therefore, metronidazole should not be used
alone since monotherapy assoc with 50% failure
rate.
Concurrent presence of aerobic and microaerophilic
strept not covered by metronidazole
Should be combined with penicillin if used.
Case 7
70 year old man with history of bronchiectasis
presents with productive green sputum and fever.

Sputum result from G.P = Pseudomonas

Pseudomonas
Sputum grows pseudomonas:
Dual pseudomonal cover:
Eg. Timentin + ciprofloxacin (or gentamicin) or instead
of timentin use 4th generation cephalosporin (cefepime,
ceftazidine) (beware only oral agent – keep in reserve)
or meropenem
Take home messages
Identify type of pneumonia:CAP vs HAP, typical vs
atypical
CAP: Usually S. pneumonia – acute Px
Atypical pneumonia: insidious onset
CAP: Often cover both typical and atypical
COPD: Need to cover G- haemophilus and moraxella
HAP – don’t forget G – or Staph
NH acquired – bigger spectrum than CAP
Pseudomonas – dual cover needed