SOUTHWESTERN UNIVERSITY MEDICAL CENTER

Post Graduate Internship | Department of Internal Medicine

st Grand
Rounds
PRESENTORS:

Cuadra, Ezekiel
Golero, Roxanne Gail
Tallo, Maverick Humphrey

December 27, 2019

SWU MC Conference Room 1
 Introduction
HPI
Salient Features
Laboratories
Outline Diagnosis
Pathogenesis
Complications
Prevention and Treatment
 OBJECTIVES

GENERAL OBJECTIVE:

To discuss the case of a 77 -year-old male patient

who came in due to difficulty of breathing
 OBJECTIVES

SPECIFIC OBJECTIVE:

To review the pathophysiology, approach &

management of CAP ATS & IDSA updated 2019
guidelines
GENERAL DATA
MN
77 yo Male
Married
Filipino
Roman Catholic
Admitted for the
2nd time
 CHIEF COMPLAINT

Difficulty of Breathing
 HISTORY OF
PRESENT ILLNESS
 (+) productive no consult done
cough
T: 39.8

9
Paracetamol 500
Days PTA mg tab
 (+) blood in
sputum for 4x
episodes

7
condition
Days PTA
tolerated
 (+) night chills
(+)body
weakness
6
condition
Days PTA
tolerated
 (+)vomiting
(+) dyspnea

3
Hrs PTA ADMIT
 PAST MEDICAL HISTORY
Medical
(+) Hypertension (2019)
(+) Diabetes mellitus (2019)
(-) Asthma
(+)PTB (2019)

Medication
1. Rosuvastatin 20mg tab OD
2. Aspirin 80mg tab OD
3. Vildagliptin 500mg tab OD
 PAST MEDICAL HISTORY
Surgery

none

Hospitalization
(+)PTB CDUH Treated 2019
 PERSONAL & SOCIAL HISTORY

smoker for 12 packed yrs

occasional alcoholic beverage
drinker
denies illicit drug use
 FAMILY HISTORY

no known heredofamilial diseases

REVIEW OF
SYSTEMS
 REVIEW OF SYSTEMS

CONSTITUTIONAL

(-) weight loss (+) fever

(+) body weakness (+) night chills

HEENT

(-) blurring of vision, (-)headache

(-) hearing loss, (-)nasal congestion, (-)sore throat
 REVIEW OF SYSTEMS

RESPIRATORY
(+) shortness of breath
(+) cough with bloody sputum

GASTROINTESTINAL
(-) abdominal pain (+) vomiting
(-) nausea (-) loose bowel of
(-) loss of appetite movement
 REVIEW OF SYSTEMS

GENITOURINARY
(-)dysuria, (-)hematuria
(-)increase urine frequency

NEUROLOGICAL
(-) syncope
(-) paralysis
(-)tremors
 REVIEW OF SYSTEMS

MUSCULOSKELETAL
(-)joint pain
(-)stiffness

ENDOCRINOLOGIC
(-) excessive sweating
(-) cold & heat intolerance
(-) palpitations
 PHYSICAL
EXAMINATION
GENERAL

awake, conscious, coherent,

in respiratory distress

VITAL SIGNS
BP 110/60 mmHg
T 35.9 C
HR 81 bpm
RR 25 cpm
O2 sat 92%
HEENT
anicteric sclera, pale palpebral
conjunctiva, no nasal & ear
discharges, moist lips, tongue
midline

NECK

supple, trachea midline, no

apparent masses
 CHEST AND LUNGS
equal chest expansion, (+) crackles
on R lung field, (+) wheeze on
upper lobes

HEART

adynamic precordium, normal

rate, regular rhythm, no murmur
ABDOMEN
flat, normoactive bowel
sounds, soft, non tender, no
organomegaly

GUT

(-)costovertebral angle
tenderness
EXTREMITIES
(-)cyanosis, (+) cold to touch,
weak peripheral pulses, CRT<2
sec,

NEUROLOGIC
GCS 15
Cranial nerves
Cerebral
Cerebellum
Sensory, Motor & Reflexes
 SALIENT FEATURES

(+)PTB (2019)
(+)productive cough with blood
sputum smoker for 12 pack years

dyspnea RR: 25 cpm

fever (Tmax 39.8) O2 sat: 92%

vomiting pale palpebral conjunctiva

(+)body weakness, chills (+) crackles on R lung field, (+)

wheeze on upper lobes
(+) Hypertension (2019)
(+) cold to touch, weak peripheral
(+) DM (2019)
pulses
 ADMITTING
DIAGNOSES

COMMUNITY ACQUIRED PNEUMONIA- MR

COPD

HCVD
 COURSE OF
HOSPITALIZATION
 AT THE ER

Diet: low salt, low fat, soft diet

IVF: heplock

CBC, UA, Na, K, Crea, ALT, FBS, Lipid Profile

Sputum GSCS, AFB x2, CXR-PA, 12L- ECG

Therapeutics:

1. Piperacillin- Tazobactam 4.5gm IV drip to run for 2-3 hrsq 8hrs

2. Azithromycin 500mg tab, 1 tab OD PO

3. Omeprazole 40mg tab, 1 tab now then OD PO ACBF

4. Tranexamic Acid 500mg cap, 1 cap TID PO

 AT THE ER

5. Butamarate citrate(Sinecod) forte tab 1 tab TID PO

6. Paracetamol 500mg/tab 1 tab q 4 hours PRN for temp > 38.0

7. Aspirin 80 mg 1 tab OD PO

8. Rosuvastatin 10mg/tab 1 tab OD PO q HS.

9. Bisoprolol + Amlodipine 5/5mg/tab 1 tab OD PO

10. Spironolactone + HCTZ (Aldazide) 25/25mg tab 1 tab OD p.o.

11. MV (Conzace)/tab 1 tab OD p.o.

12. Vitamin B complex tab 1 tab OD p.o.

13. Tiotropium + Olodaterol (Spiolto) 2.5/2.5 mcg respimat 2 puff OD

14. Fluticasone (flixotide) 125mcg MDI puff BID

 CBC
WBC 9.98
Neutrophil 80.4
Lymphocytes 8.80
Monocytes 9.6
Eosinophil 0.2
Basophil 1
RBC 4.21
Hemoglobin 12.3 g/dL
Hematocrit 34.3%
MCV 81.5 cu microns
MCH 29.3 g/dL
Platelet count 369,000
 CHEMISTRY

ALT 4.97 mg/dl

Creatinine 0.63 mmol/L

HBA1C 6.2%

Na 111 mmol/L

K 3.8 mmol/L
 URINALYSIS
Color yellow
Volume 30
Transparency hazy
Sp Gravity 1.015
Albumin 1+
pH 6.0
Ketone (-)
Blood 2+
Glucose (-)
Nitrite (-)
Bilirubin (-)
Urobilinogen Normal
WBC 0-2/HPF
RBC 2-3 HPF
Epithelial Cells few
Bacteria Rare
 CHEST X RAY
August 8, 2019 December 2019
ELECTROCARDIOGRAPH
PATHOPHYSIOLOGY
 PATHOPHYSIOLOGY

Pneumonia
-results from prolifera/on of microbial pathogens at the alveolar level
and the host’s response to those pathogens
Access:
Aspira/on from oropharynx
Hematogenous spread (e.g. Tricuspid endocardi/s)
con/guous extension from an infected pleural or medias/nal space
 PATHOPHYSIOLOGY

Mechanical factors:
Hairs and turbinates
Tracheobronchial tree’s branching architecture
Gag and cough reflex
 PATHOPHYSIOLOGY

Macrophages
assisted by proteins that are produced by the alveolar
epithelial cells (e.g. surfactant proteins A and D) and
that have intrinsic opsonizing proper/es or
an/bacterial or an/viral ac/vity
Eliminates pathogens via either the mucociliary
elevator or the lympha/cs and no longer represent an
infec/ous challenge
 PATHOPHYSIOLOGY

When the capacity of the alveolar macrophages to

ingest or kill the microorganisms is exceeded,
clinical pneumonia become manifest.

- alveolar macrophages ini/ate the inflammatory

response to bolster lower respiratory tract
defenses
 PATHOPHYSIOLOGY

Host inflammatory response

Prolifera/on of microorganisms
Triggers clinical manifesta/on of pneumonia

IL-1 and TNF – fever

IL-8 and GCSF - release of neutrophils
(leukocytosis and increased secre/ons)
PATHOPHYSIOLOGY
 PATHOPHYSIOLOGY

Severe hypoxemia

Results from interference of bacterial pathogens

with the hypoxemic vasoconstriction, normally
occurring with fluid - filled alveoli.

Respiratory alkalosis

Results from increased respiratory drive in the

systemic inflammatory response syndrome
 PATHOPHYSIOLOGY

Dyspnea
Decreased compliance due to capillary leak, hypoxemia
increased respiratory drive
increased secre/ons
occasionally infec/on-related bronchospasm

Respiratory failure and death

Severe changes in the lung mechanics secondary to
reduc/ons in lung volume and compliance and the
intrapulmonary shun/ng of blood
 PATHOPHYSIOLOGY

Normal alveolar microbiota

- Possibility of an alterna/ve pathway for
development of pneumonia
-simlar to oropharyngeal microbiota
-Gram (+)
Sources of altered microbiota:
-Viral URTI for CAP
-An/bio/c therapy for HAP/VAP
 PATHOPHYSIOLOGY

Classic pneumonia
Edema –proteinaceous exudate in the alveoli
Red hepa/za/on - erythrocytes in the cellular intra-
alveolar exudate. Neutrophil influx
Gray Hepa/za/on – lysed and degraded erythrocytes.
High neutrophil, abundant fibrin deposi/on. No bacteria.
Resolu/on – Macrophage dominance. Cleared debris of
neutrophil, bacteria and fibrin.
 Diagnosis and Treatment of
Adults with Community
Acquired Pneumonia

An Official Clinical Practice Guideline of the

American Thoracic Society & Infectious Diseases
Society of America
 We recommend not obtaining
sputum Gram stain and
culture routinely in adults
In adults with CAP, with CAP in outpatient
should Gram Stain se_ing.
and Culture of of Recommendation: We
Lower Respiratory recommend obtaining
Secretions be pretreatment Gram stain and
obtained at the Time culture of respiratory
secretions in adults with CAP
of Diagnosis?
managed in the hospital
se_ing:
1. classified as severe CAP
especially if they are
intubated OR
are being empirically
treated for MRSA or P.
aeruginosa OR
were previously infected
with MRSA or P.
aeruginosa
were hospitalized and
received parenteral
antibiotics.
In Adults With CAP, Outpatient: We recommend
not obtaining blood cultures
Should Blood
in adults with CAP.
Cultures Be Obtained
Inpatient: We suggest not
At The Time Of routinely obtaining blood
Diagnosis cultures in adults with CAP
We recommend obtaining
pretreatment blood cultures in
adults with CAP managed in
hospital se_ing who are
classified as severe CAP:
are being empirically treated
for MRSA or P. aeruginosa
or
were previously infected with
MRSA or P. aeruginosa
were hospitalized and
received parenteral
antibiotics
 we suggest not routinely testing
urine for pneumococcal antigen
Question 3: In Adults in adults with CAP except in
adults with severe CAP
With Cap, Should
we suggest not routinely testing
Legionella And urine for Legionella antigen in
Pneumococcal adults with CAP except in cases
Urinary Antigen of:
in cases where indicated by
Testing Be Performed
epidemiological factors, such as
At The Time Of association with a Legionella
Diagnosis? outbreak or recent travel OR
in adults with severe CAP
Question 4: In Adults When Influenza viruses are
With CAP, Should A circulating in the community,
we recommend testing for
Respiratory Sample
influenza with a rapid influenza
Be Tested For
molecular assay, which is
Influenza Virus At preferred over a rapid influenza
The Time Of diagnostic test.
Diagnosis?
 Question 5: In Adults
With CAP, Should We recommend that empiric
Serum Procalcitonin antibiotic therapy should be
Plus Clinical Judgment initiated in adults with clinically
Versus Clinical suspected and radiographically
Judgment Alone Be confirmed CAP regardless of
Used To Withhold initial serum Procalcitonin level.
Initiation Of Antibiotic
Treatment?
 Question 6: Should A
In addition to clinical judgment,
Clinical Prediction Rule
we recommend that clinicians
For Prognosis Plus
use a validated clinical
Clinical Judgment
prediction rule for prognosis,
Versus Clinical
preferentially Pneumonia
Judgment Alone Be
Severity Index over the
Used To Determine
CURB-65 to determine the need
Inpatient Versus
for hospitalization in adults
Outpatient Treatment
diagnosed with CAP.
Location For Adults
With CAP?
 Question 7: Should A
Clinical Prediction Rule We recommend direct admission to
For Prognosis Plus an ICU for patients with
Clinical Judgment hypotension requiring vasopressors
Versus Clinical or respiratory failure requiring
Judgment Alone Be mechanical ventilation.
For patients not requiring
Used To Determine
vasopressors or mechanical
Inpatient General ventilator support, we suggest using
Medical Versus Higher the IDSA/ATS 2007 minor severity
Levels Of Inpatient criteria together with clinical
Treatment Intensity judgment to guide the need for
( ICU, Step-down, higher levels of treatment intensity.

Telemetry Unit) For

Adults With CAP.
 Recommendation: For healthy
outpatient adults without
comorbidities listed below or risk
factors for antibiotic resistant
Question 8: In the pathogens, we recommend:
outpatient setting, Amoxicillin 1g TID
Doxycycline 100mg BID
which antibiotics are
Azithromycin 500mg on first day
recommend for then 250mg daily or
empiric treatment of Clarithromycin 500mg BID or
Clarithromycin extended release
CAP in adults?
1,000mg daily only in areas with
pneumococcal resistance to
macrolides <25%
For outpatient adults with comorbidities
such as chronic heart, lung, liver or renal
disease; diabetes mellitus; alcoholism;
malignancy; or asplenia. We recommend:

Amoxicillin/Clavulanate 500mg/125mg
TID
Amoxicillin/Clavulanate 875mg/125mg
BID
Amoxicillin/Clavulanate 2,000mg/
125mg BID or
Cefpodoxime 200mg/tab BID or
Cefuroxime 500mg BID and
Azithromycin 500mg/tab on first day
then 250mg daily, Clarithromycin
500mg BID or 1,000 mg OD, or
doxycycline 100 mg BID
 Recommendation 1: In inpatient
adults with nonsevere CAP without
risk factors for: MRSA or P.
Question 9: In the aeruginosa, we recommend the
Inpatient Setting, following empiric treatment regimens
(in no order of preference):
Which Antibiotic ampicillin + sulbactam 1.5–3 g every

Regimens Are 6 h, cefotaxime 1–2 g every 8 h,
Recommended for ceftriaxone 1–2 g daily, or
ceftaroline 600 mg every 12 h) and
Empiric Treatment of (azithromycin 500 mg daily or
CAP in Adults clarithromycin 500 mg twice daily),
without Risk Factors or
(levofloxacin 750 mg daily,
for MRSA and P. moxifloxacin 400 mg daily) (strong
aeruginosa? recommendation, high quality of
evidence).
 A third option for ampicillin 1 sulbactam,
adults with CAP who cefotaxime, ceftaroline, or
have ceftriaxone, doses as above
contraindications to and
both macrolides and doxycycline 100 mg twice
fluoroquinolones is: daily
 Question 9: In the
Recommendation 9.2. In inpatient
Inpatient Setting, adults with severe CAP without risk
Which Antibiotic factors for MRSA or P. aeruginosa, we
recommend:
Regimens Are
B-lactam plus a macrolide (strong
Recommended for recommendation, moderate quality
Empiric Treatment of of evidence); or
b-lactam plus a respiratory
CAP in Adults
fluoroquinolone (strong
without Risk Factors recommendation, low quality of
for MRSA and P. evidence).

aeruginosa?
 Question 10: In the
Inpatient Setting,
We suggest not routinely adding
Should Patients with
anaerobic coverage for suspected
Suspected Aspiration aspiration pneumonia unless lung
Pneumonia Receive abscess or empyema is suspected
(conditional recommendation, very
Additional Anaerobic
low quality of evidence).
Coverage beyond
Standard Empiric
Treatment for CAP?
 Question 11: In the We recommend abandoning use of
Inpatient Setting, the prior categorization of
Should Adults with healthcare-associated pneumonia
CAP and Risk Factors (HCAP) to guide selection of
extended antibiotic coverage in
for MRSA or P.
adults with CAP
aeruginosa Be Treated
We recommend clinicians only
with Extended-Spectrum cover empirically for MRSA or P.
Antibiotic Therapy aeruginosa in adults with CAP if
Instead of Standard CAP locally validated risk factors for
Regimens? either pathogen are present:
Empiric treatment options for
MRSA include vancomycin (15 mg/
kg every 12 h, adjust based on
levels) or linezolid (600 mg every 12
h). Empiric treatment options for P.
aeruginosa include piperacillin-
tazobactam (4.5 g every 6 h),
cefepime (2 g every 8 h), ceftazidime
(2 g every 8 h), aztreonam (2 g every
8 h), meropenem (1 g every 8 h), or
imipenem (500 mg every 6 h).
 If clinicians are currently covering
empirically for MRSA or P.
aeruginosa in adults with CAP on the
basis of published risk factors but do
not have local etiological data, we
recommend continuing empiric
coverage while obtaining culture data
to establish if these pathogens are
present to justify continued treatment
for these pathogens after the first few
days of empiric treatment
 We recommend not routinely using
corticosteroids in

adults with nonsevere CAP
We suggest not routinely using
corticosteroids in adults with severe
Question 12: In the
CAP
Inpatient Setting, We suggest not routinely using
Should Adults with corticosteroids in adults with severe
influenza pneumonia
CAP Be Treated with
We endorse the Surviving Sepsis
Corticosteroids? Campaign recommendations on the
use of corticosteroids in patients
with CAP and refractory septic
shock
 We recommend that antiinfluenza
treatment, such as oseltamivir, be
Question 13: In prescribed for adults with CAP who
test positive for influenza in the
Adults with CAP
inpatient setting, independent of
Who Test Positive for duration of illness before diagnosis
Influenza, Should We suggest that antiinfluenza
treatment be prescribed for adults
the Treatment
with CAP who test positive for
Regimen Include influenza in the outpatient setting,
Antiviral Therapy? independent of duration of illness
before diagnosis
 We recommend that standard
Question 14: In Adults antibacterial treatment be
initially prescribed for adults
with CAP Who Test
with clinical and radiographic
Positive for Influenza,
evidence of CAP who test
Should the Treatment
positive for influenza in the
Regimen Include inpatient
Antibacterial Therapy? and outpatient settings
 We recommend that the duration of
antibiotic therapy should be guided
by a validated measure of clinical
Question 15: In
stability (resolution of vital sign
Outpatient and abnormalities [heart rate, respiratory
Inpatient Adults with rate, blood pressure, oxygen
CAP Who Are saturation, and temperature], ability
Improving, What Is the to eat, and normal mentation), and
antibiotic therapy should be
Appropriate Duration of
continued until the patient achieves
Antibiotic Treatment? stability and for no less than a total of
5 days (strong recommendation,
moderate quality of evidence).
 In adults with CAP whose
Question 16: In Adults symptoms have resolved
with CAP Who Are
within 5 to 7 days, we
Improving, Should
Follow-up Chest
suggest not routinely
Imaging Be Obtained? obtaining follow-up chest
imaging
 In Adults with CAP Who Test In Adults with CAP Who
In the Inpatient Setting, Should Patients Positive for Influenza, Should the Are Improving, Should
with Suspected Aspiration Pneumonia : In the Inpatient Setting, Treatment Regimen Include Follow-up Chest Imaging
Receive Additional Anaerobic Coverage Should Adults with CAP Be Antibacterial Therapy? Be Obtained?
beyond Standard Empiric Treatment for Treated with Corticosteroids?
CAP? In the Inpatient Setting,
Should Adults with CAP and In Outpatient and Inpatient
Risk Factors for MRSA or P. Adults with CAP Who Are
In Adults with CAP Who Test
aeruginosa Be Treated with Improving, What Is the
Positive for Influenza, Should the
In the Inpatient Setting, Which Extended-Spectrum Antibiotic Appropriate Duration of
Treatment Regimen Include
Antibiotic Regimens Are Therapy Instead of Standard Antibiotic Treatment?
Antiviral Therapy?
Recommended for Empiric CAP Regimens?
Treatment of CAP in Adults
without Risk Factors for MRSA
and P. aeruginosa?

Community Acquired Pneumonia

 Community Acquired Pneumonia

In Adults with CAP, In Adults with CAP, In Adults with CAP, Should Legionella and
Should Gram Stain and Should Blood Cultures Pneumococcal Urinary Antigen Testing Be
Culture of Lower Be Obtained at the Time Performed at the Time of Diagnosis?
Respiratory Secretions of Diagnosis?
Be Obtained at the Time
of Diagnosis?

In Adults with CAP, In Adults with CAP, Should Serum Should a Clinical Prediction Rule for Should a Clinical Prediction Rule for In the Outpatient
Should a Respiratory Procalcitonin plus Clinical Judgment Prognosis plus Clinical Judgment versus Prognosis plus Clinical Judgment versus Setting, Which
Sample Be Tested for versus Clinical Judgment Alone Be Clinical Judgment Alone Be Used to Clinical Judgment Alone Be Used to Antibiotics Are
Influenza Virus at the Used to Withhold Initiation of Determine Inpatient versus Outpatient Determine Inpatient General Medical Recommended for
Time of Diagnosis? Antibiotic Treatment? Treatment Location for Adults with CAP? versus Higher Levels of Inpatient Empiric Treatment of
Treatment Intensity (ICU, Step-Down, or CAP in Adults?
Telemetry Unit) for Adults with CAP?