K. Brat Pneumonia žDifferent epidemilogical types of pneumonia require different treatment orptions and procedures ž žCAP (Community-Acquired Pneumonia) žHAP (Hospital-Acquired Pneumonia) žVAP (Ventilator-Associated Pneumonia) žHCAP (Health Care-Associated Pneumonia) CAP žCorrect diagnosis žRisk stratification: ambulatory treatment / hospital admission / intensive care žOptimal antibiotic treatment (choice and duration) žPrevention of CAP ž ž80% of pneumonia cases treated ambulatory way – mortality <1% ž20% of cases treatet in hospitals – mortality ca 14% ž ž ž Diagnosis of CAP žClinical signs, lab (CRP + leukocytes), CXR ž žIn severe CAP (PSI class IV-V) also microbiology: sputum, legionella and pneumococcal antigen in urine, blood culture, serology Mycoplasma/Chlamydophila ž Pneumonia Severity Index (PSI) >14.000 pts, confirmed by further studies CURB-65 ž SCAP – next generation risk stratification tool ž Antibiotic treatment of CAP žLow-risk patients: ž1) amoxicillin ž2) clarithromycine or doxycycline žModerate-risk patients (standard department) – start the treatment ASAP ž1) amoxicilline oral ž2) amox + clarithro iv ž3) moxifloxacin žHigh-risk patients (ICU) - start the treatment immediately: ž1) amoxicillin/clavulanic acid + clarithromycine ž2) cefuroxim + klaritromycin žI.v. antibiotics unless body temperature below 37°C for 24hrs. žDuration: low-risk pts 7 days, moderate-risk 7-10 days, high-risk may be extended up to 14-21 days Prevention of CAP… vaccination žStr.pneumoniae – patients >65 yr ž žInfluenza – patients >65, health care professionals, pts >50 let + severe CV or renal comorbidities or diabetes Treatment of HAP vHAP is the 2nd most frequent type of nosocomial infection vEmpirical antibiotics: cefotaxime / moxifloxacine / ertapenem vPseudomonas?... tazocin / meropenem / imipenem / ceftazidime + amikacin / ciprofloxacine vMRSA?...tazocin / meropenem / cefotaxime + linezolide, vancomycin ž Pleural effusion žEpidemiology - Czech Rep. (5 most frequent causes): ž žAcute heart failure (45-65%) žParapneumonic effusion/empyema (22-30%) žMalignant/paramalignant effusion (17-24%) žEffusion secondary to pulmonary embolism (cca 5-8%) žHemothorax (5-10%) ž žOther (ca 15%) ž (Marel et al. Chest 104: 1486-9) Differential diagnosis of pleural effusions ž Biochemic examination of effusions – Light`s criteria ž ž ž ž ž ž ž ž ž ž ž ž ž ž ž žMajor criteria žMinor criteria Parapneumonic effusions (infectious pleurisy) ž30-40% of pts with pneumonia develop pleural effusion ž žCa 15% of parapneumonic effusions are complicated (i.e. pH<7.20) Complicated parapneumonic effusions / empyema žThe incidence doubled in last 20 years žMorbidity: mean hospitalization duration 14 days žSurgery inavoidable in up to 35% pts ž1-year mortality 20% (no change during last 20 years) žThe most valuable predictor of poor outcome is pH<7.20 (effusion) Classification of parapneumonic effusions ž ž ž ž ž ž ž ž ž ž ž ž pH of infectious effusion – main decision-making parameter (for the introduction of invasive procedures) AJRCCM; 152: 1700-08 Presence of septation can modify lab results žpH of effusion modified also by: ž žTime delay (…lab) žAir in syringe žTraces of local anesthetics žProteus-infection Microbiology žAgent caught only in ca 50% of infectious pleurisy cases (incl. empyema!) ž Inoculation on blood culture (aerobic a anaerobic type) increases pathogen detection by 20% Menzies et al, Thorax 2011; 66:658 Is empyema just a “pneumonia gone bad?” ž ž Antibiotic treatment of infectious pleurisy ž žWrightson et al, Chest 2015 1:148(3) ž žTarget on streptococci, S.aureus, G- bacilli, anaerobes žAnaerobes are less frequent žMycoplasma and Legionella do not induce pleural effusions, i.e. no need for antibiotics targeted on „atypicals“ CXR / CT / chest ultrasound – effusion volumetry and septation žAP CXR „finds“ more than 200ml effusion / septation usually missed žSide CXR – accurate from 50ml… žCT scan / tens of mililiters… / septation of long duration – fibrous septae žChest ultrasound – accurate from tens of ml / loculation found from early stage septation … and without irradiation! ž Prediction of poor outcome in infectious pleurisy ž žUltrasound proven loculation (Chen et al, 2001 J Ultrasound Med 19:837-43): ü Longer hospital stay ü More frequent use of intrapleural fibrinolytics ü Higher rate of surgical intervention ž žRAPID score RAPID score - MIST 1 a 2 studies žChest 2015; 145(4): 848 Intrapleural treatment žMIST1 study: intrapleural streptokinase not effective (NEJM; 352: 865-874) žMIST2 study: t-PA (alteplase) + DNase increase drainage of pleural fluid, decrease the duration of hospital treatment and the rate of surgery (NEJM; 365: 518-526), but… high costs žIrrigation by 3x daily 250ml of saline increase drainage of pleural fluid and decrease the need for surgery (Hooper et al, ERJ 2015)… low cost treatment ž10/2017 MIST3 initiated: 3 cohorts are randomized> early VATS vs t-PA + DNase vs conservative therapy Further remarks žThe diameter of pleural catheter (chest tube) has no effect on treatment outcomes (Chest 2009 žPurulency of the effusion (macroscopic feature) has no prognostic value (treatment success depends on pH<7.20 and the presence of loculation) ž(medical) thoracoscopy – a rising star… 91% success rate in complicated infectious pleurisy treatment (Brutsche et al, Chest 2005;128:5) žNo study stated when is the ideal timing of surgery (if needed) Parapneumonic effusion – main points of care ØAntibiotics – empiric or microbiology-guided ØThoracentesis – effusions exceeding 300-400ml ØChest tube insertion – effusion >500ml and pH<7.2 ØIntrapleural antiseptic agents (iodpovidone, H2O2)– each effusion with pH<7.2 ØIntrapleural fibrinolytics? ØSurgery – prevent fibrothorax! ØTake care of nutrition ØRespiratory physiotherapy ØOther (oxygen, analgesics...) ž What comes after treatment failure…? ž…fibrothorax and its characteristics: pulmonary restriction, respiratory failure, decreased mucociliary clearance, locus minoris resistentiae ž…or „trapped lung“, i.e. inexpandible lung covered by fibrocortex and effusion Case management - malignant/paramalignant effusion lDiagnosis: ž- malignant cells present in cytology ž- or malignancy present in pleural space ž- biochemistry: may be both transudate or exsudate ž- often need for surgery to obtain histology… (thoracoscopy, VATS) ž lTreatment: ž- oncological (CHT, RT, biologicals) ž- thoracentesis ž- thoracic drainage ž- pleurodesis – using chemical agents (talc, bleomycine, doxycycline) ž- pleurodesis - surgical (VATS) ž- Indwelling pleural catheter Case management - hemothorax lDiagnosis: ž - check recent injury in patient history ž - may be severe thoracic bleeding with anemic shock! ž - if hemothorax suspected, perform thoracentesis immediately! ž - hematocrit effusion/periph.blood > 0.5 or hematocrit in effusion > 0.15 ž l Treatment: ž- thoracic drainage ASAP, use large calibers of chest tube (28-32F)! ž- initial treatment: conservative, but watch for continuous bleeding ž- if bleeding exceeds 200ml/hr for more than 2 hours, call the surgeon - urgent thoracoscopy is needed! Case management – TB pleurisy lCytology: lymphocytes predominant lCultivation positive only in 20-50% lHistology: caseificating granulomas in 79% (pleural biopsy) up to 100% (thoracoscopy) lPCR Myco TB: sensitivity 60-90%, specificity 80-100% lADA, ADA-2: sensitivity 75-100%, specificity 80-95% l lPatients with untreated TB pleurisy develop pulmonary TB within 5 yrs in 65% of cases lDOTS-short course - 2 months HRZE + 4 months HR lNo evidence for steroids use lComplete removal of effusion not neccessary ž ž Case management - chylothorax l Diagnosis ž - milky effusion ž - biochemistry: triacylglyceroles > 1.2 mmol/l or ratio effusion/serum >1.5 ž - perform CT scans l Frequent in malignancy (lymphoma, metastases to mediastinal lymph nodes) ž ž l Treatment: ž - thoracic drainage + parenteral nutrition 14 days ž - surgery (ligation of ductus thoracicus)