#community acquired pneumonia

[flyonthewallmedstudent]

Psittacosis

Let's open with a case report, like we're on an episode of house.

Case Report

35 yo otherwise well, suddenly presents with 2/52 of high fevers and a headache (usually this means > 39)

a/w chills and rigours, responsive to medication/presumably panadol and intermittent (would resolve then come back)

no respiratory symptoms

She had neutrophilia and intrestingly, a CRP of merely 30.

CXR revealed nonspecific consolidation in 2 lobes, they followed this up with a CT revealing pretty impressive ground glass opacities (or GGOs)

She was empirically treated on IV tazocin only (I'm used to atypical coverage empirically started if there's even a whiff of resp, which she may not have had symptoms but her CXR confirms this)

eventually she was on referred to the authors, who felt her CT findings with consistent with psittacosis and treated her with doxycycline which resolved her symptoms in 48 hrs

on further history, it was revealed that she had parrots at home, one had died 2 days preceding her symptoms and she was sleeping next to its body at night (crazy)

What is it:

psittacosis is a zoonoses (transmitted by animals, animals = reservoirs), in this case, transmitted by birds. Orthinoses if birds in general, but psittacosis if referred to macaws, parrots etc. YOu can also catch it from chickens and turkeys.

Some what related is Bird fancier's lungs. Which just sounds fancy.. I'm sure it's just an old term.

Bird fancier's lung refers to a hypersensitivty pneumonitis (ILD) caused by bird exposure. DIfferent disease process, but birds is the come denominator. INhaled bird particles

Psittacosis specifically refers to the infective disease process caused by a bacteria. It was 'identified" or reported in the 1870s, when a cluster of 7 swiss patients developed the same symptoms and found to have possessed tropical birds.

Similarly, in the 1930s there was an outbreak in the US with a mortality of up to 20% (80% in pregnant women), also attributed to parrots from South America.

Eventually, with further scientific development, the causative pathogen was identified as chlamydia psittaci, an atypical intracellular organism.

Psittacosis is a significant differential to consider in community acquired pneumonia as it has a high mortality if left untreated. But it is rare, and causes about 1% of cases in the US. Part of this is due to improved hygiene practices and strict importation guidelines of tropical birds.

It's spread through the inhalation of dust with either dried faeces or respiratory secretions from infected birds.

Clinical features

Variable! but the key thing on history is birds

incubation time can be anywhere from 2 days to 20

Flu-like (fevers/chills/myalgias/arthralgias/malaise/headache)

high fevers is key

respiratory symptoms - does not always present as per the case report, and can be mild on spectrum (dry cough) to more severe

if systemic, can also get photophobia, deafness and epistaxis

Rare (particularly where doxycycline or azith are prescribed at a low threshold): hepatosplenomegaly (look out for LFTs), GI symptoms (remember CAP can present with diarrhoea, nausea/vomiting --> always do a CXR)

even rarer: endocarditis or myocarditis, encephalitis or hepatitis (usually the complications of untreated disease)

Increased risk groups:

pet shop owners

bird owners

farmers

zoo, lab workers where birds are kept, vets, avian quarantine station workers

poultry handlers/workers

So ask if they live or work with birds, or had recent exposure.

INvestigations

serology is gold standard - so looking for antibodies in blood tests

it's intracellular - so hard to culture if even possible on standard blood cultures

elevated ESR/CRP may see LFT derangement and creatinine rise in systemic illness

CXR- usually lower lobe changes, if CT is done, you can get pulmonary infiltrates with GGOs

Treatment:

usual culprits for atypical coverage: azithromycin 3 days or doxycycline 100 mg BD for 14/7

Differentials

always broad if systemic features only (also consider IE and other causes of sepsis)

with resp symptoms - legionella, Q fever, mycoplasma, tularaemia (except for tularaemia, the rest are also covered by doxycycline)

In clinical practice, I'm so used to just having atypicals on board for any cases of atypical pneumonia. I really take it for granted. But will consider this differential more myself in cases of PUO - but I feel like there should be at least CXR findings regardless.

Anyway, prognosis is very good so long as it is treated.

Sources:

CDC guidelines

Case Report: Importance of Clinical history in Psittacosis

StatPearls

Wiki

[philphys-survivalguide]

CAP

According to the Philippine Clinical Practice Guidelines for CAP in ADULTS (2020):

Unstable Co Morbids include: -> Uncontrolled DM -> Active malignancies -> Neurologic disease in evolution -> CHF FC II-IV -> Unstable CAD -> Renal Failure on dialysis -> Uncompensated COPD -> Decompensated Liver disease

Legionella urine antigen test and Influenza test are conditional recommendation for CAP HR: -> Influenza test may be done during periods of high influenza activity (July - January) if CAP HR is preceded by inluenza-like illness symptoms such as body malaise, rhinorrhea, arthralgia, sorethroat plus risk factors such as >60y/o, pregnant, asthmatic.

DRUGS: PENICILLINS: amoxicillin MACROLIDES: clarithromycin, azithromycin BETALACTAMS: co-amoxiclav, cefuroxime TETRACYCLINES: doxycycline NON PSEUDOMONAL BETALACTAMS: ampisul, cefotaxime, ceftriaxone FLUOROQUINOLONES: levofloxacin, moxifloxacin

Atypical coverage for Aspiration Pneumonia is only recommended if with suspicion of lung abscess or empyema.

Antiviral treatment is recommended with antibiotic therapy in CAP HR with risk factors mentioned under influenza testing.

Treatment should be initiated within 4 hours regardless of risk.

Duration of treatment: -> CAP LR , CAP MR: 5 days if stable -> May extend duration if pneumonia is not resolving, complicated by sepsis, infected with less common pathogens or infected with drug-resistant pathogens.

CXR post-treatment is recommended after a minimum of 6-08 weeks to establish a baseline and exclude other conditions but it is not recommended for routine testing in stable improving patients.

Inadequate Response after 72 hours of Empiric treatment: -> Reassess for possible resistance -> Reassess for the presence of other pathogens such as M. tuberculosis, viruses, parasites, or fungi.

Philippine CPG for CAP (Adults) 2020 Downloadable Link: https://www.psmid.org/cpg-management-and-prevention-of-adult-community-acquired-pneumonia-2020/

[jppres]

The use of an antibiotic order form in a tertiary hospital: Influence on physicians’ prescribing patterns

The use of an antibiotic order form in a tertiary hospital: Influence on physicians’ prescribing patterns

Article published in the Journal of Pharmacy & Pharmacognosy Research 9(4): 474-483, 2021. Image: Pixabay Original article Duc Chien Vo1, Tuan Anh Mai2, Thu Thao Nguyen3, Dang Thoai Nguyen4, Thi Ha Vo3,4* 1Department of Respiratory Medicine, Nguyen Tri Phuong Hospital, Ho Chi Minh, V-70000, Vietnam. 2Department of Pharmacy, Hanoi Pharmacy University, Ha Noi, 100000, Vietnam. 3Department of…

[jcarriez]

Community-acquired pneumonia (CAP) / Reading and Sharing

Community-acquired pneumonia (CAP) / Reading and Sharing

Community-acquired pneumonia (CAP) is an infection that begins outside the hospital or is diagnosed within 48 hours after admission to the hospital in a person who has not resided in a long-term care facility for 14 days or more before admission (Grossman, & Porth, 2014). As according to Ferri (2017), the incidence of community-acquired pneumonia (CAP) is 1 in 100 persons. CAP is the most common…

[brooklynclinical]

CURB 65 score for Community Acquired Pneumonia

Score: +1 for each of the following: 

-------------------------

Patient confused

BUN > 19 mg/dl

RR >30

SBP< 90 mmHg or DBP < 60 mmHg 

Age >65

----------------------------

30 day risk of mortality

0= Low risk:0.6% : outpatient

1= Low risk:2.7% : outpatient

2= Moderate risk:6.7% : inpatient or outpatient with close follow up

3= Severe risk:14% :inpatient/possible ICU admission

4= Highest risk:27.8%: inpatient/possible ICU admission

[courtesy of] Critical Care Handbook (EMRA)