Author Archives: Cathy

Morning report

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Elderly immunocompromised man with several years of intermittent dry cough but more green and productive over the last month. Carries diagnosis of asthma on symbicort and PE on eliquis. Afebrile, satting well on room air, but some bibasilar crackles.

Chest imaging showed scattered opacities, slightly reticular, more at the bases. He improved with CTX/azithro; after a week, grew a variety of NTM organisms from multiple samples, including M. abscessus (usually want to treat, more likely to progress and more virulent than MAC).

Group consensus was to send for susceptibilities at National Jewish, but not to treat given symptomatic improvement and repeat CT was much improved (near normal) without treatment for NTM.

Teaching point: Susceptibility showed azithromycin susceptible but high MIC of 32, concerning for something that would have inducible azithro resistance. Functional erm gene also a marker of difficulty to eradicate.

Ongoing discussions regarding treating (if so, with what? to what goal?) and immunosuppression adjustments…

Thanks, Dr. Olson!

 

Morning report

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Thank you Dr. Olson for a fantastic morning report!

A middle-aged man s/p transplant on sirolimus and tacrolimus presents with progressive dyspnea and fevers.

Chest CT with progressive ground glass opacities in bilateral upper lobes that has progressed now to extensive cystic/cavitary disease over the last few months, despite antibiotics.

BAL with positive histo antigen in serum, urine, BAL, pleural fluid, and on Karius testing! Improves with holding immunosuppression and itraconazole treatment.

This case may have been infectious, but thank you for the great teaching point on when to consider sirolimus toxicity:

Thank you, Dr. Olson!

Updates to severe CAP recommendations and the microbiome

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Thanks to Dr. Szabo and Dr. Pickens for a fantastic grand rounds covering the new updated recommendations to severe CAP! [https://link.springer.com/article/10.1007/s00134-023-07033-8]

1) Suggest adding multiplex PCR to lower respiratory sample (very low evidence)

ResPOC trial [https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(17)30120-0/fulltext] – 720 patients presenting to ED with resp symptoms ran multiplex PCR and given information to clinical team -> slightly less abx (one dose vs 48hrs) and shorter LOS and good identification of viruses -> results 48-72hrs earlier than cultures, can quickly de-escalate or target resistance

Sputum biofires more often positive than BAL biofire (72% vs 49% and more likely polymicrobial, and also common discrepancy with cultures)

2) Consider HFNC instead of regular oxygen

RCT of standard oxygen facemask, HFNC, NIV [Frat NEJM 2015 https://pubmed.ncbi.nlm.nih.gov/25981908/] -> mortality benefit in those who got HFNC [though NIV might’ve been confounded because they targeted high tidal volumes]

3) Steroids? Based on their own meta-analysis, recommended if shock is concurrently present.

Didn’t include CAPE COD study, and driven by Meduri VA study [?confounded by gender]

Interesting thoughts on environmental ecology – examining the microbe in its true environment interacting with other bugs rather than taking it out and isolating it on a plate!

First, identify all microbes present [Human Microbiome Project – https://hmpdacc.org/]; there’s been a lot of interest recently!

The upper respiratory tract is different from the lower respiratory tract when you’re sick. Some features like bacterial burden or composition/diversity are associated with different outcomes!

Thanks, Dr. Szabo and Dr. Pickens!

Slides: 2023.05.10 grand rounds – ERS sCAP guidelines

CAPE-COD: steroids in severe CAP

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Thanks to Jose for presenting this today! CAPE-COD (paper here)

  • 800 patients with severe CAP randomized (excluded those who were on pressors, influenza, aspiration)
  • Balanced baseline groups
  • Hydrocortisone infusion 200mg/day, duration could be extended based on criteria + taper vs placebo with same protocol; median duration 5 days
  • Fewer death by day 28 in those given hydrocortisone 6.2% vs 11.9%
  • Fewer intubation by day 28 19.5% vs 27.7%
  • More insulin in steroid group
  • Especially helpful in women and age>65 by subgroup analysis
  • strengths included fast onset to medication dosage ~15 hours, and high adherence to protocol, reasonable 21% VAP rate (compared to many studies with low rates)
  • limitations: surprisingly low mortality, unstandardized microbiology (45% without identified pathogen)

Discussion points brought up included the variety of pathogens and heterogeneous groups and the syndrome of CAP, unclear exactly which subpopulation would be most benefitted (compared with COVID, where things were more clear and homogeneous), unusual population where a large number of patients had high CRP (based on a prior Spanish study that showed benefit in this population that took years to enroll a certain number of patients); steroids are a blunt instrument, choice of specific steroid (hydrocortisone vs dexametahsone). Of note – immediate meta-analysis incorporating this data – slight benefit?

Recent VA study showing no benefit (mostly men so maybe one explanation for the difference): https://link.springer.com/article/10.1007/s00134-022-06684-3

Of note – new guidelines for severe CAP including our very own Dr. Wunderink: https://link.springer.com/article/10.1007/s00134-023-07033-8

Future thoughts: designing trials better phenotyping to target specific pathways!

ISICEM and steroids in severe pneumonia

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ISICEM has begun – lots of interesting papers being presented, can follow on Twitter with #ISICEM23 [https://twitter.com/hashtag/ISICEM23?src=hashtag_click].

Some studies of high interest: anticoagulation for COVID, ravulizumab for COVID, feeding in shock, and more:  https://twitter.com/tscquizzato/status/1638128616713101313

And of special interest – CAPE COD – are steroids back in for severe pneumonia? Out in NEJM today: https://www.nejm.org/doi/full/10.1056/NEJMoa2215145?query=featured_home

TL;DR – 800 patients with severe pneumonia admitted to the ICU randomized to 200mg daily hydrocortisone vs placebo; reduced mortality (6.2% vs 11.9%), higher ICU discharge, less intubation (18% vs 29.5%)! Note those with septic shock were excluded (probably because they would receive hydrocort 50q6 anyway?).

Especially beneficial in subgroup with high CRP (makes sense)

Farkas already has his take up here: https://emcrit.org/pulmcrit/cape-cod/

Trachs 101 and Education Research Award!

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Fantastic Core IM podcast on trach pearls featuring our very own Tim Rowe!
https://www.coreimpodcast.com/2023/03/08/trac/

Including this amazing figure to demystify trachs!

Source:  https://twitter.com/COREIMpodcast/status/1633443908536483842

Congrats to Tim and Kaitlyn on the APCCMPD Education Research Award for the massive hemoptysis sim!
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Spotlight on CHI-PAP!

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CHI-PAP

We wanted to spotlight the great work fellowship-graduate Dr. Justin Fiala has been doing with CHI-PAP, an initiative to evaluate and treat sleep-related concerns. CommunityHealth is a free clinic that has multidisciplinary care under one roof. Dr. Fiala has built an amazing program that takes advantage of refurbished home sleep testing devices and donated and recycled/refurbished sleep devices and equipment to bring comprehensive sleep health to the community.

Visit their website here for more details: https://chi-pap.org/

Amazing work, Dr. Fiala!

Justin Anthony Fiala, MD | Northwestern Medicine