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Community Acquired Pneumonia

By: Junior Intern Hazel D. Reyes-Cruz March 21, 2011
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LUNGS

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Grading system for the strength of the recommendations and quality of evidence Grade Definition

Strength of recommendation
A

Good evidence to support recommendation for or against use recommendation for or against use

B Moderate evidence to support a C

Poor evidence to support recommendation for or against use

Quality of evidence
4/23/12 Level I Evidence from >1 properly

CLINICAL DIAGNOSIS
Accuracy of predicting CAP by physicians clinical

judgment is between 60-76%. (Grade B)

Clinical prediction rules combining history and physical

examination findings may be utilized to presumptively identify patients with pneumonia. (Grade B)

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LRTI acquired within the community (24

CLINICAL DIAGNOSIS: CAP

hours to less than 2 weeks)

Acute cough Abnorm al Chest Finding Tachyp nea

Tachyca rdia

Fever

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CLINICAL DIAGNOSIS: pathogen

There is no clinical feature that can reliably distinguish

pneumonia due to a typical or an atypical pathogen. (Grade A)

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CHEST RADIOGRAPHY
The chest x-ray is essential in the diagnosis of CAP,

assessing severity, differentiating pneumonia from other conditions, and in prognostication. (Grade A)

New parenchymal infiltrate REFERENCE diagnostic 4/23/12 standard for pneumonia

 A posteroanterior radiograph places the patient with his or her

CHEST RADIOGRAPHY

chest against the film, minimizing the magnification of the heart and the mediastinum on the image, thus minimizing the amount of lung obscured by these structures. (Grade A)
Standing posteroanterior and lateral views of the chest in full

inspiration comprise the best radiologic evaluation of a patient suspected of having pneumonia. (Grade A)

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CHEST RADIOGRAPHY: Pneumonitis????

There is no characteristic radiographic feature that can

predict the likely etiologic agent in CAP. (Grade B) be correlated clinically. (Grade C)

A radiographic reading of pneumonitis should always

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CHEST RADIOGRAPHY: normal

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CHEST RADIOGRAPHY: repeat

Routine follow-up chest radiograph is not needed for

patients with low-risk CAP who are clinically improving. (Grade B)

Radiolo gic baselin e 4-6 weeks in follow up visit

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SITE of CARE DECISIONS

A management-oriented risk stratification of CAP based

on the patients clinical presentation/condition, status of any co-morbid condition and chest x-ray findings should be utilized in the decision to determine the site of care for patients. (Grade A)

Patients with low-risk CAP are considered suitable for

outpatient care in the absence of contraindications. (Grade A)

These patients with moderate- and high-risk CAP need

to be hospitalized for closer monitoring and/or parenteral therapy. (Grade A)

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LOW RISK CAP Stable vital signs: RR <30 breaths per minute PR <125 beats/minute SBP >90 mmHg DBP >60 mmHG No or stable comorbid conditions

MODERATE RISK CAP Unstable vital signs: RR > 30 breaths per minute PR > 125 beats/minute Temp of >40 C or <35 C

HIGH RISK CAP

Any of the clinical features of moderate risk CAP plus any of the following: 1. Shock or signs of hypoperfusion 2. Hypoxia (PaO2 <60 mmHg) or Unstable comorbid conditions acute hypercapnea (PaCO2 >50 (uncontrolled diabetes mellitus, active mmHg) malignancies, progressing neurologic disease, congestive heart failure class II-IV, unstable coronary artery disease, renal failure on dialysis, uncompensated COPD, decompensated liver disease) Evidence of pulmonary sepsis (hepatic, hematologic, gastrointestinal, endocrine) Suspected aspiration Chest xray: Chest xray: Multilobar infiltrates Multilobar infiltrates Pleural effusion or abscess Pleural effusion or abscess Progression of findings to >50% in 24 Progression of findings to >50% in 24 hours hours

No evidence of extrapulmonary sepsis No evidence of aspiration

Chest xray: Localized infiltrates No evidence of pleural effusion nor abscess Not progressive within 24 hours

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MICROBIOLOGICAL STUDIES
In low-risk CAP, microbiologic studies are optional.

(Grade B)

In moderate-risk and high-risk CAP, blood cultures and

Gram stain and culture with antibiotic sensitivity tests of respiratory specimens should be done in laboratories with quality assurance. (Grade A)

When possible, tests to document the presence of

Leginella pneumophila are recommended in hospitalized patients with CAP. (Grade B)

Invasive procedures (i.e., transtracheal, transthoracic biopsy, bronchoalveolar lavage, and protected brush specimen) to obtain specimens for special microbiologic studies for atypical 4/23/12 pathogens (e.g., mycobacteria and other microorganisms that

TREATMENT
For patients requiring hospitalization, empiric therapy

should be initiated as soon as possible after diagnosis of CAP is made. (Grade B)

For low-risk CAP, treatment may be delayed. (Grade C)

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Empiric Antimicrobial Therapy in LOW RISK CAP

Potential Pathogen Empiric Therapy Streptococcus Previously healthy: pneumoniae Amoxicillin Haemophilus influenzae -orChlamydophilia Extended Macrolides pneumoniae (alternative: Mycoplasma pneumoniae cotrimoxazole) Moraxella catarrhalis Enteric gram-negative With stable comorbid bacilli illness: Co-Amoxiclav -orSultamicillin 4/23/12 -or-

Empiric Antimicrobial Therapy in MODERATE RISK CAP

Potential Pathogen Empiric Therapy Streptococcus IV non-pseudomonal pneumoniae beta-lactam with or Haemophilus influenzae without beta-lactamase Chlamydophilia inhibitor PLUS a pneumoniae mcarolide Mycoplasma pneumoniae Moraxella catarrhalis -orEnteric gram-negative bacilli Anti-pneumonoccal fluoroquinolones Legionella pneumophilia 4/23/12 Anaerobes

Empiric Antimicrobial Therapy in HIGH RISK CAP

Potential Pathogen Streptococcus pneumoniae Haemophilus influenzae Chlamydophilia pneumoniae Mycoplasma pneumoniae Moraxella catarrhalis Enteric gramnegative bacilli Legionella pneumophilia Empiric Therapy No risk for P. aeruginosa: IV non-pseudomonal betalactam with or without betalactamase inhibitor PLUS a IV mcarolide -orIV anti-pneumonoccal fluroquinolone With risk for P. aeruginosa:
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IV pseudomonal beta-lactam with or without beta-lactamase inhibitor

Those at risk for P. aeuroginosa history of chronic or prolonged use of broad-spectrum antibiotic therapy with severe underlying bronchopulmonary disease (COPD, bronchiectasis)
malnutrition chronic use of steroid therapy

>7.5mg/day
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TREATMENT: initial therapy assessment

Temperature, respiratory rate, heart

rate, blood pressure, sensorium, oxygen saturation and inspired oxygen concentration should bemonitored to assess response to therapy. (Grade A)
Response to therapy is expected

within 24-72 hours of initiating treatment. Failure to improve after 72 4/23/12

Treatment: de-escalation of therapy

antibiotic or combination parenteral therapy to a single narrow spectrum parenteral or oral agent based on available laboratory data is recommended once the patient is clinically improving, is hemodynamically stable and has a functioning gastrointestinal tract. (Grade B)
De-escalation of initial empiric broad-spectrum

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Indications for streamlining antibiotic therapy

TREATMENT:

1.

Resolution of fever for > 24 hours Less cough and resolution of respiratory distress

2.

3. Improving white blood cell count,

no bacteremia
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oral antibiotics for de-escalation therapy

TREATMENT:

Amoxicillin-clavulanic acid 625mg TID

or 1 gm BID
Cefaclor 500 mg TID or 750 mg BID Amoxicillin-sulbactam 1 gm TID Cefuroxime axetil 500 mg BID Sultamicillin 750 mg BID Cefdinir 300 mg BID Azithromycin dihydrate 500 mg OD
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TREATMENT:
Benefits of intravenous to oral sequential antibacterial therapy

Benefits for Patients

More convenient Less local adverse effects related to intravenous administration

Pharmacoeconomic Benefits
Less infusion equipment, cannulas, and infusion bottles required Less hospital waste to dispose of

Earlier mobilization resulting in a lower risk for thrombosis Oral antibacterials less expensive than parenteral Reduced hospital stay resulting antibacterials in a lower risk for cross or nosocomial infections Reduced storage costs for parenteral therapy

Less hospital staff time required 4/23/12

TREATMENT: duration
Low risk uncomplicated bacterial pneumonia Moderate risk CAP, High risk CAP, suspected or confirmed gram negative, S. aureus or P. aeruginosa pneumonia Mycoplasma and Chlamydophila pneumonia Discontinu Legionella pneumoniaation of treatment: Duration 5 days 14-21 days

10-14 days

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TREATMENT:
no improvement in 72 hours
The clinical history, physical

examination and the results of all available investigations should be reviewed. The patient should be reassessed for possible resistance to the antibiotics being given or for the presence of other pathogens such as M. tuberculosis, viruses, parasites or fungi. Treatment should then be revised accordingly. (Grade B)
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TREATMENT: no response to therapy

1. Incorrect

diagnosis or presence of a complicating noninfectious

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TREATMENT: discharge criteria

1. temperature of 36-37.5o C 2. pulse < 100/min 3. respiratory rate between 16-

24/minute
4. systolic BP >90 mmHg
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PREVENTION
Influenza vaccination is recommended for the

prevention of CAP. (Grade A)

Pneumococcal vaccination is recommended for the

prevention of invasive pneumococcal disease (IPD) in adults. (Grade A)

Smoking cessation is recommended for all persons with

CAP who smoke. (Grade A)

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PREVENTION: influenza vaccine INDICATIONS

All persons aged >50 yrs Chronic Illness: chronic

pulmonary (including asthma), chronic cardiovascular (except hypertension), renal, hepatic, neurological / neuromuscular, hematological or metabolic disorders (including

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0.5 ml intramuscularly once a year

PREVENTION: influenza vaccine

CONTRAINDICATIONS:
Anaphylactic reaction to a previous

dose of influenza vaccine

Allergy to eggs or to a vaccine

component
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PREVENTION: pneumococcal vaccine INDICATIONS

Persons aged >60 years of age Persons with chronic illnesses:

chronic pulmonary diseases (chronic obstructive pulmonary disease, bronchiectasis, chronic pulmonary tuberculosis), cardiovascular (including congestive heart failure and cardiomyopathies), diabetes mellitus, chronic alcoholism, chronic liver disease, chronic renal failure or 4/23/12 nephrotic syndrome, cerebrospinal

Single 0.5 ml dose given IM or

PREVENTION: pneumococcal vaccine

subcutaneously

CONTRAINDICATIONS:
Immediate anaphylactic reaction to a

previous dose of pneumococcal vaccine

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PREVENTION: cigarette smoking

Active and passive smoking Independent risk factor

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Thank yoU!
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