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Community-Acquired Pneumonia Objectives Describe the common pathogenesis and pathogens of pneumonia Discuss diagnosis and initial management of community acquired pneumonia (CAP) Understand features of the Pneumonia PORT Severity Index Discuss the IDSA/ATS guidelines and recommendations for final antibiotic choice Understand issues in basic management for pneumonia in children, nursing home patients, and immunocompromised patients. Epidemiology Unclear! Few population-based statistics on the condition alone CDC combines PNA with influenza for morbidity & mortality data PNA & influenza = 7th leading causes of death in the US (2001) Age-adjusted death rate = 21.8 per 100,000 Mortality rate: 1-5% out-Pt, 12% In-Pt, 40% ICU Death rates increase with comorbidity and age Affects race and sex equally Community Acquired Pneumonia Infection of the lung parenchyma in a person who is not hospitalized or living in a long-term care facility for ≥ 2 weeks 5.6 million cases annually in the U.S. Estimated total annual cost of health care = $8.4 billion Most common pathogen = S. pneumo (6070% of CAP cases) “Nosocomial” Pneumonia Hospital-acquired pneumonia (HAP) Occurs 48 hours or more after admission, which was not incubating at the time of admission Ventilator-associated pneumonia (VAP) Arises more than 48-72 hours after endotracheal intubation “Nosocomial” Pneumonia Healthcare-associated pneumonia (HCAP) Patients who were hospitalized in an acute care hospital for two or more days within 90 days of the infection; resided in a nursing home or LTC facility; received recent IV abx, chemotherapy, or wound care within the past 30 days of the current infection; or attended a hospital or hemodialysis clinic Guidelines for the Management of Adults with HAP, VAP, and HCAP. American Thoracic Society, 2005 Pathogenesis Inhalation, aspiration and hematogenous spread are the 3 main mechanisms by which bacteria reaches the lungs Primary inhalation: when organisms bypass normal respiratory defense mechanisms or when the Pt inhales aerobic GN organisms that colonize the upper respiratory tract or respiratory support equipment Pathogenesis Aspiration: occurs when the Pt aspirates colonized upper respiratory tract secretions Stomach: reservoir of GNR that can ascend, colonizing the respiratory tract. Hematogenous: originate from a distant source and reach the lungs via the blood stream. Pathogens CAP usually caused by a single organism Even with extensive diagnostic testing, most investigators cannot identify a specific etiology for CAP in ≥ 50% of patients. In those identified, S. pneumo is causative pathogen 60-70% of the time Streptococcus pneumonia Most common cause of CAP Gram positive diplococci “Typical” symptoms (e.g. malaise, shaking chills, fever, rusty sputum, pleuritic hest pain, cough) Lobar infiltrate on CXR Suppressed host 25% bacteremic Atypical Pneumonia #2 cause (especially in younger population) Commonly associated with milder Sx’s: subacute onset, non-productive cough, no focal infiltrate on CXR Mycoplasma: younger Pts, extra-pulm Sx’s (anemia, rashes), headache, sore throat Chlamydia: year round, URI Sx, sore throat Legionella: higher mortality rate, water-borne outbreaks, hyponatremia, diarrhea Viral Pneumonia More common cause in children RSV, influenza, parainfluenza Influenza most important viral cause in adults, especially during winter months Post-influenza pneumonia (secondary bacterial infection) S. pneumo, Staph aureus Other bacteria Anaerobes Gram negative Aspiration-prone Pt, putrid sputum, dental disease Klebsiella - alcoholics Branhamella catarrhalis - sinus disease, otitis, COPD H. influenza Staphylococcus aureus IVDU, skin disease, foreign bodies (catheters, prosthetic joints) prior viral pneumonia Diagnosis and Management Guidelines American Thoracic Society Infectious Diseases Society of America Guidelines for the Management of Adults with CA (2001) Update of Practice Guidelines for the Management of CAP in Immunocompetent adults (2003) ATS and IDSA joint effort IDSA/ATS Consensus Guidelines on the Management of CAP in Adults (March 2007) Guidelines 2001 ATS & 2003 IDSA Guideline Update Expert panels Evidence-based recommendations Recommend patient stratification to identify likely pathogens and suggested empiric abx Site of care Presence of cardiopulmonary disease Presence of “modifying factors” Clinical Diagnosis Suggestive signs and symptoms CXR or other imaging technique Microbiologic testing Signs and Symptoms Fever or hypothermia Cough with or without sputum, hemoptysis Pleuritic chest pain Myalgia, malaise, fatigue GI symptoms Dyspnea Rales, rhonchi, wheezing Egophony, bronchial breath sounds Dullness to percussion Atypical Sx’s in older patients Clinical Diagnosis: CXR Demonstrable infiltrate by CXR or other imaging technique Establish Dx and presence of complications (pleural effusion, multilobar disease) May not be possible in some outpatient settings CXR: classically thought of as the gold standard Infiltrate Patterns Pattern Possible Diagnosis Lobar S. pneumo, Kleb, H. flu, GN Atypicals, viral, Legionella Viral, PCP, Legionella Patchy Interstitial Cavitary Large effusion Anaerobes, Kleb, TB, S. aureus, fungi Staph, anaerobes, Kleb Clinical Diagnosis: Recommended testing Outpatient: CXR, sputum Cx and Gram stain not required Inpatient: CXR, Pox or ABG, chemistry, CBC, two sets of blood Cx’s If suspect drug-resistant pathogen or organism not covered by usual empiric abx, obtain sputum Cx and Gram stain. Severe CAP: Legionella urinary antigen, consider bronchoscopy to identify pathogen Clinical Diagnosis Assess overall clinical picture PORT Pneumonia Severity Index (PSI) Aids in assessment of mortality risk and disposition Age, gender, NH, co-morbidities, physical exam lab/radiographic findings IDSA: Outpt Management in Previously Healthy Pt Organisms: S. pneumo, Mycoplasma, viral, Chlamydia pneumo, H. flu Recommended abx: Advanced generation macrolide (azithro or clarithro) or doxycycline If abx within past 3 months: Respiratory quinolone (moxi-, levo-, gemi-), OR Advanced macrolide + amoxicillin, OR Advanced macrolide + amoxicillin-clavulanate IDSA: Outpt Management in Pt with comorbidities Comorbidities: cardiopulmonary dz or immunocompromised state Organisms: S. pneumo, viral, H. flu, aerobic GN rods, S. aureus Recommended Abx: Respiratory quinolone, OR advanced macrolide Recent Abx: Respiratory quinolone OR Advanced macrolide + beta-lactam IDSA: Inpt ManagementMedical Ward Organisms: all of the above plus polymicrobial infections (+/- anaerobes), Legionella Recommended Parenteral Abx: Respiratory fluoroquinolone, OR Advanced macrolide plus a beta-lactam Recent Abx: As above. Regimen selected will depend on nature of recent antibiotic therapy. IDSA: Inpt ManagementSevere/ICU One Mechanical ventilation Septic shock, OR Two of two major criteria: of three minor criteria: SBP≤90mmHg, Multilobar disease PaO2/FIO2 ratio < 250 Organisms: S. pneumo, Legionella, GN, Mycoplasma, viral, ?Pseudomonas IDSA: Inpt Management: Severe/ICU No risk for Pseudomonas IV beta-lactam plus either • IV macrolide, OR IV fluoroquinolone Risk for Pseudomonas Double therapy: selected IV antipseudomonal betalactam (cefepine, imipenem, meropenem, piperacillin/tazobactam), plus • IV antipseudomonal quinolone -OR- Triple therapy: selected IV antipseudomonal betalactam plus IV aminoglycoside plus either IV macrolide, OR IV antipseudomonal quinolone Switch to Oral Therapy Four If criteria: Improvement in cough and dyspnea Afebrile on two occasions 8 h apart WBC decreasing Functioning GI tract with adequate oral intake overall clinical picture is otherwise favorable, can can switch to oral therapy while still febrile. Management of Poor Responders Consider non-infectious illnesses Consider less common pathogens Consider serologic testing Broaden antibiotic therapy Consider bronchoscopy Prevention Smoking cessation Vaccination per ACIP recommendations Influenza • Inactivated vaccine for people >50 yo, those at risk for influenza compolications, household contacts of high-risk persons and healthcare workers • Intranasal live, attenuated vaccine: 5-49yo without chronic underlying dz Pneumococcal • Immunocompetent ≥ 65 yo, chronic illness and immunocompromised ≤ 64 yo Pneumonia in Children: Dx Symptoms Infants: non-specific manifestations • Fever, poor feeding, irritability, vomiting, diarrhea, URI Sx, cough, respiratory distress Older children: more specific • Fever, cough, chest pain, tachypnea, tachycardia, grunting, nasal flaring, retracting. Cyanosis usually very late. Signs/Physical exam RR > 60 for all ages Hypoxia Rales, wheezes, crackles, coarse breath sounds Pneumonia in Children: Pathogens 0-4 wks: GBS, GN enterics, Listeria 4-12 wks: C. trachomatis, GBS, GN enterics, Listeria, viral (RSV/parainfluenza), B. pertussis 3 mos-4 yrs: Viral, S. pneumo, H. influenza, M. catarrhalis, Grp A Strep, Mycoplasma > 5yrs: Mycoplasma (5-15yrs), C. pneumo, S. pneumo, viral Pneumonia in the Elderly Prevention important Presentation can be subtle Antibiotic choice in CAP is same as other adults Healthcare associated pneumonia Consider S. aureus (skin wounds) and GN bacteria (aspiration) • Pneumonia in Older Residents of Long-term Care Facilities. AFP 2004; 70: 1495-1500. Pneumonia in Immunocompromised Pts Smokers, alcoholics, bedridden, immunocompromised, elderly Common still common S. pneumo Mycoplasma Pneumocystis Carinii Pneumonia P. jirovecii Fever, dyspnea, non-prod cough (triad 50%), insidious onset in AIDS, acute in other immunocompromised Pts CXR: bilateral interstitial infiltrates Steroids for hypoxia TMP-SMZ still first line