Download recent updates in management of community acquired pneumonia

RECENT UPDATES IN
MANAGEMENT OF COMMUNITY
ACQUIRED PNEUMONIA
INTRODUCTION
 Improving the care of patients with (CAP)
has been the focus of many different
organizations.
 CAP, together with influenza, remains the
seventh leading cause of death in the
United States.
 915,900 episodes of CAP occur in
adults 65 years of age each year in the
US.
INTRODUCTION
 Two of the most widely referenced
guidelines for management of CAP are
those of the Infectious Diseases Society
of America (IDSA) and the American
Thoracic Society (ATS)
 In response to confusion regarding
differences between their respective
guidelines, the IDSA and the ATS
convened a joint committee to develop
a unified CAP guideline document.
INTRODUCTION
 Community-acquired pneumonia (CAP)
is defined as an acute infection of the
pulmonary parenchyma in a patient who
has acquired the infection in the
community
CLINICAL EVALUATION
 cough, fever, pleuritic chest pain, dyspnea and
sputum production .
 Chest pain occurs in 30 percent of cases, chills
in 40 to 50 percent, and rigors in 15 percent.
 Other common features are gastrointestinal
symptoms (nausea, vomiting, diarrhea), and
mental status changes.
CLINICAL EVALUATION
 Chest examination reveals audible rales in
most patients
 one-third have evidence of consolidation
 The major blood test abnormality is
leukocytosis
 Leukopenia can occur
RADIOLOGIC
EVALUATION
 an infiltrate on plain chest radiograph is
considered the gold standard for diagnosing
pneumonia
 The radiographic appearance of communityacquired pneumonia (CAP) may include lobar
consolidation
 interstitial infiltrates
 cavitation
RADIOLOGIC
EVALUATION
RADIOLOGIC
EVALUATION
Site-of-Care Decisions
Hospital admission decision
Severity-of-illness scores, such as:
- CURB-65 criteria (confusion, uremia,
respiratory rate, low blood pressure, age 65
years or greater)
- the Pneumonia Severity Index (PSI)
can be used to identify patients with CAP who
may be candidates for outpatient treatment.
PNEUMONIA SEVERITY INDEX FOR CAP
Site-of-Care Decisions
Hospital admission decision
PNEUMONIA SEVERITY INDEX FOR CAP
PSI risk
Site of care
I - II
Outpatients
III
Observation unit or with a short
hospitalization
Inpatients
IV - V
Site-of-Care Decisions
Hospital admission decision
CURB-65 criteria
1- confusion (based on a specific mental test or
disorientation to person, place, or time)
2- BUN level > 7 m mol/L (20 mg/dL)
3- respiratory rate > 30 breaths/min
4- low blood pressure (systolic, < 90 mm Hg; or
diastolic, < 60 mm Hg)
5- age > 65 years
Site-of-Care Decisions
Hospital admission decision
CURB-65
score
0-1
Site of care
2
admission
(wards)
admission
(ICU)
3
Outpatients
Site-of-Care Decisions
Hospital admission decision
Objective criteria or scores should always be
supplemented with
physician determination of subjective factors
including:
- the ability to safely reliably take oral
medication
- the availability of outpatient support resources.
ICU admission decision
Direct admission to an ICU is:
required for patients with:
- septic shock requiring vasopressors
- acute respiratory failure requiring intubation
and mechanical ventilation.
recommended for patients with:
3 of the minor criteria for severe CAP.
Criteria for severe CAP
Minor criteria
 Respiratory rate > 30 breaths/min
 PaO2/FiO2 ratio < 250
 Multilobar infiltrates
 Confusion/disorientation
 Uremia (BUN level > 20 mg/dL)
 Leukopeniac (WBC count, < 4000 cells/mm3)
 Thrombocytopenia (platelet count, < 100,000 cells/mm3)
 Hypothermia (core temperature, < 36C)
 Hypotension requiring aggressive fluid resuscitation
Major criteria
 Invasive mechanical ventilation
 Septic shock with the need for vasopressors
PaO2/FiO2 = arterial oxygen pressure/fraction of inspired oxygen
Most common etiologies
of CAP
Outpatient
Inpatient (non-ICU)
Inpatient (ICU)
S. pneumoniae
S. pneumoniae
S. pneumoniae
M. pneumoniae
M. pneumoniae
Staphylococcus
aureus
H. influenzae
C. pneumoniae
Legionella species
C. pneumoniae
H. influenzae
Gram-negative bacilli
Respiratory viruses
Legionella species
H. influenzae
Aspiration
Respiratory viruses
Empirical antimicrobial
therapy
 the initial treatment for most patients remain
empirical
 Increasing evidence has strengthened the
recommendation for combination empirical
therapy for severe CAP.
 Only 1 recently released antibiotic has been
added to the recommendations: ertapenem, as
an acceptable b-lactam alternative for
hospitalized patients with risk factors for infection
with gram-negative pathogens other than
Pseudomonas aeruginosa.
Outpatient treatment
1. Previously healthy and no risk factors
for drug-resistant S. pneumoniae
(DRSP) infection:
 A macrolide (azithromycin, clarithromycin, or
erythromycin)
 Doxycycline
Outpatient treatment
2. Presence of comorbidities such as chronic heart,
lung, liver or renal disease; diabetes mellitus;
alcoholism; malignancies; asplenia;
immunosuppressing conditions or use of
immunosuppressing drugs; or use of
antimicrobials within the previous 3 months (in
which case an alternative from a different class
should be selected):
 A respiratory fluoroquinolone (moxifloxacin,
gemifloxacin, or levofloxacin [750 mg])
 A b-lactam plus a macrolide
Outpatient treatment
3. In regions with a high rate (>25%) of
infection with high-level (MIC > 16
mg/mL)
macrolide-resistant S.pneumoniae
consider the use of alternative agents
listed above in (2) for any patient,
including those without comorbidities.
Inpatient, non-ICU
treatment
 A respiratory fluoroquinolone
 A b-lactam plus a macrolide
Inpatient, ICU treatment
A b-lactam (cefotaxime, ceftriaxone, or
ampicillin-sulbactam)
plus
either azithromycin or
a fluoroquinolone
(For penicillin-allergic patients, a respiratory
fluoroquinolone and aztreonam are
recommended.)
Special concerns
If Pseudomonas is a consideration
An antipneumococcal, antipseudomonal b-lactam 
(piperacillintazobactam, cefepime, imipenem, or meropenem) plus either
ciprofloxacin or levofloxacin (750 mg)
or
The above b-lactam plus an aminoglycoside and 
azithromycin
or
The above b-lactam plus an aminoglycoside and an 
antipneumococcal Fluoroquinolone (for penicillin-allergic
patients, substitute aztreonam for above b-lactam)
Special concerns
if CA-MRSA is a consideration
add vancomycin or linezolid
CA-MRSA = community-acquired methicillin-resistant Staphylococcus aureus
Time to first antibiotic dose
For patients admitted through the
emergency department (ED), the first
antibiotic dose should be administered
while still in the ED.
Switch from intravenous
to oral therapy




hemo-dynamically stable
improving clinically
able to ingest medications
have a normally functioning gastrointestinal
tract.
Switch from intravenous
to oral therapy
Patients should be discharged as soon as they:
 clinically stable
 no other active medical problems
 have a safe environment for continued care.
Inpatient observation while receiving oral
therapy is not necessary.
Duration of antibiotic
therapy
 Patients with CAP should be treated for
a minimum of 5 days
 before discontinuation of therapy patients
should be:
- afebrile for 48–72 h
- have no more than 1 CAP-associated sign of
clinical instability
Criteria for clinical
stability






Heart rate < 100 beats/min
Respiratory rate < 24 breaths/min
Temperature < 37.8C
Systolic blood pressure > 90 mm Hg
Arterial oxygen saturation > 90% or pO2 > 60
mm Hg on room air
Ability to maintain oral intake
Normal mental status
Deterioration or progression
Early (<72 h of treatment)
 Severity of illness at presentation
 Resistant microorganism
- Uncovered pathogen
- Inappropriate by sensitivity
 Metastatic infection
- Empyema/parapneumonic
- Endocarditis, meningitis, arthritis
 Inaccurate diagnosis
- PE, aspiration, ARDS
- Vasculitis (e.g., SLE)
Deterioration or progression
Delayed
 Nosocomial superinfection
- Nosocomial pneumonia
- Extrapulmonary
 Exacerbation of comorbid illness
 Intercurrent noninfectious disease
- PE
- Myocardial infarction
- Renal failure