© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 163 (5): ITC5-1. * For Best Viewing:...

© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.

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in the clinic

Community-Acquired Pneumonia


Who is at increased risk for CAP?

Persons with:

Comorbid illness (respiratory disease; cardiovascular disease; diabetes mellitus; chronic liver disease)

Immune suppression

Chronic kidney disease

History of splenectomy

Elderly

Cigarette smokers

Alcoholism


Who should receive pneumococcal vaccination and when? All individuals aged 65 years and older

Other high-risk persons regardless of age Those living in special environments (long-term care)

Chronic heart disease (CHF, cardiomyopathy but not HT)

Chronic lung disease (COPD but not asthma)

Diabetes mellitus; Chronic liver disease

Cerebrospinal fluid leaks; Cochlear implants

Functional or anatomical asplenia (sickle cell disease)

Immune-suppression

Cigarette smoking; Alcoholism

Alaskan natives or American Indians

Anyone hospitalized for a medical illness


When to give vaccination

In those without high-risk conditions: age 65

Risk factors: when risk first identified, irrespective of age

How to give vaccination

Timing varies by age and presence of high-risk conditions

Generally:

PCV-13 first (more immunogenic)

PPS-23 (for additional strain coverage) 6-12 mo later

In immune-compromised patients <65 years: PPS-23 only 8 weeks after PCV-13

In those who received 1 or 2 doses of PPS-23 before age 65, repeat dose at ≥65 years if ≥5 years have passed since prior dose


What is the role of influenza vaccination in preventing CAP and its complications?

Immunize yearly

All patients at increased risk for influenza complications

Anyone likely to transmit the infection to high-risk patients

Recombinant influenza vaccine: Use in adults age ≤49

Option: Live attenuated vaccine (intranasal) in healthy, nonpregnant adults age ≤49

Don’t give to health care workers in contact with severely immune-compromised patients

Don’t give to those with immunosuppression and chronic medical conditions

High-dose influenza vaccine: available for those >65


CLINICAL BOTTOM LINE: Prevention... Offer pneumococcal vaccination to those at risk for CAP

Immune-competent: PCV-13, then PPS-23 after 6-12 mo

Immune-suppressed: PCV-13, then PPS-23 after only 8 wk

If received PPS-23 previously: 1 dose PCV-13 ≥1 year after

In those ≥65 who received previous doses before age 65: repeat PPS-23 vaccination after 5 years

In immune-suppressed at at any age: repeat PPS-23 vaccination after 5 years

Offer influenza vaccine yearly to at-risk persons


Which symptoms should lead clinicians to consider CAP?

Pneumonia with respiratory and systemic symptoms

Cough, purulent sputum, pleuritic chest pain

Dyspnea, chills, fever, night sweats, weight loss

Hemoptysis suggests necrotizing infection

Most patients present with acute illness 1–2d in duration

Older patients and those with chronic illness may develop nonrespiratory symptoms only

Confusion, weakness, lethargy

Falling, poor oral intake, decompensation of chronic illness

Symptoms may be present for longer periods in elderly


Which organisms cause CAP?

Streptococcus pneumoniae (pneumococcus)

Haemophilus influenzae

Mycoplasma pneumoniae

Chlamydophila pneumoniae

Legionella

Influenza virus

Parainfluenza virus

Respiratory syncytial virus

Adenovirus


Modifying Factors That Increase the Risk for Infection With Specific Pathogens

Penicillin-resistant and drug-resistant pneumococci

Age >65; beta-lactam therapy in past 3 months; alcoholism; immune-suppressive illness; multiple medical comorbid conditions; exposure to child in day care center

Enteric gram-negative bacteria

Residence in a nursing home; underlying cardiopulmonary disease; multiple medical comorbid conditions; recent antibiotic therapy

Pseudomonas aeruginosa

Structural lung disease (bronchiectasis); corticosteroid therapy; broad-spectrum antibiotic therapy for >7 d in the past month; malnutrition


What is the role of history and physical examination in the diagnosis of CAP? Suggests the presence of pneumonia

Suggestive: fever or hypothermia, tachypnea, crackles, bronchial breath sounds on auscultation, pleural effusion

Identifies risk factors for HCAP

Predicts the cause

Identifies those who might have less common cause

Helps define severity Associated with poor outcome:

Respiratory rate >30 breaths/min Diastolic BP <60 mm Hg; systolic BP <90 mm Hg Heart rate >125 beats/min Temperature <35°C or >40°C


When should clinicians use chest radiography?

When patients have clinical features suggesting CAP

To define the presence of parenchymal lung infection

To identify certain pneumonia complications

When diagnosis is questionable

Pleural effusion, lung abscess, necrotizing pneumonia, or multilobar illness suspected

Assume pneumonia in absence of radiographic infiltrate if patient has convincing history and focal physical findings

To aid management if severe illness is present

Confirm with decubitus film, thoracic ultrasound, or CT


What is the role of other laboratory tests?

Outpatients: to assess oxygenation only (pulse oximetry)

Inpatients: to define severity and identify cause

Pulse oximetry

Arterial blood gases (if CO2 retention suspected)

Sputum (Gram stain and culture before therapy started)

Rapid diagnostic testing of respiratory secretions with molecular methods

Culture endotracheal aspirate in intubated and mechanically ventilated patients

Serum levels of C-reactive protein or procalcitonin

Severe pneumonia: collect 2 sets of blood cultures and test urine for Legionella and pneumococcal antigens


What other disorders should clinicians consider in those suspected of having CAP?

Virus or an unusual bacterial pathogens

Bronchiolitis obliterans with organizing pneumonia

Pulmonary vasculitis

Hypersensitivity pneumonitis

Interstitial diseases

Lung cancer

Lymphangitic carcinoma

Bronchoalveolar cell carcinoma

Lymphoma

Congestive heart failure

Pulmonary embolus

Antibiotic-induced colitis

Empyema, meningitis, endocarditis


When should clinicians consider specialty consultation for diagnosis, and which types of specialists should they consult?

Infectious disease

To identify infectious complications of pneumonia and unusual infections

Pulmonary specialist

To identify inflammatory lung disease and pulmonary embolus

To perform bronchoscopy and transbronchial biopsy

Surgeon

To perform thoracoscopic or open lung biopsy


CLINICAL BOTTOM LINE: Diagnosis... History helps define risk factors for specific pathogens

Physical findings help define disease severity

Confirm diagnosis with chest radiograph

Laboratory testing has limited value

Diagnosing specific pathogens early is less useful because most initial therapy is empirical

If patient does not respond to initial therapy, consult specialists and consider bronchoscopy and lung biopsy


How should clinicians determine if a patient requires outpatient, inpatient, or ICU care? Pneumonia Severity Index or British Thoracic Society rule

Guidelines support ICU care if patient: Needs assisted ventilation Has septic shock requiring vasopressors Has ≥3 of following

Respiratory rate ≥30 breaths/min PaO2/ FiO2 ratio ≤250 Multilobar infiltrates, confusion or disorientation Blood urea nitrogen ≥7.1 mmol/L (20 mg/dL) Leukocyte count <4 × 109 cells/L Platelet count <100 × 109 cells/L Temperature <36°C Hypotension requiring aggressive fluid resuscitation


What is the role of nondrug therapies?

Outpatients

Oral hydration

Hospitalized patients

IV hydration and oxygen for hypoxemia

Chest physiotherapy if >30 mL/d sputum and clearance of secretions is impaired

Severely ill ICU patient

Noninvasive ventilatory support

Mechanical ventilation for respiratory failure


Which antibiotics should be prescribed for outpatients?

If patient has no cardiopulmonary disease and no factors that increase infection risk with DRSP or enteric gram-negative bacteria

Macrolide or doxycycline

If patient has cardiopulmonary disease or factors that increase infection risk with DRSP or enteric gram-negative bacteria

Antipneumococcal quinolone or combination beta-lactam + macrolide or doxycycline

If patient received antibiotic in past 3 months, avoid using antibiotic of same class


Drug Treatment for CAP Antibiotics for community-acquired MRSA

—linezolid, clindamycin, vancomycin

Antipseudomonal beta-lactams—piperacillin/tazobactam, cefepime, imipenem, meropenem

Cephalosporins—cefuroxime, cefpodoxime, ceftriaxone, cefotaxime

Glycylcycline—tigecycline

Macrolides—azithromycin, clarithromycin

Penicillins—amoxicillin/clavulanate, ampicillin, ampicillin/sulbactam

Quinolones—ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin

Tetracyclines—doxycycline


How should clinicians follow patients during outpatient treatment? Patients should monitor response to therapy

Measure temp orally every 8h

Drink at least 1 to 2 quarts of liquid daily

Report chest pain, severe or increasing shortness of breath, or lethargy

Complete course of antibiotics on schedule

If response satisfactory: return exam in 10-14 days

Give pneumococcal and influenza vaccinations if needed

Repeat chest radiograph ≥1 month after starting therapy to screen for nonresolution of infiltrates


How soon after admission should antibiotics be started?

As soon as possible after diagnosis and before leaving the emergency department

For hospitalized patients who are not in ICU

IV azithromycin if no cardiopulmonary disease and no factors that increase risk for DRSP or gram-neg bacteria

IV or oral quinolone or combination beta-lactam + macrolide or doxycycline if have cardiopulmonary disease or factors that increase risk for DRSP or gram-neg bacteria

Individualize antibiotic choice by risk factors for MDR pathogens if patients have HCAP


Which antibiotics should be given to patients admitted to the ICU?

Do not use empirical monotherapy

Assess for risk factors for P. aeruginosa

No risk factors: IV ceftriaxone or cefotaxime plus azithromycin or quinolone

Risk factors: IV antipseudomonal beta-lactam plus IV quinolone effective against P. aeruginosa

Risk factors (alternative): IV antipseudomonal beta-lactam combined with aminoglycoside plus IV macrolide or IV antipneumococcal quinolone

If community-acquired MRSA suspected, add linezolid alone or vancomycin combined with clindamycin


What are the other components of ICU care for CAP?

Hydration

Supplemental oxygen

Chest physiotherapy

Ventilatory support for respiratory failure

Systemic corticosteroids

Especially if relative adrenal insufficiency suspected or if patient with pneumococcal pneumonia has associated meningitis

Vasopressors

Serum lactate measurement


When can clinicians switch hospitalized patients from IV to oral antibiotics?

When cough, sputum production, and dyspnea improve

When afebrile on 2 occasions 8 hours apart

When able to receive oral medications

Select oral regimen that covers all organisms isolated in blood or sputum cultures and reflects IV therapy

Patients who responded to beta-lactam–macrolide combination can be continued on macrolide monotherapy unless cultures justify dual therapy


When should a consultation be requested for hospital patients, and who should be consulted?

Infectious disease or pulmonary: Questions about initial antibiotic therapy selection or poor response to initial therapy

Pulmonary or critical care: Decisions about vasopressors use, appropriate site of care, need for ventilatory support

Pulmonary physician: If pleural effusion documented and decision needed about thoracentesis

Pulmonary or thoracic surgical: Placement of chest tube if complicated parapneumonic effusion or empyema found on thoracentesis

Thoracic surgeon: Surgical decortication for advanced and loculated pleural effusion and empyema

Cardiologist: Cardiac ischemia complications or CHF


When can inpatients be discharged from the hospital?

Once a switch to oral therapy made

Once coexisting medical conditions are under control

No proven benefit for continued hospital observation


What are the indications for follow-up chest radiography?

If patient has good clinical response to therapy

Repeat chest radiograph at least 4 to 6 weeks after initial therapy

Radiographic resolution lags behind clinical resolution by 6 to 8 weeks, but early improvement is usually substantial

If patient deteriorates despite therapy and doesn’t reach clinical stability

Conduct aggressive evaluation

Order early follow-up chest radiograph


How can patients prevent recurrent CAP?

Update pneumococcal and influenza vaccinations

Avoid smoking cigarettes

Receive optimal therapy for comorbid illnesses

Obtain care for medical conditions that predispose to recurrent infection

Pursue evaluation for aspiration risk factors

If pneumonia recurs in same location, consider possible bronchiectasis, aspirated foreign body, or endobronchial obstruction

If patient has recurrent pneumonia or pneumonia with an unusual pathogen, consider immune deficiency


CLINICAL BOTTOM LINE: Treatment...

Determine site of care (outpatient, hospital, or ICU)

Select antibiotic therapy

Deliver supportive care (oxygen, hydration)

Determine need for ventilatory support

Consult specialist in severe disease and for complications

Transition to oral antibiotics after treatment response

Delay chest radiography 4-6 weeks if responsive to therapy

Monitor for comorbid illness and update vaccinations

Encourage smoking cessation

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