Pneumonia Abhishek Achar

Ly Tran

Epidemiology

More than 3 million cases occur annually in US Pneumonia is most relevant in winter months Incidence of Pneumonia is greater in Males than in females Total number of deaths due to pneumonia has been higher

in females since 1980s Individuals 65 years and older : Pneumonia and Influenza

were 6th leading death in 2005 Close to 90% of deaths due to pneumonia and influenza

occur in this age group Adjusted death rates for females: 17.9 deaths per 100,000

population 23.9 deaths per 100,000 population for males

CAP HAP/VAP

S. Pneumonia M.Pneumonia H. Influenza C. Pneumonia Legionella RSV

P. Aeruginosa

K. Pneumonia

E.Coli

S. Marcescens

Pneumonia

Diagnosis

Treatment

Prevention

Diagnosis● CAP vs. HCAP

– Community Acquired Pneumonia● Pneumonia in a patient without extensive healthcare

contact.

Diagnosis● CAP vs. HCAP

– Healthcare Associated Pneumonia● Associated with a higher risk of multidrug resistant

bacteria. ● Pneumonia in a patient with extensive healthcare contact

– IV Drug/Chemo therapy within last 30 days– Attendance at hospital/hemodialysis clinic within last 30 days– Hospitaliztion for >2 days within last 90 days– Residence in long term care facility

Diagnosis● Common Clinical Symptoms

– Cough– Pleuritic Chest Pain– Dyspnea– GI Upset

● Common Clinical Signs– Fever– Tachychardia– Crackles in lungs– Sputum Production– AMS

Even combined, Signs and Symptoms have a sensitivity of <50%

Diagnosis

Gold StandardCXR with presence of infiltrate

Diagnosis

Diagnosis● Largely a clinical diagnosis● Testing

– Outpatient: Optional– Hospitalized: CBC (Leukocytes), Blood cultures,

Sputum Gram Strain– Refractory: Legionella UAT, Pneumococcal UAT

Diagnosis● Indications for Hospitalization/ICU

– CURB-65● Confusion● Urea (BUN > 20mg/dL)● Respiratory Rate > 30bpm● BP Systolic <90; Diastolic <60● Age >65

– Score >2 – Hospitalization– Score >3 – Consider ICU

Treatment● Empiric Treatment should be started on ALL

clinically suspected cases.– Early diagnosis and treatment significantly reduced

Mortality and Length of Stay● Antimicrobial choice based on:

– Most likely pathogens– Clinical data– Risk Factors for resistance– Comorbidities

CAP Treatment● Empiric Outpatient

– Previously healthy patient1.Macrolides (A.C.E) OR2.Doxycycline

– Comorbidities, DM, Alcoholism, Immunosuppression, Prior ABx use

1.Fluoroquinolones (-floxacins, [Levaquin]) OR2.Beta-lactam(Amoxicillin/Ceftriaxone) AND Macrolides

● Consider Antipseudomonal for COPD

CAP Treatment● Empiric Inpatient

– Non-ICU1.Respiratory Fluoroquinolones OR2.Antipseudomonal Beta-Lactam AND Macrolide

– Ceftriaxone, Cefotaxime; A.C.E.– ICU

● Antipseudomonal B-Lactam AND Azithromycin● Antipseudomonal B-Lactam AND Fluoroquinolone● Fluoroquinolone AND Azetreonam

– MRSA● Add Vancomycin OR Linezolid

CAP Treatment● Empiric Inpatient

– Discharge appropriate when:● Stable from pneumonia● Tolerates PO meds● No active medical conditions● Safe environment for discharge

– There is no need for overnight observations when switching from IV to PO meds.

HAP/VAP Treatment● Empiric Inpatient

– One of the following (Gram Positive coverage):● Antipseudomonal Cephalosporin: Cefepime, etc.● Antipseudomonal Cabepenem: Imipenem, etc.● Pipercillin-Tazobactam● Penicillin Allergies

– Mild: Simple Graded Challenge– Severe: Azetreonam

HAP/VAP Treatment● Empiric Inpatient

– PLUS One of the following (B-lactam resistant Gram Negative coverage):

● Antipseudomonal Fluoroquinolone: Ciprofloxacin● Aminoglycoside: Gentamycin

– PLUS One of the following (MRSA coverage):● Linezolid● Vancomycin● Telavacin

HAP/VAP Treatment● Targeted Treatment

– MSSA: Naficillin, Oxacillin– Legionella: Fluoroquinolone– Anerobes (Aspiration): Clindamycin, Carbapenem

Prevention● Risk Factor Reduction

– Smoking Cessation– Vaccination

● Influenza– Yearly, all patients

● Pneumococcal– Once, Age <65, w/ indications

● Asplenia, Immunocomp., Smoker, Alcoholism, Cochlear Implants, DM, etc

– Once/Again, Age >65, w/o indication

END