ADULT PNEUMONIA

LIZA D. MARIPOSQUE, M.D.

July 1, 2008

DefinitionDefinitionInfection of the pulmonary parenchyma Infection of the pulmonary parenchyma

caused by various bacterial species, caused by various bacterial species, virus, virus, fungi and parasitesfungi and parasites

• Not a single disease, but a group of specific

infection, each having different

epidemiology, pathogenesis, clinical

manifestations and clinical course.

EpidemiologyEpidemiology

6th leading cause of death in the US 6th leading cause of death in the US

Leading cause of death from an Leading cause of death from an infectious infectious disease disease

Mortality ranges 2Mortality ranges 2--30% in hospitalized patients 30% in hospitalized patients and and averages 14% averages 14%

Mortality if admitted to ICU nearly 50% Mortality if admitted to ICU nearly 50%

Between 1979 and 1994, age adjusted death Between 1979 and 1994, age adjusted death rates rates increased 22%increased 22%

EtiologyEtiology

Factors that determine the etiologic agentFactors that determine the etiologic agent

1.1. Setting from which infection is acquiredSetting from which infection is acquiredCommunityCommunity

HospitalHospital

2.2. AgeAge

3.3. ComorbidComorbid conditioncondition

 

 

 

 

 

Table 255-1. Microbial Pathogens That Cause Pneumonia

Community-Acquired Hospital-Acquired HIV Infection-Associated  

Mycoplasma pneumoniaeStreptococcus pneumoniaeHaemophilus influenzaeChlamydia pneumoniaeLegionella pneumophilaOral anaerobesMoraxella catarrhalisStaphylococcus aureusNocardia spp.VirusesaFungibMycobacterium tuberculosisChlamydia psittaci

Enteric aerobic gram-negative bacilli

Pseudomonas aeruginosa

S. aureusOral anaerobes

Pneumocystis cariniiM. tuberculosisS. pneumoniaeH. influenzae

 

a Influenza virus, cytomegalovirus, respiratory syncytial virus, measles virus, varicella-zoster virus, and hantavirus.

b Histoplasma, Coccidioides, and Blastomyces spp.

DEFENSE MECHANISMS

Ciliary movements

Epithelial lining fluids- lyse microbial pathogens

Alveolar macrophages, lymphocytes & polymorphonuclear leukocytes

Sneeze & cough reflex

Routes of Infection

1. Microaspiration

2. Gross Aspiration

3. Aerosolization/inhalation

4. Hematogenos route

5. Contiguous spread

Microaspiration

Oropharyngeal secretions colonized with pathogenic microorganisms.

The most common route.

Most common: S. pneumonia, H. influenzae

Anaerobic organism from gingival crevices & dental plaque.

Gross aspiration

Occurs in patient with CNS disorders that affect swallowing- stroke, seizure

In those with impaired consciousness – alcoholic, IV drug users

During anesthesia or intubation.

Anaerobic organisms & gram negative bacilli.

Inhalation of infectious aerosolsInhalation of infectious aerosols–– Size factor:Size factor:

>10 um diameter = nose and upper airway>10 um diameter = nose and upper airway

<5 um diameter (airborne) =deposited in small bronchiole and <5 um diameter (airborne) =deposited in small bronchiole and alveolialveoli

Etiologies acquired by inhalation:

TB

Influenza

Legionella

Psittacosis

Histoplasma

Q fever

Hantavirus (HPS)

HematogenousHematogenous Dissemination from an Dissemination from an extrapulmonatyextrapulmonaty sitesite–– EgEg: : staphstaph aureusaureus-- IV drug user, abscessIV drug user, abscess

–– FusobacteriumFusobacterium –– from from retrophangealretrophangeal tissuetissue((LemierreLemierre’’ss syndrome)syndrome)

Direct inoculation and contiguous Direct inoculation and contiguous spreadspread

EgEg: stab wound, tracheal : stab wound, tracheal intubationintubation

Contiguous spread from adjacent site of infectionContiguous spread from adjacent site of infection

PNEUMONIA is an infection of the alveoli, distal airways, and interstitium of the lungs.

LOBAR PNEUMONIA: involvement of the entire lung lobe.

BRONCHOPNEUMONIA: patchy consolidation in 1 or several lobes, usually in dependent lower or posterior portions centered around bronchi & bronchioles.

INTERSTITIAL PNEUMONIA: Inflammation of the interstitium, including the alveolar walls and connective tissue around the bronchovascular tree.

MILIARY PNEUMONIA: Numerous discrete lesions due to hematogenous spread.

Community Acquired Pneumonia

- typical pneumonia

- atypical pneumonia

Nosocomial Pneumonia

Aspiration Pneumonia

CAP:COMMUNITY-ACQUIRED PNEUMONIA

More common among patients with severe underlying illness, those with defects in phagocytosis or ciliary function, and those with anatomical defects such as bronchiectasis.Factors that influence the types of pathogens.Most causes by S. pneumonia (50% hosp.)

Most typical symptoms: fever, cough, pleuritic chest pain, chills or rigors, and dyspnea.

Frequent symptoms: HA, N/V, diarrhea, fatigue and confusion.

PE: tachypnea, dullness to percussion, inc. tactile & vocal fremitus, egophony, whispering pectoriloquy, crackles, and pleural friction rub.

RR>30/min – the most useful sign of severe pneumonia in a person without underlying lung disease.

ATYPICAL PNEUMONIA

TYPICAL PNEUMONIA

Etiology M.pneumonia, Legionellasp.C. pneumonia, Mycoplasma, viruses

S.pneumonia, H. influenza, Klebsiella, mixed aerobic & anaerobic oral flora

Onset gradual Abrupt

Cough Dry cough Productive cough

Sputum Scanty Purulent

Extra-pulmonary symptoms

Prominent (HA,myalgia, fatigue, N/V, diarrhea

Not prominent

the less frequently encountered pathogens C. psittaci, Coxiella burnetii, Francisella tularensis, H. capsulatum, and Coccidioides immitis.

Atypical pneumonia

Certain viruses also produce pneumonia that is usually characterized by an atypical presentation: Primary viral pneumonia can be caused by influenza virus (usually as part of a community outbreak in winter).- respiratory syncytial virus (in children and immunosuppressed individuals)- measles or varicella-zoster virus (accompanied by the characteristic rash)- cytomegalovirus (in patients immunocompromised by HIV infection or by therapy given in association with organ transplantation).

CAP

Any of the ff:1. RR 30 or >2. PR 125 or >3. Temp 40C or <35C4. Extrapulmonary evidence

of sepsis5. Suspected aspiration6. Unstable comorbid7. CXR: multilobar

Pleural effusionAbscess50% progression in 24hr

NO

Low

yes

Any of the ff:1.Shock or

Signs of hypoperfusion-hypotension-altered sensorium-UO<30ml/hr

2. PaO2 <60or PaCO2>50

NOModerate

YESHigh

OPD

In-patient

ICU

Algorithm for the management-oriented risk stratification of CAP in immunocompetent adults (PCPG)

ANY OF THE FF:

• DM

•Neoplastic dse

•Neurologic dse

•Chf, copd

•Renal insufficiency

•Chronic liverdse

•alcoholism

Unstable

LOWRISK

CAP II

OPDMINIMAL RISK

CAP I

MODERATE RISK

CAP III

WARD

Demographic Fc:-age-men age yr

women age-10Nursing home res. +10Coexisting illnessNeosplatic dse +30liver dse +20CHF +10CVD +10Renal dse +10

PE Findings:-altered ms +20-RR>30 +20SBP <90 +20T<35/>40C +15PR>125 +10Labs:-art.pH<7.35 +30-BUN>30mg/dl +20-Na<130 +20-glucose>250 +10-hct<30 +10-PPA <60/O2 Sat +10-pleural effusion

PORT SCORE:Criteria for hosp.of Px with pneumonia

Risk class

No. of points Recommendations for site of care

I No prediction OPD

II <70 OPD

III 71-90 IN PATIENT

IV 91-130 ICU

V >130 ICU

American Thoracic Society (ATS) CAP GuidelinesAmerican Thoracic Society (ATS) CAP Guidelines(Patient stratification)(Patient stratification)

CAP ICAP I–– Outpatient with no history of CP disease, no modifying Outpatient with no history of CP disease, no modifying

factorsfactors

CAP IICAP II–– Outpatient w/ CP disease and/or modifying factorsOutpatient w/ CP disease and/or modifying factors

CAP III= Inpatient CAP III= Inpatient –– III A: With CP disease and/or modifying factorsIII A: With CP disease and/or modifying factors–– III B: No CP disease and no modifying factorsIII B: No CP disease and no modifying factors

CAP IV= ICUCAP IV= ICU–– IV A: No risk for P. IV A: No risk for P. aeruginosaaeruginosa–– IV B: Risk for P. IV B: Risk for P. aeruginosaaeruginosa

HAP:HOSP.-ACQUIRED (NOSOCOMIAL) PNEUMONIA

Defined as a new or progressive infiltrate on CXR plus at least two of the ff: T>37.8C, WBC>10T and production of purulent sputum.Pneumonia develop at least 48 hrs after hospital admission.Occurs most frequently in ICU patients on mechanical vent.The highest morbidity and mortality rates of all nosocomial infections

the patients at greatest risk for nosocomial pneumonia are most likely to be heavily colonized with potential pulmonary pathogens in the oropharyngeal or tracheobronchial mucosa.the presence of these organisms in gram-stained preparations or cultures of respiratory tract secretions does not necessarily confirm the diagnosis of pneumonia.

Risk of Pseudomonas Risk of Pseudomonas aeruginosaaeruginosainfectioninfection

1.1. Structural Lung DiseaseStructural Lung Disease

2.2. Corticosteroid therapy (prednisone > Corticosteroid therapy (prednisone > 10mg/day)10mg/day)

3.3. Broad spectrum antibiotic for >7 days in Broad spectrum antibiotic for >7 days in the past monththe past month

4.4. MalnutritionMalnutrition

Aspiration PneumoniaAspiration Pneumonia–– Sudden onset of dyspnea, wheezing, Sudden onset of dyspnea, wheezing,

hypoxemia hypoxemia

–– CXR: Infiltrate in the right lower lobeCXR: Infiltrate in the right lower lobe

–– Result in putrid sputum, tissue necrosis & Result in putrid sputum, tissue necrosis & pulmonary cavitiespulmonary cavities

Etiology:Etiology:

–– OropharygealOropharygeal pathogenpathogenAnaerobesAnaerobes

–– Chemical Chemical PneumonitisPneumonitis ((MendelsonMendelson’’sssyndrome)syndrome)

Diagnosis

A. History & P.E.

- 60% accuracy

B. CXR

C. Sputum examinaton

Laboratory ExaminationLaboratory Examination

A. Chest X ray (PAA. Chest X ray (PA--Lateral Lateral views)views)

–– New New parenchymalparenchymalinfiltrateinfiltrate

–– Confirms the diagnosisConfirms the diagnosis

–– Assess the severity / Assess the severity / prognosticationprognostication

–– May suggest the etiologyMay suggest the etiology

Oral anaerobes, S. aureus, S. pneumoniae serotype III, aerobic gram-negative bacilli, M. tuberculosis, and fungi as well as certain noninfectious conditions can produce tissue necrosis and pulmonary cavities.H. influenzae, M. pneumoniae, viruses, and most other serotypes of S. pneumoniae almost never cause cavities.Apical disease, with or without cavities, suggests reactivation tuberculosis.

Anaerobic abscesses are located in dependent, poorly ventilated, and poorly draining bronchopulmonary segments and characteristically have air-fluid levels, unlike the well-ventilated, well-drained upper-lobe cavities caused by M. tuberculosis, an obligate aerobe. Air-fluid levels may also be present in cavities due to pulmonary necrosis of other infectious etiologies, such as S. aureus and aerobic gram-negative bacilli. Mucor and Aspergillus invade blood vessels and cause pleural-based, wedge-shaped areas of pulmonary infarction.

In the patient with an uncomplicated course, chest radiographs need not be repeated before discharge, since the resolution of infiltrates may take up to 6 weeks after initial presentation.

In patients who do not respond clinically, who have a pleural effusion on admission, who may have postobstructive pneumonia, or who are infected with certain pathogens (e.g., S. aureus, aerobic gram-negative bacilli, or oral anaerobes) need more intensive surveillance.

Laboratory ExaminationLaboratory Examination

B. Sputum ExaminationB. Sputum Examination–– Gram stainGram stain

Good specimen: Good specimen: >25 PMN; <10 >25 PMN; <10 epithepith cell per LPFcell per LPF

Sensitivity: 60Sensitivity: 60--80%80%

Specificity: 85% in identifying Specificity: 85% in identifying pneumococcuspneumococcus

–– CultureCulture4040--60% specificity60% specificity

–– BAL, TTA, PSB, LA BAL, TTA, PSB, LA not routinely donenot routinely done

Better specificityBetter specificity

Satisfactory sputum specimenSatisfactory sputum specimen

Amount: at least 5ml ( 1 teaspoon)Amount: at least 5ml ( 1 teaspoon)

Microscopic criteria:Microscopic criteria:

–– >25 PMN/HPF>25 PMN/HPF

–– < 10 epithelial cells/LPF< 10 epithelial cells/LPF

–– presence of alveolar macrophagespresence of alveolar macrophages

Expectorated sputum usually is easily collected from patients with a vigorous cough but may be scant in patients with an atypical syndrome, in the elderly, and in persons with altered mental status. If the patient is not producing sputum and can cooperate, respiratory secretions should be induced with ultrasonic nebulization of 3% salineGram's staining is more specific and probably more sensitive than the sputum culture. The finding of mixed flora on Gram's staining of an uncontaminated sputum specimen suggests an anaerobic infection.

TreatmentTreatmentA. Empiric Antibiotic TherapyA. Empiric Antibiotic TherapyB. Specific Antimicrobial based on isolated B. Specific Antimicrobial based on isolated

organism cultureorganism cultureC. OthersC. Others

–– MucolyticsMucolyticsNN--acetylcysteineacetylcysteine ((fluimucilfluimucil), ), EctrinEctrin, , ambroxolambroxol

–– ExpectorantExpectorantGlycerylGlyceryl GuiacolateGuiacolate

–– Nebulization Nebulization salbutamolsalbutamol

Empiric TreatmentEmpiric TreatmentLOW RISK CAPLOW RISK CAP

Previously healthyPreviously healthy: amoxicillin or extended : amoxicillin or extended macrolidemacrolide, alternative: , alternative: cotrimoxazolecotrimoxazole

with stable co morbid illnesswith stable co morbid illness: co: co--amoxyclavamoxyclav or or sultamicillinsultamicillin or 2or 2ndnd gengencephalosporin or extended cephalosporin or extended macrolidemacrolide

MODERATE RISK CAPMODERATE RISK CAP-- IV non IV non pseudomonalpseudomonal B B lactamslactams w/ or w/o B w/ or w/o B lactameselactamese inhibitor plus inhibitor plus macrolidemacrolide OR OR antipneumococcalantipneumococcal fluoroquinolonefluoroquinolone

HIGH RISK CAPHIGH RISK CAPNo risk for P. No risk for P. aeruginosaaeruginosa: IV non: IV non--pseudomonalpseudomonal B B lactamlactam w/ or w/o B w/ or w/o B lactamaselactamase inhibitor plus IV inhibitor plus IV macrolidemacrolide OR IV OR IV antipneumococcalantipneumococcalfluoroquinolonefluoroquinolone

W/ risk of P. W/ risk of P. aeruginosaaeruginosa: IV : IV antipseudomonalantipseudomonal B B lactamlactam w/ or w/o B w/ or w/o B lactamaselactamase inhibitor plus IV inhibitor plus IV macrolidemacrolide or IV or IV antipeumoccocalantipeumoccocalfluoroquinolonefluoroquinolone +/+/-- aminoglycosideaminoglycoside or IV ciprofloxacinor IV ciprofloxacin

Table 255-5. Empirical Oral Antimicrobial Therapy for Outpatient Management of Community-Acquired Pneumonia  

Value of Indicated Antimicrobiala

Pathogen Penicillin G

Amoxicillin/Clavulanate

Cefuroxime

Trimethoprim-Sulfamethoxazol

e

Doxycycline

Erythromycin

Ciprofloxacin

NewerFluoroquinolonesb  

Streptococcus pneumoniae

±c ±c ±c ±c +c ±c ± +c 

Haemophilus influenzae

- + + + + -d + + 

Moraxella catarrhalis

- + + + + + + + 

Anaerobes ± + ± - - - - ±  

Mycoplasma pneumoniae

- - - - + + + + 

Chlamydia pneumoniae

- - - - + + + + 

Legionella pneumophila

- - - ± ± + + + 

a +, effective; -, ineffective; ±, sometimes effective.  

b Levofloxacin, gatifloxacin, moxifloxacin, and sparfloxacin.  

c In the United States, about 42% of strains are currently resistant to penicillin (15% with high-level penicillin resistance), 20% to amoxicillin and cefuroxime, 20-30% to trimethoprim-sulfamethoxazole, 7-10% to doxycycline (tetracycline), 14% to erythromycin, and <4% to the newer fluoroquinolones.

 

d The new macrolides azithromycin and clarithromycin are more active against H. influenzae than erythromycin and are equally or more active against other respiratory pathogens.

 

EMPIRIC Rx FOR CAP:

Rx Settings Regimen

OPD, no CP disease, no risk factors

Clarithromycin 500mg BIDx10 days; Azithromycin 500mg PO 1 dose then 250 mg/d x 4 days; Doxycyline 100mg BID x 10 days.

Rx Settings Regimen

OPD, CP disease and/or risk factors; high prevalence in the comunity

Quinolone with enhanced activity against S. pneumonia- Levox, Moxifloxacin; B-Lactam (cefpodoxime, amox, co-amox.); Telithromycin

Table 255-6. Empirical Antimicrobial Therapy for the Management of Hospitalized Patients with Community-Acquired Pneumonia  

Value of Indicated Antimicrobiala

Pathogen Penicillin G

Second-Generatio

nCephalos

porins

Third- andFourth-

GenerationCephalospo

rinsb

Metronidazole

Trimethoprim-

Sulfamethoxazole

Erythromycin

Ampicillin/

Sulbactam

Newer Fluoro-

quinolonesc

 

Streptococcus pneumoniae

±d

±d +d - ±d ±d ±d +d 

Staphylococcus aureus - + + - + + + +  

Haemophilus influenzae

- + + - + - + + 

Moraxella catarrhalis - + + - + + + +  

Anaerobic gram-positive cocci

+

+ + ± - ± + ± 

Anaerobic gram-negative bacilli

- - - + - - + ± 

Chlamydia pneumoniae - - - - - + - +  

Legionella pneumophila

- - - - ± + - + 

Mycoplasma pneumoniae

- - - - - + - + 

a +, effective; -, ineffective; ±, sometimes effective.  

b Ceftriaxone, cefotaxime, and cefepime.  

c Levofloxacin, gatifloxacin, moxifloxacin, and sparfloxacin.  

d In the United States, about 42% of strains are currently resistant to penicillin (15% with high-level penicillin resistance; ampicillin slightly less active than penicillin), 20% are resistant to cefuroxime (similar activity displayed by the first-generation cephalosporin cephalothin), 4-5% are highly resistant to third- or fourth-generation cephalosporins, 20-30% are resistant to trimethoprim-sulfamethoxazole, 7-10% are resistant to doxycycline (tetracycline), 14% are resistant to erythromycin, and <4% are resistant to the newer fluoroquinolones.

 

Table 255-7. Dosage of Antimicrobial Agents for the Treatment of Pneumonia in Hospitalized Patientsa

Drug Dosage  

Ampicillin/sulbactam 3 g IV q6h  

Aztreonam 2 g IV q8h  

Cefazolin 1-2 g IV q8h  

Cefepime 2 g IV q8h  

Cefotaxime, ceftizoxime 1-2 g IV q8-12h  

Ceftazidime 2 g IV q8h  

Ceftriaxone 1-2 g IV q12h  

Cefuroxime 750 mg IV q8h  

Ciprofloxacin 400 mg IV or 750 mg PO q12h  

Clindamycin 600-900 mg IV q8h  

Erythromycin 0.5-1.0 g IV q6h  

Gentamicin (or tobramycin) 5 mg/kg/d in 3 equally divided doses IV q8h  

Imipenem 500 mg IV q6h  

Levofloxacin 500 mg IV or PO q24h  

Metronidazole 500 mg IV or PO q6h  

Nafcillin 2 g IV q4h  

Penicillin G 3 million units IV q4-6h  

Piperacillin/tazobactam 4.5 g IV q6h  

Ticarcillin/clavulanate 3.1 g IV q4h  

Vancomycin 1 g (15 mg/kg) IV q12h  

a Dosage must be modified for patients with renal failure. Guidelines on the duration of therapy for each pathogen are given in the text of this chapter and of chapters on specific infecting agents.

Table 255-8. Empirical Antimicrobial Therapy, Based on Gram's Staining of Sputum, for Institutionally Acquired Pneumonia

Etiology Regimen  

Presumptive Staphylococcus aureus Nafcillin or vancomycina  

Presumptive enteric aerobic gram-negative bacilli or Pseudomonas aeruginosa

1. Ceftazidime or cefepime ± aminoglycoside2. Ticarcillin/clavulanate or piperacillin/tazobactam ± aminoglycoside3. Aztreonam ± aminoglycoside4. Imipenemb ± aminoglycoside5. Fluoroquinolonec ± aminoglycoside or b-lactam

 

Mixed flora 1. Ceftazidime or cefepime + clindamycin (or metronidazole) ± aminoglycosidee2. Ticarcillin/clavulanate or piperacillin/tazobactam ± aminoglycosidee3. Aztreonam + clindamycin (or metronidazoled) ± aminoglycosidee4. Imipenemb ± aminoglycosidee5. Fluoroquinolonec+ clindamycin (or metronidazoled) ± aminoglycoside or b-lactam

 

a If methicillin-resistant S. aureus is known to exist in the institution, use vancomycin; otherwise, use an antistaphylococcal b-lactam such as nafcillin or cefazolin.

b Use when extended-spectrum b-lactamase producers are endemic in the institution.

c Use when chromosomally encoded, inducible b-lactamase producers are endemic in the institution.

d Metronidazole must be combined with vancomycin or another antimicrobial that covers microaerophilic and anaerobic gram-positive cocci.

e Add vancomycin if methicillin-resistant S. aureus is present in the institution.

Rx Settings Regimen

ICU; no risk factors for P.aeruginosa infxn

Azithromycin 1G iv then 500mg OD + ceftriaxone or cefotaxime or quinolone

ICU; risk factors Imipenem/meropenem 500mg q6h or Piperacillin/tazobactam 3.375g q6h + ciproflox

Rx Settings Regimen

Aspiration pneumonitis Wait 24H; if symptoms persist, give antibiotic

aspiration pneumonia Metronidazole or Piperacillin/tazobactam 3.375 g q6h or

Imipenem 500mg q6h or Levofloxacin, ceftri,or cefotaxime

Prevention of CAPPrevention of CAP

Recommendation for Recommendation for pneumococcalpneumococcal vaccination:vaccination:

–– Age 60 or olderAge 60 or older

–– Chronic illness: COPD, Chronic illness: COPD, bronchiectasisbronchiectasis, chronic PTB, , chronic PTB, cardiovascular cardiovascular dsedse, DM, Chronic liver , DM, Chronic liver dsedse, CRF, , CRF, nephroticnephroticsyndrome, syndrome, aspleniaasplenia

–– ImmunosuppressionImmunosuppression: HIV, congenital : HIV, congenital iimunodeficiencyiimunodeficiency, , malignancy, transplant patients, chemotherapy, systemic malignancy, transplant patients, chemotherapy, systemic steroids.steroids.

–– Residents of nursing homes & longResidents of nursing homes & long--term care facilitiesterm care facilities

Adult dose: 0.5ml IM or SC (revaccination in 5 yrs.)Adult dose: 0.5ml IM or SC (revaccination in 5 yrs.)

Precautions/contraindicationsPrecautions/contraindications

–– Allergy, acute illness, pregnancyAllergy, acute illness, pregnancyPCPG in CAP 2004 updatePCPG in CAP 2004 update

Prevention of CAPPrevention of CAP

Influenza vaccination:Influenza vaccination:–– Age 50 & olderAge 50 & older–– Chronic illnesses; Chronic illnesses; ImmunosuppressionImmunosuppression–– Residents of chronic care facilitiesResidents of chronic care facilities–– Pregnant on 2Pregnant on 2ndnd or 3or 3rdrd trimestertrimester–– Health care workersHealth care workers–– Household contacts of persons w/ medical illnessHousehold contacts of persons w/ medical illness–– Providers of essential/emergency servicesProviders of essential/emergency services–– Students & persons in institutional settingsStudents & persons in institutional settings–– Any personAny person……

Adult dose: 0.5 ml yearlyAdult dose: 0.5 ml yearlyPrecautions: Allergy/acute illness/GBSPrecautions: Allergy/acute illness/GBS

PROGNOSIS

CATEGORY MORTALITY RATE

Low Risk 1 – 5%

Moderate risk 5 – 25%

High risk >50%