© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
in the clinic
Community-Acquired Pneumonia
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
Which organisms cause CAP?
Streptococcus pneumoniae (pneumococcus)
Haemophilus influenzae
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella
Influenza virus
Parainfluenza virus
Respiratory syncytial virus
Adenovirus
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 163 (5): ITC5-1.
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