View
0
Download
0
Category
Preview:
Citation preview
4/24/2018
1
0
PNEUMONIACOMMUNITY-ACQUIRED
PNEUMONIA IN ADULTSSarah Kamara MSN, APRN,
AGACNP-BC, FNP-C
1
• To discuss the recommendations and guidelines as
outlined by the Infectious Diseases Society of
America and American Thoracic Society’s
guidelines on the management of community
acquired pneumonia
CAP:
OBJECTIVE
2
• CAP is defined as an acute infection of the
pulmonary parenchyma in a patient who has
acquired the infection in the community as
distinguished from hospital-acquired
(nosocomial) pneumonia
• An infection of the lower respiratory tract
CAP:
Definition
D
4/24/2018
2
3
• Seventh leading cause of death in the US along
with influenza
• 915,900 episodes in adults 65 and older
• More than 60,000 deaths per year
• $8.4-10 billion spent yearly on treatment
• Higher in men and blacks as compared to women
and Caucasians
• Seasonal, occurs more during the winter months
• Strep pneumoniae is the most common causative
agent
CAP:
Epidemiology
4
• Age ≥65 years
• COPD and/or smoking
• Malnutrition
• Alcohol consumption
• Immunosuppression
• Underlying lung disease
• Altered mental status
• Aspiration
CAP:
Risk Factors
5
• Cough (typically productive)
• Fever with chills and sweats
• Shortness of breath, dyspnea
• Tachycardia, tachypnea,
• Chest pain (typically pleuritic)
• Crackles/rhonchi on lung exam
• Leukocytosis
• Headache
• Fatigue
CAP:
Clinical Presentation
4/24/2018
3
6
• Streptococcus pneumoniae (most common)
• Haemophilus influenzae
• Staphylococcus aureus
• Pseudomonas aeruginosa
• Legionella pneumoniae
• Mycoplasma pneumoniae atypical pathogens
• Chlamydophila pneumoniae
• Respiratory viruses (Influenza, RSV, parainfluenza,
human metapneumovirus
CAP:
Common Etiologies
Etiologies
7
1. Severity of Illness
-CURB-65 (confusion, uremia, respiratory rate,
hypotension, age 65 years or greater)
-Score ≥ 2 = more intensive treatment
2. Prognostic Models
-PSI(Pneumonia severity Index)
3. Ability to tolerate oral medications
4. Availability of outpatient support/resources
Hospital Admission Criteria
8
Scoring criteria
CAP: CURB65 Criteria
Score Risk Disposition
0 or 1 1.5% mortality Outpatient care
2 9.2% mortality
Inpatient vs.
observation
admission
≥ 3 22% mortality
Inpatient
admission with
consideration for
ICU admission
with score of 4 or
5
4/24/2018
4
9
• Septic Shock
• Invasive Mechanical Ventilation
• 3 of the minor criteria as listed
-RR ≥ 30
-PaO2/FiO2 ratio ≤ 250
-Multilobar pneumonia
-Uremia (BUN ≥ 20 mg/dl)
-Leukopenia (<4000), Thrombocytopenia (<100k)
-Hypothermia (<36ºC)
-Hypotension
ICU Admission Criteria
10
• Chest xray: Infiltrate or consolidation
• Blood cultures x 2
• Lactic acid, CBC, CMP
• Sputum gram stain and cultures
• Urine legionella pneumophila and streptococcus
pneumoniae
• If clinical suspicion of CAP, but negative CXR,
consider CT chest or repeat CXR in 24-48 hours
CAP:
Work-up
11
CAP:
Diagnosis and Imaging
• lg
4/24/2018
5
12
Diagnosis and imaging
13
• At least 50% of all cases are among adults 65
years and older
• Those living in a long term care facility have a 30%
risk of pneumonia over a period of 2 years
• Most common pathogens are streptococcus
pneumoniae, H. influenza, Moraxella catarrhalis, klebsiella and staph aureus
Clinical PEARLS in the
Elderly
14
Clinical findings
• Classic, expected signs may be absent
• Weakness, decreased ADL
• Tachypnea and or/SOB
• Tachycardia
• Fever with productive cough
• Confusion or mental status change
Clinical PEARLS in the
Elderly
4/24/2018
6
15
Chest x-ray findings
• May have multiple presentations based on the
offending pathogen
• Bacterial pneumonia can present with either
bronchopneumonia or lobar pneumonia
• Viral pneumonia may present as bilateral
interstitial infiltrates
Clinical PEARLS in the
Elderly
16
Outpatient TreatmentOutpatient TreatmentOutpatient TreatmentOutpatient Treatment
Previously healthy, no use of antibiotics within the
previous 3 months, no risk for drug resistant to strep
pneumoniae
-Macrolide (azithromycin, clarithromycin or
erythromycin)
OR
-Doxycycline
CAP:
Outpatient Treatment
17
Comorbidities Comorbidities Comorbidities Comorbidities or use of antibiotics within the previous or use of antibiotics within the previous or use of antibiotics within the previous or use of antibiotics within the previous
3 3 3 3 months, risk for drug resistant strep pneumoniaemonths, risk for drug resistant strep pneumoniaemonths, risk for drug resistant strep pneumoniaemonths, risk for drug resistant strep pneumoniae
Antipneumococcal fluoroquinolone
-levofloxacin, moxifloxacin, gemifloxacin
OR
Beta-lactam plus a macrolide
-Amoxicillin, amoxicillin/clavulanate
cefpodoxime, cefuroxime
Doxycycline as an alternative to a macrolide
CAP:
Outpatient Treatment
4/24/2018
7
18
Antipneumococcal fluoroquinolone
-Levofloxacin, gemifloxacin, maxifloxacin
Beta lactam plus a macrolide
-Ceftrioxone, cefataxime, ampicillin, ertapenem
• Doxycycline as an alternative to a macrolide
• Respiratory fluoroquinolone as an alternative for
PCN allergic patients
CAP: Inpatient (Non-ICU)
19
• B-lactam plus macrolide or an antipneumococcal
fluoroquinolone
• Fluoroquinolone or aztreonem recommended for
PCN allergic patients
• If concern for pseudomonas infection, use an
antipseudomonal b-lactam plus either ciprofloxacin or levaquin
CAP: Inpatient (ICU)
TREATMENT
20
Pseudomonas consideration cont.
• B-lactam plus an aminoglycoside and azithromycin
• B-lactam plus aminoglycoside and a
fluoroquinolone
• If CA-MRSA is a concern, add vancomycin or
linezolid
CAP: Inpatient (ICU)
Treatment
4/24/2018
8
21
• Adjust antibiotic once culture results are available
• Treat influenza A positive patients with oseltamivir
or zanamivir within 48 hours of onset
• Oseltamivir and zanamivir not recommended for
uncomplicated influenza with onset >48 hours
• Droplet precaution if influenza positive
• Test for H5N1 infection with known exposure
• Treat suspected H5N1 infection with oseltamivir
and ABX targeting S. Pneumoniae and S. aureus
Pathogen Directed
Therapy
22
• Should be started in the ED
• Within one hour with s/s of sepsis
Time to first antibiotic
dose
23
• Temperature <37.8C
• Heart rate <100 beats/min
• Respiratory rate <24 breaths/min
• 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
CAP: Criteria for clinical
stability
4/24/2018
9
24
• Minimum of 5 days of antibiotic
• Afebrile for 48-72 hours
• No more than 1 CAP-associated sign of clinical
instability before discontinuation of therapy
• Longer duration may be needed based on culture
results or complication by extra pulmonary
infections such as meningitis or endocarditis
CAP: Duration of Therapy
25
Switch to oral antibiotic when…
-Hemodynamically stable
-Clinically improving
-Able to tolerate po
-Have normal GI tract function
CAP: IV to Oral Abx
Therapy
26
• Clinically stable
• No other active medical problems
• Safe environment for continued care
CAP: Discharge Criteria
4/24/2018
10
27
• Pneumonia vaccines for age 65 or greater or high
risk diseases
• One-time revaccination after 5 years for adults
>65, if the first vaccine was received before age
65, asplenia and immunocompromised persons
• Yearly influenza vaccines
• Smoking cessation
• Respiratory hygiene measures
CAP: Pneumonia
Prevention
28
• Amy is a 66 yo female with diabetes who presents
to the ED with fever, cough, sputum production,
and pleuritic chest pain. She denies associated
N/V/D. Vital signs: T100.7, RR 24, BP 110/70, P 100, Spo2 90 on RA. Exam: A&O x 4, left basilar
rhonchi. Cxray: left lower lobe infiltrate. Labs: WBC
14k, gluc 215, BUN 27, cr 1.2.
• Should Amy be admitted?
CAP:
Case Study
29
• CURB-65 criteria
– Confusion
– Uremia (BUN >20)
– Respiratory rate (RR >30)
– Blood pressure (SBP <90 or DBP < 60)
– Age 65 years or greater
• Amy’s score = 2…Recommend admission
CAP: Case Study
4/24/2018
11
30
• What additional work-up would you recommend?
CAP:Case study
31
CAP:Case Study
• Blood cultures x 2
• Sputum Gram stain and culture
• Consider urinary pneumococcal antigen
32
• Amy has no drug allergies.
• What antibiotic treatment would you recommend?
CAPCase Study
4/24/2018
12
33
• Respiratory quinolone alone
orororor
• Beta-lactam ++++ macrolide or doxycycline
• If Amy tells you that she took ciprofloxacin for a UTI
last month, how would that change your rx choice?
CAP:Case Study
34
• Amy rapidly improves with antibiotics and
hydration. After two days of hospitalization, she is
afebrile with normal vital signs. She continues to
tolerate oral medications without problem.
• When can you discharge Amy?
• How many more days of antibiotic therapy does she require?
CAPCase Study
35
• Amy can be discharged today on po abx to
complete a total of 5 days of abx therapy.
CAP:Case Study
4/24/2018
13
36
• Unfortunately, we are not done with Amy…
• Approximately a month after discharge, Amy falls and breaks her leg. She requires casting, which limits her mobility. She begins to note increasing shortness of breath, low grade fever, and a return of her cough, prompting her to present to her primary care provider for further evaluation.
CAP:Case Study
37
• Amy is sent for CT angiogram of the chest which is
negative for pulmonary embolus, but does show a
new infiltrate in her right lower lobe with some
areas of cavitation.
• Should Amy be re-admitted to the hospital?
• What antibiotics should she receive?
CAPCase Study
38
• Amy now has HCAP and is at risk for resistant
pathogens, such as Pseudomonas and MRSA.
• She should be admitted for IV abx.
• Rx with beta-lactam (piperacillin-tazobactam,
cefepime, imipenem, or meropenem) +
ciprofloxacin or levofloxacin + vancomycin or linezolid.
CAPCase Study
4/24/2018
14
39
• Not all patients with CAP require hospitalization
• Outpatients should be stratified by drug-resistant pneumococcus risk, comorbidities, and prior abxuse in the past 3 months
• Inpatients should be stratified by severity of illness and Pseudomonas/MRSA risk
• Patients should be treated with a minimum of 5 days of abx
CAPConclusion
40
• Mandell, L.A., Wunderink, R.G., Anzueto, A., Barlett, G., Campbell, G., Dean, N.C., Dowell, S.F., File, T.M., Musher, D.M., Niederman,
M.S., Torres, A., Whitney, C.G. (2007). Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults, Vol 44, Pg S27-S92. Retrieved from
http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_By_Organ_System-
81567/Lower/Upper_Respiratory/Community-Acquired_Pneumonia_(CAP)/
• Kaysin, A., Viera, A.J. (2016) Nov 1;94(9):698-706. Community-Acquired Pneumonia in Adults: Diagnosis and Management Retrieved from https://www.aafp.org/afp/2016/1101/p698.pdf
References
41
Any Questions???
CAP:Conclusion
Recommended