9/2/14  

1  

Catherine “Casey” S. Jones, PhD, RN, ANP-C, AE-C

Community Acquired Pneumonia

Catherine “Casey” S. Jones, PhD, RN, ANP-C, AE-C

Texas Pulmonary & Critical Care

Consultants, PA &

Adjunct Professor at Texas Woman’s University in Dallas

Disclosures

No financial relationship with any pharmaceutical manufacturer or medical

device company

9/2/14  

2  

Objectives

�  Compare the different types of pneumonia according to the patient’s current location or residence and risk factors.

�  Assess the patient’s susceptibility for hospitalization using CURB-65.

�  Recommend appropriate therapy for individuals with community acquired pneumonia.

Types of Pneumonia

� Community acquired pneumonia – (CAP) � Hospital acquired (nosocomial) pneumonia

(HAP) – occurs 48 hours or more after admission

� Ventilator acquired (VAP) – more than 48-72 hours after endotracheal intubation

Types of Pneumonia

� Healthcare-associated - (HCAP) - ¡ Nursing homes ¡ Dialysis centers ¡ Outpatient clinics ¡ Within 90 days of discharge from acute or

chronic care facility ¡ Recent IV antibiotic therapy, chemotherapy

or wound care within the past 30 days � Aspiration pneumonitis & pneumonia

9/2/14  

3  

Prevalence

� 2009 – 1.1 million in U.S. hospitalized with pneumonia

� Average length of stay - 5.2 days � Nursing home – 33,700 residents with

pneumonia or 2.3 % in 2004 � More than 50,000 deaths in 2010

� CDC

How do we defend against pneumonia?

�  Nose �  Coughing & sneezing reflexes �  Mucus Blanket �  Cilia (mucociliary escalator) �  Macrophages �  Leukocytes

Etiology

�  Most pneumonias are caused by micro-aspiration or inhalation of bacteria or viruses into the lung.

�  Usually the body’s defenses will prevent infection, but at times of low resistance pathogenic organisms may overwhelm the usual protective mechanisms.

�  Commonly 10-14 days after an upper respiratory infection (URI).

9/2/14  

4  

Who is at risk for developing pneumonia?

� Elderly � Dormitory or Barrack

Conditions � Hospitalized � Exposure to Smoke

and Chemicals � Genetics

� Drug & Alcohol Users � Chronic Lung

Conditions � Compromised

Immunity � Asthmatics � Newborns

Risk Factors Continued

� Age �  Stroke � Neuromuscular

disease �  Sedatives & Alcohol

� Poor Nutrition � Prior Infections � Anatomic Changes � Tumor � Granulocytopenia

Microbial diagnosis made in only 7.6 % of cases in 2009

Bacterial > Viral

Community Acquired Pneumonia

9/2/14  

5  

CAP: Definition

�  CAP occurs outside the hospital or within 24 hours of admission to a hospital or LTC facility.

�  By definition, the person must NOT have been in a

LTC facility within 90 days prior to onset of symptoms

Common Bacterium

� Streptococcus pneumoniae (65%) � Mycoplasma pneumoniae – historically

children & adolescents – increasing high rates in adults – especially elderly adults

� Chlamydophilia pneumoniae (previously named Chlamydia) (0-20%)

� Legionella (2-9%) – classically contaminated water sources in hospitals & hotels – resistant to all beta-lactams

Common Bacterium

� Haemophilus influenzae � Neisseria meningitidis � Moraxella catarrhalis � Klebsiella pneumoniae � Staphylococcus aureus - infrequent

pulmonary pathogen – watch for patients with recent influenza – (MRSA – only 2 % of infections were pneumonia)

9/2/14  

6  

Common Viruses

�  Influenza virus �  Respiratory syncytial virus (RSV) �  Adenovirus �  Parainfluenza virus �  Human metapneumovirus �  Middle East respiratory syndrome

coronavirus – patients from Saudi Arabia or other Middle East countries - 2012

Etiology of Viral Pneumonias

�  Most common causative organisms are Respiratory Syncytial Virus (RSV), influenza, parainfluenza, adenoviruses, measles, and chicken pox.

�  Symptoms usually milder than bacterial

pneumonia. Initially fever, dry cough, headache, muscle pain and weakness. In 12-36 hours dyspnea occurs, fever increases, and cough produces a scant sputum.

Viral Pneumonia

� An acute infection of the pulmonary parenchyma with viral origin

� Perhaps accounts for half of all pneumonia cases.

� Symptoms subside in 2-5 days.

9/2/14  

7  

Examples of “Exposure-Specific” Infections

�  Chlamydia psittaci (psittacosis) �  Coxiella burnetii (Q Fever) �  Francisella tularensis (Tularemia) �  Endemic Fungi (blastomyces, coccidioides,

histoplasma) �  Sin Nombre virus (hantavirus pulmonary syndrome) �  Yersinia pestis (pneumonic plague)

Pleural Effusion

�  If a pleural effusion is evident on the chest x-ray, the patient should be referred for evaluation promptly

�  Failure to recognize an early empyema may mean

therapy involves thoracotomy rather than simpler procedures such as thoracentesis or chest tube placement

Clinical Pearl

�  The chest x-ray should normalize in 8 weeks in normals, 12 weeks in those with underlying lung disease (COPD)

�  You must show resolution of the pneumonia on chest x-ray in this time frame

�  If the pneumonia does not resolve on chest x-ray, refer to specialist

9/2/14  

8  

Symptoms of Community-Acquired Pneumonia

Fever (80 %) Cough

Mucopurulent – bacterial Scant/watery - atypical

Dyspnea Pleuritic Chest Pain (30 %) Hypoxia Tachypnea (45-70 %) Tachycardia

Chills (40-50 %) Sweats &/or Rigors (15 %) Crackles &/or Rhonchi Hemoptysis Fatigue Myalgias GI symptoms (nausea,

vomiting, diarrhea) Mental status changes

Typical Presentation

�  TYPICAL PNEUMONIA: ¡  Sudden onset of fever ¡  Cough productive of purulent sputum ¡  Chest pain ¡  Shaking chills ¡  Headache ¡  Dullness with bronchial signs of lung consolidation

Typical Pneumonia

�  Localized X-ray findings �  Leukocytosis – 15,000 – 30,000 per mm3 �  Bacterial

9/2/14  

9  

Atypical Pneumonia

�  Gradual onset �  Dry cough �  Headache �  Myalgia �  Fatigue �  Sore throat �  Nausea, vomiting

�  Diarrhea �  Physical findings

minimal �  Leukocyte count <15,000 �  Examples:

¡  Viral ¡  Mycoplasma pneumoniae ¡  Chlamydophila

pneumoniae

Elderly

Ø Elderly patients may have fewer symptoms than younger patients or no symptoms at all

Ø If an elderly person has a minor cough and weakness for 1 day, they need to be evaluated

Ø Some exhibit only confusion, lethargy, and general disorientation

Elderly Presentation

�  Mental status change �  Falls �  Incontinence �  Failure to thrive �  Metabolic changes �  Fever - frequently absent

9/2/14  

10  

Subjective Data

� Recent URI � Cough: ranges from hacking, non-productive

(mycoplasma, viral) to productive with rusty or yellow sputum (bacterial)

�  Fever, chills � Myalgia, pleuritic pain, dyspnea � Malaise, headache, loss of appetite � Nausea, vomiting � Occasional sore throat

Objective Data

�  Physical exam may be normal in early stages �  Increased temperature, pulse �  Nasal flaring, tachypnea �  Lungs: dullness to percussion and auscultation

over site of consolidation, diffuse crackles and wheezes, rhonchi

Physical Examination

�  Auscultation ¡  Crackles or rhonchi ¡  Bronchial breath

sounds ¡  Consolidation

�  Percussion �  Palpation

¡  Feel Tactile Fremitus

�  Signs of consolidation: ¡  Bronchophony

÷ Exaggerated vocal resonance over consolidated area

¡  Egophony ÷  (E to A)

¡  Whispered pectoriloquy ÷  Increased resonance

9/2/14  

11  

Diagnosis & Initial Assessment of CAP

� Chest X-Ray – gold standard – not helpful with identifying pathogen

� Screening pulse oximetry � Routine diagnostic testing is optional ● Initial assessment of severity

Differential Diagnosis

� Chronic pulmonary disease: asthma, COPD, chronic bronchitis

� Atelectasis � Damage from physical

agents: near drowning, smoke inhalation

� CHF � Neoplasms �  Lung abscess � Tuberculosis � Pulmonary embolism

Severity of Illness Scoring

� CURB-65 ¡ Confusion of new onset ¡ Urea greater than 7 mmol/l (19 mg/dL)* ¡ Respiratory rate of ≥ 30 breaths/minute ¡ Blood pressure < 90 mmHg systolic or diastolic ≤ 60 mm Hg ¡ 65 or older

* May omit if unavailable in office setting

9/2/14  

12  

CURB-65

� Scoring ¡ 0 to 1 treat as out-patient ¡ 2 short stay @ hospital ¡ 3 to 5 hospital with probable ICU

admission

Severity of Illness Scoring

� Pneumonia Severity Index (PSI) ¡ Need more laboratory values ¡ More complicated ¡ Calculator online @

÷ http://pda.ahrq.gov/clinic/psi/psicalc.asp Risk classes I - V

Categorizing Severity to Assess for Hospitalization Need (PSI)

Class I Class II Class III Class IV Class V

Low Risk Low Risk Low Risk Mod. Risk High Risk

Outpatient Outpatient Inpatient – brief

Inpatient Inpatient

9/2/14  

13  

Outpatient Versus Hospitalization

� Cost of inpatient versus outpatient management is up to 25 times greater!

� Outpatients resume normal activity sooner. � 80 % prefer outpatient therapy. � Hospitalization increases thromboembolic

events & superinfection by more-virulent or resistant hospital bacteria.

Criteria for Hospitalization

� ~ 10 % of hospitalized patients with CAP requires ICU admission

� One of most important determinants for ICU care is presence of chronic comorbid conditions

� 1/3 of patients with severe CAP were previously healthy

Antibiotics of Choice: Outpatient Therapy

� Previously healthy & no risk factors for drug-resistant S. pneumoniae infection: ¡  Macrolide (azithromycin, clarithromycin or erythromycin) ¡  Doxycycline

� Comorbidities or use of antimicrobials within previous 3 months: ¡  Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or

levofloxacin 750 mg) ¡  Β-lactam PLUS a macrolide (high-dose amoxicillin or

amoxicillin-clavulanate) ¡  Alternatives – ceftriaxone, cefpodoxime & cefuroxime,

doxycycline

9/2/14  

14  

Antibiotic Choice in the Elderly

� Use macrolide for those 65 and older � Proven to increase survival

Antibiotic Stewardship

� Avoid use of respiratory quinolones if not indicated.

�  Save quinolones for patients who really need these medications! No new antibiotics in the near future.

�  Limit duration of therapy to recommended time periods.

� Probiotics probably help limit development of C. diff, decreasing use of subsequent antibiotics

Ancillary Therapies

� Increased fluids, good nutrition � Expectorants (marginal utility) � Cough suppressants with care, usually just at

bedtime � Analgesics, acetaminophen for high fever � If likely diagnosis influenza pneumonia,

consider Tamiflu � Tobacco cessation

9/2/14  

15  

Prevention

� Good Lifestyle Habits ¡ Hygiene ¡ Diet ¡ Low Stress

� Influenza Vaccine � Pneumococcal Vaccine

Prevention Continued - Influenza Vaccine

� 70% - 100% effective in healthy adults � 30% - 60% effective in the elderly & children

with a poor match, but is effective for flu complications (pneumonia, CVA, MI, all cause mortality)

� Vaccinated adults have lower hospitalization rates and death

Prevention Continued - Influenza Vaccine

� Annual vaccination in ~ October – all persons age 6 months and older

� Contraindicated with significant egg allergy - hives

� Killed, inactivated - IM injection

�  Live attenuated – intranasal – only for < 50 who are healthy

9/2/14  

16  

Prevention Continued – Pneumovax Vaccine

� PPSV23: � Those 65 and older � Chronic comorbidities � All cigarette smokers � Asthmatics

� Booster - one after age 65

� PCV13: Immunocompromised or children

� Now approved for adults

Hospitalization

Diagnosis for Hospitalized Patients

�  Chest X-Ray – gold standard �  WBC (leukocytosis or leukopenia) �  Blood Cultures �  Sputum Gram stain & Culture �  Urine Antigens for Legionella & pneumococcus �  CT scan (rarely) �  PPD (R/O TB)

9/2/14  

17  

Diagnosis for Hospitalized Patients

�  Procalcitonin – peptide precursor of calcitonin released by parenchymal cells in response to bacterial toxins – elevated serum levels with bacterial infections

�  <0.1 mcg/L = too low to treat with antibiotics �  >0.25 mcg/L = treat with antibiotics �  Distinguish between bacterial versus viral

pneumonia �  Reduce antibacterial use �  Predict survival

Hospital Management (Class III-V)

� Antibiotic treatment is based on the organism identified

� Anywhere from 10-14 days

� Start IV then switch to PO

� Clinical stability: ¡ Temp <100 ¡ Pulse <100 ¡ Resp <24 ¡ SBP >90 ¡ Pulse Oximeter ≥ 90 % ¡ Ability to maintain

oral intake ¡ Normal mental

status

References

�  Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. ATS/IDSA Guidelines. (2005). American Journal of Respiratory & Critical Care Medicine, vol 171, 388-416.

�  Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the management of community-acquired pneumonia in adults. (2007). Clinical Infectious Diseases. 44, S27-72.

9/2/14  

18  

References

�  Rello, J. & Chastre, J. (2013). Update in pulmonary infections 2012. American Journal of Respiratory & Critical Care Medicine. Vol. 187, 1061-1066.

caseyjonesnp@gmail.com

Thank you!