MANAGEMENT OFCOMMUNITY-ACQUIRED    PNEUMONIA      Prepared by   DR.NAHID SHERBIN  INTERNAL MEDICINE
THE CLINICAL PROPLEMA  65-Y old man with hypertension and  degenerative joint disease presents to  emergency department w...
 WBC   14,000per cubic millimeter ,all  biochemical results are normal. CXR show an infiltrate in the right lower  lobe....
STATISTICS4  million cases of CAP in USA each year. Around 1 million hospitalization. Inpatient management of pneumonia...
DIAGNOSIS AND TREATMENT Usual   presentationCough                      >90percentDyspnea                    66percentSput...
 All definitions of pneumonia require the  finding of a pulmonary infiltrate on chest  radiograph. The initial antibioti...
Recommendation for initial     empirical treatment of pneumoniaHospital setting   Antibiotic therapy                   Com...
 Two  large observational studies found that  antibiotic regimens that cover both typical  and atypical organisms are ass...
Risk stratification& decision to hospitalize 30-50% of patient who are hospitalized  have low risk class. The decision t...
 The  most widely disease-specific  prediction rules used is–The Pneumonia Severity Index-5 risk classes,mortality rate f...
Step I          PATIENT WITH COMMUNITY                  ACQUIRED PNEUMONIA                    IS THE PATIENT>50Y?         ...
Step II             character               No. of points                                            assignedDemorphic fac...
Cont.               character              No. of pointsLab &          Arterial pH<7.35      +30               BUN>30mg/...
Stratification of risk scoreRisk         Risk class   Score       MortalityLow          I            Based on    0.01%    ...
Algorithm for Determining    Whether a Patient with    Community-Acquired          PneumoniaShould be Admitted or Treated ...
Diagnosis of pneumonia is confirmed                          in immunocompetent adult with CAP          Absolute contra in...
Cont. All patients with suppurative or metastatic  diseases( Empyema, Lung abscess ,  Endocarditis ,Meningitis or Osteomy...
A controlled trial of a critical   pathway for treatment of CAP This is a strongest evidence ,it is a  randomized control...
Results of the study1.   There were no significant difference     between groups in the hospitalization     rates among mo...
Results of the study3. Applying this protocol   60     decrease initial                            50    hospitalization ...
Results of the study4. The most common reasons for admission    of low risk patients include: presence of    coexisting co...
Criteria for stability &discharge1.Pt. vital signs are stable for 24h periodT<37.8’C , RR<24 , HR<100b/minSys BP>90mmHg ,O...
 The  median time to clinical stability is ~ low risk       3 days moderate       4 days high           6 days Several s...
The American thoracic society     recommend following criteria for      switching to oral antimicrobial                  a...
 Patientneed to be told that they will  probably feel sick for awhile (few weeks) One week after            *80% of CAP ...
Guidelines of Infectious Diseases    Society of America (IDSA) CLASS I & II  DON’T REQUIRE  HOSPITALIZATION CLASS III ...
A  65-Y old man with hypertension and  degenerative joint disease presents to  emergency department with a3-days  history...
Finally, AnswerOF the case in 1st slide PSI =65 Class II Outpatient Treatment : advanced Macrolide or  Fluroquinolone.
MAIN SOURSES THE   NEW ENGLAND JOURNAL OF  MEDICINE 2004 IDSA GUIDELINES www.nejm.org http://ursa.kcom.edu/CAPcalc/def...
Management of community acquired pneumonia
Management of community acquired pneumonia
Management of community acquired pneumonia
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Management of community acquired pneumonia

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Management of community acquired pneumonia

  1. 1. MANAGEMENT OFCOMMUNITY-ACQUIRED PNEUMONIA Prepared by DR.NAHID SHERBIN INTERNAL MEDICINE
  2. 2. THE CLINICAL PROPLEMA 65-Y old man with hypertension and degenerative joint disease presents to emergency department with a3-days history of a productive cough and fever. 0E Temp38.8’C ,BP144/92mmHg ,RR22/min ,HR90/min ,O2 sat 92percent.Chest auscultation reveals crackles and egophony in the right lower lung field.
  3. 3.  WBC 14,000per cubic millimeter ,all biochemical results are normal. CXR show an infiltrate in the right lower lobe. How should this patient be treated?
  4. 4. STATISTICS4 million cases of CAP in USA each year. Around 1 million hospitalization. Inpatient management of pneumonia is more than 20 times as expensive as outpatient care. The length of hospitalization is the key determinant of inpatient costs. 30-50 percent of hospitalized patients have low-risk cases.
  5. 5. DIAGNOSIS AND TREATMENT Usual presentationCough >90percentDyspnea 66percentSputum production 66percentPleuritic chest pain 50percentNon respiratory symptoms
  6. 6.  All definitions of pneumonia require the finding of a pulmonary infiltrate on chest radiograph. The initial antibiotics regimen should be chosen empirically to cover both typical and atypical pathogen. Atypical organisms in 20%-40% of CAP.
  7. 7. Recommendation for initial empirical treatment of pneumoniaHospital setting Antibiotic therapy Common organismGeneral word 3rd gen.ceph+macrolide+or doxycycline Typical: Strept.pneumonia Antipneumoccocal fluroquinolone Haemophilius B-lactam-b-lactamase Atypical: Mycoplasma inhibitor+macrolide+or doxycycline Legionella,chlamydiaICU (no risk of 3rd gen.cepha+antipneumoccocal Same+staph.aurus,drug fluroquinolone or macrolide resistant strep.&G-rodspseudomonas. B-lactam-b-lactamaseaeroginosa) inhibitor+fluroqunilone or macrolideICU (risk of Antipseudomonous B-lactam Same+pseudomonus.ae +aminoglycoside+fluroquinolone or oginosa &other resistantpseudomonas. G-ve rods macrolideAeroginosa) Antipseudomonal B-lactam+Cipro
  8. 8.  Two large observational studies found that antibiotic regimens that cover both typical and atypical organisms are associated with a lower risk of death than regimens that cover just typical bacteria.#Gleason#Houk PM Duration 10-14 Days
  9. 9. Risk stratification& decision to hospitalize 30-50% of patient who are hospitalized have low risk class. The decision to admission based on : stability of the clinical condition ,risk of death ,complication ,presence or absence of active medical problems.
  10. 10.  The most widely disease-specific prediction rules used is–The Pneumonia Severity Index-5 risk classes,mortality rate from 1%-27% The higher the score ----the higher risk of death---adm to ICU---readm---longer stay. So, What are the steps and criteria of PSI?
  11. 11. Step I PATIENT WITH COMMUNITY ACQUIRED PNEUMONIA IS THE PATIENT>50Y? yes no DOSE THE PATIENT HAVE A HISTORY OF ANY OF THE FOLLOWING COEXISTING CONDITIONS? yes -NEOPLASTIC DISEASE -LIVER DISEASE -CHF-CVA-CRF no DOSE THE PATIENT HAVE y ASSIGN PATIENT TO n ANY OF FOLLOWING e RISK CLASS II,III,IV&VASSIGN PATIENT o ABNORMALITIES? s ACCOURDING TO TOTALTO RISK CLASS I -ALTERED MENTAL STATUS SCORE USING THE -RR>30/min –P>125/min PREDICTION RULE. -SYSTOLIC BP<90mmHg -TEMP<35’C OR >40’C
  12. 12. Step II character No. of points assignedDemorphic factors Age :men Age in years women Age -10y Nursing home care +10 Coexisting condition: Neoplastic dis +30 Liver dis +20 CHF +10 CVA +10 CRF +10Finding on Alteredmental status +20 RR>30/min +20physical exam Sys BP<90mmHg +20 T<35’C or >40’C +15 Pulse>125 b/min +10
  13. 13. Cont. character No. of pointsLab & Arterial pH<7.35 +30 BUN>30mg/dl +20radiographic =(11mmol/l)finding Na<130mmol/l +10 Glu>250mg/dl +10 =(14mmol/l) Haematocrit<30% +10 Partial pressure of arterial oxygen<60mmHg +10 Or O2 sat<90% Pleural effusion +10
  14. 14. Stratification of risk scoreRisk Risk class Score MortalityLow I Based on 0.01% algorithmLow II <70 0.6%Low III 71-90 0.9%Moderate IV 91-130 9.3%High V >130 27%
  15. 15. Algorithm for Determining Whether a Patient with Community-Acquired PneumoniaShould be Admitted or Treated as Outpatient
  16. 16. Diagnosis of pneumonia is confirmed in immunocompetent adult with CAP Absolute contra indication to out pt treatment • Hypoxemia (O2 sat<90%) yes •Haemodynamic instability. •Active coexisting condition requiring hospital. •Inability to tolerate oral medication. no Use PSI to determine the risk. yes Risk class I,II,III Risk class IV,VOther mitigating factorsFrail physical condition yesNo response to oral therapy InpatientUnstable living condition treatment no Out patient treatment Intermediate options
  17. 17. Cont. All patients with suppurative or metastatic diseases( Empyema, Lung abscess , Endocarditis ,Meningitis or Osteomyelitis) or infections due to high risk pathogens( e.g staph.aurus ,G-ve rods or anaerobes) should be admitted. Several studies have established safety and effectiveness of PSI.
  18. 18. A controlled trial of a critical pathway for treatment of CAP This is a strongest evidence ,it is a randomized controlled trial involving 19 hospitals. The hospitals that were randomly assigned to study admitted fewer low risk patients than did the control hospitals (31%vs.49%).
  19. 19. Results of the study1. There were no significant difference between groups in the hospitalization rates among moderate –high risk patients whom the protocol recommend admission .2. The intervention reduced the overall number of hospital bed-days per patient without any increase in deaths, complications,use of ICU or readmission.
  20. 20. Results of the study3. Applying this protocol 60  decrease initial 50 hospitalization rates of death among low 40 risk without any change in the rates 30 no PSI of death, symptom 20 PSI resolution, functional recovery 10 and patient stratification. 0 %
  21. 21. Results of the study4. The most common reasons for admission of low risk patients include: presence of coexisting conditions ,patient preference and inadequate home support.5. Selected elderly patient can be treated as outpatient in good results.*This study mentioned in JAMA 2002
  22. 22. Criteria for stability &discharge1.Pt. vital signs are stable for 24h periodT<37.8’C , RR<24 , HR<100b/minSys BP>90mmHg ,O2 sat>90% in room air2.Take oral antibiotic3.Maintain adequate hydration and nutrition4.Normal mental status5.Has no other active clinical or psychosocial problems requiring hospitalization.
  23. 23.  The median time to clinical stability is ~ low risk 3 days moderate 4 days high 6 days Several studies confirm safety of this type of discharge criteria. Data from controlled trials and prospective studies indicate that early conversion from IV to oral therapy doesn’t adversely affect outcomes & no need to observe patients for 24h after a switch to oral therapy.
  24. 24. The American thoracic society recommend following criteria for switching to oral antimicrobial agents1. Improvement in cough & dyspnea.2. T<37.8’C two times 8h apart.3. Decrease in WBC.4. Functioning GIT with adequate oral intake.
  25. 25.  Patientneed to be told that they will probably feel sick for awhile (few weeks) One week after *80% of CAP patients have cough and fatigue. *50% have dyspnea and sputum
  26. 26. Guidelines of Infectious Diseases Society of America (IDSA) CLASS I & II  DON’T REQUIRE HOSPITALIZATION CLASS III  BREIF HOSPITAL STAY CLASS IV & V SHOULD BE HOSPITALIZED
  27. 27. A 65-Y old man with hypertension and degenerative joint disease presents to emergency department with a3-days history of a productive cough and fever. 0E Temp38.8’C ,BP144/92mmHg ,RR22/min ,HR90/min ,O2 sat 92percent.Chest auscultation reveals crackles and egophony in the right lower lung field. WBC 14,000per cubic millimeter ,all biochemical results are normal.
  28. 28. Finally, AnswerOF the case in 1st slide PSI =65 Class II Outpatient Treatment : advanced Macrolide or Fluroquinolone.
  29. 29. MAIN SOURSES THE NEW ENGLAND JOURNAL OF MEDICINE 2004 IDSA GUIDELINES www.nejm.org http://ursa.kcom.edu/CAPcalc/default.htm

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