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MANAGEMENT OFCOMMUNITY-ACQUIRED PNEUMONIA Prepared by DR.NAHID SHERBIN INTERNAL MEDICINE
THE CLINICAL PROPLEMA 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. CXR show an infiltrate in the right lower lobe. How should this patient be treated?
STATISTICS4 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.
DIAGNOSIS AND TREATMENT Usual presentationCough >90percentDyspnea 66percentSputum production 66percentPleuritic chest pain 50percentNon respiratory symptoms
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.
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
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
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.
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?
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
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
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
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%
Algorithm for Determining Whether a Patient with Community-Acquired PneumoniaShould be Admitted or Treated as Outpatient
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
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.
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%).
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.
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 %
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
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.
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.
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.
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
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
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.
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/default.htm