MANAGEMENT OF MANAGEMENT OF COMMUNITY-ACQUIRED COMMUNITY-ACQUIRED

PNEUMONIAPNEUMONIA

Prepared by Prepared by

DR.NAHID SHERBINDR.NAHID SHERBIN

INTERNAL MEDICINEINTERNAL MEDICINE

THE CLINICAL PROPLEMTHE CLINICAL PROPLEM

A 65-Y old man with hypertension and A 65-Y old man with hypertension and degenerative joint disease presents to degenerative joint disease presents to emergency department with a3-days emergency department with a3-days history of a productive cough and fever.history of a productive cough and fever.

0\E 0\E Temp38.8’C ,BP144/92mmHg Temp38.8’C ,BP144/92mmHg ,RR22/min ,HR90/min ,O2 sat 92percent.,RR22/min ,HR90/min ,O2 sat 92percent.

Chest auscultation reveals crackles and Chest auscultation reveals crackles and egophony in the right lower lung field.egophony in the right lower lung field.

WBC 14,000per cubic millimeter ,all WBC 14,000per cubic millimeter ,all biochemical results are normal.biochemical results are normal.

CXR show an infiltrate in the right lower CXR show an infiltrate in the right lower lobe.lobe.

How should this patient be treated?How should this patient be treated?

STATISTICSSTATISTICS

4 million cases of CAP in USA each year.4 million cases of CAP in USA each year.Around 1 million hospitalization.Around 1 million hospitalization. Inpatient management of pneumonia is Inpatient management of pneumonia is

more than 20 times as expensive as more than 20 times as expensive as outpatient care.outpatient care.

The length of hospitalization is the key The length of hospitalization is the key determinant of inpatient costs.determinant of inpatient costs.

30-50 percent of hospitalized patients 30-50 percent of hospitalized patients have low-risk cases.have low-risk cases.

DIAGNOSIS AND TREATMENTDIAGNOSIS AND TREATMENT

Usual presentationUsual presentation

Cough >90percentCough >90percent

Dyspnea 66percentDyspnea 66percent

Sputum production 66percentSputum production 66percent

Pleuritic chest pain 50percentPleuritic chest pain 50percent

Non respiratory symptomsNon respiratory symptoms

All definitions of pneumonia require the All definitions of pneumonia require the finding of a pulmonary infiltrate on chest finding of a pulmonary infiltrate on chest radiograph.radiograph.

The initial antibiotics regimen should be The initial antibiotics regimen should be chosen empirically to cover both typical chosen empirically to cover both typical and atypical pathogen.and atypical pathogen.

Atypical organisms in 20%-40% of CAP.Atypical organisms in 20%-40% of CAP.

Recommendation for initial Recommendation for initial empirical treatment of pneumoniaempirical treatment of pneumonia

Hospital settingHospital setting Antibiotic therapyAntibiotic therapy Common organismCommon organism

General wordGeneral word 33rdrd gen.ceph+macrolide+or gen.ceph+macrolide+or doxycyclinedoxycycline

Antipneumoccocal fluroquinoloneAntipneumoccocal fluroquinolone

B-lactam-b-lactamase B-lactam-b-lactamase inhibitor+macrolide+or doxycyclineinhibitor+macrolide+or doxycycline

Typical: Typical: Strept.pneumoniaStrept.pneumonia

HaemophiliusHaemophilius

Atypical: MycoplasmaAtypical: Mycoplasma

Legionella,chlamydiaLegionella,chlamydia

ICU (no risk of ICU (no risk of pseudomonas.pseudomonas.

aeroginosa)aeroginosa)

33rdrd gen.cepha+antipneumoccocal gen.cepha+antipneumoccocal fluroquinolone or macrolidefluroquinolone or macrolide

B-lactam-b-lactamase B-lactam-b-lactamase inhibitor+fluroqunilone or macrolideinhibitor+fluroqunilone or macrolide

Same+staph.aurus,drug Same+staph.aurus,drug resistant strep.&G-rodsresistant strep.&G-rods

ICU (risk of ICU (risk of pseudomonas.pseudomonas.

Aeroginosa)Aeroginosa)

Antipseudomonous B-lactamAntipseudomonous B-lactam

+aminoglycoside+fluroquinolone or +aminoglycoside+fluroquinolone or macrolidemacrolide

Antipseudomonal B-lactam+CiproAntipseudomonal B-lactam+Cipro

Same+pseudomonus.aerSame+pseudomonus.aeroginosa &other resistant oginosa &other resistant G-ve rodsG-ve rods

Two large observational studies found that Two large observational studies found that antibiotic regimens that cover both typical antibiotic regimens that cover both typical and atypical organisms are associated and atypical organisms are associated with a lower risk of death than regimens with a lower risk of death than regimens that cover just typical bacteria.that cover just typical bacteria.

#Gleason#Gleason

#Houk PM#Houk PM

Duration 10-14 DaysDuration 10-14 Days

Risk stratification& decision to hospitalize30-50% 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 The most widely disease-specific prediction rules used isprediction rules used is

– –The Pneumonia Severity Index-The Pneumonia Severity Index-

5 risk classes,mortality rate from 1%-27%5 risk classes,mortality rate from 1%-27%The higher the score ----the higher risk of The higher the score ----the higher risk of

death---adm to ICU---readm---longer stay.death---adm to ICU---readm---longer stay.So, What are the steps and criteria of PSI?So, What are the steps and criteria of PSI?

PATIENT WITH COMMUNITY ACQUIRED PNEUMONIA

IS THE PATIENT>50Y?

DOSE THE PATIENT HAVE A HISTORY OF ANY OF THE FOLLOWING COEXISTING CONDITIONS?-NEOPLASTIC DISEASE-LIVER DISEASE-CHF-CVA-CRF

DOSE THE PATIENT HAVEANY OF FOLLOWINGABNORMALITIES?-ALTERED MENTAL STATUS-RR>30/min –P>125/min-SYSTOLIC BP<90mmHg-TEMP<35’C OR >40’C

ASSIGN PATIENT TORISK CLASS II,III,IV&VACCOURDING TO TOTALSCORE USING THEPREDICTION RULE.

ASSIGN PATIENTTO RISK CLASS I

yes

yes

yes

no

no

no

Step I

charactercharacter No. of points No. of points assignedassigned

Demorphic factorsDemorphic factors Age :menAge :men

womenwomen

Nursing home careNursing home care

Coexisting condition:Coexisting condition:

Neoplastic disNeoplastic dis

Liver disLiver dis

CHFCHF

CVACVA

CRFCRF

Age in yearsAge in years

Age -10yAge -10y

+10+10

+30+30

+20+20

+10+10

+10+10

+10+10

Finding on Finding on physical examphysical exam

Altered mental statusAltered mental statusRR>30/minRR>30/minSys BP<90mmHgSys BP<90mmHgT<35’C or >40’CT<35’C or >40’CPulse>125 b/minPulse>125 b/min

+20+20

+20+20

+20+20

+15+15

+10+10

Step II

Cont.Cont.

charactercharacter No. of pointsNo. of points

Lab & Lab & radiographic radiographic findingfinding

Arterial pH<7.35Arterial pH<7.35BUN>30mg/dlBUN>30mg/dl

=(11mmol/l)=(11mmol/l)Na<130mmol/lNa<130mmol/lGlu>250mg/dlGlu>250mg/dl

=(14mmol/l)=(14mmol/l)Haematocrit<30%Haematocrit<30%Partial pressure of Partial pressure of arterial arterial oxygen<60mmHgoxygen<60mmHg

Or O2 sat<90%Or O2 sat<90%Pleural effusionPleural effusion

+30+30

+20+20

+10+10

+10+10

+10+10

+10+10

+10+10

Stratification of risk scoreStratification of risk score

RiskRisk Risk classRisk class ScoreScore MortalityMortality

LowLow

LowLow

LowLow

ModerateModerate

High High

II

IIII

IIIIII

IVIV

VV

Based on Based on algorithmalgorithm

<70<70

71-9071-90

91-13091-130

>130>130

0.01%0.01%

0.6%0.6%

0.9%0.9%

9.3%9.3%

27%27%

Algorithm for Determining Algorithm for Determining Whether a Patient with Whether a Patient with Community-Acquired Community-Acquired

PneumoniaPneumoniaShould be Admitted or Treated Should be Admitted or Treated

as Outpatientas Outpatient

Diagnosis of pneumonia is confirmed in immunocompetent adult with CAP

Absolute contra indication to out pt treatment

• Hypoxemia (O2 sat<90%)

•Haemodynamic instability.

•Active coexisting condition requiring hospital.

•Inability to tolerate oral medication.

Use PSI to determine the risk.

Risk class I,II,III Risk class IV,V

Other mitigating factors

Frail physical condition

No response to oral therapy

Unstable living condition

Out patient treatment Intermediate options

Inpatienttreatment

no

yes

yes

yes

no

Cont.Cont.

All patients with suppurative or metastatic All patients with suppurative or metastatic diseases( Empyema, Lung abscess , diseases( Empyema, Lung abscess , Endocarditis ,Meningitis or Osteomyelitis) Endocarditis ,Meningitis or Osteomyelitis) or infections due to high risk or infections due to high risk pathogens( e.g staph.aurus ,G-ve rods or pathogens( e.g staph.aurus ,G-ve rods or anaerobes) should be admitted.anaerobes) should be admitted.

Several studies have established safety Several studies have established safety and effectiveness of PSI.and effectiveness of PSI.

A controlled trial of a critical A controlled trial of a critical pathway for treatment of CAPpathway for treatment of CAP

This is a strongest evidence ,it is a This is a strongest evidence ,it is a randomized controlled trial involving 19 randomized controlled trial involving 19 hospitals.hospitals.

The hospitals that were randomly The hospitals that were randomly assigned to study admitted fewer low risk assigned to study admitted fewer low risk patients than did the control hospitals patients than did the control hospitals (31%vs.49%).(31%vs.49%).

Results of the studyResults of the study

1.1. There were no significant difference There were no significant difference between groups in the hospitalization between groups in the hospitalization rates among moderate –high risk rates among moderate –high risk patients whom the protocol recommend patients whom the protocol recommend admission .admission .

2.2. The intervention reduced the overall The intervention reduced the overall number of hospital bed-days per patient number of hospital bed-days per patient without any increase in deaths, without any increase in deaths, complications,use of ICU or readmission.complications,use of ICU or readmission.

Results of the studyResults of the study

3. Applying this protocol 3. Applying this protocol decrease initial decrease initial hospitalization rates hospitalization rates of death among low of death among low risk without any risk without any change in the rates change in the rates of death, symptom of death, symptom resolution, resolution, functional recovery functional recovery and patient and patient stratification.stratification.

0

10

20

30

40

50

60

%

no PSI

PSI

Results of the studyResults of the study

4. The most common reasons for admission 4. The most common reasons for admission of low risk patients include: presence of of low risk patients include: presence of coexisting conditions ,patient preference coexisting conditions ,patient preference and inadequate home support.and inadequate home support.

5. Selected elderly patient can be treated as 5. Selected elderly patient can be treated as outpatient in good results.outpatient in good results.

*This study mentioned in JAMA 2002*This study mentioned in JAMA 2002

Criteria for stability &dischargeCriteria for stability &discharge

1.Pt. vital signs are stable for 24h period 1.Pt. vital signs are stable for 24h period T<37.8’C , RR<24 , HR<100b/min T<37.8’C , RR<24 , HR<100b/min Sys BP>90mmHg ,O2 sat>90% in room airSys BP>90mmHg ,O2 sat>90% in room air

2.Take oral antibiotic2.Take oral antibiotic3.Maintain adequate hydration and nutrition3.Maintain adequate hydration and nutrition4.Normal mental status4.Normal mental status5.Has no other active clinical or 5.Has no other active clinical or

psychosocial problems requiring psychosocial problems requiring hospitalization. hospitalization.

The median time to clinical stability is ~The median time to clinical stability is ~

low risk 3 dayslow risk 3 days

moderate 4 daysmoderate 4 days

high 6 dayshigh 6 daysSeveral studies confirm safety of this type Several studies confirm safety of this type

of discharge criteria.of discharge criteria.Data from controlled trials and prospective Data from controlled trials and prospective

studies indicate that early conversion from studies indicate that early conversion from IV to oral therapy doesn’t adversely affect IV to oral therapy doesn’t adversely affect outcomes & no need to observe patients outcomes & no need to observe patients for 24h after a switch to oral therapy.for 24h after a switch to oral therapy.

The American thoracic society The American thoracic society recommend following criteria for recommend following criteria for switching to oral antimicrobial switching to oral antimicrobial

agentsagents

1.1. Improvement in cough & dyspnea.Improvement in cough & dyspnea.

2.2. T<37.8’C two times 8h apart.T<37.8’C two times 8h apart.

3.3. Decrease in WBC.Decrease in WBC.

4.4. Functioning GIT with adequate oral Functioning GIT with adequate oral intake.intake.

Patient need to be told that they will probably Patient need to be told that they will probably feel sick for awhile (few weeks)feel sick for awhile (few weeks)

One week after One week after

*80% of CAP patients have *80% of CAP patients have cough and fatigue. cough and fatigue.

*50% have dyspnea and sputum *50% have dyspnea and sputum production.production.

Guidelines of Infectious Diseases Guidelines of Infectious Diseases Society of America (IDSA)Society of America (IDSA)

CLASS I & II CLASS I & II DON’T REQUIRE DON’T REQUIRE HOSPITALIZATIONHOSPITALIZATION

CLASS III CLASS III BREIF HOSPITAL STAY BREIF HOSPITAL STAYCLASS IV & V CLASS IV & V SHOULD BE SHOULD BE

HOSPITALIZEDHOSPITALIZED

A 65-Y old man with hypertension and A 65-Y old man with hypertension and degenerative joint disease presents to degenerative joint disease presents to emergency department with a3-days emergency department with a3-days history of a productive cough and fever.history of a productive cough and fever.

0\E 0\E Temp38.8’C ,BP144/92mmHg Temp38.8’C ,BP144/92mmHg ,RR22/min ,HR90/min ,O2 sat 92percent.,RR22/min ,HR90/min ,O2 sat 92percent.

Chest auscultation reveals crackles and Chest auscultation reveals crackles and egophony in the right lower lung field.egophony in the right lower lung field.

WBC 14,000per cubic millimeter ,all WBC 14,000per cubic millimeter ,all biochemical results are normal.biochemical results are normal.

Finally,Finally,

Answer Answer

OF the case in 1OF the case in 1stst slide slidePSI =65PSI =65Class IIClass IIOutpatientOutpatientTreatment : advanced Macrolide or Treatment : advanced Macrolide or

Fluroquinolone.Fluroquinolone.

MAIN SOURSES MAIN SOURSES

THE NEW ENGLAND JOURNAL OF THE NEW ENGLAND JOURNAL OF MEDICINE 2004MEDICINE 2004

IDSA GUIDELINESIDSA GUIDELINESwww.nejm.orghttp://ursa.kcom.edu/CAPcalc/default.htm http://ursa.kcom.edu/CAPcalc/default.htm