Community-acquired pneumonia medical therapy: Difference between revisions
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In a [[randomized controlled trial]] of adults with community-acquired pneumonia, the [[relative risk ratio]] of [[prednisone]] 50 mg daily for 7 days, as compared to [[placebo]], reduced the time to median time to clinical stability from 4.4 to to 1.3 days. <ref name="pmid25608756">{{cite journal| author=Blum CA, Nigro N, Briel M, Schuetz P, Ullmer E, Suter-Widmer I et al.| title=Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial. | journal=Lancet | year= 2015 | volume= | issue= | pages= | pmid=25608756 | doi=10.1016/S0140-6736(14)62447-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25608756 }} </ref> | |||
In another [[randomized controlled trial]] of adults with community-acquired pneumonia, [[dexamethasone]] can reduce length of hospital stay. <ref name="pmid21636122">{{cite journal| author=Meijvis SC, Hardeman H, Remmelts HH, Heijligenberg R, Rijkers GT, van Velzen-Blad H et al.| title=Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2011 | volume= 377 | issue= 9782 | pages= 2023-30 | pmid=21636122 | doi=10.1016/S0140-6736(11)60607-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21636122 }} </ref> | |||
==Management of Pneumonia with Parapneumonic Effusion== | ==Management of Pneumonia with Parapneumonic Effusion== |
Revision as of 19:52, 31 January 2015
Community-Acquired Pneumonia Microchapters |
Differentiating Community-acquired pneumonia from other Diseases |
Diagnosis |
Treatment |
Case Studies |
Community-acquired pneumonia medical therapy On the Web |
American Roentgen Ray Society Images of Community-acquired pneumonia medical therapy |
Directions to Hospitals Treating Community-acquired pneumonia |
Risk calculators and risk factors for Community-acquired pneumonia medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2]; Alejandro Lemor, M.D. [3]
Overview
Community acquired pneumonia treatment includes using the appropriate antibiotic and managing complications. An empirical therapy may be started while awaiting culture results. Once culture results are available specific treatment may be started. Empiric therapy is classified according to severity using the Pneumonia severity scale (PSI) and the CURB-65 score. Empirical therapy usually includes coverage for atypical and typical bacteria.
Antibiotic Therapy
Choice of antibiotic therapy
- Infectious diseases society of America and American thoracic society (IDSA-ATS) recommend the following guidelines for patients admitted to hospital.[1]
- Respiratory fluoroquinolone- Moxifloxacin 400 mg / day or levofloxacin 750 mg / day OR
- Use a combination of second generation or third generation cephalosporin and a macrolide.
- Macrolides, Doxycycline, fluoroquinolones are most appropriate for atypical bacteria.
- In severe community acquired pneumonia start a cephalosporin with either a fluoroquinolone or a macrolide.
- Hospitalized patients with community acquired pneumonia should be treated with a respiratory fluoroquinolone or a combination of cephalosporin and macrolide should be used.
- Before initiating therapy the patient should be evaluated according to the following criteria:
- The level of testing needed to find out the etiology
- Class of antibiotic to be started
- Site-of-care decisions (outpatient, inpatient, or intensive care unit)
- The proper antibiotic therapy is the one that provides coverage for
- Streptococcus pneumoniae
- Atypical bacteria (Mycoplasma, Chlamydophila, Legionella, etc.)
Following are the guidelines to treat community acquired pneumonia.
- For patients treated in the outpatient department coverage for atypical organisms should be added. Young individuals usually gain herd immunity from infants and children who have been vaccinated with pneumococcal vaccination.[2]
- Macrolides have a better outcome than fluoroquinlones which may be due to nonbactericidal effects.[3][4]
- Empirical therapy with coverage for Pseudomonas aeruginosa and MRSA should be started for patients with risk factors for healthcare-associated pneumonia.[5] The pneumonia specific criteria according to Shindo et al is[6]
- Hospitalization for >2 days
- Antibiotic use during previous admission
- Non-ambulatory status
- Tube feedings
- Immunocompromised status
- Use of gastric acid suppressive agents
- Some useful interventions to decrease mortality and tranfer from floor to ICU include[7]:
- Aggressive fluid resuscitation[8]
- Prompt antibiotic initiation
- Measure arterial blood gas in patients who have borderline hypoxemia or lactate
- Treat co-existing illness like asthma and COPD with bronchodilators.
Timing and duration of antibiotic therapy
- High priority should be provided in the emergency room and should be immediately admitted to the intensive care unit for patients who present with 3 or more of the minor criteria:
- Elevated blood urea nitrogen
- Confusion
- High respiratory rate
- First antibiotic dose should be administered within 6 hours of admission into the emergency room.[9]
- An increased in deaths were noted when antibiotic were administered after 4 hours of administration.[10][11]
- Inadvertently use of antibiotic for patients without community-acquired pneumonia who require treatment before 4 hours may increase the risk of Clostridium difficile colitis.[11]
- Shock is an exception where antibiotic should be started within an hour of hypotension. A decrease in 8% of survival rate for each hour of delay is noted.[12]
- Antibiotic therapy for a duration of 5-7 days has been considered as adequate for treatment of community-acquired pneumonia.[13]
Location of treatment
- IDSA-ATS guidelines suggest that if three or more out of the nine minor criteria is present then the patient must be moved to the ICU.[13]
- Other scores have also been developed which help to distinguish moderately ill to severely ill patients.[14][15][16]
Empirical Treatment
▸ Click on the following categories to expand treatment regimens.
Community-Acquired Pneumonia ▸ Neonates, Age < 1 month ▸ Outpatient Therapy ▸ Inpatient Therapy, NON-ICU ▸ Inpatient Therapy, ICU ▸ Adult Special Concerns |
|
Pathogen Based Treatment
▸ Click on the following categories to expand treatment regimens.[17]
Bacteria ▸ Streptococcus pneumoniae ▸ Haemophilus influenzae ▸ Bacillus anthracis (inhalation) ▸ Enterobacteriaceae ▸ Pseudomonas aeruginosa ▸ Staphylococcus aureus ▸ Bordetella pertussis ▸ Anaerobe (aspiration) ▸ Mycobacterium tuberculosis ▸ Yersinisa pestis |
|
Atypical Bacteria ▸ Mycoplasma pneumoniae ▸ Chlamydophila pneumoniae ▸ Legionella species ▸ Chlamydophila psittaci ▸ Coxiella burnetii ▸ Francisella tularensis ▸ Burkholderia pseudomallei ▸ Acinetobacter species |
|
Virus ▸ Influenza virus |
|
Fungi ▸ Coccidioides species ▸ Histoplasmosis ▸ Blastomycosis |
|
Corticosteroids
In a randomized controlled trial of adults with community-acquired pneumonia, the relative risk ratio of prednisone 50 mg daily for 7 days, as compared to placebo, reduced the time to median time to clinical stability from 4.4 to to 1.3 days. [18]
In another randomized controlled trial of adults with community-acquired pneumonia, dexamethasone can reduce length of hospital stay. [19]
Management of Pneumonia with Parapneumonic Effusion
Shown below is an algorithm for the management of parapneumonic effusion in pediatric patients based on the 2011 Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.[20]
Abbreviations:
Confirm pleural effusion with chest X-ray. If not conclusive, order chest ultrasound or CT | |||||||||||||||||||||||||||||||||||||||||||||||
Determine the size of the effusion | |||||||||||||||||||||||||||||||||||||||||||||||
Small < 25% opacification of the thorax | Moderate Between 25-50% opacification of the thorax | Large > 50% opacification of the thorax | |||||||||||||||||||||||||||||||||||||||||||||
Is the patient improving? | Does the patient has respiratory distress? |
Is the pleural effusion loculated? | |||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Yes | No | Yes "Complicated" | No "Simple" | ||||||||||||||||||||||||||||||||||||||||||
Continue antibiotic therapy | Reassess the size of the effusion and follow the algorithm according to the size of effusion. | Follow algorithm for large effusion |
| 3 options for drainage:
| |||||||||||||||||||||||||||||||||||||||||||
Management of Non-responding Pneumonia
Definition
A failure to response even after 7 days of antibiotic treatment is categorized into non responding pneumonia. A progressive or deterioration causing respiratory faiure as septic shock within 72 hrs of hospital admission.
Management
The following steps should be taken as soon as the patient doesn't respond to treatment
- Transfer to a higher centre
- Order further diagnostic tests
- Change treatment
After a failure of treatment the following causes should be considered before proceeding further.
- Resistant microorganism
- Uncovered pathogen
- Nosocomial superinfection/Pneumonia
- Complication of pneumonia (e.g., BOOP)
- Misdiagnosis:
- Inaccurate diagnosis
The following actions are performed to find out the cause of a non responding pneumonia.
Cultures
A repeat blood culture should be performed if the pneumonia deteriorates .Inspite of treatment with prior antibiotic therapy blood cultures might still show high colonies.[21]
Rapid urinary antigens
S. pneumoniae and L. pneumophila may remain positive inspite of starting antibiotic therapy.[22][23]
Stopping B-Lactam
Stopping B-Lactam component of the combination may be important to rule out drug fever.[24]
Pneumococcal Antigen test
Some host may be have poor immunity and hence a pneumococcal antigen test should be scheduled to rule out that the cause was not incorrect antibiotics.
Obtain cultures from catheters
Extrapulmonary infection in ICU patients should be ruled out by obtaining cultures from intravascular catheter. A culture must also be obtained to rule out urinary, abdominal and skin infections which may be the result of the non response to treatment.
Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Empiric Antibiotic Treatment of Community-acquired Pneumonia in Adults [25] (DO NOT EDIT)
“ |
Previously Healthy and No Risk Factors for Drug Resistant Streptococcus Pneumoniae
Presence of Comorbidities or Other Risks for Drug Resistant Streptococcus PneumoniaePresence of comorbidities, such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected); or other risks for DRSP infection:
In Regions With a High Rate (>25%) of InfectionIn regions with a high rate (>25%) of infection with high-level (minimal inhibitory concentration [MIC], >16 micrograms/mL) macrolide-resistant S. pneumoniae, consider the use of alternative agents for any patient, including those without comorbidities. (Moderate recommendation; level III evidence) Inpatient, Non-ICU TreatmentThe following regimens are recommended for hospital ward treatment.
Inpatient, ICU TreatmentThe following regimen is the minimal recommended treatment for patients admitted to the ICU.
or the above beta-lactam plus an aminoglycoside and azithromycin or the above beta-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin-allergic patients, substitute aztreonam for the above beta-lactam). (Moderate recommendation; level III evidence)
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” |
For Level of evidence classification click here.
Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Pandemic Influenza Community-acquired pneumonia in Adults[25] (DO NOT EDIT)
“ |
Pathogen Directed Therapy
Pandemic Influenza
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” |
For Level of evidence classification click here.
Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Time, Route, and Duration of Community-acquired pneumonia in Adults[25] (DO NOT EDIT)
“ |
Time to First Antibiotic Dose
Switch from Intravenous to Oral Therapy
Duration of Antibiotic Therapy
|
” |
For Level of evidence and classes click here.
Other Treatments Consideration
Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Other Treatments Considerations for Acquired Pneumonia in Adults [25] (DO NOT EDIT)
“ |
|
” |
For Level of evidence and classes click here.
Management of Non-responding Pneumonia
Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Non Responding Acquired Pneumonia in Adults[25] (DO NOT EDIT)
“ |
|
” |
For Level of evidence and classes click here.
References
- ↑ Solomon, Caren G.; Wunderink, Richard G.; Waterer, Grant W. (2014). "Community-Acquired Pneumonia". New England Journal of Medicine. 370 (6): 543–551. doi:10.1056/NEJMcp1214869. ISSN 0028-4793.
- ↑ Griffin, MR.; Zhu, Y.; Moore, MR.; Whitney, CG.; Grijalva, CG. (2013). "U.S. hospitalizations for pneumonia after a decade of pneumococcal vaccination". N Engl J Med. 369 (2): 155–63. doi:10.1056/NEJMoa1209165. PMID 23841730. Unknown parameter
|month=
ignored (help) - ↑ Brown, RB.; Iannini, P.; Gross, P.; Kunkel, M. (2003). "Impact of initial antibiotic choice on clinical outcomes in community-acquired pneumonia: analysis of a hospital claims-made database". Chest. 123 (5): 1503–11. PMID 12740267. Unknown parameter
|month=
ignored (help) - ↑ Metersky, ML.; Ma, A.; Houck, PM.; Bratzler, DW. (2007). "Antibiotics for bacteremic pneumonia: Improved outcomes with macrolides but not fluoroquinolones". Chest. 131 (2): 466–73. doi:10.1378/chest.06-1426. PMID 17296649. Unknown parameter
|month=
ignored (help) - ↑ "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia". Am J Respir Crit Care Med. 171 (4): 388–416. 2005. doi:10.1164/rccm.200405-644ST. PMID 15699079. Unknown parameter
|month=
ignored (help) - ↑ Shindo, Y.; Ito, R.; Kobayashi, D.; Ando, M.; Ichikawa, M.; Shiraki, A.; Goto, Y.; Fukui, Y.; Iwaki, M. (2013). "Risk factors for drug-resistant pathogens in community-acquired and healthcare-associated pneumonia". Am J Respir Crit Care Med. 188 (8): 985–95. doi:10.1164/rccm.201301-0079OC. PMID 23855620. Unknown parameter
|month=
ignored (help) - ↑ Lim, HF.; Phua, J.; Mukhopadhyay, A.; Ngerng, WJ.; Chew, MY.; Sim, TB.; Kuan, WS.; Mahadevan, M.; Lim, TK. (2013). "IDSA/ATS minor criteria aided pre-ICU resuscitation in severe community-acquired pneumonia". Eur Respir J. doi:10.1183/09031936.00081713. PMID 24176994. Unknown parameter
|month=
ignored (help) - ↑ Rivers, E.; Nguyen, B.; Havstad, S.; Ressler, J.; Muzzin, A.; Knoblich, B.; Peterson, E.; Tomlanovich, M. (2001). "Early goal-directed therapy in the treatment of severe sepsis and septic shock". N Engl J Med. 345 (19): 1368–77. doi:10.1056/NEJMoa010307. PMID 11794169. Unknown parameter
|month=
ignored (help) - ↑ Wilson, KC.; Schünemann, HJ. (2011). "An appraisal of the evidence underlying performance measures for community-acquired pneumonia". Am J Respir Crit Care Med. 183 (11): 1454–62. doi:10.1164/rccm.201009-1451PP. PMID 21239689. Unknown parameter
|month=
ignored (help) - ↑ Houck, PM.; Bratzler, DW.; Nsa, W.; Ma, A.; Bartlett, JG. (2004). "Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia". Arch Intern Med. 164 (6): 637–44. doi:10.1001/archinte.164.6.637. PMID 15037492. Unknown parameter
|month=
ignored (help) - ↑ 11.0 11.1 Meehan, TP.; Fine, MJ.; Krumholz, HM.; Scinto, JD.; Galusha, DH.; Mockalis, JT.; Weber, GF.; Petrillo, MK.; Houck, PM. (1997). "Quality of care, process, and outcomes in elderly patients with pneumonia". JAMA. 278 (23): 2080–4. PMID 9403422. Unknown parameter
|month=
ignored (help) - ↑ Kumar, A.; Roberts, D.; Wood, KE.; Light, B.; Parrillo, JE.; Sharma, S.; Suppes, R.; Feinstein, D.; Zanotti, S. (2006). "Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock". Crit Care Med. 34 (6): 1589–96. doi:10.1097/01.CCM.0000217961.75225.E9. PMID 16625125. Unknown parameter
|month=
ignored (help) - ↑ 13.0 13.1 Mandell, LA.; Wunderink, RG.; Anzueto, A.; Bartlett, JG.; Campbell, GD.; Dean, NC.; Dowell, SF.; File, TM.; Musher, DM. (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin Infect Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083. Unknown parameter
|month=
ignored (help) - ↑ Restrepo, MI.; Mortensen, EM.; Rello, J.; Brody, J.; Anzueto, A. (2010). "Late admission to the ICU in patients with community-acquired pneumonia is associated with higher mortality". Chest. 137 (3): 552–7. doi:10.1378/chest.09-1547. PMID 19880910. Unknown parameter
|month=
ignored (help) - ↑ Renaud, B.; Labarère, J.; Coma, E.; Santin, A.; Hayon, J.; Gurgui, M.; Camus, N.; Roupie, E.; Hémery, F. (2009). "Risk stratification of early admission to the intensive care unit of patients with no major criteria of severe community-acquired pneumonia: development of an international prediction rule". Crit Care. 13 (2): R54. doi:10.1186/cc7781. PMID 19358736.
- ↑ Charles, PG.; Wolfe, R.; Whitby, M.; Fine, MJ.; Fuller, AJ.; Stirling, R.; Wright, AA.; Ramirez, JA.; Christiansen, KJ. (2008). "SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia". Clin Infect Dis. 47 (3): 375–84. doi:10.1086/589754. PMID 18558884. Unknown parameter
|month=
ignored (help) - ↑ Mandell, L. A.; Wunderink, R. G.; Anzueto, A.; Bartlett, J. G.; Campbell, G. D.; 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". Clinical Infectious Diseases. 44 (Supplement 2): S27–S72. doi:10.1086/511159. ISSN 1058-4838.
- ↑ Blum CA, Nigro N, Briel M, Schuetz P, Ullmer E, Suter-Widmer I; et al. (2015). "Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicentre, double-blind, randomised, placebo-controlled trial". Lancet. doi:10.1016/S0140-6736(14)62447-8. PMID 25608756.
- ↑ Meijvis SC, Hardeman H, Remmelts HH, Heijligenberg R, Rijkers GT, van Velzen-Blad H; et al. (2011). "Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial". Lancet. 377 (9782): 2023–30. doi:10.1016/S0140-6736(11)60607-7. PMID 21636122.
- ↑ Bradley, J. S.; Byington, C. L.; Shah, S. S.; Alverson, B.; Carter, E. R.; Harrison, C.; Kaplan, S. L.; Mace, S. E.; McCracken, G. H.; Moore, M. R.; St Peter, S. D.; Stockwell, J. A.; Swanson, J. T. (2011). "The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America". Clinical Infectious Diseases. 53 (7): e25–e76. doi:10.1093/cid/cir531. ISSN 1058-4838.
- ↑ Metersky, ML.; Ma, A.; Bratzler, DW.; Houck, PM. (2004). "Predicting bacteremia in patients with community-acquired pneumonia". Am J Respir Crit Care Med. 169 (3): 342–7. doi:10.1164/rccm.200309-1248OC. PMID 14630621. Unknown parameter
|month=
ignored (help) - ↑ Murdoch, DR.; Laing, RT.; Cook, JM. (2003). "The NOW S. pneumoniae urinary antigen test positivity rate 6 weeks after pneumonia onset and among patients with COPD". Clin Infect Dis. 37 (1): 153–4. doi:10.1086/375610. PMID 12830428. Unknown parameter
|month=
ignored (help) - ↑ Smith, MD.; Derrington, P.; Evans, R.; Creek, M.; Morris, R.; Dance, DA.; Cartwright, K. (2003). "Rapid diagnosis of bacteremic pneumococcal infections in adults by using the Binax NOW Streptococcus pneumoniae urinary antigen test: a prospective, controlled clinical evaluation". J Clin Microbiol. 41 (7): 2810–3. PMID 12843005. Unknown parameter
|month=
ignored (help) - ↑ Plouffe, JF.; Breiman, RF.; Fields, BS.; Herbert, M.; Inverso, J.; Knirsch, C.; Kolokathis, A.; Marrie, TJ.; Nicolle, L. (2003). "Azithromycin in the treatment of Legionella pneumonia requiring hospitalization". Clin Infect Dis. 37 (11): 1475–80. doi:10.1086/379329. PMID 14614670. Unknown parameter
|month=
ignored (help) - ↑ 25.0 25.1 25.2 25.3 25.4 Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083. Retrieved 2012-09-06. Unknown parameter
|month=
ignored (help)