Assessing Severity Of Disease And Treatment Location
Therefore, in general, validated clinical prediction scores for prognosis can be used in patients with HIV in conjunction with clinical judgement to guide treatment location for CAP. Low risk patients for whom there are no other concerns regarding adherence or complicating factors can be treated as outpatients. Patients with severe CAP, including those presenting with shock or respiratory failure, usually require a higher level of care, typically ICU admission. Additionally, severe CAP criteria can include PSI risk class of III or IV or CURB-65 scores â¥3. Patients with â¥3 of the ATS/IDSA minor severity criteria for CAP57 often require ICU or higher level of care as well.
Question 1: In Adults With Cap Who Test Positive For Influenza Should The Treatment Regimen Include Antibacterial Therapy
We recommend that standard antibacterial treatment be initially prescribed for adults with clinical and radiographic evidence of CAP who test positive for influenza in the inpatient and outpatient settings .
Summary of the evidence
Bacterial pneumonia can occur concurrently with influenza virus infection or present later as a worsening of symptoms in patients who were recovering from their primary influenza virus infection. As many as 10% of patients hospitalized for influenza and bacterial pneumonia die as a result of their infection . An autopsy series from the 2009 H1N1 influenza pandemic found evidence of bacterial coinfection in about 30% of deaths .
S. aureus is one of the most common bacterial infections associated with influenza pneumonia, followed by S. pneumoniae, H. influenzae, and group A Streptococcus other bacteria have also been implicated . Given this spectrum of pathogens, appropriate agents for initial therapy include the same agents generally recommended for CAP. Risk factors and need for empiric coverage for MRSA would follow the guidelines included earlier in this document. Rapidly progressive severe pneumonia with MRSA has been described in previously healthy young patients, particularly in the setting of prior influenza however, it is typically readily identified in the nares or sputum and should be identified by following the recommendations of earlier recommendations in this guideline.
Rationale for the recommendation
Usual Duration Of Therapy
Rapid improvement or minimal change in ventilator settings of 5 cm H2O and daily minimum fraction of inspired oxygen of 40% on the day antibiotics were started and the following 2 calendar days):
- Stop within 1-3 days
- Target therapy based on Endotracheal Tube Aspirate or Bronchoalveolar Lavage
- Complete 7 days of total therapy
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Current Status Of Scoring Systems For The Assessment Of Cap Severity At Admission And Scoring Systems For Early Identification Of Risk For The Need Ventilatory And/or Vasopressor Support To Prevent The Development Of Severe Sepsis Or Treatment Failure What Are The Recommendations
Patients with a diagnosis of CAP should always be assessed for disease severity, a precaution that has a direct positive impact on mortality.- Currently available prognostic scoring systems measure severity and help predict prognosis in CAP, informing the decision regarding site of care , the need for etiologic investigation, and the choice of antibiotics and their route of administration.,
Validated instruments include the Pneumonia Severity Index mental Confusion, Urea, Respiratory rate, Blood pressure, and age 65 years CRB-65 the 2007 American Thoracic Society/Infectious Diseases Society of America guidelines Systolic blood pressure, Multilobar involvement, Albumin, Respiratory rate, Tachycardia, Confusion, Oxygenation, and pH and Severe Community-Acquired Pneumonia -the last three being related to severe pneumonia and ICU admission.-
It is important to stress that disease severity as determined by scoring systems is a major factor in the decision regarding hospital admission however, other factors, such as the possibility of using oral drugs, comorbidities, psychosocial factors and socioeconomic characteristics that indicate vulnerability of the individual, should be taken into account.,, Ideally, SpO2 should always be monitored: SpO2 values below 92% should be an indication for hospital admission.,
Outpatient Vs Inpatient Treatment
Choosing between outpatient and inpatient treatment is a crucial decision because of the possible risk of death.9,15,16 This decision not only influences diagnostic testing and medication choices, it can have a psychological impact on patients and their families. On average, the estimated cost for inpatient care of patients with CAP is $7,500. Outpatient care can cost as little as $150 to $350.1719 Hospitalization of a patient should depend on patient age, comorbidities, and the severity of the presenting disease.9,20
Physicians tend to overestimate a patients risk of death14 therefore, many low-risk patients who could be safely treated as out-patients are admitted for more costly inpatient care. The Pneumonia Severity Index was developed to assist physicians in identifying patients at a higher risk of complications and who are more likely to benefit from hospitalization.9,15,16 Investigators developed a risk model based on a prospective cohort study16 of 2,287 patients with CAP in Pittsburgh, Boston, and Halifax, Nova Scotia. By using the model, the authors found that 26 to 31 percent of the hospitalized patients were good outpatient candidates, and an additional 13 to 19 percent only needed brief hospital observation. They validated this model using data17 from more than 50,000 patients with CAP in 275 U.S. and Canadian hospitals.1517,21,22
Information from reference 15.
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Special Considerations During Pregnancy
The diagnosis of bacterial respiratory tract infections in pregnant women is the same as in those who are not pregnant, with appropriate shielding of the abdomen during radiographic procedures. Bacterial respiratory tract infections should be managed in pregnant women as in women who are not pregnant, with certain exceptions. Among macrolides, clarithromycin is not recommended because of an increased risk of birth defects seen in some animal studies. Two studies, each involving â¥100 women with first-trimester exposure to clarithromycin, did not document a clear increase in or specific pattern of birth defects, although an increased risk of spontaneous abortion was noted in one study.107,108 Azithromycin did not produce birth defects in animal studies, but experience with human use in the first trimester is limited. Azithromycin is recommended when a macrolide is indicated in pregnancy . Arthropathy has been noted in immature animals with in utero exposure to quinolones. Studies evaluating quinolone use in pregnant women did not find an increased risk of birth defects or musculoskeletal abnormalities.109,110 When indicated, quinolones can be used in pregnancy for serious respiratory infections only when a safer alternative is not available .111
Question : Should A Clinical Prediction Rule For Prognosis Plus Clinical Judgment Versus Clinical Judgment Alone Be Used To Determine Inpatient Versus Outpatient Treatment Location For Adults With Cap
In addition to clinical judgement, we recommend that clinicians use a validated clinical prediction rule for prognosis, preferentially the Pneumonia Severity Index over the CURB-65 , to determine the need for hospitalization in adults diagnosed with CAP.
Summary of the evidence
Both the PSI and CURB-65 were developed as prognostic models in immunocompetent patients with pneumonia, using patient demographic and clinical variables from the time of diagnosis to predict 30-day mortality . When compared with CURB-65, PSI identifies larger proportions of patients as low risk and has a higher discriminative power in predicting mortality .
Two multicenter, cluster-randomized trials demonstrated that use of the PSI safely increases the proportion of patients who can be treated in the outpatient setting . These trials and one additional randomized controlled trial support the safety of using the PSI to guide the initial site of treatment of patients without worsening mortality or other clinically relevant outcomes . Consistent evidence from three prepost intervention studies and one prospective controlled observational study support the effectiveness and safety of using the PSI to guide the initial site of treatment .
The PSI may underestimate illness severity among younger patients and oversimplify how clinicians interpret continuous variables . Therefore, when used as a decision aid, the PSI should be used in conjunction with clinical judgment.
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Pneumonia In The Context Of Bioterrorism
There is increasing appreciation of the potential for bioterrorism, either from dissidents or from foreign countries. The relevance of this to pneumonia guidelines is based on the observation that several microbes that could be used as weapons would be expressed as pneumonia. A number of microbes could be disseminated as biological weapons by aerosol as an invisible, odorless, tasteless inoculum that could afflict as many as thousands of patients after an incubation period of days to weeks. In this setting, the etiologic agents most likely to cause severe pulmonary infection are Bacillus anthracis, Yersinia pestis, and F. tularensis . Recognition of these conditions would be by medical practitioners, and it is critical to implement appropriate strategies to establish the diagnosis, treat afflicted patients, and provide preventive treatment to those exposed. Thus, the first responders for bioterrorism are expected to be physicians in office practice, emergency rooms, ICUs, and in the discipline of infectious diseases. It should be acknowledged that national planning for a civilian medical and public health response is only now being initiated.
Biological warfare agents that would cause pulmonary disease.
Question 1: In Adults With Cap Who Are Improving Should Follow
In adults with CAP whose symptoms have resolved within 5 to 7 days, we suggest not routinely obtaining follow-up chest imaging .
Summary of the evidence
There are limited data on the clinical usefulness of reimaging patients with pneumonia. Most available data have evaluated whether reimaging patients detects lung malignancy not recognized at the time of treatment for pneumonia. Reported rates of malignancy in patients recovering from CAP range from 1.3% to 4% . When unsuspected nonmaligant pathology is included, the rate of abnormal findings may reach 5%.
Almost all patients with malignancy in reported series were smokers or ex-smokers. One longer-term study found 9.2% of CAP survivors in the Veterans Affairs system had a new diagnosis of cancer, with a mean time to diagnosis of 297 days. However, only 27% were diagnosed within 90 days of discharge from hospital, suggesting the yield of routine follow-up post discharge would be low .
Rationale for the recommendation
Available data suggest the positive yield from repeat imaging ranges from 0.2% to 5.0% however many patients with new abnormalities in these studies meet criteria for lung cancer screening among current or past smokers .
Research needed in this area
Further research may clarify subgroups of patients who may benefit from further radiological assessment after initial therapy for pneumonia.
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Pocus Perfomed By Experienced Operators Is More Accurate Than Chest X
A 2014 meta-analysis concluded that, in the hands of experienced operators, ultrasound examination has a sensitivity and specificity as high as 94% and 96%, respectively. Ultrasound examination may offer an ideal alternative diagnostic modality in pediatric patients and critically ill patients in whom it is difficult to obtain a 2-view chest x-ray. However, for patients who are stable enough to go to the radiology department to get a 2 view chest x-ray, the time required to complete a thorough lung POCUS exam may be a limiting factor.
Adults Older Than 18 Years
Diagnosis. In adults, CAP typically presents as a constellation of suggestive features including cough, fever, sputum production, and pleuritic chest pain, along with the presence of an acute infiltrate on chest radiograph, with or without microbiological data . As in children, the management and prognosis of CAP in adults depend on the initial assessment of severity of illness. Once again, history and physical examination are important parts of the evaluation. If there is infiltrate on the chest x-ray of an otherwise healthy adult, community-acquired pneumonia should be strongly considered.
When evaluating adults with CAP, prognostic models can be helpful in determining the severity and therefore treatment setting of illness . According to the Infectious Disease Society of America 2010 clinical practice guideline for CAP, criteria for severe CAP include but are not limited to rapid respiratory rate , hypoxemia, uremia, altered sensorium, leukopenia, hypotension requiring fluids or vasopressors, and multilobar infiltrates. Inpatient admission and discharge criteria should also take into consideration compliance and support on an outpatient basis .
As always, special consideration should be applied to patients with complicated pneumonia or evidence of pleural effusion, or patients requiring intensive care.
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Diagnosis And Treatment Of Adults With Community
American Journal of Respiratory and Critical Care Medicine, Volume 200, Issue 7, 1 October 2019, Pages e45-e67, 01 October 2019
Joshua P. Metlay, Grant W. Waterer, Ann C. Long, Antonio Anzueto, Jan Brozek, Kristina Crothers, Laura A. Cooley, Nathan C. Dean, Michael J. Fine, Scott A. Flanders, Marie R. Griffin, Mark L. Metersky, Daniel M. Musher, Marcos I. Restrepo, and Cynthia G. Whitney on behalf of the American Thoracic Society and Infectious Diseases Society of America
Duration Of Antibiotic Therapy For Outpatients And Inpatients With Cap
The optimal duration of antibiotic therapy for the treatment of CAP has yet to be definitively established. Short-term antibiotic therapy seems to be the most appropriate, given that it provides less patient exposure to the effects of antibiotics, reduces the occurrence of adverse effects, reduces the development of drug resistance by microorganisms, improves patient adherence, and can minimize length of hospital stay and financial costs. In addition, very long-term treatments favor the development of bacterial resistance and the occurrence of potentially severe adverse effects, such as infections with Clostridium difficile. However, short-term treatment should be as effective as longer-term treatments in terms of rates of mortality, complications, and disease recurrence.
Recommendations regarding the optimal duration of antibiotic therapy have changed over time, and there are discrepancies on this issue across guidelines .
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Question : In Adults With Cap Should Blood Cultures Be Obtained At The Time Of Diagnosis
We recommend not obtaining blood cultures in adults with CAP managed in the outpatient setting .
We suggest not routinely obtaining blood cultures in adults with CAP managed in the hospital setting .
We recommend obtaining pretreatment blood cultures in adults with CAP managed in the hospital setting who:
1. are classified as severe CAP or
a. are being empirically treated for MRSA or P. aeruginosa or
b. were previously infected with MRSA or P. aeruginosa, especially those with prior respiratory tract infection or
c. were hospitalized and received parenteral antibiotics, whether during the hospitalization event or not, in the last 90 days .
Summary of the evidence
There are no high-quality studies that specifically compared patient outcomes with and without blood culture testing. One large observational study found lower mortality for hospitalized patients associated with obtaining blood cultures at the time of admission . Three subsequent observational studies found similar associations between in-hospital mortality and having blood cultures within 24 hours of admission, but the results were not statistically significant .
Rationale for the recommendation
In severe CAP, delay in covering less-common pathogens can have serious consequences. Therefore, the potential benefit of blood cultures is much larger when results can be returned within 24 to 48 hours.
Children Between 60 Days And 18 Years Of Age
Diagnosis. History taking and a complete physical exam are critical to diagnose CAP in children. History of the patient should include the age of the child, type of symptoms and date of onset, immunization status , possibility of aspiration, and recent exposure to tuberculosis. The complete physical exam, including vital signs, can often help determine the severity of pneumonia. Severely ill children should be evaluated for signs of parapneumonic effusion or empyema, including dyspnea, dry cough, pleuritic chest pain, frictional rub on auscultation, or diminished breath sounds. In less acutely ill children, the following combinations of clinical findings are the most predictive of severe CAP :
- In infants less than 12 months of age: nasal flaring and oxygen saturation less than 96 percent on room air and respiratory rate above 50 and intercostal retractions.
- In children 1 to 5 years of age: SpO2 less than 96 percent and respiratory rate above 40.
- In children greater than 5 years of age: SpO2 less than 96 percent and respiratory rate above 30.
In the outpatient setting, high-dose amoxicillin has been demonstrated to be a reasonable option for CAP, since Streptococcus pneumoniae is a common pathogen among children. According to the Te xas Childrens Hospital clinical guideline, outpatient treatment differs by age group:
In an inpatient, non-ICU setting, recommended therapy according to age groups is:
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Antibiotic Recommendations For Community Acquired Pneumonia In Ontario
Consult your local biogram for recommendations in your area
- No risk factors for MRSA or pseudomonas, hemodynamically stable, non-ICU: amoxicillin or doxycycline or amoxicillin-clavulanic acid
- No risk factors for MRSA or pseudomonas and are hemodynamically unstable, or have ICU admission planned, or are unable to tolerate oral antibiotics: IV ceftriaxone
- MRSA risk factors: add vancomycin or linezolid
- Pseudomonas risk factors: piperacillin-tazobactam or miropenem
The vast majority of pneumonias are caused by only 2 bacteria: Streptococcus pneumonia and Haemophilus influenzae. All strep pneumonia and most H flu are susceptible to penecillin or amoxicillin. Therefore,the first line antibiotic for CAP patients without risk factors for MRSA or pseudomonas and who are hemodynamically stable, based on a Cochrane review is amoxicillin 1g po bid.
For patients with true penicillin allergy doxycycline 100mg po bid is the recommended first line antibiotic for these with CAP. It has good atypical coverage and a low risk for C. diff.
Amoxacillin-clavulinic acid does not appear to confer added coverage against strep pneumo , however it can be considered as an alternative to amoxicillin or doxycycline in patients with poor oral hygiene and for non-ICU inpatients.
Fluoroquinolones should not be first or even second line therapy. Serious adverse reactions include:
- Partial treatment of tuberculosis leading to diagnostic delay
- Increased risk of aortic dissection
Principles Of Antibiotic Treatment Of Community
- John SegretiCorrespondenceRequests for reprints should be addressed to John Segreti, MD, Rush Medical College, Rush University Medical Center, 600 South Paulina, Suite 143, Chicago, Illinois 60612.AffiliationsDepartment of Internal Medicine, Section of Infectious Diseases, Rush Medical College, Rush University Medical Center, Chicago, Illinois, USA
- Robert E. SiegelAffiliationsCritical Care Center, Bronx Veterans Affairs Medical Center, Mount Sinai School of Medicine, New York, New York, USA
Streptococcus pneumoniaeS pneumoniaeS pneumoniae
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