Escolar Documentos
Profissional Documentos
Cultura Documentos
http://www.mevis-research.de/~hhj/Lunge/ima/InfInt_zu_AlvThA15_8.JPG
Bronchitis vs. Pneumonia
http://www.medtogo.com/bronchitis-pneumonia.html
CAP Facts & Epidemiology
~5.6 million cases/yr in the United States
1.1 million hospitalization
~ $8.4 billion annual cost for CAP
92% of cost with inpatient therapy
60% of adults 65 years and over received a
pneumococcal vaccination (2008)
Hospital discharges annually: 1.2 million
Average length of stay: 5.1 days
Early Release of Selected Estimates from the National Health Interview Survey,data table
for figure 5.1
2006 National Hospital Discharge Survey, tables 2,4
CAP Facts & Epidemiology
Mortality
Number of deaths: 55,477a
Deaths rate: 18.5 per 100,000
populationa
Percent of hospital inpatient deaths from
pneumonia: 5.4%b
Riquelme-R et al. Community-acquired pneumonia in the elderly: A multivariate analysis of risk and
prognostic factors. Am J Respir Crit Care Med 1996;154:1450-5
How is CAP described by causative
pathogen?
Typical: 60-70%
Usually Streptococcus pneumonia 40-60%
H. influenzae 3-10%
Atypical: 30-40%
Mycoplasma pneumoniae
Legionella pneumophila
Chlamydia pneumoniae
Viruses: Influenza, Adenovirus
Gram-negative bacteria up to ~5-10%
Staphylococcal up to 5-10%
IV drug abuse (with right-sided endocarditis),
immunocompromised, chronic lung disease, post-op
more common after an episode of influenza
CAP symptoms
Cough, fever, chills, fatigue, dyspnea,
rigors, and pleuritic chest pain
May include headache and myalgia
Depending on the pathogen, cough
may be persistent and dry, or it may
produce sputum
Legionella may produce
gastrointestinal symptoms
CAP Signs & Symptoms
http://upload.wikimedia.org/wikipedia/commons/0/07/Main_symptoms_of_infectious_pneumonia.png
CAP Physical Exam
Dullness to percussion of chest, crackles on
auscultation, bronchial breath sounds,
tactile fremitus, egophony, whispered
pectoriloquy, bronchophony
Tachypnea may be present
Patients with typical pneumonia are more
likely to present with dyspnea and
bronchial breath sounds on auscultation
Exam
Traditional chest physical
examination not sufficiently
accurate to confirm or exclude
diagnosis of pneumonia
48-71% positive predictive value
55-72% negative predictive value
Unknown if inclusion of history would
improve accuracy of clinical diagnosis
Campbell SG, Marrie TJ, Anstey R, et al. The contribution of blood cultures to the clinical management of
adult patients admitted to the hospital with community-acquired pneumonia. Chest 2003; 123:1142-50.
Lab Test: Blood cultures
Do not seem necessary for patients
with routine community-acquired
pneumonia and no underlying risk
factors
Blood cultures and sputum studies do
not seem warranted in patients with
mild pneumonia and no co-morbid
conditions
Adults
trial involving 1502 adults attending an
emergency department found no significant
difference in length of illness, the single
outcome prespecified for this review (mean
of 16.9 days in radiograph group versus
17.0 days in control group, P > 0.05).
Swingler, George H; Zwarenstein, Merrick; Swingler, George H. Chest radiograph in acute respiratory
infections (Cochrane Review). In: The Cochrane Library 2009 Issue 2. Chichester, UK: John Wiley and
Sons, Ltd.
Management
Inpatient ($7,000 - $8,000)
Outpatient ($150 - $300)
CAP Prognosis
Pneumonia Severity CURB 65
Index Risk of mortality
30-day mortality 0 points 0.7%
based on risk class 1 point 3.2%
I - 0-0.4% 2 points 3%
II - 0.4-0.9% 3 points 17%
III - 0-2.8% 4 points 41.5%
IV - 8.2-12.5% 5 points 57%
V - 0.6-10.6%
Fine MJ, et al. N Engl J Med 1997; 336: 243-50. Aujesky D, Auble TE, Yealy DM, et al.
Prospective comparison of three validated prediction rules for prognosis in
community-acquired pneumonia. Am J Med 2005; 118: 384-92.
Aujesky D, Auble TE, Yealy DM, et al. Prospective comparison of three validated prediction rules for
prognosis in community-acquired pneumonia. Am J Med 2005; 118: 384-92.
FACTORS THAT INCREASE THE RISK OF
INFECTION WITH SPECIFIC PATHOGENS
Penicillin-resistant and drug-resistant pneumococci
Age > 65 yr
Beta-Lactam therapy within the past 3 mo
Alcoholism
Immune-suppressive illness (including therapy with corticosteroids)
Multiple medical co-morbidities
Exposure to a child in a day care center
Enteric gram-negatives
Residence in a nursing home
Underlying cardiopulmonary disease
Multiple medical co-morbidities
Recent antibiotic therapy
Pseudomonas aeruginosa
Structural lung disease (bronchiectasis)
Corticosteroid therapy (>10 mg of prednisone per day)
Broad-spectrum antibiotic therapy for >7 d in the past month
Malnutrition
Outpatients: without cardiopulmonary
disease and no modifying factor
Organisms Therapy
Streptococcus Advanced generation
pneumoniae
macrolide:
Mycoplasma pneumoniae
azithromycin or
Chlamydia pneumoniae
(alone or as mixed clarithromycin
infection)
Hemophilus influenzae or
Respiratory viruses
Miscellaneous
Legionella spp. Doxycycline
Mycobacterium
tuberculosis
Endemic fungus
<8 days Abx same as >8 days
Organism Therapy
S. Pneumoniae IV azithromycin alone
H. influenzae If macrolide allergy or
M. pneumoniae intolerant:
C. pneumoniae Doxycycline + Beta-lactam
Mixed infection
(bacteria plus atypical or
pathogen)
Viruses Monotherapy with an
Legionella spp. antipneumococcal
Miscellaneous fluoroquinolone
M. tuberculosis
endemic fungi
P. carinii
Inpatient NOT in ICU
WITH Cardiopulmonary Ds and/or Modifying
Factors (Incl. from Nursing Home)
Organism Therapy
S. Pneumoniae IV Beta-lactam (cefotaxime,
H. influenzae ceftriaxone,ampicillin/sulba
M. pneumoniae ctam, high-dose
ampicillin) plus
C. pneumoniae macrolide or doxycycline
Mixed infection
(bacteria plus atypical or
pathogen)
Viruses IV antipneumococcal
Legionella spp. fluoroquinolone alone
Miscellaneous
M. tuberculosis
endemic fungi
P. carinii
Inpatient in ICU
No Risks for Pseudomonas
aeruginosa
IV Beta-lactam (cefotaxime,
ceftriaxone) plus
either IV macrolide (azithromycin)
or IV fluoroquinolone
Inpatient in ICU
Risks for Pseudomonas aeruginosa
Metersky ML, Ma A, Bratzler DW, Houck PM. Predicting bacteremia in patients with community-
acquired pneumonia. Am J Respir Crit Care Med 2004; 169:342-47.
Does all this matter?
Yes
Using Abx empirically per guidelines in
hospitalized patients
less CAP deaths at 48-96 hrs
less overall death
shorter hospital stay
shorter time to oral abx
http://firstwatch.jwatch.org/cgi/content/full/2006/1010/3
Medicare/Joint Commission National
Hospital Inpatient Quality Measures
http://dynaweb.ebscohost.com/Detail.as
px?docid=/dynamed/Blankmisc207&si
d=446993f2-d2b2-4af0-b068-
e82c8bcd7d55@sessionmgr14
More to Pneumonia than CAP
Chronic Eosinophilic
Nursing-home Not pneumonia
so fast…
acquired Chemical pneumonia
Ventilator-acquired Aspiration
Nosocomial pneumonia
Chronic Dust pneumonia
Severe acute Necrotizing
respiratory syndrome pneumonia
(SARS)
Opportunistic
Bronchiolitis
obliterans organizing pneumonia
pneumonia (BOOP)
Objectives
Identify common causes of CAP
Select appropriate antibiotics for CAP
Be aware of CAP Quality Measures
Rethink antibiotic timing
References
http://dynaweb.ebscohost.com
www.essentialevidenceplus.com
http://en.wikipedia.org/wiki/Pneumonia
http://www.mercksource.com/pp/us/cns/cns_hl_dorlands_split.jsp?p
g=/ppdocs/us/common/dorlands/dorland/six/000084139.htm
http://www2.merriam-webster.com/cgi-
bin/mwmednlm?book=Medical&va=consolidation
http://www.lakeridgehealth.on.ca/patient_care/interventional_radiol
ogy/presentations/radiology/pneumonia.jpg
http://www.medtogo.com/bronchitis-pneumonia.html
http://www.mevis-
research.de/~hhj/Lunge/ima/InfInt_zu_AlvThA15_8.JPG
Valenzuela, Peter. Community Acquired Pneumonia. www.fmdrl.org
Harrison, Bradley K. Community Acquired Pneumonia (CAP).
www.fmdrl.org
http://www.cdc.gov/nchs/FASTATS/pneumonia.htm
http://upload.wikimedia.org/wikipedia/commons/0/07/Main_sympto
ms_of_infectious_pneumonia.png
References
Early Release of Selected Estimates from the National Health
Interview Survey, data table for figure 5.1
2006 National Hospital Discharge Survey, tables 2,4
Deaths: Final Data for 2006, tables 10, 11
National Hospital Discharge Survey: 2004 Annual Summary
With Detailed Diagnosis and Procedure Data, table 25
Riquelme-R et al. Community-acquired pneumonia in the
elderly: A multivariate analysis of risk and prognostic factors.
Am J Respir Crit Care Med 1996;154:1450-5
Arch Intern Med 1999 May 24;159(10):1082
Christ-Crain M, Jaccard-Stolz D, Bingisser R, et al. Effect of
procalcitonin-guided treatment on antibiotic use and outcome
in lower respiratory tract infections: cluster-randomised,
single-blinded intervention trial. Lancet 2004; 363:600-07.
References
Campbell SG, Marrie TJ, Anstey R, et al. The contribution of blood
cultures to the clinical management of adult patients admitted to the
hospital with community-acquired pneumonia. Chest 2003; 123:1142-
50.
Swingler, George H; Zwarenstein, Merrick; Swingler, George H. Chest
radiograph in acute respiratory infections (Cochrane Review). In: The
Cochrane Library 2009 Issue 2. Chichester, UK: John Wiley and Sons,
Ltd.
Ann Emerg Med 2005 Nov;46(5):393
Chest 2001 Jan;119;181 in Am Fam Physician 2001 Aug 15;64(4):665
Fine MJ, et al. N Engl J Med 1997; 336: 243-50. Aujesky D, Auble TE,
Yealy DM, et al. Prospective comparison of three validated prediction
rules for prognosis in community-acquired pneumonia. Am J Med 2005;
118: 384-92.
Aujesky D, Auble TE, Yealy DM, et al. Prospective comparison of three
validated prediction rules for prognosis in community-acquired
pneumonia. Am J Med 2005; 118: 384-92.
Am. J. Respir. Crit. Care Med., Volume 163, Number 7, June 2001,
1730-1754