Escolar Documentos
Profissional Documentos
Cultura Documentos
Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management, and Prevention Presented by : of Community-acquired Andrea Kristina Baliton Pneumonia (CAP) 2010 Update
3/12/12
Pneumonia is the third leading cause of morbidity (2001) and mortality (1998) in Filipinos based on the Philippine Health Statistics from the Department of Health.
3/12/12
3/12/12
CAP is commonly defined as an acute infection of the pulmonary parenchyma with symptoms of acute illness accompanied by abnormal chest findings.
3/12/12
CAP is a lower respiratory tract infection acquired in the community within 24 hours to less than 2 weeks.
presents with an acute cough. tachypnea (respiratory rate >20bpm) tachycardia (cardiac rate >100/minute) fever (temperature >37.8C) At least one abnormal chest fi nding of
3/12/12
Prediction rules combining history and physical examination significantly affect the probability of pneumonia.( sensitivity of 95%, a specificity of 56%)
There is no clinical feature that can reliably distinguish pneumonia due to a typical or an atypical pathogen. (Grade A) 3/12/12
Pneumonia may vary because of three reasons: The virulence factors of the pathogens; the advanced age of the host; and the presence of coexisting illnesses of the host.
3/12/12
3/12/12
The
chest x-ray is essential in the diagnosis of CAP, assessing severity, differentiating pneumonia from other conditions, and in prognostication. (Grade A)
3/12/12
Standing
posteroanterior and lateral views of the chest in full inspiration comprise the best radiologic evaluation of a patient suspected of having pneumonia. (Grade A)
3/12/12
There
is no characteristic radiographic feature that can predict the likely etiologic agent in CAP. (Grade B) initial normal chest x-ray may connote a radiographic lag phase. > it may be reasonable to treat
An
their condition presumptively with 3/12/12 antibiotics and repeat the imaging in
Routine
follow-up chest radiograph is not needed for patients with lowrisk CAP who are clinically improving. (Grade B). chest CT scan has no routine role in the evaluation of CAP. (GradeB)
The
> Physicians ability to assess CAP on clinical grounds is low and cannot 3/12/12
Patients
with low-risk CAP are considered suitable for outpatient care in the absence of contraindications. (Grade A). with moderate- and highrisk CAP need to be hospitalized for closer monitoring and/or parenteral therapy. (Grade A)
Patients
3/12/12
3/12/12
3/12/12
3/12/12
3/12/12
In In
low-risk CAP, microbiologic studies are optional. (Grade B) moderate-risk and high-risk CAP, blood cultures and Gram stain and culture with antibiotic sensitivity tests of respiratory specimens should be done in laboratories with quality assurance. (Grade A)
3/12/12
Low-risk
The most common etiologic agents are bacterial (S. pneumoniae, H. infl uenzae) and atypical pathogens (M. pneumoniae, C. pneumoniae). 3/12/12
Moderate-
and high-risk CAP: In hospitalized patients, there are more pathogens to consider in addition to the above organisms (enteric Gram negatives, P . aeruginosa, S. aureus, L. pneumophila).
3/12/12
L.
pneumophila causes severe pneumonia with the majority of patients requiring intensive care. greatest risk of death occurs in the elderly and immunocompromised patients and delay in treatment is associated with increased mortality.
The
3/12/12
Invasive
> transtracheal aspiration > bronchoalveolar lavage > protected specimen brush > lung aspiration are associated with complications and are not routine procedures. 3/12/12
These
should only be done in patients with nonresolving pneumonia, immunocompromised patients, and in those without adequate respiratory specimens despite routine diagnostic testing.
3/12/12
3/12/12
For
patients requiring hospitalization, empiric therapy should be initiated as soon as possible after diagnosis of CAP is made. (Grade B) low-risk CAP, treatment
3/12/12
For
For
low-risk CAP without comorbid illness, amoxicillin remains the standard drug of choice (Grade A).
Extended
macrolides are recommended when atypical pathogens are suspected. (Grade A). 3/12/12
3/12/12
For low-risk CAP with stable comorbid illness, -lactam with lactamase inhibitor combinations (BLIC) (Grade A) or secondgeneration cephalosporins (Grade A).
Macrolides
Azithromycin Clarithromycin Dirithromycin Erythromycin Roxythromycin
3/12/12
Penicillins
Benzathine Methicillin Oxacillin Nafcillin Floxacillin
3/12/12
penicillin
Amoxicillin
3/12/12
With anti-Pseudomonasactivity:
3/12/12
> Ceftazidime
For moderate-risk CAP, a combination of an IV nonantipseudomonal -lactam (BLIC, cephalosporin or carbapenem) with either an extended macrolide or respiratory fluoroquinolone is recommended as initial antimicrobial treatment. (Grade B)
3/12/12
3/12/12
For
high-risk CAP without risk for Pseudomonas aeruginosa, a combination of an IV nonantipseudomonal -lactam (BLIC,
cephalosporin or carbapenem) with either an IV extended macrolide or IV respiratory fl uoroquinolone is recommended as an initial antimicrobial treatment. (Grade A)
3/12/12
3/12/12
3/12/12
3/12/12
3/12/12
3/12/12
Response to therapy
Temperature, respiratory rate, heart rate, blood pressure, sensorium, oxygen saturation and inspired oxygen concentration should be monitored to assess response to therapy. Response to therapy is expected within 24-72 hours of initiating treatment. Failure to improve afer 72 hours of treatment is an indication to repeat the chest radiograph. (Grade A)
3/12/12
of treatment is 5 to 7 days for low risk uncomplicated bacterial pneumonia. (Grade B) For moderate-risk and high-risk CAP or for those with suspected or confirmed Gram-negative, S. aureus or P aeruginosa pneumonia, . treatment should be prolonged to 14 to 21 days. (Grade B)
5-day course of oral or IV therapy for low-risk CAP and a 10-day course for Legionella pneumonia is possible with new agents such as the azalides, which possess a long half-life and achieve high tissue levels that prolong it duration of effect. (Grade B)
3/12/12
3/12/12
3/12/12
Influenza
vaccination is recommended for the prevention of CAP. (Grade A) vaccination is recommended for the prevention of invasive pneumococcal disease (IPD) in adults. (Grade A)
Pneumococcal
3/12/12
3/12/12
3/12/12
3/12/12
The
influenza vaccine should be stored at 2oC 8oC and should not be frozen. For adults, the infl uenza vaccine is administered at a dose of 0.5 mL intramuscularly every year.
Annual
3/12/12
3/12/12
END
3/12/12