Community acquired pneumonia resident survival guide: Difference between revisions
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==Do's== | ==Do's== | ||
*Obtain a sputum gram stain, sputum culture and blood cultures before initiating antibiotic therapy. | |||
*Provide coverage for [[Streptococcus pneumoniae]] and atypical bacteria like ([[Mycoplasma]], [[Chlamydophila]], [[Legionella]] ).<ref name="www.nejm.org">{{Cite web | last = | first = | title = MMS: Error | url = http://www.nejm.org/doi/pdf/10.1056/NEJMcp1214869 | publisher = | date = | accessdate = }}</ref> | *Provide coverage for [[Streptococcus pneumoniae]] and atypical bacteria like ([[Mycoplasma]], [[Chlamydophila]], [[Legionella]] ).<ref name="www.nejm.org">{{Cite web | last = | first = | title = MMS: Error | url = http://www.nejm.org/doi/pdf/10.1056/NEJMcp1214869 | publisher = | date = | accessdate = }}</ref> | ||
*Consider acute and convalescent serologic testing to identify atypical pathogens like C.pneumoniae, Q fever and Hantavirus. | |||
*Perform aggressive fluid resuscitation, prompt antibiotic initiation, measure arterial blood gas in patients who have borderline [[hypoxemia]] or [[lactate]].<ref name="Rivers-2001">{{Cite journal | last1 = Rivers | first1 = E. | last2 = Nguyen | first2 = B. | last3 = Havstad | first3 = S. | last4 = Ressler | first4 = J. | last5 = Muzzin | first5 = A. | last6 = Knoblich | first6 = B. | last7 = Peterson | first7 = E. | last8 = Tomlanovich | first8 = M. | title = Early goal-directed therapy in the treatment of severe sepsis and septic shock. | journal = N Engl J Med | volume = 345 | issue = 19 | pages = 1368-77 | month = Nov | year = 2001 | doi = 10.1056/NEJMoa010307 | PMID = 11794169 }}</ref> | *Perform aggressive fluid resuscitation, prompt antibiotic initiation, measure arterial blood gas in patients who have borderline [[hypoxemia]] or [[lactate]].<ref name="Rivers-2001">{{Cite journal | last1 = Rivers | first1 = E. | last2 = Nguyen | first2 = B. | last3 = Havstad | first3 = S. | last4 = Ressler | first4 = J. | last5 = Muzzin | first5 = A. | last6 = Knoblich | first6 = B. | last7 = Peterson | first7 = E. | last8 = Tomlanovich | first8 = M. | title = Early goal-directed therapy in the treatment of severe sepsis and septic shock. | journal = N Engl J Med | volume = 345 | issue = 19 | pages = 1368-77 | month = Nov | year = 2001 | doi = 10.1056/NEJMoa010307 | PMID = 11794169 }}</ref> | ||
*Treat co-existing illness like [[asthma]] and [[COPD]] with [[bronchodilators]]. | *Treat co-existing illness like [[asthma]] and [[COPD]] with [[bronchodilators]]. | ||
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* Treat with antibiotics for atleast 5-7 days. | * Treat with antibiotics for atleast 5-7 days. | ||
* Narrow down antibiotic therapy as soon as a specific microbiological etiology is identified. | * Narrow down antibiotic therapy as soon as a specific microbiological etiology is identified. | ||
* Chest X-ray should be performed and checked for signs of consolidation, cavitation or interstitial infiltrates. | |||
* Use fibre-optic bronchoscopy in immunocompromised individuals to detect less common organisms, do a tissue biopsy and identify anatomic lesions if any. | |||
==Dont's== | ==Dont's== | ||
Revision as of 01:13, 21 February 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2]
Definition
A lower respiratory tract infection in a previously normal individual acquired through normal social contact rather than contracting it in a hospital.
Causes
Life Threatening Causes
No life threatening causes have been noted. However, complications of pneumonia could lead to life threatening situations like pleural effusion, lung abscess, bacteremia, septicemia or a secondary infection involving other organ systems.
Common Causes
- Typical Bacteria
- Streptococcus pneumoniae
- Haemophilus influenzae
- Escherichia coli
- Klebsiella pneumoniae
- Pseudomonas aeruginosa
- Atypical Bacteria
- Viruses
| Location | Etiologies of Community-Acquired Pneumonia[1][2][3] |
| ▸ Outpatient | ▸ Streptococcus pneumoniae |
| ▸ Mycoplasma pneumoniae | |
| ▸ Haemophilus influenzae | |
| ▸ Chlamydophila pneumoniae | |
| ▸ Influenza A and B, adenovirus, respiratory syncytial virus, parainfluenza | |
| ▸ Inpatient (non-ICU) | ▸ Streptococcus pneumoniae |
| ▸ Mycoplasma pneumoniae | |
| ▸ Chlamydophila pneumoniae | |
| ▸ Haemophilus influenzae | |
| ▸ Legionella | |
| ▸ Aspiration | |
| ▸ Influenza A and B, adenovirus, respiratory syncytial virus, parainfluenza | |
| ▸ Yersinia enterocolitica | |
| ▸ Inpatient (ICU) | ▸ Streptococcus pneumoniae |
| ▸ Staphylococcus aureus | |
| ▸ Legionella | |
| ▸ Gram-negative bacilli | |
| ▸ Haemophilus influenzae | |
| ▸ Acinetobacter baumannii |
Management
Please find below an algorithm that summarizes the approach to community acquired pneumonia.
Do's
- Obtain a sputum gram stain, sputum culture and blood cultures before initiating antibiotic therapy.
- Provide coverage for Streptococcus pneumoniae and atypical bacteria like (Mycoplasma, Chlamydophila, Legionella ).[4]
- Consider acute and convalescent serologic testing to identify atypical pathogens like C.pneumoniae, Q fever and Hantavirus.
- Perform aggressive fluid resuscitation, prompt antibiotic initiation, measure arterial blood gas in patients who have borderline hypoxemia or lactate.[5]
- Treat co-existing illness like asthma and COPD with bronchodilators.
- Start empirical therapy with coverage for Pseudomonas aeruginosa and MRSA if patient is hospitalized for more than 2 days.[6]
- Give high priority to patients with elevated blood urea nitrogen (BUN), confusion and high respiratory rate.[7]:
- First antibiotic dose should be administered within 6 hours of admission into the emergency room.[8]
- 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.[9]
- Treat with antibiotics for atleast 5-7 days.
- Narrow down antibiotic therapy as soon as a specific microbiological etiology is identified.
- Chest X-ray should be performed and checked for signs of consolidation, cavitation or interstitial infiltrates.
- Use fibre-optic bronchoscopy in immunocompromised individuals to detect less common organisms, do a tissue biopsy and identify anatomic lesions if any.
Dont's
- Use antibiotics judiciously. Inadvertently use of antibiotic for patients without community-acquired pneumonia who require treatment before 4 hours may increase the risk of Clostridium difficile colitis.[10]
- Dont discontinue antibiotics till the patient is afebrile for 48 to 72 hours and has signs of clinical improvement.
References
- ↑ 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. Unknown parameter
|month=ignored (help) - ↑ Wong, KK.; Fistek, M.; Watkins, RR. (2013). "Community-acquired pneumonia caused by Yersinia enterocolitica in an immunocompetent patient". J Med Microbiol. 62 (Pt 4): 650–1. doi:10.1099/jmm.0.053488-0. PMID 23242642. Unknown parameter
|month=ignored (help) - ↑ Oh, YJ.; Song, SH.; Baik, SH.; Lee, HH.; Han, IM.; Oh, DH. (2013). "A case of fulminant community-acquired Acinetobacter baumannii pneumonia in Korea". Korean J Intern Med. 28 (4): 486–90. doi:10.3904/kjim.2013.28.4.486. PMID 23864808. Unknown parameter
|month=ignored (help) - ↑ "MMS: Error".
- ↑ 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) - ↑ "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) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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)