Antibiotics For Pneumonia In Adults

Can Pneumonia Be Prevented

Immunisation against the pneumococcus and having the annual flu virus immunisation are advised if you are at greater risk of developing these infections.

See the separate leaflets called Pneumococcal Immunisation and Influenza Immunisation for further details.

Cigarette smoke damages the lining of the airways and makes the lungs more prone to infection. So stopping smoking will lessen your risk of developing lung infections.

Can The Aetiology Of Cap Be Predicted From Clinical Features

There have been a large number of publications looking at the possibility of predicting the aetiological agent from the clinical features at presentation however, while certain symptoms and signs are more common with specific pathogens, none allow accurate differentiation. This led to a suggestion that the term âatypicalâ pneumonia be abandoned. As explained in Section 1.3.2, the term âatypical pathogensâ remains useful and there is evidence that pleuritic pain is less likely in pneumonia secondary to these agents.

Summary

• The likely aetiological agent causing CAP cannot be accurately predicted from clinical features.

• The term âatypicalâ pneumonia should be abandoned as it incorrectly implies that there is a characteristic clinical presentation for patients with infection caused by âatypicalâ pathogens.

Antibiotics For Community Acquired Pneumonia In Adult Outpatients

Cochrane Database of Systematic Reviews 2009 October 7, : CD002109

BACKGROUND: Community-acquired pneumonia , the sixth most common cause of death worldwide, is a common condition representing a significant disease burden for the community, particularly in the elderly. Antibiotics are helpful in treating CAP and are the standard treatment. CAP contributes significantly to antibiotic use, which is associated with the development of bacterial resistance and side-effects. Several studies have been published concerning treatment for CAP. Available data arises mainly hospitalized patients studies. This is an update of our 2004 Cochrane Review.

OBJECTIVES: To summarize current evidence from randomized controlled trials concerning the efficacy of different antibiotic treatments for CAP in participants older than 12.

SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials which contains the Cochrane Acute Respiratory Infections Group’s Specialized Register MEDLINE , and EMBASE .

SELECTION CRITERIA: RCTs in which one or more antibiotics were tested for the treatment of CAP in ambulatory adolescents or adults. Studies testing one or more antibiotics and reporting the diagnostic criteria as well as the clinical outcomes achieved, were considered for inclusion.

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Severity Assessment Of Cap In Patients Seen In Hospital

The severity assessment of CAP in patients seen in hospital is shown in .

Recommendations

• For all patients, the CURB65 score should be interpreted in conjunction with clinical judgement.

• Patients who have a CURB65 score of 3 or more are at high risk of death. These patients should be reviewed by a senior physician at the earliest opportunity to refine disease severity assessment and should usually be managed as having high severity pneumonia. Patients with CURB65 scores of 4 and 5 should be assessed with specific consideration to the need for transfer to a critical care unit .

• Patients who have a CURB65 score of 2 are at moderate risk of death. They should be considered for short-stay inpatient treatment or hospital-supervised outpatient treatment.

• Patients who have a CURB65 score of 0 or 1 are at low risk of death. These patients may be suitable for treatment at home.

• When deciding on home treatment, the patientâs social circumstances and wishes must be taken into account in all instances.

Antibiotic Route Of Administration

• Intravenous antibiotics switching to oral antibiotics after 2 to 4 days if there was clinical improvement was not significantly different to continuous intravenous antibiotics for mortality, treatment success or recurrence of infection in adults with moderate to high severity community-acquired pneumonia. However, there were significantly fewer days in hospital and adverse events with the switch to oral antibiotics .

• Oral antibiotics were not significantly different to intravenous or intermuscular penicillins for clinical failure rate in children and young people with non-severe community-acquired pneumonia .

• Oral antibiotics were significantly better than intravenous or intramuscular penicillins for mortality , in children and young people with severe community-acquired pneumonia. However, there were no significant differences in the rates of cure, clinical failure, hospitalisation or relapse, including when oral amoxicillin was analysed separately .

Committee discussions on antibiotic route of administration

In line with the NICE guideline on antimicrobial stewardship and Public Health England’s Start smart then focus, the committee agreed that if intravenous antibiotics are used initially, this should be reviewed by 48 hours and switched to oral treatment where possible.

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D Studies Of Prognosis Prognostic Index

â¡ Was a defined sample of patients assembled at an early stage of the disease?

â¡ Were patients followed up long enough for the outcome to develop?

â¡ Was the outcome clearly defined, objective and assessed blind to exposure in all cases?

â¡ Was the performance of any prognostic index tested on a fresh set of cases?

Antibiotic Resistance Of Respiratory Pathogens

The rate of increase in resistance among respiratory pathogens has tended to level off in recent years.

Resistance to penicillin , erythromycin and tetracycline among selected Streptococcus pneumoniae isolates from laboratories reporting to the Public Health Laboratory Service.

Beta-lactamase production among H influenzae varies geographically but ranges from 2% to 17% in various parts of the UK. Data from the BSAC surveillance programme in the UK and Ireland 1999/2000 to 2006/7 suggest that β-lactamase production in H influenzae has been relatively stable at around 15% over the study period. However, this is an uncommon cause of pneumonia and, unless local data suggest otherwise, there is insufficient justification to include a β-lactamase resistant antibiotic regimen in initial empirical therapy of low or moderate severity CAP. M catarrhalis is an even rarer cause of CAP, for which the same argument applies.

S aureus is widely resistant to penicillin, and an increasing number are now methicillin-resistant . When occurring in the community within the UK, this generally reflects hospitalisation within the recent past or residence within a nursing home. Hence, β-lactamase unstable penicillins and, in the case of MRSA, isoxazolyl penicillins and cephalosporins are inappropriate for such infections.

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Types Of Antibiotics For Pneumonia

Pneumonia is a respiratory infection that affects the lower part of the respiratory system, primarily the lungs or the bronchi.

The bronchi are the air passages that connect the lungs to the windpipe.

Because pneumonia causes the air sacs in your lungs fill with pus and fluid, pneumonia can make it harder to take in oxygen and expel carbon dioxide.

Pneumonia is typically caused by a virus or bacterial infection.

Sometimes fungal infections can lead to pneumonia, but that is rarer, and typically occurs in people with weak immune systems due to other diseases.

Viral pneumonia will often resolve on its own, though it still frequently requires medical care for supportive treatment.

Sometimes pneumonia occurs during or after another viral illness, like the flu or a cold.

If your pneumonia is caused by a virus, antibiotics wont help unless there is also a secondary bacterial infection.

If you have bacterial pneumonia, you will need antibiotics to prevent complications and to help your body clear the infection.

Even with antibiotics, it can still take 4-6 weeks to recover from bacterial pneumonia.

Most bacterial pneumonia that is community-acquired comes from the bacteriaStreptococcus pneumoniae.

There are several different antibiotics are effective at treating this bacterial infection.

What Severity Assessment Strategy Is Recommended For Cap

We have been keen to recommend one severity assessment strategy that is applicable to adults of all ages, simple to remember and practical to implement both in the community and in hospital.

With these principles in mind, the CURB65 score in conjunction with clinical judgement is recommended as the initial severity assessment strategy in hospitals for CAP. The evidence base for the CURB65 score is robust and continues to increase, adding to the strength of the current recommendation. The simplified CRB65 score which only relies on clinical factors in conjunction with clinical judgement is recommended as the severity assessment strategy in community or primary care settings for CAP.

Summary of the CURB65 score

• Confusion: New mental confusion, defined as an Abbreviated Mental Test score of 8 or less.

• Urea: Raised > 7 mmol/l .

• Respiratory rate: Raised ⩾30/min.

• Recognition of two persons

• Recall address

• Date of First World War

• Name of monarchs

• Count backwards 20 â 1

A score of 8 or less has been used to define mental confusion in the CURB65 severity score.

6.4.1 Clinical judgement

Clinical judgement is essential when deciding on the management of all patients with CAP, particularly in the following three areas with regard to severity assessment:

Recommendations

• Clinical judgement is essential in disease severity assessment.

• The stability of any comorbid illness and a patientâs social circumstances should be considered when assessing disease severity.

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Causative Bacteria Of Community

Most antibiotic treatments for pneumonia depend on the empirical method. Since the distribution of causative bacteria and antibiotic resistance vary between countries, it is necessary to develop an appropriate antibiotic treatment guideline based on domestic epidemiological data . This guideline summarizes domestic research findings on the causative bacteria of community-acquired pneumonia affecting Korean adults, and the current level of antibiotic resistance in Korea.

When To Contact A Medical Professional

• Cough that brings up bloody or rust-colored mucus
• Breathing symptoms that get worse
• Chest pain that gets worse when you cough or breathe in
• Fast or painful breathing
• Night sweats or unexplained weight loss
• Shortness of breath, shaking chills, or persistent fevers
• Signs of pneumonia and a weak immune system
• Worsening of symptoms after initial improvement

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Why Is Severity Assessment Important

CAP presents to physicians both in primary and secondary care as a wide spectrum of illness from mild and self-limiting to life-threatening and occasionally fatal disease. This breadth of illness severity is reflected in the variable mortality rates reported by studies of CAP in different clinical settings.

The decision regarding the most appropriate site of care, including whether hospitalisation of a patient with CAP is warranted, is the first and single most important decision in the overall management of CAP. It has consequences both on the level of treatment received by the patient as well as the overall costs of treatment. This decision is best informed by an accurate assessment of the severity of illness at presentation and the likely prognosis. The recognition of patients at low risk of complicationsâand therefore suitable for treatment out of hospitalâhas the potential to reduce inappropriate hospitalisation and consequently inherent morbidity and costs.

When hospital admission is required, further management is also influenced by illness severity. This includes the extent of microbiological investigation, the choice of initial empirical antimicrobial agents, route of administration, duration of treatment and level of nursing and medical care. Early identification of patients at high risk of death allows initiation of appropriate antibiotic therapy and admission to an intensive care setting where assisted ventilation can be readily initiated if necessary.

Specific Clinical Features Of Particular Respiratory Pathogens

Clinical features associated with specific pathogens are described below and summarised in box 1.

Box 1 Some clinical features reported to be more common with specific pathogens

• Streptococcus pneumoniae: increasing age, comorbidity, acute onset, high fever and pleuritic chest pain.

• Bacteraemic S pneumoniae: female sex, excess alcohol, diabetes mellitus, chronic obstructive pulmonary disease, dry cough.

• Legionella pneumophila: younger patients, smokers, absence of comorbidity, diarrhoea, neurological symptoms, more severe infection and evidence of multisystem involvement .

• Mycoplasma pneumoniae: younger patients, prior antibiotics, less multisystem involvement.

• Chlamydophila pneumoniae: longer duration of symptoms before hospital admission, headache.

• Coxiella burnetii: males, dry cough, high fever.

Streptococcuspneumoniae

One study using discriminant function analysis found pneumococcal aetiology to be more likely in the presence of cardiovascular comorbidity, an acute onset, pleuritic chest pain and less likely if patients had a cough or flu-like symptoms or had received an antibiotic before admission.

Bacteraemic pneumococcal pneumonia was found to be more likely in those patients who had at least one of the following features: female, history of no cough or a non-productive cough, history of excess alcohol, diabetes mellitus or COPD.

Legionellapneumophila

Mycoplasmapneumoniae

Chlamydophilapneumoniae

Coxiellaburnetii

Klebsiellapneumoniae

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Legionella Mycoplasma Chlamydophila Pcr

1) Legionella PCR

Whereas the Legionella urinary antigen test can only diagnose the L. pneumophila serogroup 1, PCR can diagnose all serogroups, and thus has higher sensitivity for Legionella diagnosis. In a recent systematic review, the sensitivity of the Legionella PCR test using respiratory organ samples was 97.4%, and its specificity was 98.6% . Legionella PCR may be performed using nasopharyngeal samples or nasal swabs when no sputum is secreted even in the induced sputum analysis, but this testing method has a lower diagnosis rate compared with when sputum samples are used .

2) Mycoplasma PCR

Various serological tests have been traditionally used to diagnose Mycoplasma. These tests may fail to detect antibodies in the early period after infection , and IgM antibody reactions may not occur in adults aged 40 years or older . Mycoplasma PCR, which uses various respiratory organ samples has higher sensitivity, has higher sensitivity than serological tests , and has similar sensitivity to that of Legionella PCR . Just as Legionella PCR, Mycoplasma PCR has a lower diagnosis rate with nasopharyngeal samples than with sputum samples .

3) Chlamydophila PCR

Questions To Ask Your Doctor

• I have a chronic condition. Am I at higher risk for pneumonia?
• Do I have bacterial, viral, or fungal pneumonia? Whats the best treatment?
• Am I contagious?
• How serious is my pneumonia? Will I need to be hospitalized?
• What can I do at home to help relieve my symptoms?
• What are the possible complications of pneumonia? How will I know if Im developing complications?
• What should I do if my symptoms dont respond to treatment or get worse?
• Do we need to schedule a follow-up exam?
• Do I need any vaccines?

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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.

Summary Of The Evidence

This is a summary of the evidence. For full details, see the evidence review.

• Communityacquired pneumonia is a lower respiratory tract infection that is most commonly caused by bacterial infection .

• The main bacterial pathogen is Streptococcus pneumoniae , however Mycoplasma pneumoniae occurs in outbreaks approximately every 4 years in the UK and is much more common in school-aged children .

• Although bacterial infection is the most common cause of community-acquired pneumonia, viral infection causes approximately 13% of cases in adults and approximately 66% of cases in children and young people .

• Low-severity, community-acquired pneumonia in adults includes people with pneumonia severity index score of I or II, CRB65 score 0 or CURB65 score 0 or 1. Moderate- to high-severity, community-acquired pneumonia in adults includes people with PSI score of III to V, CRB65 score 1 to 4 or CURB65 score 2 to 5.

• The severity of infection was not always clearly defined in the studies, and was often based on clinical judgement. The management setting was used to indicate the severity of symptoms when this was not described in the studies .

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What General Management Strategy Should Be Offered To Patients Treated In The Community

Patients with CAP may present with fever, cough, sputum production or pleuritic pain and usually have localised signs on chest examination. They should be advised to rest and avoid smoking and, especially when febrile, be encouraged to drink plenty of fluids. It is important to relieve pleuritic pain using simple analgesia such as paracetamol or non-steroidal anti-inflammatory drugs. Physiotherapy is of no proven benefit in acute pneumonia. Nutritional status appears important both to the outcome and the risk of acquiring pneumonia and, in prolonged illness, nutritional supplements may be helpful. Patients with pneumonia are often catabolic and those aged > 55 years who are malnourished appear to be at greater risk of developing pneumonia.

Patients who fall outside the low severity criteria for CAP should be assessed for the need for hospital referral . Social factors will also play an important part in the decision to refer a patient to hospital. Patients with moderate or high severity pneumonia should be admitted to hospital and managed, where possible, with input from a physician with an interest in respiratory medicine.

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