Community Acquired Pneumonia Moderate Risk

Causative Agents Of Cap

The bacterial aetiology of CAP is well established and dictates the choice of empirical antibiotic therapy. The most common causative agent is Streptococcus pneumoniae, which is responsible for almost 50% of cases other common causes are respiratory viruses and the atypical bacteria Chlamydophila pneumoniae and Mycoplasma pneumoniae. Less common bacterial causes are Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis and Legionella pneumophila. A significant number of patients with CAP have no microbial cause identified, even after extensive testing whether these cases are the result of a novel pathogen or of false negative tests for established pathogens remains unknown. Microorganisms causing CAP reach the lungs either by inhalation of droplets created by sneezing or coughing from an infected contact or environmental source , or by microaspiration after colonisation of the nasopharynx with a potential pathogen . The reasons for the dominance of S. pneumoniae as a cause of CAP compared with other common nasopharyngeal commensals are poorly understood, but if elucidated could help identify novel preventative strategies.

Criteria For Clinical Improvement

In our institution, patients are considered to reach clinical improvement at the point they reach clinical stability and are candidates for switch therapy. Then, the clinical outcome is considered as clinical improvement when these three criteria are met: cough and shortness of air are improving, the patient is afebrile for at least 8 hours, and the white blood cell count is normalizing. If criteria are met during the first 3 days of hospitalization, the outcome is classified as early clinical improvement. If criteria are met from days 4 to 7, the outcome is classified as late clinical improvement.

Data Abstraction And Analysis

We first abstracted the study characteristics, including the combination of signs, symptoms, or POC tests that were used to diagnose CAP. Articles were assessed for bias using the Quality Assessment Tool for Diagnostic Accuracy Studies framework adapted for our study. The evaluation consists of 4 areas: patient selection, index test, reference standard, and flow and timing. For each, a set of questions assess the article for bias, answering yes, no, high, low, or unknown. A final overall assessment for each article was given a low, moderate, or high risk for bias.

When available, true positive , false positive , true negative and false negative rates of each CDR were recorded. When not directly provided, they were calculated using data from the study. These data were used to calculate positive and negative likelihood ratios for CDRs reporting a dichotomous outcome of CAP versus no CAP, and stratum-specific likelihood ratios for CDRs reporting more than 2 possible outcomes . Post-test probabilities were calculated for standardized low-prevalence and high-prevalence populations, to represent typical outpatient primary care and emergency department populations respectively, using summary estimates of likelihood ratios for high-performing CDRs.,

Lastly, we calculated 3 risk groups as part of a post-hoc analysis of any CDR that was based on a multichotomous score., The risk groups were assigned based on the distribution of likelihood ratios from the studies published data.

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Timing Of Antibiotic Administration

Recent data in the management of CAP indicate that delay in the initiation of anti-infective therapy is associated with longer hospital stay and decreased patient outcome . Thus, it is suggested that hospitalized patients with CAP should have prompt initiation of empiric therapy.

A delay in administration of antibiotic may be secondary to a delay from a patient waiting to be seen by a physician after the patient arrived at the emergency room or a delay in the administration of antibiotics after the diagnosis of CAP was already performed.

Length Of Stay Related To Community

The most common scenario for hospitalized patients with community-acquired pneumonia is a rapid clinical improvement after initiation of appropriate empiric therapy. The great majority of these patients can be switched to oral therapy and discharged from the hospital to complete the course of therapy at home . Once a patient is switched to oral therapy, there is no need to maintain the patient in the hospital for a period of observation to evaluate the clinical response to oral therapy .

Because length of hospitalization is not influenced by any other factor outside of the pulmonary infection, patients are considered to have length of stay related only to pneumonia. In this type of patient, the length of hospital stay can be considered inappropriate if the switch to oral antibiotic was delayed more than 24 hours after the patient was considered a candidate for switch therapy or if the patient remains hospitalized for clinical observation in oral therapy.

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Characteristics Of The Studies

Twenty studies had a case-control design, 8 had a cohort design, and 1 had a cross-sectional design . The case-control and cross-sectional studies included 29,018 participants. The cohort studies were prospective in 6 cases and retrospective in 2, and overall they included more than 140,000 participants. The cohort studies were published between 1994 and 2015, with the longest follow-up being 16 years and 11 months. Most studies focused on elderly subjects 65 years of age or mixed populations where the participants’ age was > 14 years , and a few studies considered only the age range between 18 and 60 years. The definitions used for cases and controls, as well as exposed and nonexposed subjects, in each of the included studies are detailed in online supplementary Table 2.

Table 2

General characteristics of the 29 studies included in the systematic review of risk factors for CAP

Why Is Classification Important For The Treatment

Community-acquired pneumonia is usually caused by pneumococci, whereas nocosomial pneumonia is often connected with staphylococci, various intestinal , and special germs such as Pseudomonas aeruginosa. Some of those bacteria can be multi-resistant, meaning they are resistant to several . That is why different antibiotics are usually need than for treating community-acquired pneumonia.

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Evaluation Of Local Practice

Patients who warrant scrutiny for follow-up care includes those infected by more virulent microbes: Streptococcus pneumoniae, S. aureus, Legionellaspecies and those with underlying co-morbid or immunosuppressive illnesses ” rel=”nofollow”> Table 2). Relapse may be more likely so we encourage these high risk patients to call the physician at any sign of fever or return of symptoms.

Evaluation of final outcome requires a patient visit to a clinic or a telephone contact. In the clinical situation in which the patient does not return for a scheduled follow-up clinic visit and the patient cannot be contacted by telephone, the lack of documented final outcome is considered as a justified variance from recommended care.

The Importance Of Defining The Etiology Of Community

Defining the etiology of pneumonia may have significant implications for patient management. In patients who are clinically improving after initiation of broad-spectrum empiric therapy, knowing the etiology may allow streamlining the regimen with therapy directed to the identified pathogen. Antibiotic streamlining may prevent selection of resistant bacteria and decrease cost of therapy. In the hospitalized patient with pneumonia who suffers clinical deterioration after initial empiric therapy, defining the etiology of pneumonia may explain the reason for the deterioration, help in the selection of alternative therapy, and improve clinical outcome. Other potential benefits of defining the etiology of CAP include the appropriate isolation of patients infected with pathogens that can be transmitted to other patients or health care personnel .

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Proportion Of Patients Evaluated For Or Given Pneumococcal Vaccine

The proportion of patients evaluated for or given pneumococcal vaccine can be used as a quality indicator. For this indicator, the numerator is the total number of patients evaluated for or given pneumococcal vaccination, and the denominator is the total number of patients discharged with CAP. The goal is to improve quality by preventing a new episode of pneumococcal CAP.

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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Diagnosis And Management Of Community

RICHARD R. WATKINS, MD, MS, Akron General Medical Center, Akron, Ohio

TRACY L. LEMONOVICH, MD, University Hospitals Case Medical Center, Cleveland, Ohio

Am Fam Physician. 2011 Jun 1 83:1299-1306.

• References

Community-acquired pneumonia is a significant cause of morbidity and mortality in adults. CAP is defined as an infection of the lung parenchyma that is not acquired in a hospital, long-term care facility, or other recent contact with the health care system. Table 1 includes common etiologies of CAP.13 This article discusses the important studies and guidelines for CAP that have been published since the topic was last reviewed in American Family Physician.4

SORT: KEY RECOMMENDATIONS FOR PRACTICE

In patients with clinically suspected CAP, chest radiography should be obtained to confirm the diagnosis.

Pneumonia Severity Index :

• Class I is determined by absence of the following risk factors:

• Age > 50 or temperature > 40°C

• Diastolic blood pressure < 60 mmHg

• Elevated BUN > 20 mg/dL

These criteria are reliable, except in patients with underlying renal insufficiency and in the elderly. A multivariate analysis of 1,068 patients allowed for the development of the modified six-point CURB-65 score, which includes the same criteria as above plus the additional criteria of Age > 65 years. A score of at least 3 indicates ICU care. The CURB scoring system tends to be favored over the PSI method because it directly measures the severity of CAP vs. the risk of mortality.

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Criteria For Clinical Stability And Switch Therapy

The traditional approach to therapy of hospitalized patients with CAP has been the use of intravenous antibiotics during the entire recovery phase until the patient achieved definitive clinical improvement. At this point, usually after several days of hospitalization, the intravenous antibiotics were discontinued and the patient was discharged from the hospital.

With the switch therapy approach, one needs to identify the point of clinical stability during the recovery phase. At this point, when the patient is entering the period of initial clinical improvement, intravenous antibiotics are switched to oral antibiotics .

A patient can be considered to reach the point of clinical stability when these three criteria are met: cough and shortness of air are improving, the patient is afebrile for at least 8 hours, the white blood cell count is normalizing, A fourth criteria, adequate oral intake and gastrointestinal absorption, should be met for a patient to be considered a switch therapy candidate. As soon as a patient meets the four switch therapy criteria, intravenous antibiotics can be safely switched to oral antibiotics . Switch therapy can be safely performed even in patients with documented pneumococcal bacteremia at the time of hospital admission .

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Enhancing Healthcare Team Outcomes

Patients with community pneumonia may present to the primary care provider or the emergency department. Hence these professionals should be aware of the signs and symptoms. The health care team can improve outcomes. The team can include primary care, emergency department personnel, specialists, nurses, and pharmacists. If the diagnosis is not clear cut, then an infectious disease or pulmonology consult is recommended. Most patients do respond to outpatient antibiotic therapy for 5-7 days. Patients who are short of breath, febrile, and in respiratory distress need to be admitted. Some patients may present with a parapneumonic effusion, which may require drainage. Nurses monitor the patients and report current status and updates to the rest of the team. Pharmacists evaluate medication choice, check for allergies and interactions, and educate patients about side effects and the importance of compliance. The providers should encourage all patients to get the annual influenza vaccine. In addition, all adults 65 years and older and those considered at risk for pneumonia must receive the pneumococcal vaccination. The outcomes in most patients with community-acquired pneumonia are excellent.

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Indications For The Vaccine

• Adults aged 60 years or older

• Individuals between 2 and 59 years of age with chronic heart disease, chronic lung disease, sickle cell disease, diabetes, alcoholism, liver cirrhosis, cerebrospinal fluid fistulas, or cochlear implants

• Individuals between 2 and 59 years of age with an immunosuppressive disease or condition, such as Hodgkin disease, lymphoma, or leukemia kidney failure multiple myeloma nephrotic syndrome HIV infection or AIDS damaged spleen or no spleen, or organ transplant

• Individuals between 2 and 59 years of age who are receiving immunosuppressive drugs, such as long-term corticosteroids or drugs used to treat cancer, or who have undergone radiotherapy

• Adults between 19 and 59 years of age who smoke or have asthma

• Residents of nursing homes or long-term care facilities

Recommendations For Corticosteroid Use As Adjuvant Treatment In Cap

During an infectious course, an adequate balance between activation of the immune response and control of inflammation is key to fighting the infection without adjacent tissue injury. Activation of the hypothalamic-pituitary-adrenal axis is responsible for the production of cortisol, an endogenous corticosteroid, which, during an pneumonic course, induces the expression of anti-inflammatory proteins and the inhibition of pro-inflammatory molecules.101101 Rhen T, Cidlowski JA. Antiinflammatory action of glucocorticoids–new mechanisms for old drugs. N Engl J Med. 2005 353:1711-23. https://doi.org/10.1056/NEJMra050541

Table 2

In conclusion, corticosteroid use in severe CAP has proved to be both safe and beneficial in several important clinical outcomes. However, further studies are needed to confirm the impact of corticosteroid therapy on CAP-related mortality, although meta-analyses have suggested a reduction in this rate, especially in the subgroup of patients with a more severe presentation.

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Quality Improvement And Prevention

• References

The Centers for Medicare and Medicaid Services has developed a set of core measures for CAP that is collected for every hospital and reported on the Hospital Compare Web site . Adhering to national guidelines has been shown to improve length of hospital stay and other outcomes33,34 however, they do not take into account individual patient differences and should not supplant physician judgment. Pneumococcal vaccination is recommended for all persons 65 years and older, adults younger than 65 years who have chronic illness or asplenia, and all adults who smoke or have asthma.35 However, effectiveness may decrease with age, and studies evaluating its effectiveness against pneumonia without bacteremia have been mixed.3638 The influenza vaccine is also important for the prevention of CAP. However, its effectiveness is influenced by host factors and how closely the antigens in the vaccine are matched with the circulating influenza strain.12 The influenza vaccine has also been shown to effectively prevent pneumonia, hospitalization, and death in older persons.39

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Mild Moderate Or Severe Pneumonia

To be able to provide the right treatment, doctors also classify community-acquired pneumonia as mild, moderate or severe. They take the risk of complications into account as well.

Pneumonia is considered to be mild with no increased risk if the patient

• is younger than 65 years old,
• is conscious and lucid,
• has normal blood pressure and pulse,
• is not breathing too fast ,
• has enough oxygen in their blood,
• has not been given any in the past three months,
• has not been in the hospital in the past three months, and
• does not have any other severe medical conditions.

People with mild pneumonia can be treated at home and are given in tablet form.

The signs of moderate pneumonia include drowsiness and confusion, low blood pressure, worsening shortness of breath, and risk factors such as old age and underlying diseases. People with these symptoms need to have treatment at a hospital. Some will be given a combination of two different , at least at the beginning of the treatment.

Pneumonia is classified as severe when the heart, the kidneys or the circulatory system are at risk of failing, or if the lungs can no longer take in enough oxygen. Treatment with an antibiotic infusion in intensive care is then usually needed, sometimes with artificial respiration or additional drugs such as corticosteroids.

Pneumonia in children is only classified as either not severe or severe.

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