Cebu Normal University GRADUATE SCHOOL Osmeňa Blvd., Cebu City PNEUMONIA John Louis S. Ricamora, AHSE, BSN, RN MSN 4006 – Advanced Psychopathology
Pneumonia - is an infection of the pulmonary tissue - can be community acquired or hospital acquired - caused by a virus, mycoplasmal agents, bacteria, or the aspiration of foreign substances.
Types of Pneumonia
Viral pneumonia Assessment: a. Mild fever, slight cough and malaise, to high fever, severe cough, and prostration b. Nonproductive or productive cough of small amounts of whitish sputum c. Wheezes or fine crackles
Interventions: a. Administer oxygen with cool mist as prescribed. b. Increase fluid intake. c. Administer antipyretics for fever as prescribed. d. Administer CPT as prescribed. e. Antimicrobial therapy is reserved for children in whom the presence of infection is demonstrated by cultures.
Primary atypical pneumonia ( Mycoplasma pneumoniae ) - most common cause of pneumonia in children between the ages of 5 and 12 years - more prevalent in crowded living conditions
Assessment: a. Fever, chills, anorexia, headache, malaise and muscle pain b. Rhinitis, sore throat, and dry, hacking cough c. Nonproductive cough initially; then production of seromucoid sputum that becomes mucopurulent or blood streaked Interventions: symptomatic
Bacterial pneumonia - hospitalization is indicated when pleural effusion or empyema accompanies the disease and is mandatory for children with staphylococcal pneumonia
Assessment: a. Acute onset, fever, toxic appearance b. Infant: irritability, lethargy, poor feeding, abrupt fever (may be accompanied by seizures); respiratory distress (air hunger, tachypnea, and circumoral cyanosis) c. Older child: headache, chills, abdominal pain, chest pain, meningeal symptoms (meningism)
d. Hacking, nonproductive cough e. Diminished breath sounds or scattered crackles f. As the infection resolves, coarse crackles and wheezing are heard and the cough becomes productive with purulent sputum.
Interventions: a. Antimicrobial therapy is initiated as soon as the diagnosis is suspected. b. Administer oxygen (via hood, mist tent, or nasal cannula) for respiratory distress as prescribed. c. Place the child in a mist tent as prescribed; cool humidification moistens the airways and assists in temperature reduction.
d. Suction mucus from the infant to maintain a patent airway if the infant is unable to handle secretions. e. Administer CPT q 4 hours as prescribed. f. Encourage the child to lie on the affected side (if pneumonia is unilateral) to splint the chest and reduce the discomfort caused by pleural rubbing.
g. Provide liberal fluid intake (administer cautiously to prevent aspiration); IV administered fluids may be necessary. h. Administer antipyretics for fever as prescribed; monitor temperature frequently because of the risk for febrile seizures. i. Institute isolation precautions with pneumococcal or staphylococcal pneumonia (according to agency policy).
j. Administer antitussives as prescribed. k. Continuous closed chest drainage may be instituted if purulent fluid is present. l. Promote bed rest to conserve energy. m. Fluid accumulation in the pleural cavity may be removed by thoracentesis; thoracentesis also provides a means of obtaining fluid for culture and for instilling antibiotics directly into the pleural cavity.
Organisms that cause pneumonia and their treatments
Streptococcus Pneumoniae - most common cause of a bacterial pneumonia there is usually an abrupt onset of the illness with shaking chills, fever, and production of a rust-colored sputum.
Pneumococcal Conjugate Vaccine (PCV7; Prevnar) - is part of the routine infant immunization schedule in the U.S. and is recommended for all children < 2 years of age and children 2-4 years of age who have certain medical conditions.
Pneumococcal Polysaccharide Vaccine (PPV23; Pneumovax) - is recommended for adults at increased risk for developing pneumococcal pneumonia including the elderly, people who have diabetes , chronic heart, lung, or kidney disease, those with alcoholism, cigarette smokers , and in those people who have had their spleen removed.
- Antibiotics often used in the treatment of this type of pneumonia include penicillin , amoxicillin and clavulanic acid (Augmentin, Augmentin XR), and macrolide antibiotics including erythromycin , azithromycin (Zithromax, Zmax), and clarithromycin (Biaxin).
Klebsiella pneumoniae and Hemophilus influenzae - are bacteria that often cause pneumonia in people suffering from chronic obstructive pulmonary disease (COPD) or alcoholism. - Useful antibiotics in this case are the second- and third-generation cephalosporins, amoxicillin and clavulanic acid, fluoroquinolones ( levofloxacin [Levaquin], moxifloxacin-oral [Avelox], gatifloxacin-oral [Tequin], and sulfamethoxazole and trimethoprim [Bactrim, Septra]).
Mycoplasma pneumoniae - is a type of bacteria that often causes a slowly developing infection. Symptoms include fever, chills, muscle aches, diarrhea , and rash . This bacterium is the principal cause of many pneumonias in the summer and fall months, and the condition often referred to as "atypical pneumonia." - Macrolides (erythromycin, clarithromycin, azithromycin, and fluoroquinolones) are antibiotics commonly prescribed to treat Mycoplasma pneumonia .
Legionella pneumoniae - most often found in contaminated water supplies and air conditioners. It is a potentially fatal infection if not accurately diagnosed. Pneumonia is part of the overall infection, and symptoms include high fever, a relatively slow heart rate, diarrhea, nausea, vomiting, and chest pain. Older men, smokers, and people whose immune systems are suppressed are at higher risk of developing Legionnaire's disease. - Fluoroquinolones are the treatment of choice in this infection. This infection is often diagnosed by a special urine test looking for specific antibodies to the specific organism.
Chlamydia pneumoniae - all cause a syndrome known as "atypical pneumonia." In this syndrome, the chest x-ray shows diffuse abnormalities, yet the patient does not appear severely ill. These infections are very difficult to distinguish clinically and often require laboratory evidence for confirmation.
Pneumocystis carinii - pneumonia is another form of pneumonia that usually involves both lungs. It is seen in patients with a compromised immune system, either from chemotherapy for cancer, HIV/AIDS, and those treated with TNF (tumor necrosis factor), such as for rheumatoid arthritis. - Once diagnosed, it usually responds well to sulfa-containing antibiotics. Steroids are often additionally used in more severe cases.
Viral pneumonias - do not typically respond to antibiotic treatment. These infections can be caused by adenoviruses, rhinovirus, influenza virus (flu), respiratory syncytial virus (RSV), and parainfluenza virus (that also causes croup). These pneumonias usually resolve over time with the body's immune system fighting off the infection. It is important to make sure that a bacterial pneumonia does not secondarily develop. If it does, then the bacterial pneumonia is treated with appropriate antibiotics. In some situations, antiviral therapy is helpful in treating these conditions.
Fungal infections - that can lead to pneumonia include histoplasmosis, coccidiomycosis, blastomycosis, aspergillosis, and cryptococcosis. These are responsible for a relatively small percentage of pneumonias in the United States. - Each fungus has specific antibiotic treatments, among which are amphotericin B, fluconazole (Diflucan), penicillin, and sulfonamides.
Guidelines on Pneumonia Empiric Therapy: (Usual Recommended Dosages of Antibiotics in Adults, 50-60 Kg Body Weight, with Normal Liver and Renal Function)
1. Low Risk CAP (Out-Patient) Common Organisms: 1. Strep. Pneumoniae, 2. H. influenzae, 3. M. pneumoniae, 4. C. pneumoniae, 5. M. catarrhalis; Mortality rate at 1-5% a. For previously healthy, choice of: Amoxicillin 500 mg cap TID PO (standard regimen) or Co-trimoxazole forte (Globaxol forte) tab BID PO or Macrolides like: - Roxithromycin (Macrol, Rulid) 150 mg tab BID PO x 7 days - Clarithromycin (Klaricid) 500 mg tab BID PO x 7 days - Azithromycin 500 mg tab OD x 3 days or 2 grams single dose
b. For those with stable co-morbid illness, choice of: Co-Amoxiclav (Amoclav, Augmentin) 375-625 mg tab TID PO or Cefuroxime (Zegen) 250-500 mg tab BID PO or Macrolides as above.
2. Moderate Risk CAP (In-Patient) Common Organisms: Above organisms plus: 1. Enteric gram-negative bacilli, 2. Anaerobic bacteria, 3. Legionella pneumophilia; Mortality rate 5-25% a. Choice of: Cefuroxime (Zegen, Zinacef) 750 mg q 8 hr IV Ampicillin-Sulbactam (Unasyn) 750 mg-1.5 gm q 8 hr IV Co-Amoxiclav (Amoclav, Augmentin) 600 mg-1.2 gm q 8 hr IV plus b. Azithromycin IV or c. New Fluoroquinolones Alone PO: (Cheaper option) Ex. Levofloxacin (Levox) 500 mg tab OD PO x 5-7 days
3. High Risk CAP (Intensive Care) Common Organisms: Above organisms plus: 1. Staphylococcus aureus, 2. Pseudomonas aeruginosa; Mortality rate at 50% a. Choice of: Ceftazidime 1-2 gm q 8 hr IV or Piperacillin-Tazobactam (Tazocin) 2.25 gm q 6-8 hr IV or Meropenem 500 mg q 8 hr IV or Cefepime 1-2 gm q 12 hr IV plus b. Azithromycin IV or Levofloxacin (Levox) 500 mg IV OD x 3 days then 500 mg tab PO x 4 days +/- c. For those with risk for Pseudomonas: Ciprofloxacin 200 mg q 12 hr IV x 3 days then 500 mg tab PO x 4 days or Amikacin 500 mg IV q 12 hr or Gentamicin IV
4. For Aspiration Pneumonia: a. Aspiration Pneumonia (community-acquired) Clindamycin 300-600 mg q 6-8 hr IV or Penicillin G 1-2 millions units q 4 hr IV b. Aspiration Pneumonia (nosocomial) Piperacillin-Tazobactam (Tazocin) 2.25 gm q 6-8 hr IV or Clindamycin 300-600 mg q 6-8 hr IV plus Tobramycin 80 mg q 8 hr IV
5. Treatment Based on Typical and Atypical Clinical Presentation: a. Typical Presentation: Fever, acute onset, pleuritic chest pain, lobar consolidation by x-ray, yellow copious phlegm, pleural effusion. Treatment: Beta-lactams (e.g. Co-amoxiclav) or Cephalosporins (e.g. Cefuroxime) b. Atypical Presentation: No fever, chronic, intersitial infiltrates by x-ray, scanty white phlegm Treatment: Macrolides (e.g. Clarithromycin)
6. Cheeper Antibiotic Options: a. For CAP Category I and Category II: Amoxicillin PO for Typical Pneumonia Roxithromycin PO for Atypical Pneumonia b. For CAP Category III: New Fluoroquinolones Alone PO Ex. Levofloxacin (Levox) 500 mg tab OD PO
Therapeutics: 1. Antibiotic regimen as listed above given for a maximumof 7-8 days only to minimize the emergence of resistance. 2. Berodual nebulization (10 gtts in 3 ml NSS) q 6 hours and prn
3. Switch Therapy: Intravenous antibiotic treatment may be shifted to oral antibiotics after 48-72 hours if the following parameters are fulfilled: (a) there is less cough and resolution of respiratory distress (normalization of respiratory rate), (b) the temperature is normalizing, (c) the etiology is not a high risk (virulent/resistant) pathogen, (d) there is no unstable co-morbid conditions or life-threatening complications, and (e) oral antibiotics are tolerated.
4. For abundant secretions, may give Acetylcysteine (Fluimucil) 100 mg or 200 mg sachet disolved in ½ glass H2O TID. Discontinue if patient has wheezing.
Integrated Management on Childhood Illness (IMCI)
How is pneumonia prevented? - Vaccines are available for the prevention of specific types of pneumonia. This is usually given to persons not less than 65 years old and children. Ask your doctor about it. - Maintain a healthy, clean lifestyle, eat a balanced diet, get enough rest, and exercise regularly to enhance your immune system. - Stop smoking! Smoking destroys the natural defense of the lungs and may lead to other lung diseases. - Avoid crowded places especially when your immune system is low (after an illness).