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Pneumonia
- 1. Pneumonia Done by : Raniya.Khaled @Rania1997301 Reference : IDSA/ATS Hospital-Acquired (HAP) and Ventilator-Associated (VAP) Pneumonia Clinical Practice Guidelines 2016 Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. doi:10.1164/rccm.201908-1581ST
- 2. Definition • Pneumonia is Inflammation of one or both lungs, with dense areas of lung inflammation. • Pneumonia is frequently but not always due to infection. • The infection may be bacterial, viral, fungal, or parasitic. Symptoms may include fever, chills, cough with sputum production, chest pain, and shortness of breath. • Pneumonia is suggested by the symptoms and confirmed by chest X-ray testing. Raniya.Khaled @Rania1997301
- 3. Causes of hospital-acquired pneumonia Common organisms 1. Gram-negative bacteria: Pseudomonas aeruginosa E. coli Klebsiella spp. 2. Gram-positive bacteria: S. pneumoniae S. aureus including MRSA Causes of community-acquired pneumonia Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus Klebsiella pneumoniae Legionella pneumophila Mycoplasma pneumoniae Chlamydophila pneumoniae Chlamydophila psittaci Coxiella burnetii Viruses : Several viruses can cause pneumonia in adults, including influenza, parainfluenza and varicella zoster viruses Common Organisms in Pneumonia Raniya.Khaled @Rania1997301
- 5. CURB 65 Score – Pneumonia Clinical Prediction Tool Component Measurement Points Confusion Altered mental status 1 Urea/BUN Urea >7 mmol/L or BUN >20 mg/dL 1 Respiratory Rate >30 breaths/min 1 Blood Pressure Systolic <90 or diastolic <60 mmHg 1 Age 65 or older 1 Total Score Mortality Disposition 0-1 <5% Can treat as outpatient 2-3 5-15% Consider hospitalization 4-5 15-30% Consider ICU Raniya.Khaled @Rania1997301
- 6. Type of Pneumonia Type of Pneumonia Community-acquired pneumonia (CAP) Hospital-acquired pneumonia (HAP) Ventilator-associated pneumonia (VAP) Definition Pneumonia developing outside the hospital or<48 hours after hospital admission Pneumonia developing >48 hours after hospital admission Pneumonia developing >48 hours after endotracheal intubation Risk Factors Age >65 years Diabetes mellitus Asplenia Chronic cardiovascular, pulmonary, renal, and/or liver disease Smoking and/or alcohol abuse Witnessed aspiration COPD, ARDS, or coma Administration of antacids, H, antagonists, or proton pump inhibitor Supine position Enteral nutrition, nasogastric tube Reintubation, tracheostomy, or patient transport Head trauma, ICP monitoring Age >60 years MOR risk (eg, MRSĄ, MDR Pseudomonas) if IV antibiotic use within 90 days As hospital acquired + MOR risk with IV antibiotics in past 90 days, septic shock, ARDS preceding VAP, acute renal replacement therapy preceding VAP or 5+ days of hospitalization preceding VAP Raniya.Khaled @Rania1997301
- 7. Initial Treatment Strategies for Inpatients with Community-acquired Pneumonia by Level of Severity and Risk for Drug Resistance 1- Standard Regimen Prior Respiratory Isolation of MRSA Prior Respiratory Isolation of Pseudomonas aeruginosa Recent Hospitalization and Parenteral Antibiotics and Recent Hospitalization and Parenteral Antibiotics and Locally Validated Risk Factors for P. aeruginosa Nonsevere inpatient pneumonia b-Lactam 1 macrolide (Ampicillin 1 sulbactam 1.5–3 g every 6 hours, cefotaxime 1–2 g every 8 hours, ceftriaxone 1–2 g daily, or ceftaroline 600 mg every 12 hours AND azithromycin 500 mg daily or clarithromycin 500 mg twice daily. or Respiratory fluroquinolone (Levofloxacin 750 mg daily or moxifloxacin 400 mg daily. Add MRSA coverage (vancomycin15 mg/kg every 12 h, adjust based on levels) or linezolid (600 mg every 12 h). and obtain cultures/nasal PCR to allow deescalation or confirmation of need for continued therapy Add coverage for P. aeruginosa Piperacillin-tazobactam (4.5 g every 6 h), cefepime (2 g every 8 h), ceftazidime (2 g every 8 h), imipenem (500 mg every 6 h), meropenem (1 g every 8 h), or aztreonam (2 g every 8 h). and obtain cultures to allow deescalation or confirmation of need for continued therapy Obtain cultures but withhold MRSA coverage unless culture results are positive. If rapid nasal PCR is available, withhold additional empiric therapy against MRSA if rapid testing is negative or add coverage if PCR is positive and obtain cultures Obtain cultures but initiate coverage for P. aeruginosa only if culture results are positive Raniya.Khaled @Rania1997301
- 8. Initial Treatment Strategies for Inpatients with Community-acquired Pneumonia by Level of Severity and Risk for Drug Resistance 2- Standard Regimen Prior Respiratory Isolation of MRSA Prior Respiratory Isolation of Pseudomonas aeruginosa Recent Hospitalization and Parenteral Antibiotics and Recent Hospitalization and Parenteral Antibiotics and Locally Validated Risk Factors for P. aeruginosa Severe inpatient pneumonia b-Lactam 1 macrolide or b-lactam + Fluroquinolone Add MRSA coverage and obtain cultures/nasal PCR to allow deescalation or confirmation of need for continued therapy Add coverage for P. aeruginosa and obtain cultures to allow deescalation or confirmation of need for continued therapy Add MRSA coverage and obtain nasal PCR and cultures to allow deescalation or confirmation of need for continued therapy Add coverage for P. aeruginosa and obtain cultures to allow deescalation or confirmation of need for continued therapy Raniya.Khaled @Rania1997301
- 9. Suggested Empiric Treatment Options for Clinically Suspected Ventilator-Associated Pneumonia in Units Where Empiric Methicillin-Resistant Staphylococcus aureus Coverage and Double Antipseudomonal/Gram-Negative Coverage Are Appropriate Gram-Positive Antibiotics With MRSA Activity Gram-Negative Antibiotics With Antipseudomonal Activity: à-Lactam–Based Agents Gram-Negative Antibiotics With Antipseudomonal Activity: Non-à- Lactam–Based Agents Glycopeptides Vancomycin 15 mg/kg IV q8–12h (consider a loading dose of 25– 30 mg/kg × 1 for severe illness) Antipseudomonal penicillins Piperacillin- tazobactam 4.5 g IV q6h Fluoroquinolones Ciprofloxacin 400 mg IV q8h Levofloxacin 750 mg IV q24h OR Cephalosporins: Cefepime 2 g IV q8h Ceftazidime 2 g IV q8h OR Aminoglycosides Amikacin 15–20 mg/kg IV q24h Gentamicin 5–7 mg/kg IV q24h Tobramycin 5–7 mg/kg IV q24h OR Oxazolidinones: Linezolid 600 mg IV q12h OR Carbapenems: Imipenem 500 mg IV q6h Meropenem 1 g IV q8h Polymyxins Colistin 5 mg/kg IV × 1 (loading dose) followed by 2.5 mg × (1.5 × CrCl + 30) IV q12h (maintenance dose Polymyxin B 2.5–3.0 mg/kg/d divided in 2 daily IV doses OR Monobactams: Aztreonam 2 g IV q8h Raniya.Khaled @Rania1997301
- 10. Recommended Initial Empiric Antibiotic Therapy for Hospital-Acquired Pneumonia (Non-Ventilator-Associated Pneumonia) Not at High Risk of Mortality and no Factors Increasing the Likelihood of MRSA Not at High Risk of Mortality but With Factors Increasing the Likelihood of MRSA High Risk of Mortality or Receipt of Intravenous Antibiotics During the Prior 90 One of the following: Piperacillin-tazobactam 4.5 g IV q6h OR Cefepime 2 g IV q8h OR Levofloxacin 750 mg IV daily Imipenem 500 mg IV q6h Meropenem 1 g IV q8h One of the following: Piperacillin-tazobactam 4.5 g IV q6h OR Cefepime or ceftazidime 2 g IV q8h OR Levofloxacin 750 mg IV daily Ciprofloxacin 400 mg IV q8h OR Imipenem 500 mg IV q6h Meropenem 1 g IV q8h OR Aztreonam 2 g IV q8h Plus Vancomycin 15 mg/kg IV q8–12h with goal to target 15–20 mg/mL trough level (consider a loading dose of 25–30 mg/kg × 1 for severe illness) OR Linezolid 600 mg IV q12h Two of the following, avoid 2 à-lactams Piperacillin-tazobactam 4.5 g IV q6h OR Cefepime or ceftazidime 2 g IV q8h OR Levofloxacin 750 mg IV daily Ciprofloxacin 400 mg IV q8h OR Imipenem 500 mg IV q6h Meropenem 1 g IV q8h OR Amikacin 15–20 mg/kg IV daily Gentamicin 5–7 mg/kg IV daily Tobramycin 5–7 mg/kg IV daily OR Aztreonam 2 g IV q8h Plus: Vancomycin 15 mg/kg IV q8–12h with goal to target 15–20 mg/mL trough level (consider a loading dose of 25–30 mg/kg IV × 1 for severe illness) OR Linezolid 600 mg IV q12h Raniya.Khaled @Rania1997301
- 11. Recommended Initial Empiric Antibiotic Therapy for Hospital-Acquired Pneumonia (Non-Ventilator-Associated Pneumonia) Not at High Risk of Mortality and no Factors Increasing the Likelihood of MRSA Not at High Risk of Mortality but With Factors Increasing the Likelihood of MRSA High Risk of Mortality or Receipt of Intravenous Antibiotics During the Prior 90 One of the following: Piperacillin-tazobactam 4.5 g IV q6h OR Cefepime 2 g IV q8h OR Levofloxacin 750 mg IV daily Imipenem 500 mg IV q6h Meropenem 1 g IV q8h One of the following: Piperacillin-tazobactam 4.5 g IV q6h OR Cefepime or ceftazidime 2 g IV q8h OR Levofloxacin 750 mg IV daily Ciprofloxacin 400 mg IV q8h OR Imipenem 500 mg IV q6h Meropenem 1 g IV q8h OR Aztreonam 2 g IV q8h Plus Vancomycin 15 mg/kg IV q8–12h with goal to target 15–20 mg/mL trough level (consider a loading dose of 25–30 mg/kg × 1 for severe illness) OR Linezolid 600 mg IV q12h Two of the following, avoid 2 à-lactams Piperacillin-tazobactam 4.5 g IV q6h OR Cefepime or ceftazidime 2 g IV q8h OR Levofloxacin 750 mg IV daily Ciprofloxacin 400 mg IV q8h OR Imipenem 500 mg IV q6h Meropenem 1 g IV q8h OR Amikacin 15–20 mg/kg IV daily Gentamicin 5–7 mg/kg IV daily Tobramycin 5–7 mg/kg IV daily OR Aztreonam 2 g IV q8h Plus: Vancomycin 15 mg/kg IV q8–12h with goal to target 15–20 mg/mL trough level (consider a loading dose of 25–30 mg/kg IV × 1 for severe illness) OR Linezolid 600 mg IV q12h