Pneumonia
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This document provides information about pneumonia, including epidemiology, common causes, diagnosis, treatment, and prevention. It notes that pneumonia affects over 3 million people annually in the US, with higher rates in winter and among males and those over 65. Diagnosis involves clinical assessment of symptoms and signs, with chest x-ray and testing to confirm. Treatment depends on location of acquisition and risk factors, starting with broad-spectrum antibiotics and later targeting likely pathogens. Prevention focuses on vaccination, especially for influenza and pneumococcus, and reducing risk factors like smoking.
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Pneumonia
- 6. Epidemiology More than 3 million cases occur annually in US Pneumonia is most relevant in winter months Incidence of Pneumonia is greater in Males than in females Total number of deaths due to pneumonia has been higher in females since 1980s Individuals 65 years and older : Pneumonia and Influenza were 6th leading death in 2005 Close to 90% of deaths due to pneumonia and influenza occur in this age group Adjusted death rates for females: 17.9 deaths per 100,000 population 23.9 deaths per 100,000 population for males
- 17. CAP HAP/VAP S. Pneumonia M.Pneumonia H. Influenza C. Pneumonia Legionella RSV P. Aeruginosa K. Pneumonia E.Coli S. Marcescens
- 19. Diagnosis ● CAP vs. HCAP – Community Acquired Pneumonia ● Pneumonia in a patient without extensive healthcare contact.
- 20. Diagnosis ● CAP vs. HCAP – Healthcare Associated Pneumonia ● Associated with a higher risk of multidrug resistant bacteria. ● Pneumonia in a patient with extensive healthcare contact – IV Drug/Chemo therapy within last 30 days – Attendance at hospital/hemodialysis clinic within last 30 days – Hospitaliztion for >2 days within last 90 days – Residence in long term care facility
- 21. Diagnosis ● Common Clinical Symptoms – Cough – Pleuritic Chest Pain – Dyspnea – GI Upset ● Common Clinical Signs – Fever – Tachychardia – Crackles in lungs – Sputum Production – AMS Even combined, Signs and Symptoms have a sensitivity of <50%
- 22. Diagnosis Gold Standard CXR with presence of infiltrate
- 23. Diagnosis
- 24. Diagnosis ● Largely a clinical diagnosis ● Testing – Outpatient: Optional – Hospitalized: CBC (Leukocytes), Blood cultures, Sputum Gram Strain – Refractory: Legionella UAT, Pneumococcal UAT
- 25. Diagnosis ● Indications for Hospitalization/ICU – CURB-65 ● Confusion ● Urea (BUN > 20mg/dL) ● Respiratory Rate > 30bpm ● BP Systolic <90; Diastolic <60 ● Age >65 – Score >2 – Hospitalization – Score >3 – Consider ICU
- 26. Treatment ● Empiric Treatment should be started on ALL clinically suspected cases. – Early diagnosis and treatment significantly reduced Mortality and Length of Stay ● Antimicrobial choice based on: – Most likely pathogens – Clinical data – Risk Factors for resistance – Comorbidities
- 27. CAP Treatment ● Empiric Outpatient – Previously healthy patient 1.Macrolides (A.C.E) OR 2.Doxycycline – Comorbidities, DM, Alcoholism, Immunosuppression, Prior ABx use 1.Fluoroquinolones (-floxacins, [Levaquin]) OR 2.Beta-lactam(Amoxicillin/Ceftriaxone) AND Macrolides ● Consider Antipseudomonal for COPD
- 28. CAP Treatment ● Empiric Inpatient – Non-ICU 1.Respiratory Fluoroquinolones OR 2.Antipseudomonal Beta-Lactam AND Macrolide – Ceftriaxone, Cefotaxime; A.C.E. – ICU ● Antipseudomonal B-Lactam AND Azithromycin ● Antipseudomonal B-Lactam AND Fluoroquinolone ● Fluoroquinolone AND Azetreonam – MRSA ● Add Vancomycin OR Linezolid
- 29. CAP Treatment ● Empiric Inpatient – Discharge appropriate when: ● Stable from pneumonia ● Tolerates PO meds ● No active medical conditions ● Safe environment for discharge – There is no need for overnight observations when switching from IV to PO meds.
- 30. HAP/VAP Treatment ● Empiric Inpatient – One of the following (Gram Positive coverage): ● Antipseudomonal Cephalosporin: Cefepime, etc. ● Antipseudomonal Cabepenem: Imipenem, etc. ● Pipercillin-Tazobactam ● Penicillin Allergies – Mild: Simple Graded Challenge – Severe: Azetreonam
- 31. HAP/VAP Treatment ● Empiric Inpatient – PLUS One of the following (B-lactam resistant Gram Negative coverage): ● Antipseudomonal Fluoroquinolone: Ciprofloxacin ● Aminoglycoside: Gentamycin – PLUS One of the following (MRSA coverage): ● Linezolid ● Vancomycin ● Telavacin
- 32. HAP/VAP Treatment ● Targeted Treatment – MSSA: Naficillin, Oxacillin – Legionella: Fluoroquinolone – Anerobes (Aspiration): Clindamycin, Carbapenem
- 33. Prevention ● Risk Factor Reduction – Smoking Cessation – Vaccination ● Influenza – Yearly, all patients ● Pneumococcal – Once, Age <65, w/ indications ● Asplenia, Immunocomp., Smoker, Alcoholism, Cochlear Implants, DM, etc – Once/Again, Age >65, w/o indication
- 34. END