Catherine Casey S. Jones,

Transcription

1 Community Acquired Pneumonia Catherine Casey S. Jones, PhD, RN, ANP-C, AE-C Catherine Casey S. Jones, PhD, RN, ANP-C, AE-C Texas Pulmonary & Critical Care Consultants, PA & Adjunct Professor at Texas Woman s University in Dallas Disclosures No financial relationship with any pharmaceutical manufacturer or medical device company 1

2 Objectives Compare the different types of pneumonia according to the patient s current location or residence and risk factors. Assess the patient s susceptibility for hospitalization using CURB-65. Recommend appropriate therapy for individuals with community acquired pneumonia. Types of Pneumonia Community acquired pneumonia (CAP) Hospital acquired (nosocomial) pneumonia (HAP) occurs 48 hours or more after admission Ventilator acquired (VAP) more than hours after endotracheal intubation Types of Pneumonia Healthcare-associated - (HCAP) - Nursing homes Dialysis centers Outpatient clinics Within 90 days of discharge from acute or chronic care facility Recent IV antibiotic therapy, chemotherapy or wound care within the past 30 days Aspiration pneumonitis & pneumonia 2

3 Prevalence million in U.S. hospitalized with pneumonia Average length of stay days Nursing home 33,700 residents with pneumonia or 2.3 % in 2004 More than 50,000 deaths in 2010 CDC How do we defend against pneumonia? Nose Coughing & sneezing reflexes Mucus Blanket Cilia (mucociliary escalator) Macrophages Leukocytes Etiology Most pneumonias are caused by microaspiration or inhalation of bacteria or viruses into the lung. Usually the body s defenses will prevent infection, but at times of low resistance pathogenic organisms may overwhelm the usual protective mechanisms. Commonly days after an upper respiratory infection (URI). 3

4 Who is at risk for developing pneumonia? Elderly Dormitory or Barrack Conditions Hospitalized Exposure to Smoke and Chemicals Genetics Drug & Alcohol Users Chronic Lung Conditions Compromised Immunity Asthmatics Newborns Risk Factors Continued Age Stroke Neuromuscular disease Sedatives & Alcohol Poor Nutrition Prior Infections Anatomic Changes Tumor Granulocytopenia Community Acquired Pneumonia Microbial diagnosis made in only 7.6 % of cases in 2009 Bacterial > Viral 4

5 CAP: Definition CAP occurs outside the hospital or within 24 hours of admission to a hospital or LTC facility. By definition, the person must NOT have been in a LTC facility within 90 days prior to onset of symptoms Common Bacterium Streptococcus pneumoniae (65%) Mycoplasma pneumoniae historically children & adolescents increasing high rates in adults especially elderly adults Chlamydophilia pneumoniae (previously named Chlamydia) (0-20%) Legionella (2-9%) classically contaminated water sources in hospitals & hotels resistant to all beta-lactams Common Bacterium Haemophilus influenzae Neisseria meningitidis Moraxella catarrhalis Klebsiella pneumoniae Staphylococcus aureus - infrequent pulmonary pathogen watch for patients with recent influenza (MRSA only 2 % of infections were pneumonia) 5

6 Common Viruses Influenza virus Respiratory syncytial virus (RSV) Adenovirus Parainfluenza virus Human metapneumovirus Middle East respiratory syndrome coronavirus patients from Saudi Arabia or other Middle East countries Etiology of Viral Pneumonias Most common causative organisms are Respiratory Syncytial Virus (RSV), influenza, parainfluenza, adenoviruses, measles, and chicken pox. Symptoms usually milder than bacterial pneumonia. Initially fever, dry cough, headache, muscle pain and weakness. In hours dyspnea occurs, fever increases, and cough produces a scant sputum. Viral Pneumonia An acute infection of the pulmonary parenchyma with viral origin Perhaps accounts for half of all pneumonia cases. Symptoms subside in 2-5 days. 6

7 Examples of Exposure-Specific Infections Chlamydia psittaci (psittacosis) Coxiella burnetii (Q Fever) Francisella tularensis (Tularemia) Endemic Fungi (blastomyces, coccidioides, histoplasma) Sin Nombre virus (hantavirus pulmonary syndrome) Yersinia pestis (pneumonic plague) Pleural Effusion If a pleural effusion is evident on the chest x-ray, the patient should be referred for evaluation promptly Failure to recognize an early empyema may mean therapy involves thoracotomy rather than simpler procedures such as thoracentesis or chest tube placement Clinical Pearl The chest x-ray should normalize in 8 weeks in normals, 12 weeks in those with underlying lung disease (COPD) You must show resolution of the pneumonia on chest x-ray in this time frame If the pneumonia does not resolve on chest x-ray, refer to specialist 7

8 Symptoms of Community-Acquired Pneumonia Fever (80 %) Cough Mucopurulent bacterial Scant/watery - atypical Dyspnea Pleuritic Chest Pain (30 %) Hypoxia Tachypnea (45-70 %) Tachycardia Chills (40-50 %) Sweats &/or Rigors (15 %) Crackles &/or Rhonchi Hemoptysis Fatigue Myalgias GI symptoms (nausea, vomiting, diarrhea) Mental status changes Typical Presentation TYPICAL PNEUMONIA: Sudden onset of fever Cough productive of purulent sputum Chest pain Shaking chills Headache Dullness with bronchial signs of lung consolidation Typical Pneumonia Localized X-ray findings Leukocytosis 15,000 30,000 per mm 3 Bacterial 8

9 Atypical Pneumonia Gradual onset Dry cough Headache Myalgia Fatigue Sore throat Nausea, vomiting Diarrhea Physical findings minimal Leukocyte count <15,000 Examples: Viral Mycoplasma pneumoniae Chlamydophila pneumoniae Elderly Ø Elderly patients may have fewer symptoms than younger patients or no symptoms at all Ø If an elderly person has a minor cough and weakness for 1 day, they need to be evaluated Ø Some exhibit only confusion, lethargy, and general disorientation Elderly Presentation Mental status change Falls Incontinence Failure to thrive Metabolic changes Fever - frequently absent 9

10 Subjective Data Recent URI Cough: ranges from hacking, non-productive (mycoplasma, viral) to productive with rusty or yellow sputum (bacterial) Fever, chills Myalgia, pleuritic pain, dyspnea Malaise, headache, loss of appetite Nausea, vomiting Occasional sore throat Objective Data Physical exam may be normal in early stages Increased temperature, pulse Nasal flaring, tachypnea Lungs: dullness to percussion and auscultation over site of consolidation, diffuse crackles and wheezes, rhonchi Physical Examination Auscultation Crackles or rhonchi Bronchial breath sounds Consolidation Percussion Palpation Feel Tactile Fremitus Signs of consolidation: Bronchophony Exaggerated vocal resonance over consolidated area Egophony (E to A) Whispered pectoriloquy Increased resonance 10

11 Diagnosis & Initial Assessment of CAP Chest X-Ray gold standard not helpful with identifying pathogen Screening pulse oximetry Routine diagnostic testing is optional Initial assessment of severity Differential Diagnosis Chronic pulmonary disease: asthma, COPD, chronic bronchitis Atelectasis Damage from physical agents: near drowning, smoke inhalation CHF Neoplasms Lung abscess Tuberculosis Pulmonary embolism Severity of Illness Scoring CURB-65 Confusion of new onset Urea greater than 7 mmol/l (19 mg/dl)* Respiratory rate of 30 breaths/minute Blood pressure < 90 mmhg systolic or diastolic 60 mm Hg 65 or older * May omit if unavailable in office setting 11

12 CURB-65 Scoring 0 to 1 treat as out-patient 2 short hospital 3 to 5 hospital with probable ICU admission Severity of Illness Scoring Pneumonia Severity Index (PSI) Need more laboratory values More complicated Calculator Risk classes I - V Categorizing Severity to Assess for Hospitalization Need (PSI) Class I Class II Class III Class IV Class V Low Risk Low Risk Low Risk Mod. Risk High Risk Outpatient Outpatient Inpatient brief Inpatient Inpatient 12

13 Outpatient Versus Hospitalization Cost of inpatient versus outpatient management is up to 25 times greater! Outpatients resume normal activity sooner. 80 % prefer outpatient therapy. Hospitalization increases thromboembolic events & superinfection by more-virulent or resistant hospital bacteria. Criteria for Hospitalization ~ 10 % of hospitalized patients with CAP requires ICU admission One of most important determinants for ICU care is presence of chronic comorbid conditions 1/3 of patients with severe CAP were previously healthy Antibiotics of Choice: Outpatient Therapy Previously healthy & no risk factors for drugresistant S. pneumoniae infection: Macrolide (azithromycin, clarithromycin or erythromycin) Doxycycline Comorbidities or use of antimicrobials within previous 3 months: Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin 750 mg) Β-lactam PLUS a macrolide (high-dose amoxicillin or amoxicillin-clavulanate) Alternatives ceftriaxone, cefpodoxime & cefuroxime, doxycycline 13

14 Antibiotic Choice in the Elderly Use macrolide for those 65 and older Proven to increase survival Antibiotic Stewardship Avoid use of respiratory quinolones if not indicated. Save quinolones for patients who really need these medications! No new antibiotics in the near future. Limit duration of therapy to recommended time periods. Probiotics probably help limit development of C. diff, decreasing use of subsequent antibiotics Ancillary Therapies Increased fluids, good nutrition Expectorants (marginal utility) Cough suppressants with care, usually just at bedtime Analgesics, acetaminophen for high fever If likely diagnosis influenza pneumonia, consider Tamiflu Tobacco cessation 14

15 Prevention Good Lifestyle Habits Hygiene Diet Low Stress Influenza Vaccine Pneumococcal Vaccine Prevention Continued - Influenza Vaccine 70% - 100% effective in healthy adults 30% - 60% effective in the elderly & children with a poor match, but is effective for flu complications (pneumonia, CVA, MI, all cause mortality) Vaccinated adults have lower hospitalization rates and death Prevention Continued - Influenza Vaccine Annual vaccination in ~ October all persons age 6 months and older Contraindicated with significant egg allergy - hives Killed, inactivated - IM injection Live attenuated intranasal only for < 50 who are healthy 15

16 Prevention Continued Pneumovax Vaccine PPSV23: Those 65 and older Chronic comorbidities All cigarette smokers Asthmatics Booster - one after age 65 PCV13: Immunocompromised or children Now approved for adults Hospitalization Diagnosis for Hospitalized Patients Chest X-Ray gold standard WBC (leukocytosis or leukopenia) Blood Cultures Sputum Gram stain & Culture Urine Antigens for Legionella & pneumococcus CT scan (rarely) PPD (R/O TB) 16

17 Diagnosis for Hospitalized Patients Procalcitonin peptide precursor of calcitonin released by parenchymal cells in response to bacterial toxins elevated serum levels with bacterial infections <0.1 mcg/l = too low to treat with antibiotics >0.25 mcg/l = treat with antibiotics Distinguish between bacterial versus viral pneumonia Reduce antibacterial use Predict survival Hospital Management (Class III-V) Antibiotic treatment is based on the organism identified Anywhere from days Start IV then switch to PO Clinical stability: Temp <100 Pulse <100 Resp <24 SBP >90 Pulse Oximeter 90 % Ability to maintain oral intake Normal mental status References Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. ATS/IDSA Guidelines. (2005). American Journal of Respiratory & Critical Care Medicine, vol 171, Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the management of community-acquired pneumonia in adults. (2007). Clinical Infectious Diseases. 44, S

18 References Rello, J. & Chastre, J. (2013). Update in pulmonary infections American Journal of Respiratory & Critical Care Medicine. Vol. 187, Thank you! 18