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Clinical Presentation of Pneumonia: S/Sx
- • Abrupt onset of fever, chills, dyspnea, and productive cough
- • Rust-colored sputum or hemoptysis, pleuritic CP
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Clinical Presentation of Pneumonia: S/Sx (Respiratory)
- • Dyspnea
- • Cough
- • Fever
- • Sputum production
- • Chills
- • Pleuritic chest pain
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Clinical Presentation of Pneumonia: S/Sx (Hemodynamic)
- • Hypotension
- • Shock
- • Tachycardia
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Clinical Presentation of Pneumonia: S/Sx (Extratoracic)
- • Otitis, pharyngitis
- • Skin alteration
- • Hemolytic anemia
- • Headache
- • GI symptoms
- • Confusion
- • Hyponatremia
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Clinical Presentation of Pneumonia: Physical Examination
- • Tachypnea and tachycardia
- • Dullness to percussion
- • Increased tactile fremitus, whisper pectoriloquy, and egophony
- • Chest wall retractions and grunting respirations
- • Diminished breath sound over affected area
- • Inspiratory crackles during lung expansion
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Clinical Presentation of Pneumonia: Chest Radiography
• Dense lobar or segmental infiltrate
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Clinical Presentation of Pneumonia: Labs
- • Leukocytosis with predominance of PMNs
- • Low oxygen saturation on arterial blood gas or pulse oximetry
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Other Diagnostic Tests
- • Tests for etiology
- → Blood cultures, sputum culture, Legionella urinary antigen, Pneumococcal urinary antigen
- • CRP
- → If less than 20 mg/L without convincing diagnosis may not need antibiotics for CAP
- • PCT
- → If <0.1 mcg/L antibiotics discouraged
- → If >0.25 mcg/L antibiotics encouraged
- → If >0.5 mcg/L antibiotics strongly encouraged
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CAP
- • Definition
- → Pneumonia developing in patients with no contact to a medical facility
- • Symptoms
- → Sudden onset of fever, chills, pleuritic chest pain, ±productive cough, dyspnea
- • Radiographic examination
- → Lobar or subsegmental infiltrate
- • No risk factors for HCAP
- • Occurs as an outpatient or < 48 hours after admission or incubating at time of admission
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CURB-65 in CAP
- • Confusion (based on specific mental test or disorientation to person, place, or time)
- • Uremia: BUN level >20 mg/dL
- • Respiratory rate ≥30 breaths/min
- • Low Blood pressure (systolic <90 mm="" hg="" or="" diastolic="" 60="" br="">• Age ≥65
- • 0-1: Outpatient
- • 2: Outpatient or inpatient
- • 3: Inpatient
- • 4-5: Inpatient ( ICU)
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CAP ICU Admission Criteria
- • ≥ 3 minor criteria
- → Respiratory rate ≥30 breaths/min
- → PaO2/FiO2 ratio ≤250
- → Multilobar infiltrates
- → Confusion/disorientation
- → Uremia (BUN level ≥20 mg/dL)
- → Leukopenia (WBC count <4000 cells/mm3)
- → Thrombocytopenia (platelet count <100,000 cells/mm3)
- → Hypothermia (core temperature <36◦C)
- → Hypotension requiring aggressive fluid resuscitation
- • ≥ 1 major criteria
- → Invasive mechanical ventilation
- → Septic shock with the need for vasopressors
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CAP Usual Micoorganisms
- “Should Have put A CAP on My Childs Lungs”
- • Streptococcus pneumoniae
- • Haemophilus influenzae
- • Atypicals
- → Mycoplasma pneumoniae
- → Chlamydophila pneumoniae
- → Legionella pneumophila (Freshwater exposure/environments, serious pneumonia, need for hospitalization)
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Outpatient CAP Microorganisms
- • Streptococcus pneumoniae
- • Mycoplasma pneumoniae
- • Haemophilus influenzae
- • Chlamydophila pneumoniae
- • Respiratory viruses
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Inpatient (non-ICU) CAP Microorganisms
- • Streptococcus pneumoniae
- • Mycoplasma pneumoniae
- • Haemophilus influenzae
- • Chlamydophila pneumoniae
- • Legionella species
- • Aspiration
- • Respiratory viruses
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Inpatient (ICU) CAP Microorganisms
- • Streptococcus pneumoniae
- • Staphylococcus aureus
- • Legionella species
- • Gram-negative bacilli
- • Haemophilus influenza
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CAP Drug-resistant S. pneumoniae (DRSP) Risk Factors
- • Age <2 years or >65 years
- • Antibiotic therapy within the previous 3 months
- • Alcoholism
- • Medical comorbidities
- • Immunosuppressive illness or therapy
- • Exposure to a child in a day care center
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CAP Drug-resistant Community Acquire-MRSA Risk Factors
- • End stage renal disease
- • IV drug abuse
- • Prior influenza
- • Prior antibiotic therapy
- • Carries the gene for the Panton-Valentine leukocidin (PVL) toxin,
- → Clinical presentation of cavitary lung lesion
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CAP Drug-resistant Pseudomonas aeruginosa Risk Factors
- • Cystic fibrosis
- • COPD
- • Bronchiectasis
- • Not common in CAP
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CAP Outpatient Treatment (No Risk Factors for DSRP)
- • Duration: Minimum of 5 days. Most patients treated for 7-10 days or longer
- • Macrolide
- → Azithromycin 500 mg (Day 1), 250 mg Daily (Days 2-5)
- • Doxycycline 100 mg BID
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CAP Outpatient Treatment (Comorbidities and/or No Risk Factors for DSRP)
- • Duration: Minimum of 5 days. Most patients treated for 7-10 days or longer
- • Levofloxacin 750 mg IV/PO Daily
- • Moxifloxacin 400 mg IV/PO Daily
- • β-lactam PLUS a macrolide (or doxycycline)
- → Amoxicillin-clavulanate 2g PO BID (preferred)
- → High-dose amoxicillin 1g PO TID
- → Cefpodoxime 200 mg PO BID
- → Cefuroxime 500 mg PO BID
- → Ceftriaxone 1g IV Daily
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CAP Atypical Coverage
- • M. pneumo, C. pneumo, Legionella
- → Macrolides
- → Fluoroquinolones
- → Tetracyclines
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CAP Inpatient Treatment (Moderately-Severe)
- • Levofloxacin 750 mg IV/PO Daily
- • Moxifloxacin 400 mg IV/PO Daily
- • β-lactam PLUS a macrolide (or doxycycline)
- → Ceftriaxone 1-2 g IV Daily
- → Ampicillin 1-2 g IV Q4-6H
- → Azithromycin 500 mg (Day 1), 250 mg Daily (Days 2-5)
- → Azithromycin 500 mg IV x3 days
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CAP Inpatient Treatment (Severe requiring ICU admission)
- • β-lactam PLUS respiratory FQ or macrolide
- → β-lactam: ampicillin-sulbactam 1.5-3g IV q6h or ceftriaxone 1-2g IV daily
- → FQ: moxifloxacin 400 mg IV daily or levofloxacin 750 mg IV daily
- → Macrolide: azithromycin 500mg IV
- • May need to broaden coverage if suspecting P. aeruginosa or MRSA (Ex. CA-MRSA)
- → Vancomycin or clindamycin
- → Ceftaroline (newer agent)
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CAP Tx Duration
- • Longer duration may be necessary with the following
- → Initial therapy was not active against the identified pathogen
- → Complicated by an extrapulmonary infection
- → Bacteremic S. aureus pneumonia
- → Presence of cavities or other signs of tissue necrosis
- → Infected with less common pathogens (e.g., Burkholderia pseudomallei or endemic fungi)
- → Pseudomonas aeruginosa pneumonia
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Healthcare-Associated Pneumonia (HCAP)
- • Hospitalized for ≥ 2 days within 90 days of infection
- • Resided in nursing home or long-term care facility
- • Received recent IV antibiotic therapy, chemotherapy, or wound care within 30 days of infection
- • Chronic dialysis within 30 days
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Hospital-Acquired Pneumonia (HAP)
Occurs ≥ 48 hours after admission, not incubating at time of admission
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Ventilator-Associated Pneumonia (VAP)
Arises > 48 to 72 hours after endotracheal intubation
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Nosocomial Pneumonia Most Common Microorganisms
- • S. aureus
- • P. aeruginosa
- • Klebsiella
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Nosocomial Pneumonia: Early Onset HAP, Not at Risk of MDR Microorganisms
- • MSSA
- • H. influenza
- • Strep pneumo
- • Enterobacter
- • E. coli
- • Klebsiella
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Nosocomial Pneumonia: Early Onset HAP, at Risk of MDR Microorganisms
- • MSSA
- • H. influenza
- • Strep pneumo
- • Enterobacter
- • E. coli
- • Klebsiella
- • Serratia
- • Proteus
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Nosocomial Pneumonia: Late Onset HAP Microorganisms
- • MRSA
- • P. aeruginosa
- • Actinobacter baumannii
- • Enterobacteriaceae expressing ESBL and AmpC E-lactamases, conferring resistance to PCNs and cephalosporins
- • Polymicrobial
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Nosocomial Pneumonia: Risk Factors for MDR Pathogens
- • Current hospitalization ≥ 5 days
- • Antimicrobial therapy in preceding 90 days
- • High frequency of antibiotic resistance in the community or in the specific hospital unit
- • Presence of risk factors for HCAP
- → Hospitalization for 2 days or more in the preceding 90 days
- → Residence in a nursing home or extended care facility
- → Home infusion therapy (including antibiotics)
- → Chronic dialysis within 30 days
- → Home wound care
- → Family member with MDR pathogen
- • Immunosuppressive disease and/or therapy
- • Additional development and validation of prediction scores based on more refined risk factors still need
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Nosocomial Pneumonia: Early Onset and No Risk for MDR Pathogens
- • Duration: 14-21 days
- • Ceftriaxone 1 g IV Daily
- • Fluoroquinolones
- → Levofloxacin 750 mg IV daily
- → Moxifloxacin 400 mg IV daily
- • Ampicillin/sulbactam 3 g IV q6h
- • Ertapenem 1 g IV daily (reserve for select patients)
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Nosocomial Pneumonia: Late Onset or if P. aeruginosa
- • Duration: may require longer than 14-21 days
- • Antipneumococcal, antipseudomonal β-lactam
- → Piperacillin-tazobactam 4.5 g IV q6h (extended infusion)
- → Cefepime 1-2 g IV q8-12h
- → Ceftazidime 2 g IV q 8h
- → Imipenem 500 mg IV q6h or 1 g IV q8h
- → Meropenem 1 g IV q8h
- → OR if PCN-allergic: substitute aztreonam for above β-lactam
- • PLUS
- → Ciprofloxacin or levofloxacin
- → OR an aminoglycoside + azithromycin
- → OR an aminoglycoside + respiratory fluoroquinolone
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Nosocomial Pneumonia: Late onset or if MRSA
- • Same as Late Onset or if P. aeruginosa PLUS
- • Add vancomycin (goal trough 15-20) or linezolid 600 mg IV q12h
- → Alternative: telavancin (newer agent for HAP/VAP)
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Aspiration Pneumonia
- • May occur due to aspiration of colonized gastric contents into the lower respiratory tract
- • Risk factors: decreased consciousness, impaired swallowing, NG tube/ET tube/tracheotomy, periodontal disease, elevated gastric pH
- • Tx: Beta-lactam/beta-lactamase inhibitor combinations, carbapenems, clindamycin
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