Pneumonia 2.0 Flashcards
Community-Acquired Pneumonia – Outpatient Empiric Treatment
Mild & Moderate
see slide 42
Community-Acquired Pneumonia - Hospitalized Empiric Treatment
Non-severe (Moderate)
see slide 43
Community-Acquired Pneumonia - Hospitalized Empiric Treatment
Severe / ICU
what ar eMRSA risk factorsÉ
see slide 44
Macrolides - Immunomodulation
Please check slide 45 for correctness of this flash card, thanks.
Macrolides suppress production of inflammatory cytokines and expression of adhesion molecules
• Many, but not all, retrospective studies have shown
addition of a macrolide to a β -lactam results in
reduced morbidity and mortality in pneumococcal or
all-cause CAP
- presumably due to inhibiting inflammatory response
• No randomized trials
• Concerns - Small increase in sudden cardiac deaths
with azithromycin (NEJM 2012 366:1881-90)
(but clarithromycin and erythromycin not included in
study)
Please check slide 45 for correctness of this flash card, thanks.
Monitoring
temp = 37.8 HR = 100 RR = 24 SPH >/= 90 O2 sat >/= 90% or pO2 >/= 60mmHg ability to maintian oral intake normal mental status
Follow-up
• Patients should begin to respond to therapy within 24 -
48 hr
• Outpatients – monitor temperature, shortness of
breath
• Follow-up chest x-ray recommended at 6 weeks in
some patients
radiographic changes can lag behind clinical changes
Follow-up
X-ray pictures
see slide 48
Follow-up
Follow-up X-ray recommended at 6 weeks - controversial ?
- Extensive/necrotizing pneumonia
- Smoker*
- Alcoholism
- COPD
- > 5% weight loss in past month
- > 50 years old*
Patient Information re: CAP Rate of Improvement
May vary with severity of pneumonia. Most people can expect that by:
• 1 week – fever should be resolved
• 4 weeks – chest pain and sputum should be
substantially reduced
• 6 weeks – cough and breathlessness should be
reduced
• 3 months – most symptoms should be resolved, but
fatigue may be present
• 6 months – most people should feel back to normal
Nursing Home-Acquired Pneumonia (NHAP)
Diagnosis
• Diagnosis can be more difficult
• If no X-ray available:
Tachypnea most notable clinical factor
• RR ≥ 25 increased morbidity and mortality
• RR ≥ 40 transfer to hospital
• Plus 2 or more of the following:
- Fever ≥ 37.8 o C or > 1.1 o C higher than baseline
- New productive cough (unproductive uncommon)
- Pleuritic chest pain
- Crackles, wheezes
- New onset delirium
- Dyspnea
- Tachycardia
- New or worsening hypoxemia
- O 2 therapy if O 2 Saturation ≤ 90%
Nursing Home-Acquired Pneumonia (NHAP)
Empiric Therapy should cover ?
Empiric Therapy should cover: • S. pneumoniae • H. influenzae • S. aureus • Enterobacterales • C. pneumoniae
Essentially treated as for CAP (with comorbidities)
Hospital-Aquired Pneumonia (HAP)
Pathogens & Empiric Treatment
Late Onset HAP (> 4 days in hospital) – non-ICU
see slide 55
If early onset (≤ 4 days hospitalized) treat as Community-Acquired hospitalized Pneumonia
Hospital-Aquired Pneumonia (HAP)
Pathogens & Empiric Treatment
Late Onset HAP with Risk Factors
what are the risk factors?
what if its MRSA suspectedÉ
see slide 56
If early onset (≤ 4 days hospitalized) treat as Community-Acquired hospitalized Pneumonia
Late Onset HAP (> 4 days in hospital) - prior broad spectrum
antibiotics(< 90 days), structural lung disease, immunosuppressed
MRSA: vacomycin or linezolid
Ventilator-Associated Pneumonia (VAP)
Pathogens & Empiric Treatment
see slide 58
Ventilator-Associated Pneumonia (VAP)
Prevention
Prevention: • Elevate head of bed 30-45º • Mouth care with chlorhexidine • Remove NG, ET tubes asap • Continuous sub-glottic suctioning • Limit stress ulcer prophylaxis • Hand hygiene of health care workers
