Pneumonia in adults, Community Acquired, (Inpatient)

Clinic A/P, adults, Hospital A/P, Adults

Inpatient Management of Community-Acquired Pneumonia (CAP) in adults

Diagnosis
H&P:
Dx: Hypoxemic Respiratory distress likely 2/2 CAP in the context of possible COPD
CURB-65 score and Pneumonia Severity Index (PSI) score:
-Admit to telemetry
-Reviewed respiratory hx
-Reviewed CXR, VS
-Reviewed CBC, CMP
-CBC and BMP in the AM
-f/u on sputum culture, sputum gram stain,  and blood culture
-Repeat lactic acid as needed.
-Consider Procalcitonin
-Consider ABG
-Consider PFTs to evaluate for COPD
Treatment
-Ceftriaxone and Azithromycin [or Levofloxacin if pt allergic to PCN)
-Oxygen if saturation < 90 %
–Steroids (AAFP 2016 recs)
-IVF as needed.
-DuoNebs as needed
-Prevention: Vaccination with PCV-13 followed 12 months later by PCV-23 of patients 65 and older. Also, flu if in flu season. Tobacco Cessation.

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  • Steroids Beneficial As Adjunctive Treatment for Community-Acquired Pneumonia. Am Fam Physician. 2016 Feb 1;93(3):227. See here.

“Clinical presentation: Acute onset fever/chills, cough, sputum production, dyspnea, and sometimes pleuritic chest pain. Maybe producing blood-tinged sputum that appears rust colored, a classic sign of PNA due to S. pneumoniae.
Extrapulmonary s/sx: N/V/D, abdominal pain, headache, confusion, arthralgia, myalgias, and change in mental status. PE: Rales or rhonchi. Labs: Leukocytosis with a left shift (i.e. increased band forms), pulmonary s/sx. CXR: A new infiltrate seen on CXR.”

Other Abx for CAP in a hospitalized patient:  (3rd-gen Ceph. + Macrolide) or respiratory fluoroquinolone or (3rd-gen Ceph. + Doxycycline)

Discharge Meds
Mdulli recommends discharging patient treated for CAP with Ceftriaxone and Azithromycin for two days in hospital home on either Levofloxacin or Moxifloxacin (but not cipro b/c of resistance to strep). In peds, kids treated with ceftriaxone are sent home with cefdinir, a po cephalosporin. Mdulli thought that sending someone home on Cefdinir and azithromycin would be acceptable, but that’s two drugs instead of one and you have to consider compliance issues.

Immunocompromised Patients
** Dr. Mdulli, ID expert told me that “Even if a patient is immunosuppressed, the most common cause of CAP is still the same, strep pneumonia. As such the tx is same, Ceftriaxone and Azithromycin.” The only time you change is if the patient doesn’t have what fits the definition of CAP. I’d asked him because some Imed attendings thought I should have put an HIV patient on with CAP on Vanc (MRSA), Zosyn, and Azithromycin or some other bigger guns.
**Ceftriaxone and azithromycin = broad coverage for CAP. Empiric coverage is based on the SOURCE of the infection. You don’t need to use Vanc unless you suspect MRSA.

Severe community-acquired pneumonia

“The criteria for severe community-acquired pneumonia are divided into minor criteria and major criteria. Minor criteria include a respiratory rate ≥30 breaths/min, a PaO2/FiO2 ratio ≥250, multilobar infiltrates, confusion/disorientation, uremia (BUN level ≥20 mg/dL), leukopenia (WBC count <4000/mm3), thrombocytopenia (platelet count <100,000/mm3), hypothermia (core temperature <36°C), and hypotension requiring aggressive fluid resuscitation. Major criteria include invasive mechanical ventilation and septic shock requiring the use of vasopressors.

The CURB-65 score can also be used for rating the severity of pneumonia. This score is practical and can be used at the bedside. The other objective score is the Pneumonia Severity Index (PSI), which is more complex to calculate. CURB-65 stands for Confusion (based on a specific mental test or disorientation to person, place, or time), Uremia (BUN level >7 mmol/L or 20 mg/dL), Respiratory rate ≥30 breaths/min, low Blood pressure (systolic <90 mm Hg or diastolic ≤60 mm Hg), and age ≥65 years. One point is assigned for each criterion that the patient meets.

Guidelines recommend urine testing for Legionella antigen. Infection with β-lactam–resistant Streptococcus pneumoniae should be considered in a patient exposed to a child attending daycare. Monotherapy with a fluoroquinolone is inadequate because of the possibility of drug-resistant streptococcal pneumonia.”

Reference

http://www.aafp.org/afp/2011/0601/p1299.html

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