MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA - SITE OF CARE.pdf

This presentation primarily discusses about the site of care for a pateint with community acquired pneumonia.

Also included are the duration of therapy , complications that can arise and follow up.

1. MANAGEMENT OF
COMMUNITY ACQUIRED
PNEUMONIA
Based on

ATS IDSA 2019 Guidelines
&
Harrison’s Principles of Internal Medicine 21st edition

2. Where to treat a patient with CAP ?

-As OP / IP ?

-If as IP , in ICU or NON ICU ?
The cost of inpatient management exceeds that of outpatient treatment by a
factor of 20, and hospitalization accounts for most CAP-related
expenditures. Thus the decision to hospitalize a patient with CAP has
considerable implications, and late admission to the ICU is associated
with increased mortality risk.

3. ATS / IDSA 2019 Clinical Practice Guidelines

Should a Clinical Prediction Rule for Prognosis plus Clinical Judgment
versus Clinical Judgment Alone Be Used to Determine Inpatient versus
Outpatient Treatment Location for Adults with CAP ?

4. Tools that objectively assess the risk of adverse outcomes,
including severe illness and death, can minimize unnecessary
hospital admissions.
Although a number of prediction rules exist, the two most
frequently used are the Pneumonia Severity Index (PSI), a
prognostic model used to identify patients at low risk of
dying, and the CURB-65 criteria, a severity-of-illness score.

5. ATS / IDSA 2019 Clinical Practice Guidelines

In addition to clinical judgement, we recommend that clinicians use a
validated clinical prediction rule for prognosis, preferentially the
Pneumonia Severity Index (PSI) over the CURB-65 (tool based on
confusion, urea level, respiratory rate, blood pressure, and age >65) to
determine the need for hospitalization in adults diagnosed with CAP.

8. The prediction rule assigns points based on age and the presence of coexisting disease,
abnormal physical findings (such as a respiratory rate of >30 per minute or a
temperature of >40°C), and abnormal laboratory findings (such as a pH <7.35, a blood
urea nitrogen concentration >30 mg per deciliter [11 mmol per liter] or a sodium
concentration <130 mmol per liter) at presentation.
PNEUMONIA SEVERITY INDEX

9. There are 20 questions in
pneumonia severity index

10. On the basis of the resulting score, patients are assigned to one
of five classes with the following mortality rates :
class 1, 0.1%;
class 2, 0.6%;
class 3, 2.8%;
class 4, 8.2%; and
class 5, 29.2%.

11. PORT - Patient Outcomes Research Team

12. Clinical severity is not the only consideration in
determining the need for hospital admission .

Some patients have medical and/or psychosocial
contraindications to outpatient therapy, such as inability to
maintain oral intake, history of substance abuse, cognitive
impairment, severe comorbid illnesses, and impaired functional
status.

13. Problems with PSI
The PSI may underestimate illness severity among younger patients and
oversimplify how clinicians interpret continuous variables (e.g., all systolic blood
pressures ,90 mm Hg are considered abnormal, regardless of the patient’s
baseline and actual measurement). Therefore, when used as a decision aid, the
PSI should be used in conjunction with clinical judgment.

Determination of the PSI is often impractical in a busy emergency-department
setting because of the number of variables.
The PSI and CURB-65 were not designed to help select the level of care
needed by a patient who is hospitalized for CAP.

15. ATS / IDSA 2019 Clinical Practice Guidelines

Should a Clinical Prediction Rule for Prognosis plus Clinical
Judgment versus Clinical Judgment Alone Be Used to Determine
Inpatient General Medical versus Higher Levels of Inpatient
Treatment Intensity (ICU, StepDown, or Telemetry Unit) for Adults
with CAP?

16. We recommend direct admission to an ICU for patients with
hypotension requiring vasopressors or respiratory failure requiring
mechanical ventilation.
For patients not requiring vasopressors or mechanical ventilator support,
we suggest using the IDSA/ATS 2007 minor severity criteria together
with clinical judgment to guide the need for higher levels of treatment
intensity.

17. The 2007 IDSA/ATS CAP
guidelines recommended a set of
two major and nine minor criteria
to define severe pneumonia
requiring ICU admission.

All elements are routinely
available in emergency
department settings and are
electronically calculable.

18. IRVS - Intensive Respiratory or Vasopressor Support

20. The eight SMART-COP criteria and the nine 2007
IDSA/ATS minor criteria have five overlapping elements:
hypoxia, confusion, respiratory rate, multilobar radiographic
opacities, and low systolic blood pressure.

21. Summary :
In an adult patient with CAP ,
●Use either PSI or CURB 65 to determine the site of care
( OP or IP )
●The ATS IDSA guidelines recommend PSI over CURB
65
●The IDSA ATS minor criteria and SMART COP are tools
to help regarding the need for ICU admission.

22. ATS / IDSA 2019 Clinical Practice Guidelines

In Outpatient and Inpatient Adults with CAP Who Are
Improving, What Is the Appropriate Duration of
Antibiotic Treatment?

23. We recommend that the duration of antibiotic therapy should be
guided by a validated measure of clinical stability (resolution of vital
sign abnormalities [heart rate, respiratory rate, blood pressure, oxygen
saturation, and temperature], ability to eat, and normal mentation),
and antibiotic therapy should be continued until the patient
achieves stability and for no less than a total of 5 days

Longer courses of antibiotic therapy are recommended for
1) pneumonia complicated by meningitis, endocarditis, and other
deep-seated infection; or
2) infection with other, less-common pathogens not covered in these
guidelines (e.g., Burkholderia pseudomallei, Mycobacterium tuberculosis
or endemic fungi).

24. FAILURE TO IMPROVE ?
Patients slow to respond to therapy should be reevaluated at about day 3
(sooner if their condition is worsening rather than simply not improving),


Is it a non infectious condition ?

A number of noninfectious conditions mimic pneumonia, including
pulmonary edema, pulmonary embolism, lung carcinoma, radiation and
hypersensitivity pneumonitis, and connective tissue disease involving the
lungs.

25. True CAP , but still the response is inadequate ?
●The pathogen may be resistant to the drug selected
●A sequestered focus (e.g., lung abscess or empyema) may be
blocking access of the antibiotic(s) to the pathogen.
●The patient may be getting either the wrong drug or the
correct drug at the wrong dose or frequency of
administration.
●Another possibility is that CAP is the correct diagnosis but an
unsuspected pathogen (e.g., CA-MRSA, M. tuberculosis, or a
fungus) is the cause.
●Nosocomial superinfections—both pulmonary and
extrapulmonary—are other possible explanations for a
hospitalized patient’s failure to improve or deterioration.

26. In all cases of delayed response or worsening condition,
the patient must be carefully reassessed and appropriate
studies initiated, possibly including procedures such as CT
or bronchoscopy.

27. COMPLICATIONS
Complications of severe CAP include respiratory failure, shock and
multiorgan failure, coagulopathy, and exacerbation of comorbid illnesses.

Three particularly noteworthy conditions are metastatic infection, lung
abscess, and complicated pleural effusion.

28. FOLLOW UP
Fever and leukocytosis usually resolve within 2–4 days in otherwise healthy
patients with CAP, but physical findings may persist longer.
Chest radiographic abnormalities are slowest to resolve (4–12 weeks),
with the speed of clearance depending on the patient’s age and underlying
lung disease.
Patients may be discharged from the hospital once their clinical conditions,
including comorbidities, are stable.
The site of residence after discharge (nursing home, home with family, home
alone) is an important discharge consideration, particularly for elderly
patients.