How To Diagnose And Treat Community Acquired Pneumonia
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1 Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Prina E, Ranzani OT, Torres A. Community-acquired pneumonia. Lancet 2015; published online Aug 13.
2 Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. Supplement to: Prina E, Ranzani OT, Torres A. Community-acquired pneumonia. Lancet Seminar efigure 1: Symptoms and signs of community-acquired pneumonia etable 1: Differential diagnosis in community-acquired pneumonia efigure 2: Risk factors for community-acquired pneumonia efigure 3: Framework for community-acquired pneumonia efigure 4: Risk factors for resistant pathogens in community-acquired pneumonia etable 2: Antibiotics suggested for specific pathogens in community-acquired pneumonia etable 3: Clinical stability criteria and expected time for resolution etable 4: Bundles for prevention to reduce the risk of community-acquired pneumonia in adults
3 efigure 1: Symptoms and signs of community acquired pneumonia Respiratory Dyspnoea Cough Fever Sputum production Chills Pleuritic chest pain Haemodynamic Hypotension Shock Tachycardia Extratoracic Otitis, pharyngitis Skin alteration Haemolytic anaemia Headache Gastrointestinal symptoms Confusion Hyponatremia
4 etable 1: Differential diagnosis in community-acquired pneumonia Diagnosis Symptoms and sings Chest-X-ray Key points Acute bronchitis Acute lung injury secondary to sepsis Congestive heart failure Acute exacerbation of COPD Acute exacerbation of asthma Pulmonary infarction Lung Cancer or pulmonary metastasis Acute exacerbation of bronchiectasis Acute exacerbation of pulmonary fibrosis Other lung infections (Tuberculosis / Histoplasmosis) Autoimmune disease with lung involvement Pleural empyema Pulmonary toxicities due to medications Mild symptoms, not dyspnoea, not lung crackles Dyspnoea, symptoms of another infection Dyspnoea, tachycardia, chest pain Dyspnoea, increased expectoration and cough Dyspnoea, cough, signs of bronchospasm DVT, dyspnoea, tachycardia, chest pain Dyspnoea, Constitutional symptoms Dyspnoea, increased expectoration and cough Dyspnoea, dry cough, fine basal late inspiratory crackles Constitutional symptoms, prolonged time of symptoms Dyspnoea, extra pulmonary manifestations Dyspnoea, Constitutional symptoms Dyspnoea No condensation Bilateral alveolar-interstitial pattern Bilateral interstitial pattern (>apical), pleural effusion No condensation No condensation Focal condensation, small pleural effusion Focal or multiple condensation, pleural effusion No condensation Interstitial pattern Focal consolidation, cavitation, linfoadenopaties Interstitial pattern Signs of pleural effusion, considered loculated pleural effusion Prevalent interstitial pattern, condensation and nodules Limited use of antibiotics (in most of the cases are viral infection) Respiratory symptoms in patients with infection in other site History of cardiac disease, alteration of echocardiogram Resolution after NIV History of COPD / smoking History of asthma Risk factors for thrombosis History of smoking, no-resolving pneumonia, history of cancer History of bronchiectasis / repetitive infections History of pulmonary fibrosis History of specific exposure (contacts, cave) History of autoimmune disease Improvement with corticosteroid History of recent respiratory infection History of medications COPD denotes chronic respiratory disease, DVT denotes deep-venous thrombosis, NIV denotes noninvasive ventilation
5 efigure 2: Risk factors for community-acquired pneumonia 1
6 efigure 3: Framework for community-acquired pneumonia Suspect of CAP Need for different approach Immunosuppression Risk factors for aspiration Risk factors for resistant pathogens Viral pneumonia Standard CAP antibiotic treatment
7 efigure 4: Risk factors for resistant pathogens in community-acquired pneumonia 2-10 Comorbidities: Chronic lung disease Immunosuppression Cerebrovascular disease Heart failure Diabetes mellitus Chronic renal disease Haemodialysis Previous pneumonia Habits: Smoking Alcohol abuse Medication: Gastric Acid Suppression Previous antibiotic use RESISTANT PATHOGENS Previous Infection: MRSA colonization Prior CAP due to resistant pathogen Acquired dysfunction: Cognitive impairment Poor Functional Status Oropharyngeal dysphagia Patient status: Tube Feeding Indwelling Catheter Health Care Contact: Prior Hospitalization Long Term Care Wound Care Infusion Therapy
8 etable 2: Antibiotics suggested for specific pathogens in community-acquired pneumonia 9,11,12 Pathogen Streptococcus pneumoniae Non-resistant (MIC <2 µg/ml) Streptococcus pneumoniae Suspected or Resistant (MIC 2 µg/ml) P. aeruginosa Preferred antibiotic treatment Penicillin G or Amoxicillin Agents identified using in vitro susceptibility tests, including cefotaxime, ceftriaxone, fluoroquinolone Antipseudomonal Beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin or aminoglycoside Alternative antibiotic treatment Macrolide, cephalosporins, clindamycin, doxycyline, respiratory fluoroquinolone Vancomycin, linezolid, high-dose amoxicillin Aminoglycoside plus (ciprofloxacin or levofloxacin) MRSA Vancomycin Linezolid Enterobacteriaceae ESBL+ Carbapenemics Beta-lactam/ Betalactamase inhibitor; aminoglycoside MIC denotes Minimal Inhbitor Concentration; MRSA denotes Methicillin-resistant Staphylococcus aureus meticilline resistant staphilococcus aereus; ESBL denotes extended-spectrum β-lactamase positive bacteria
9 etable 3: Clinical stability criteria and expected time for resolution 12,13 Clinical stability criteria Temperature 37.8 C Heart rate 100 beats/min Respiratory rate 24 breaths/min Systolic blood pressure 90 mmhg Arterial oxygen saturation 90% or po2 60 mmhg on room air Ability to maintain oral intake Normal mental status Expected time for resolution of symptoms and signs Temperature 37.8 C 3 days Median time of clinical stability 4 days Cough 8 days Crackles 3 weeks Persistence of pneumonia-related symptom 2 weeks to long-term Chest-X-ray resolution 4 to 8 weeks
10 etable 4: Bundles for prevention to reduce the risk of CAP in adults 1 Risk factor Evidence Recommendation Vaccination against influenza Current guideline Following the guideline and S. pneumoniae Smoking Risk of CAP increase in Stop smoking smoker and passive smoker Alcohol Alcohol abuse increase risk for Stop alcohol CAP Nutritional status Malnutrition is a risk for CAP, more controversial data Maintain good nutritional status regarding obesity Swallowing disturbance is a Specialist evaluation Swallowing disturbance risk factor for pneumonia and recurrent pneumonia Recent visit decrease risk for Regular dental visits Dental hygiene CAP CAP denotes Community Acquired Pneumonia; S. pneumoniae denotes Streptococcus pneumoniae
11 References: 1. Torres A, Peetermans WE, Viegi G, Blasi F. Risk factors for community-acquired pneumonia in adults in Europe: a literature review. Thorax 2013; 68(11): Aliberti S, Cilloniz C, Chalmers JD, et al. Multidrug-resistant pathogens in hospitalised patients coming from the community with pneumonia: a European perspective. Thorax 2013; 68(11): Shorr AF, Zilberberg MD, Reichley R, et al. Validation of a clinical score for assessing the risk of resistant pathogens in patients with pneumonia presenting to the emergency department. Clin Infect Dis 2012; 54(2): Shorr AF, Myers DE, Huang DB, Nathanson BH, Emons MF, Kollef MH. A risk score for identifying methicillinresistant Staphylococcus aureus in patients presenting to the hospital with pneumonia. BMC Infect Dis 2013; 13(1): Shindo Y, Ito R, Kobayashi D, et al. Risk factors for drug-resistant pathogens in community-acquired and healthcare-associated pneumonia. Am J Respir Crit Care Med 2013; 188(8): Gross AE, Van Schooneveld TC, Olsen KM, et al. Epidemiology and predictors of multidrug-resistant community-acquired and health care-associated pneumonia. Antimicrob Agents Chemother 2014; 58(9): Webb BJ, Dascomb K, Stenehjem E, Dean N. Predicting risk of drug-resistant organisms in pneumonia: Moving beyond the HCAP model. Respir Med Prina E, Ranzani OT, Polverino E, et al. Risk factors associated with potentially antibiotic-resistant pathogens in community-acquired pneumonia. Ann Am Thorac Soc 2015; 12(2): Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin InfectDis 2007; 44 Suppl 2: S27-S American Thoracic S, Infectious Diseases Society of A. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. American Journal of Respiratory and Critical Care Medicine 2005; 171: Lim WS, Baudouin SV, George RC, et al. BTS guidelines for the management of community acquired pneumonia in adults: update Thorax 2009; 64 Suppl 3: iii NICE. Pneumonia: Diagnosis and management of community- and hospital-acquired pneumonia in adults. NICE guidelines, (accessed Jan 15, 2015). 13. Halm EA, Fine MJ, Marrie TJ, et al. Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines. JAMA 1998; 279(18):
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