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. http://dx.doi.org/10.1016/s0140-6736(15)60733-4.
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 2015. 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
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
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
efigure 2: Risk factors for community-acquired pneumonia 1
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
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
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
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
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
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