9/2/14 1 Catherine “Casey” S. Jones , PhD, RN, ANP-C, AE-C Community Acquired Pneumonia Catherine “Casey” S. Jones, PhD, RN, ANP-C, AE-C Texas Pulmonary & Critical Care Consultants, PA & Adjunct Professor at Texas Woman’s University in Dallas Disclosures No financial relationship with any pharmaceutical manufacturer or medical device company
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9/2/14
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Catherine “Casey” S. Jones, PhD, RN, ANP-C, AE-C
Community Acquired Pneumonia
Catherine “Casey” S. Jones, PhD, RN, ANP-C, AE-C
Texas Pulmonary & Critical Care
Consultants, PA &
Adjunct Professor at Texas Woman’s University in Dallas
Disclosures
No financial relationship with any pharmaceutical manufacturer or medical
device company
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Objectives
� Compare the different types of pneumonia according to the patient’s current location or residence and risk factors.
� Assess the patient’s susceptibility for hospitalization using CURB-65.
� Recommend appropriate therapy for individuals with community acquired pneumonia.
� Most pneumonias are caused by micro-aspiration or inhalation of bacteria or viruses into the lung.
� Usually the body’s defenses will prevent infection, but at times of low resistance pathogenic organisms may overwhelm the usual protective mechanisms.
� Commonly 10-14 days after an upper respiratory infection (URI).
� Physical exam may be normal in early stages � Increased temperature, pulse � Nasal flaring, tachypnea � Lungs: dullness to percussion and auscultation
over site of consolidation, diffuse crackles and wheezes, rhonchi
Physical Examination
� Auscultation ¡ Crackles or rhonchi ¡ Bronchial breath
sounds ¡ Consolidation
� Percussion � Palpation
¡ Feel Tactile Fremitus
� Signs of consolidation: ¡ Bronchophony
÷ Exaggerated vocal resonance over consolidated area
¡ Egophony ÷ (E to A)
¡ Whispered pectoriloquy ÷ Increased resonance
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Diagnosis & Initial Assessment of CAP
� Chest X-Ray – gold standard – not helpful with identifying pathogen
� Screening pulse oximetry � Routine diagnostic testing is optional ● Initial assessment of severity
events & superinfection by more-virulent or resistant hospital bacteria.
Criteria for Hospitalization
� ~ 10 % of hospitalized patients with CAP requires ICU admission
� One of most important determinants for ICU care is presence of chronic comorbid conditions
� 1/3 of patients with severe CAP were previously healthy
Antibiotics of Choice: Outpatient Therapy
� Previously healthy & no risk factors for drug-resistant S. pneumoniae infection: ¡ Macrolide (azithromycin, clarithromycin or erythromycin) ¡ Doxycycline
� Comorbidities or use of antimicrobials within previous 3 months: ¡ Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or
levofloxacin 750 mg) ¡ Β-lactam PLUS a macrolide (high-dose amoxicillin or
� Procalcitonin – peptide precursor of calcitonin released by parenchymal cells in response to bacterial toxins – elevated serum levels with bacterial infections
� <0.1 mcg/L = too low to treat with antibiotics � >0.25 mcg/L = treat with antibiotics � Distinguish between bacterial versus viral
pneumonia � Reduce antibacterial use � Predict survival
Hospital Management (Class III-V)
� Antibiotic treatment is based on the organism identified
� Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. ATS/IDSA Guidelines. (2005). American Journal of Respiratory & Critical Care Medicine, vol 171, 388-416.
� Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the management of community-acquired pneumonia in adults. (2007). Clinical Infectious Diseases. 44, S27-72.
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References
� Rello, J. & Chastre, J. (2013). Update in pulmonary infections 2012. American Journal of Respiratory & Critical Care Medicine. Vol. 187, 1061-1066.