Pneumonia (main): Difference between revisions

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''For pediatrics see [[Pneumonia (peds)|pediatric pneumonia]]''
{{Adult top}} [[pneumonia (peds)]]''
==Background==
==Background==
===General Approach===
*Definition: infection of lung parenchyma
'''3 questions:'''
*Empirically classified based upon location/risk factors
* Does this pt have pneumonia?
* If yes, does this pt need to be admitted?
* If yes, admit to the ward or ICU?


===Health care–associated PNA risk factors===
===Hospital-acquired pneumonia (HAP)===
*Hospitalized for 2 or more days within past 90 days
*HCAP no longer entity in ISDA/American Thoracic Society guidelines<ref> Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America [https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67] </ref>
*Nursing home/long-term care residents
*ISDA recommends only covering empirically for [[MRSA]] or [[pseudomonas]] in adults with CAP if "locally validated" risk factors for either pathogen and then, continuing empiric coverage while obtaining culture data to justify extended coverage
*Receiving home IV antibiotics
*Commonly accepted risk factors for resistant pathogens (e.g. MRSA, pseudomonas) historically include:
*Dialysis
**Hospitalized for 2 or more days within past 90 days
*Receiving chronic wound care
**Nursing home/long-term care residents
*Receiving chemotherapy
**Receiving home IV antibiotics
*Immunocompromised
**[[dialysis complications|Dialysis]]
**Receiving chronic wound care
**Receiving chemotherapy
**Immunocompromised


===[[Pseudomonas]] risk factors===
===[[Pseudomonas]] risk factors===
* Alcoholism
*[[Alcoholism]]
* Immunosuppression (including steroids)
*Immunosuppression (including steroids)
* Structural lung disease
*Structural lung disease
* Malnutrition
*[[Malnutrition]]
* Recent antibiotics
*Recent antibiotics
* Recent hospital stay
*Recent hospital stay


===Causes of [[Pneumonia]]===
{{Causes of pneumonia}}
====Bacteria====
*[[Gram-positive]]
**Streptococcus pneumoniae
**Staphylococcus aureus
*[[Gram-negative]]
**Haemophilus influenzae
**Klebsiella pneumoniae
**Escherichia coli
**Pseudomonas aeruginosa
**Moraxella catarrhalis
*Atypical
**Chlamydophila pneumoniae
**[[Chlamydophila psittaci]]
**Mycoplasma pneumoniae
**Coxiella burnetti
**Legionella pneumophila
 
====Viral====
*Common
** [[Influenza]]
** [[Respiratory syncytial virus]]
** Parainfluenza
*Rarer
** [[Adenovirus]]
** Metapneumovirus
** [[SARS]]
** [[MERS]]
*Cause other diseases, but sometimes cause pneumonia
** [[Herpes simplex virus]]
** [[Varicella-zoster]] (VZV)
** [[Measles]]
** [[Rubella]]
** [[Cytomegalovirus]]
** [[Smallpox]]
**[[Dengue]]
 
====Fungal====
*[[histoplasmosis]]
*[[coccidioidomycosis]]
*pulmonary [[blastomycosis]]
*[[pneumocystis pneumonia]]
*[[sporotrichosis]]
*[[cryptococcosis]]
*[[aspergillosis]]
*[[candidiasis]]
 
====Parasitic====
*[[Ascariasis]]
*[[Schistosoma]]
*[[Toxoplasma gondii]]


===Commonly Encountered Pathogens by Risk Factor===
===Commonly Encountered Pathogens by Risk Factor===
====Alcoholism====
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Risk Factor'''
| align="center" style="background:#f0f0f0;"|'''Associated Organism'''
|-
| [[Alcoholism]]||
*[[Streptococcus pneumoniae]]
*[[Streptococcus pneumoniae]]
*[[Anaerobes]] (e.g. [[Klebsiella pneumoniae]])
*[[Anaerobes]] (e.g. [[Klebsiella pneumoniae]])  
*[[Mycobacterium tuberculosis]]
*[[Mycobacterium tuberculosis]]
====[[COPD]] and/or Smoking====
|-
*[[S. pneumoniae]]
| [[COPD]] and/or Smoking||
*[[Haemophilus influenzae]]
*[[S. pneumoniae ]]
*[[Moraxella]]
*[[Haemophilus influenzae]]  
*[[Moraxella ]]
*[[Legionella]]
*[[Legionella]]
====Nursing Home====
|-
*[[S. pneumoniae]]
| Nursing Home||
*[[Gram-negative bacilli]]
*[[S. pneumoniae ]]
*[[H. influenzae]]
*[[Gram-negative]] bacilli
*[[Staphylococcus aureus]]
*[[H. influenzae ]]
*[[Anaerobes]]
*[[Staphylococcus aureus ]]
*[[Chlamydophilia pneumoniae]]
*[[Anaerobes]]  
====Exposure to bird droppings====
*[[Chlamydophila pneumoniae]]
*[[Histoplasma capsulatum]]
|-
====Exposure to birds====
| Exposure to bird droppings||[[Histoplasma capsulatum]]
*[[Chlamydophilia psittaci]]
|-
====Exposure to rabbits====
| Exposure to birds||[[Chlamydophila psittaci]]
*[[Francisella tularensis]]
|-
====Exposure to farm animals====
| Exposure to rabbits||[[Francisella tularensis]]
*[[Coxiella burnetii]] ([[Q fever]])
|-
====Exposure to southwestern US====
| Exposure to farm animals||[[Coxiella burnetii]] (Q fever)
*[[Coccidiomycosis]] (Valley fever)<br/>
|-
====HIV====
| Exposure to southwestern US||[[Coccidiomycosis]] (Valley fever)
*Early
|-
**[[S. pneumoniae]]
| Early [[HIV]]||
**[[H. influenzae]]
*[[S. pneumoniae ]]
**[[M. tuberculosis]]
*[[H. influenzae ]]
*Late (as above, plus:)
*[[M. tuberculosis]]
**[[Pneumocystis jiroveci]] (formerly Pneumocystis carinii)
|-
**[[Cryptococcus]]
| Late [[HIV]] (as above, plus:)||
**[[Histoplasma species]]
*[[Pneumocystis jiroveci]]  
====Aspiration====
*[[Cryptococcus ]]
*Anaerobes
*[[Histoplasma]]
====Structural Lung Disease (CF, bronchiectasis)====
|-
*[[Pseudomonas aeruginosa]]
| Aspiration||[[Anaerobes]]
*Burkholderia (Pseudomonas) cepacia
|-
| Structural Lung Disease ([[Cystic fibrosis|CF]], [[bronchiectasis]])||
*[[Pseudomonas aeruginosa ]]
*[[Burkholderia cepacia ]]
*[[S. aureus]]
*[[S. aureus]]
====Injection Drug Use====
|-
*[[S. aureus]]
| [[Injection drug use]]||
*[[Anaerobes]]
*[[S. aureus ]]
*[[M. tuberculosis]]
*[[Anaerobes ]]
*[[M. tuberculosis ]]
*[[S. Pneumo]]
*[[S. Pneumo]]
====[[Influenza]]====
|-
*[[Influenza]]
| [[Influenza]]||
*[[S. pneumoniae]]
*Influenza  
*[[S. aureus]]
*[[S. pneumoniae ]]
*[[S. aureus ]]
*[[H. influenzae]]
*[[H. influenzae]]
===[[Ventilator Associated Pneumonia]]===
|-
*[[Pseudomonas aeruginosa]]
| Ventilator Associated Pneumonia||
*[[Acinetobacter sp.]]
*[[Pseudomonas aeruginosa ]]
*[[Acinetobacter]] sp.  
*[[Stenotrophomonas maltophilia]]
*[[Stenotrophomonas maltophilia]]
|}


==Clinical Features==
==Clinical Features==
*[[Fever]], chills, pleuritic [[chest pain]], productive [[cough]]
*[[Fever]], chills, pleuritic [[chest pain]], productive [[cough]]
**Fever is seen in 80%
**Fever is seen in 80%
*Tachypnea
*[[Tachypnea]]
**Most sensitive sign in elderly  
**Most sensitive sign in elderly  
*[[Abdominal pain]], [[N/V]], [[diarrhea]] may be seen with [[Legionella]] infection
*[[Abdominal pain]], [[nausea and vomiting]], [[diarrhea]] may be seen with [[Legionella]] infection
*[[Myalgia]], [[fatigue]]


==Differential Diagnosis==
==Differential Diagnosis==
{{SOB DDX}}
{{SOB DDX}}


== Diagnosis ==
==Evaluation==
[[File:PneumonisWedge09.jpg|thumb|[[CXR]] showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial [[pneumonia]].]]
[[File:PneumonisWedge09.jpg|thumb|[[CXR]] showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial [[pneumonia]].]]
[[File:CT scan of the chest, demonstrating right-sided pneumonia.jpg|thumb|CT chest showing right sided pneumonia]]
[[File:CT scan of the chest, demonstrating right-sided pneumonia.jpg|thumb|CT chest showing right sided pneumonia]]
*[[CXR]]
*[[CXR]]
**Immunocompromised patients may not manifest radiographic evidence of pneumonia despite suggestive clinical findings
**Clinical and radiographic findings do not necessarily correspond: the patient may be improving  cliniclly despite having a worsening appearance on the CXR
*CBC  
*CBC  
*Chemistry
*Chemistry
*IDSA does not support using initial serum [[procalcitonin]] levels to determine whether empiric antibiotics should be initiated. **Clinical judgement ''plus'' radiographic evidence alone should guide therapy (strong recommendation, moderate quality of evidence)


If pt will be admitted:  
If patient will be admitted:  


*[[Blood Cultures]] are '''ONLY''' indicated for CAP patients with:
*[[Blood Cultures]] are '''ONLY''' indicated for CAP patients with:
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**Multi-lobar
**Multi-lobar
**Pleural effusion
**Pleural effusion
**Cavitary lesions
**Leukopenia
**Prosthetic valves
**IV drug users
**Parenteral antibiotics in the last 90 days
**Consider for higher-risk patients admitted with CAP  
**Consider for higher-risk patients admitted with CAP  
***Liver disease
***Liver disease
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**Septic emboli
**Septic emboli
**Right sided [[endocarditis]]
**Right sided [[endocarditis]]
*Legionella urine antigen test
**ICU patients
**Alcoholics
**Outbreaks
**Recent (within 2 weeks) travel history


==Management==
==Management==
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==Disposition==
==Disposition==
'''IDSA 2019 guidelines recommend clinical judgement plus PSI over CURB-65.''' <ref>Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America [https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST AJRCCM Vol. 200, No. 7, Oct 01, 2019]</ref>
{{Port score}}
{{Port score}}



Revision as of 00:58, 26 June 2020

This page is for adult patients. For pediatric patients, see: pneumonia (peds)

Background

  • Definition: infection of lung parenchyma
  • Empirically classified based upon location/risk factors

Hospital-acquired pneumonia (HAP)

  • HCAP no longer entity in ISDA/American Thoracic Society guidelines[1]
  • ISDA recommends only covering empirically for MRSA or pseudomonas in adults with CAP if "locally validated" risk factors for either pathogen and then, continuing empiric coverage while obtaining culture data to justify extended coverage
  • Commonly accepted risk factors for resistant pathogens (e.g. MRSA, pseudomonas) historically include:
    • Hospitalized for 2 or more days within past 90 days
    • Nursing home/long-term care residents
    • Receiving home IV antibiotics
    • Dialysis
    • Receiving chronic wound care
    • Receiving chemotherapy
    • Immunocompromised

Pseudomonas risk factors

  • Alcoholism
  • Immunosuppression (including steroids)
  • Structural lung disease
  • Malnutrition
  • Recent antibiotics
  • Recent hospital stay

Causes of Pneumonia

Bacteria

Viral

Fungal

Parasitic

Commonly Encountered Pathogens by Risk Factor

Risk Factor Associated Organism
Alcoholism
COPD and/or Smoking
Nursing Home
Exposure to bird droppings Histoplasma capsulatum
Exposure to birds Chlamydophila psittaci
Exposure to rabbits Francisella tularensis
Exposure to farm animals Coxiella burnetii (Q fever)
Exposure to southwestern US Coccidiomycosis (Valley fever)
Early HIV
Late HIV (as above, plus:)
Aspiration Anaerobes
Structural Lung Disease (CF, bronchiectasis)
Injection drug use
Influenza
Ventilator Associated Pneumonia

Clinical Features

Differential Diagnosis

Acute dyspnea

Emergent

Non-Emergent

Evaluation

CXR showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial pneumonia.
CT chest showing right sided pneumonia
  • CXR
    • Immunocompromised patients may not manifest radiographic evidence of pneumonia despite suggestive clinical findings
    • Clinical and radiographic findings do not necessarily correspond: the patient may be improving cliniclly despite having a worsening appearance on the CXR
  • CBC
  • Chemistry
  • IDSA does not support using initial serum procalcitonin levels to determine whether empiric antibiotics should be initiated. **Clinical judgement plus radiographic evidence alone should guide therapy (strong recommendation, moderate quality of evidence)

If patient will be admitted:

  • Blood Cultures are ONLY indicated for CAP patients with:
    • ICU (required)
    • Multi-lobar
    • Pleural effusion
    • Cavitary lesions
    • Leukopenia
    • Prosthetic valves
    • IV drug users
    • Parenteral antibiotics in the last 90 days
    • Consider for higher-risk patients admitted with CAP
      • Liver disease
      • Immunocompromised
      • Significant comorbidities
      • Other risk factors
  • Sputum staining
    • If concern for particular organism

Chest X-Ray Mimics

  • Legionella urine antigen test
    • ICU patients
    • Alcoholics
    • Outbreaks
    • Recent (within 2 weeks) travel history

Management

Outpatient

Coverage targeted at S. pneumoniae, H. influenzae. M. pneumoniae, C. pneumoniae, and Legionella

Healthy[2]

No comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) and no or risk factors for MRSA or Pseudomonas aeruginosa (include prior respiratory isolation of MRSA or P. aeruginosa or recent hospitalization AND receipt of parenteral antibiotics (in the last 90 d))

  • Amoxicillin 1 g three times daily (strong recommendation, moderate quality of evidence), OR
  • Doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence), OR
  • Macrolide in areas with pneumococcal resistance to macrolides <25% (conditional recommendation, moderate quality of evidence).
  • Duration of therapy 5 days minimum

Unhealthy[3]

If patient has comorbidities or risk factors for MRSA or Pseudomonas aeruginosa

  • Combination therapy:
    • Amoxicillin/Clavulanate
      • 500 mg/125 mg TID OR amox/clav 875 mg/125 mg BID OR 2,000 mg/125 mg BID. Duration is for a minimum of 5 days and varies based on disease severity and response to therapy; patients should be afebrile for ≥48 hours and clinically stable before therapy is discontinued[4]
    • OR cephalosporin
    • AND macrolide
      • Azithromycin 500 mg on first day then 250 mg daily
      • OR clarithromycin 500 mg BID OR clarithromycin ER 1,000 mg daily]) (strong recommendation, moderate quality of evidence for combination therapy)
    • OR doxycycline 100 mg BID (conditional recommendation, low quality of evidence for combination therapy)
  • Monotherapy: respiratory fluoroquinolone (strong recommendation, moderate quality of evidence):

Inpatient

  • Monotherapy or combination therapy is acceptable
  • Combination therapy includes a cephalosporin and macrolide targeting atypicals and Strep Pneumonia [5]
  • The use of adjunctive corticosteroids (methylprednisolone 0.5 mg/kg IV BID x 5d) in CAP of moderate-high severity (PSI Score IV or V; CURB-65 ≥ 2) is associated with:[6]
    • ↓ mortality (3%)
    • ↓ need for mechanical ventilation (5%)
    • ↓ length of hospital stay (1d)

Community Acquired (Non-ICU)

Coverage against community acquired organisms plus M. catarrhalis, Klebsiella, S. aureus

Hospital Acquired or Ventilator Associated Pneumonia

Ventilator Associated Pneumnoia

  • High Risk of MRSA: Use 3-Drug Regimen. Several options are available, but recommendation is to include an antibiotic from each of these categories:[8]

ICU, low risk of pseudomonas

ICU, risk of pseudomonas

Disposition

IDSA 2019 guidelines recommend clinical judgement plus PSI over CURB-65. [9]

Pneumonia severity index (Port Score)

Risk Factors

Points
Demographic Factors
Age for men
Age
Age for women
Age -10
Nursing home resident
+10
Coexisting Illnesses

Neoplastic disease (active)
+30
Chronic liver disease
+20
Heart Failure
+10
Cerebrovascular disease
+10
Chronic renal disease
+10
Physical Exam

AMS
+20
RR > 30/min
+20
Sys BP < 90
+20
Temp <35 or >40
+15
Pulse > 125
+10
Lab and xray findings

Arterial pH < 7.35
+30
BUN > 30
+20
Na <130
+20
Glucose > 250
+10
Hematocrit <30%
+10
PaO2 < 60 or SpO2 < 90%
+10
Pleural effusion
+10

Classification

Class
Points
Mortality
I
<51 0.1%
II
51-70 0.6%
III
71-90
0.9%
IV
91-130
9.3%
V
>130
27%

Disposition Pathway

  • Classes I and II: consider discharge
  • Class III: discharge verus admit based on clinical judgment
  • Classes IV and V: consider admission

CURB-65

  1. Confusion
  2. bUn > 19 mg/dl
  3. RR > 30
  4. BP < 90 SBP, or < 60 DBP
  5. Age > 65
  • Approximate 30-day mortalities and Tx considerations
    • +1 --> 3%, outpt tx
    • +2 -->7%, inpt, possible outpt
    • +3 --> 14% inpt, possible ICU
    • +4-5 --> 30% ICU

Prognosis

  • Half of patients are still symptomatic at 30 days, with a significant minority of patients experiencing chest pain, malaise or mild dyspnea even 2 to 3 months after treatment
  • In adults with CAP whose symptoms have resolved within 5-7 days, it is not recommended to routinely obtain follow-up chest imaging

See Also

External Links

References

  1. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67
  2. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67
  3. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67
  4. IDSA. Mandell 2007
  5. Chokshi R, Restrepo MI, Weeratunge N, Frei CR, Anzueto A, Mortensen EM. Monotherapy versus combination antibiotic therapy for patients with bacteremic Streptococcus pneumoniae community-acquired pneumonia. Eur J Clin Microbiol Infect Dis. Jul 2007;26(7):447-51
  6. Siemieniuk RA, Meade MO, Alonso-Coello P, Briel M, Evaniew N, Prasad M, Alexander PE, Fei Y, Vandvik PO, Loeb M, Guyatt GH. Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. Ann Intern Med. Aug 11, 2015
  7. Luther MK, Timbrook TT, Caffrey AR, Dosa D, Lodise TP, LaPlante KL. Vancomycin Plus Piperacillin-Tazobactam and Acute Kidney Injury in Adults: A Systematic Review and Meta-Analysis. Crit Care Med. 2018;46(1):12-20.
  8. Kalil AC, Metersky ML, Klompas M et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63(5):e61-e111.
  9. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America AJRCCM Vol. 200, No. 7, Oct 01, 2019