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Pneumonia Health Article

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Epidemiology Patient Evaluation Diagnosis Management Evidence-based Medicine Related Articles References

Textbook of Primary Care Medicine, 3rd ed.
By: Randolph J. Lipchik
© 2005 ELSEVIER Inc. All Rights Reserved

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Management

Management of pneumonia must include both antibiotic therapy directed against the causative organism and supportive measures. The latter include rest, adequate hydration to correct for fever-induced fluid loss and poor intake, supplemental oxygen for saturation less than 90%, and analgesia for chest pain. Chest percussion and postural drainage may be useful in selected patients with bronchiectasis or those too weak to generate an adequate cough. Routine use of this time-consuming and labor-intensive modality, however, is not beneficial in uncomplicated pneumonias.

Antibiotic therapy should be administered as quickly as possible once the diagnosis has been confirmed radiographically. Ideally the choice of antibiotic should be guided by a Gram's stain of sputum. Many polymorphonuclear neutrophils (PMNs), no epithelial cells, and a predominant organism allow more specific therapy; most often, however, the choice is empiric, and all the clinical data must be considered before deciding on a regimen. In 1993 the American Thoracic Society published guidelines for the initial management of patients with CAP. ⁷ In 1998 the Infectious Diseases Society of America published their guidelines for CAP in immunocompetent adults, which is evidence based where possible. ² Both these documents are guidelines and require prospective validation.

Unless the presentation or history suggests a particular pathogen, the macrolides, newer fluoroquinolones, and doxycycline are the drugs of first choice because they are effective for the agents causing the vast majority of CAPs (i.e., S. pneumoniae, M. pneumoniae ). For sicker patients with comorbidities, initial therapy may need to be broader. Therapy can be altered or narrowed if sputum or blood cultures yield an organism.

Penicillin-resistant Pneumococci

The empiric use of penicillin for CAP is no longer acceptable given the rise of penicillin-resistant pneumococci. The incidence of penicillin resistance is approximately 23% in selected centers in western Europe and the United States ⁵ but as high as 50% to 60% in South Africa, Spain, eastern Europe, and Korea. The resistance is caused by alteration in penicillin-binding proteins, not the production of a β-lactamase. Of even more concern is the parallel resistance seen to other antibiotics, such as macrolides, trimethoprim-sulfamethoxazole (TMP-SMX), and tetracycline. About 30% of penicillin-resistant pneumococci are resistant to erythromycin, which predicts resistance to azithromycin and clarithromycin. Primary care physicians must be aware of the microbiology in their institutions and geographic locales to provide effective empiric antibiotic therapy.

Elderly Patients

The diagnosis of pneumonia and therapy in the geriatric population deserves special attention, particularly if the patient is a nursing home resident. Classic symptoms of cough, sputum production, chest pain, and fever occur much less often in weak, debilitated patients. Coughing requires adequate muscle strength, and pleuritic pain and fever result from a vigorous inflammatory response; these may be lacking in elderly patients with poor nutrition or poor general health. Confusion and mental status changes may be the predominant clinical findings. Although S. pneumoniae is the most common pathogen, other agents such as H. influenzae (which produces β-lactamase in greater than 15% of cases) and M. catarrhalis must be considered, particularly in patients with COPD. Gram-negative bacilli are also more common, particularly in the chronically institutionalized patient. M. pneumoniae is an uncommon pathogen in the older patient. Legionella incidence is variable, being more prevalent in certain U.S. regions and during epidemic outbreaks.

Immunocompromised Patients

Altered immunity can result from HIV infection, leukemia or lymphoma, chemotherapy-induced granulocytopenia, or treatment for a variety of illnesses with long-term steroids and cytotoxic agents. The evaluation and treatment of a pneumonia in these patients should be in hospital. Because the morbidity and mortality of infections are much higher than in the general population, prompt empiric therapy and diagnostic procedures are essential. Initial empiric antibiotic therapy must cover multiple potential pathogens (Table 73-5). Because of the possibility of unusual and multiple pathogens, invasive diagnostic procedures such as bronchoscopy with bronchoalveolar lavage are considered in the first 24 to 48 hours in addition to cultures of sputum, blood, and other fluids. Although pulmonary infiltrates may also represent drug or radiation toxicity or an underlying leukemia or lymphoma, these can be considered only after an infectious etiology has been ruled out.

Once therapy has been initiated, fever, respiratory and cardiovascular status, and general features such as energy and appetite should be monitored. Most patients receiving appropriate antibiotics will improve within 48 to 72 hours. Fever that continues 24 hours into therapy is not necessarily a failure of antibiotics. A gradual decrease in the maximum daily temperature is the usual response to therapy. Persistent fever with worsening clinical status may indicate a suppurative complication (e.g., empyema), an inappropriate choice of antibiotics, the wrong diagnosis, or drug fever.

Few data address duration of therapy for pneumonia in general. S. pneumoniae should be treated until the patient has been afebrile for at least 72 hours. Mycoplasma and Chlamydia pneumonia should be treated for 14 days, and confirmed cases of Legionella require 14 to 21 days. For hospitalized patients, controversy surrounds when to switch from intravenous to oral antibiotics. In general, once a patient has become afebrile, is clinically improving, can tolerate oral intake, and has a functioning gastrointestinal tract, oral antibiotics can be considered. Radiographic infiltrates may completely clear only after many weeks, particularly with pneumococcal pneumonia. Slow radiographic resolution does not mean a failure of therapy in the face of clinical response, and frequent chest radiographs are not necessary. Consultation by a pulmonary or infectious diseases specialist should be considered for immunocompromised patients, those who fail to respond in a typical manner, and those with suppurative complications or respiratory compromise.

Indications for Hospitalization

The need for hospitalization must be carefully considered because inadequate therapy can lead to increased morbidity and mortality (Box 73-1). Because rates of hospitalization vary greatly from region to region, data from more than 38,000 patients were used to develop a prediction rule to identify patients with CAP at low risk for mortality. ³ This was then validated prospectively on approximately 2200 patients in the pneumonia patient outcomes (PORT) cohort study. An algorithm stratifies patients into different risk groups. Outpatient therapy for patients in risk classes I and II, brief inpatient observation for risk class III, and standard inpatient care for risk classes IV and V would theoretically have reduced the number of patients receiving inpatient therapy by more than 30%. When this prediction rule was later used in an emergency department, the percentage of patients initially treated as outpatients increased from 42% to 57%, although this was offset somewhat by a 9% increase in the number of outpatients subsequently admitted to hospital. ¹ Use of such a prediction rule requires further study. Clinical judgment must still ultimately guide such decisions in individual cases.

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Table 73-1	Table 73-2	Table 73-3
Table 73-4	Table 73-5	Box 73-1

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