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Pneumonias Classification
CAP
HCAP HAP
ICUAP VAP
3
Nosocomial Pneumonias
Hospital Acquired
ICU Acquired Ventilator Acquired
Why Guidelines?
Evidence-based practice
Best outcome for patients Best use of resource Restricts idiosyncratic behaviour
Legal protection
Identify research needs
Atypical
Gradual & insidious onset Low grade fever Dry cough, No blood tinge Good GC Walking CAP Low mortality 1-2%; except in cases of Legionellosis Mycoplasma, Chlamydiae, Legionella, Ricketessiae, Viruses are causative
CAP Pathogenesis
Inhalation Aspiration
Hematogenous
Age Obesity; Exercise is protective Smoking, PVD Asthma, COPD Immuno-suppression, HIV Institutionalization, Old age homes etc Dementia
ID Clinics 1998;12:723. Am J Med 1994;96:313
S.pneumoniae H.influenza Chlamydia Legionella spp S.aureus Mycoplasma Gram Neg bacilli Viruses
11
Streptococcus pneumonia
(Pneumococcus)
400
200 0
<5 5 to 17 18-24 25-44 45-64 >65
15
70
60 50 40 30 20 10 0 0 <4 0 5 to 14 0 15-24 2 25-44 5.7 45-64 >65
# of deaths
16
CAP Risk Factors for Mortality Age > 65 Bacteremia (for S. pneumoniae) S. aureus, MRSA , Pseudomonas
19
No Infiltrate
Infiltrate or Clinical evidence of CAP Evaluate need for Admission Out Patient PORT & CURB 65 Medical Ward
Alternate Dx.
ICU Adm.
20
21
Clinical Parameter Age in years For Men (Age in yrs) For Women (Age -10) NH Resident Co-morbid Illnesses Neoplasia Liver Disease CHF CVD Renal Disease (CKD)
Clinical Parameter
Clinical Findings
Altered Sensorium Respiratory Rate > 30 SBP < 90 mm Temp < 350 C or > 400 C Pulse > 125 per min Investigation Findings Arterial pH < 7.35
BUN > 30
Serum Na < 130 Hematocrit < 30% Blood Glucose > 250 Pa O2
20 points
20 points 10 points 10 points 10 points
Class II
70
Class III
71 90
Class IV
91 - 130
Class V
> 130
23
Class III
Class IV Class V
71 - 90
91 - 130 > 130
0.9 2.8
8.5 9.3 27 31.1
Brief hospitalization
Inpatient IP - ICU
24
CURB 65 Confusion BUN > 30 RR > 30 BP SBP <90 DBP <60 Age > 65
25
Algorithmic Approach
Step 4 Step 1
< 50 Years
Step 2
No Co-morbidity
Step 3
Class I
No CURB
Only OP
CURB +
CAP Patient
Co-morbidity Present
50 Years
PORT 26
Class III
Class IV and V
28
30
31
57 % 97 %
82 % 99 %
95 %
71 %
93 %
96 %
32
11% 16%
68%
33
K. pneumoniae S. aureus -
35.7 %
31.8 %
14.7 %
12.0 % 9.8 % 7.4 %
35
36
Objective 1
Objective 2
37
45
17
CAP
HAP
HAP on CAP
Kollef, et al. Chest 1999;115:462474
38
39
41
Fluroquinolone-FQ
Levofloxacin
Moxifloxacin
Betalactum B
Ceftriaoxone Cefotaxime
B Inhibitor BI
Gatifloxacin
Trovafloxacin
Doxycycline
42
Antibiotic
Doxyclycline
Azithromycin
Clarithromycin
Telithromycin
Levofloxacin
Gatifloxacin Moxifloxacin Gemifloxacin Amoxyclav Ceftriaxone
43
Ertapenum
45
46
47
Duration of Therapy
Minimum of 5 days Afebrile for at least 48 to 72 h No > 1 CAP-associated sign of clinical instability Longer duration of therapy If initial therapy was not active against the identified pathogen or complicated by extra pulmonary infection
49
Survival (%)
50
FQ + AZ B 3G + AZ
52
If overall clinical picture is otherwise favorable, hemodynamically stable; can switch to oral therapy while still febrile.
54
55
CAP Complications
Hypotension and septic shock
57