NR 566 Week 2 Ch 42, 43, & 45
Chapter 42: Pneumonia
Etiology
PNA develops when an organism invades the lung parenchyma, and the host defenses are depressed.
Chronically ill patients of all ages are more prone to PNA
Diagnosis
PNA should be considered in any patient who presen...
Etiology
PNA develops when an organism invades the lung parenchyma, and the host defenses are
depressed.
Chronically ill patients of all ages are more prone to PNA
Diagnosis
PNA should be considered in any patient who presents with respiratory symptoms such as
cough, dyspnea, or sputum production.
Fever or abnormal breath sounds (crackles) would strengthen the suspicion for PNA
CxR- to confirm the dx of PNA
Classification
Typical
o Caused by S. pneumoniae, H. influenzae, S. aureus, or gram-negative bacteria
o S/Sx:
fever, chills
yellow or green sputum
pleuritic chest pain
(+) lobar consolidation on CxR
Atypical
o Caused by M. pneumoniae, Legionella pneumophila, viral infection
o S/Sx:
Gradual onset of cough
No or scant sputum
Low-grade fever
Myalgias
Arthralgias
(-) consolidation on CxR
Therapy and Goals of Treatment
GOAL: return to the respiratory status a patient had before the illness
o Improved clinical condition in 48-72hrs after empirical abx tx
o Fever should resolve in 2-4 days
o Leukocytosis usually resolves by day 4 of tx
o NOTE: clear CxR is not an indicator of successful tx (may take time to be normal)
Children: 6-8 weeks
<50 yo: within 4 wks
Older patients w/ comorbidity: on 4th week of tx
Common Bacterial Pathogens
Streptococcus pneumonia- predominant organism (60%-75% for adults) except neonates.
Haemophilus influenzae and Moraxella catarrhalis- common pathogens in patients with
underlying lung disease
, Staphylococcus aureus- common co-pathogen in influenza-associated PNA
Mycoplasma pneumoniae- pathogen difficult to detect on Gram’s stain or culture, is another
common cause of PNA
Clinical Practice Guidelines for CAP Treatment
A practitioner will determine whether a patient needs an outpatient vs. inpatient treatment
Criteria for hospital admission for PNA:
o RR >30
o T >101 F
o PaO2 <60 mmHg or PaCO3 >50 mmHg on RA
o Co-morbidities: DM, COPD, chronic renal failure, CHF, chronic live disease, ETOH abuse,
malnutrition (all these increase mortality of PNA)
o Age >65 yo
Guideline in decision making for outpt vs. inpt
o Severity-of-illness scale: CURB-65 or PORT/PSI Score
CURB-65:
confusion, uremia, RR, low BP, age 65yo or above
score of 2 and above = INPATIENT
o over-all clinical presentation (in the absence of guidelines)
INITIAL EMPIRIC THERAPY:
o GROUP 1: Previously healthy outpatient with no cardiopulmonary disease, no abx in the
past months (no risk for DRSP), and no modifying factors:
FIRST LINE: Azithromycin or clarithromycin (Erythromycin is less expensive but
can cause GI upset)
Azithromycin 500mg on day 1, then 250mg daily on days 2 and 3
Clarithromycin 250mg-500mg BID x 7-10 days
Erythromycin 500mg QID x 7-10 days (250mg QID if gi upset occurs)
SECOND LINE: doxycycline
Treatment should not be altered for 72hrs!
CAP- minimum 5 days treatment
Patient should exhibit clinical response in 48-72hrs
Patient should be afebrile for 48-72hrs.
o GROUP 2: Presence of comorbidities, immunosuppression, previous abx use for the last
3 months, other risk for DRSP infection:
FIRST LINE: fluroquinolones (levofloxacin, moxifloxacin, gemifloxacin)
SECOND LINE: beta lactam + macrolide
Preferred choice: high dose of amoxicillin (1gm TID) or
amoxicillin/clavulanate (Augmentin)
Alternatives: cefpodoxime, cefuroxime, IV ceftriaxone followed by PO
cefpodoxime
Doxycycline- can be an alternative to macrolide
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