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Community Acquired Pneumonia

Community Acquired Pneumonia. CAP - Bugs. * Influenza A and B, adenovirus, respiratory syncytial virus, and parainfluenza. CAP- epidemiologic considerations. CAP – Clinical Features. Productive cough Fever Pleuritic chest pain Dyspnea GI symptoms Mental status changes.

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Community Acquired Pneumonia

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  1. Community Acquired Pneumonia

  2. CAP - Bugs *Influenza A and B, adenovirus, respiratory syncytial virus, and parainfluenza.

  3. CAP- epidemiologic considerations

  4. CAP – Clinical Features • Productive cough • Fever • Pleuritic chest pain • Dyspnea • GI symptoms • Mental status changes

  5. CAP - Physical Exam Findings • Febrile • RR >24 breaths/minute • Tachycardia • Rales • +egophany

  6. CAP - Diagnosis • Chest Xray with infiltrate • Leukocytosis • Blood cultures • Sputum – gram stain and culture • Urine antigens • Influenza testing • Viral culture • ABG **If hospitalized within last 90 days or if lives at ECF, received outpatient dialysis then patient would be considered as hospital or healthcare associated pneumonia

  7. CAP - Admit or Not? • Severity Scores • CURB-65 • PSI = Pneumonia Severity Index • Helps to determine severity of illness • Helps to determine if patient should be admitted and whether needs admitted to ICU

  8. CAP - CURB 65 • Confusion • Urea (BUN >20mg/dL) • Respiratory Rate > 30 breaths/minute • Blood Pressure (systolic <90mmHg or diastolic <60mmHg) • Age >65 years * 1 point for each

  9. CAP – CURB65

  10. CAP - PSI

  11. CAP - PSI

  12. CAP – Inpatient Treatment

  13. CAP – Inpatient Treatment • Suspected MRSA- add vancomycin or linezolid • Suspected aspiration- ertapenem or moxifloxacin • *Pseudomonal risk factors = • Bronchiectasis documented on admission • Structural lung disease and h/o pneumonias or chronic steroid use

  14. CAP – Inpatient Treatment • Switch to Oral Therapy • When clinically improving, hemodynamically stable, able to take oral meds • Duration of Hospitalization • Several studies support that it is not necessary to observe pt overnight after change to PO antibiotics • Consider discharge after no signs of clinical instability which is defined as: Temp >100, RR>24, SBP <90, HR>100, O2 sat <90, altered mental status, inability to take PO • Duration of Treatment • Minimum of 5 days (most treat 7-14 days) • Before consideration of discontinuing abx need to have: • Afebrile for 48-72 hours • No supplemental O2 • No signs of clinical instability

  15. CAP – Follow Up Recs • When should you get a follow up CXR? • No clear evidence • Most recommend f/u CXR for patients >40 years and h/o smoking to document resolution of disease and no underlying malignancy • Obtain CXR 7-12 weeks after completion of treatment

  16. CAP Quality Measures • Blood cultures prior to first antibiotic dose • Oxygen assessment • Initial antibiotics within 6 hours of presentation • Appropriate antibiotic selection • Pneumococcal vaccine for pts >65 • Influenza vaccine for pts >50 during Oct-March • Smoking cessation counseling

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