NR566 Week 2 Ch 42, 43, & 45 Complete Study Guide

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 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 o GROUP 3: Patients >60 yo, or with comorbidities; and is stable enough for home therapy BUT with poor intake/PO intake is not assured:  IV home abx is an opton  DRUG OF CHOICE: • IV or IM ceftriaxone 1gm daily • IV levofloxacin 500mg IV daily  Consider adding macrolide to ceftriaxone for coverage against staphylococcal pathogens if indicated.  Switch to PO therapy once clinical response is observed. o Patient with Nursing Home-acquired PNA  Classified under GROUP 2 (nursing home residence as a modifying factor)  S. pneumoniae- common pathogen (but also S. aureus and H. influenzae)  (+) dentition or swallowing issues: consider anaerobes