Академический Документы
Профессиональный Документы
Культура Документы
DRSP: drug-resistant S. pneumoniae; #: chronic heart failure, COPD, chronic kidney or liver disease, diabetes mel-
litus, cancer, asplenia or immunosuppression; ¶: also in regions with a high prevalence of macrolide-resistant
S. pneumoniae; +: high-dose amoxicillin (1 g t.i.d.) or amoxi/clavulanate (2 g b.i.d.), ceftriaxone, cefpodoxime,
and cefuroxime (500 mg b.i.d.); ƒ: or doxycycline (level III evidence); §: cefotaxime, ceftriaxone, ampicillin
(ertapenem for selected patients); ##: monotherapy with macrolide is not suggested routinely because of the
increasing resistance rate; ¶¶: macrolides are not recommended if patients have received an antibiotic of this class
in the previous 3 months; ++: piperacillin/tazobactam, cefepime, imipenem, meropenem.
treated wth oseltamivir (level II) and Table 4 Criteria defining clinical
covered for S. pneumoniae and S. aureus stability
(level III). Droplet precautions should be
used (moderate, level III). Temperature ≤37.8ºC
Heart rate ≤100 beats per min
Is the recommended empirical Respiratory rate ≤24 breaths per min
Systolic blood pressure ≥90 mmHg
antibiotic treatment a panacea for Sa,O2 ≥90% or PO2 ≥60 mmHg on room air
all patients? Ability to maintain oral intake#
No. The suggested regimens are effective for the Normal mental status#
vast majority of patients, with two important #
: important for discharge or oral switch decision but
exceptions: not necessarily for determination of nonresponse.
• Pneumonia sustained by drug-resistant Reproduced from [1], with permission from the
S. Pneumoniae and MRSA. publisher.
• Pneumonia sustained by P. aeruginosa.
Resistence to empirical antibiotic treatment and has no more than one sign of clinical insta-
depends on geography. The best approach to bility (moderate recommendation).
this important issue is the knowledge of local The authors suggest a longer treatment if
resistance patterns, most reliably by local hospi- the identified pathogen was not covered by
tal antibiograms, and the modifications of guide- empirical antibiotic therapy, or in case of extra-
lines accordingly. pulmonary complications (weak recommenda-
Physicians are encouraged to search for epi- tion, level III evidence).
demiological and clinical risk factors for these Discharge is suggested when patients are
pathogens, as outlined in the guidelines [1]. clinically stable, are able to take oral drugs,
comorbidities have been treated and there is no
When should I administer the first need for additional diagnostic tests, provided
antibiotic dose? that social needs are met.
• As soon as possible.
The authors recommend administering the What additional treatments are
first antibiotic as soon as possible after the diag- important?
nosis of CAP. For patients who present to an • Treat the patient, not only the infected
emergency department, it seems reasonable to lung!
administer the first dose of antibiotic while still • Always search for sepsis; consider a
in the department (moderate recommendation, cautious noninvasive ventilation (NIV) trial
level III evidence). if respiratory distress is present.
The key factor is that the approach to pneu-
When should I switch from i.v. monia is not only the treatment of an infected
to oral antibiotic? For how long lung, but also the management of a patient as a
should I treat my patient with whole, with a special attention to signs and
antibiotic? When should I symptoms of sepsis.
discharge my patient? Treat the patient in septic shock with ade-
• Switch to oral therapy when the patient is quate fluid resuscitation and, if still nonrespon-
clinically stable. sive, consider the use of drotrecogin α within
• Treat until at least 2–3 days after 4 h of admission (weak, level II), and test for
defervescence. occult adrenal insufficiency (moderate, level II).
• Discharge when the patient is clinically If the patient is hypoxaemic or in respiratory
stable, comorbidities are treated and social distress, consider a brief and cautious trial of
needs are met. NIV. However, if improvement in respiratory rate,
The switch to oral antibiotics is suggested for Pa,O2/FI,O2 ratio and/or Pa,CO2 does not occur
all patients who are clinically stable and have within 1–2 h, prompt intubation is warranted,
normal gastrointestinal function (strong recom- since mortality increases when intubation is pre-
mendation, level II evidence). Table 4 shows the ceded by a long NIV trial. Patients with acute res-
criteria defining clinical stability, which are also piratory distress syndrome (ARDS) or a
useful for discharge. Pa,O2/FI,O2 ratio <150 are poor candidates
The authors suggest treating patients with for NIV (moderate recommendation, level I
antibiotics for ≥5 days (level I evidence), evidence).
provided that the patient is afebrile for 48–72 h, Patients intubated for ARDS should be
ventilated with low tidal volume strategy risk; pregnancy; long-term facility residence;
(6 mL per kg of ideal body weight; strong aspirin therapy if aged ≤18 years), household
recommendation, level I evidence). contacts of high-risk people and healthcare work-
ers (strong recommendation, level I evidence).
What should I do if my patient The pneumococcal polysaccharide vaccine is
does not respond? recommended for persons aged ≥65 years and
• Identify risk factors for clinical failure and those at high-risk (strong recommendation, level
intensify diagnostic work-up, if present. II evidence).
• Search regularly for clinical failure, either In patients hospitalised with CAP, vaccina-
early (<72 h) or delayed. tion status should be assessed on admission
• Use a systematic approach for possible (moderate recommendation, level III evidence),
causes. and nonvaccinated at-risk patients should be
When a patient shows an inadequate clini- offered vaccination (moderate recommendation,
cal response despite antibiotic treatment, the level III evidence).
authors suggest using a systematic classification Smoking cessation should be offered to
based on the kind of failure (failure to improve patients with pneumonia (moderate recommen-
versus deterioration/progression) and the tim- dation, level III evidence), and pneumococcal
ing of failure (early (<72 h) versus delayed; mod- and influenza vaccination should be performed
erate recommendation, level II evidence) [1]. in those who do not quit (weak recommenda-
Microbiological assessment in nonres- tion, level III evidence).
ponding pneumonia is critical. The causal iden- Other measures to reduce the transmission
tification of failure is easier when initial microbi- of respiratory pathogens include the prompt
ological work-up results are available; therefore, notification of cases of pneumonia of public
it is crucial to recognise the presence of risk fac- health concern to the local health authority
tors for failure [1], in order to maximise initial (strong recommendation, level III evidence), and
diagnostic work-up (table 2). the use of respiratory hygiene measures (hand
washing, masks; strong recommendation, level
Is pneumonia prevention useful III evidence).
and feasible?
• Yes, pneumonia is preventable using How should I monitor/audit
vaccination. outcome?
• Identify vaccination status on admission, • Use performance indicators and modify
and manage accordingly. your approach according to results.
Influenza vaccination has been shown to Quality control plays a crucial role in clinical
reduce pneumonia, hospitalisation and death practice. The authors suggest four performance
rate. Invasive pneumococcal diseases (bacter- indicators.
aemia and meningitis) are effectively reduced by 1. Initial empirical antibiotic treatment
the use of pneumococcal vaccines among the should be consistent with guidelines.
elderly and subjects with certain chronic medical 2. The first treatment dose should be
conditions. administered in the emergency
For these reasons, vaccination represents a department.
key factor for the prevention of pneumonia [1], 3. Data on mortality and severity on
considering also that the use of vaccination in admission should be recorded, including
clinical practice is suboptimal. the number of patients with severe
The US Centers for Disease Control and pneumonia initially admitted to a general
Prevention recommend annual influenza vacci- ward.
nation with an inactivated vaccine for persons 4. Data on actual vaccination rate in the
aged ≥50 years, those at high-risk (e.g. chronic at-risk population should be recorded.
cardiovascular and pulmonary disease; chronic A deviation is expected, and should be
renal and metabolic diseases; haemoglobino- specified in the clinical chart. Compliance of
pathies; immunodeficiency; increased aspiration ~80–95% is considered acceptable.
References
1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44: Suppl. 2, S27–S72.
[Available free of charge online at www.thoracic.org/sections/publications/statements/pages/mtpi/idsaats-cap.html]
2. American Thoracic Society/Infectious Diseases Society of America. Guidelines for the management of adults with hospital-
acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171: 388–416.