IN ADULTS
Risk Factors for Severe Disease
Point Scoring System
Need for Hospitalization
Recommended
Empiric Therapy
About this Document
Prevention
Organism
· Vaccine for S Pneumoniae is available.
· Many adult infections originate in the pediatric population adults benefit from disease management in children
· Commonest cause of bacterial meningitis in N.American children
· Commonest bacterial cause of otitis media and pediatric pneumonia
· High rates of antibiotic resistance
· Most invasive pediatric infections occur prior to age 2
· In Canada, 7 of 90 serotypes cause 80% of infection
High-Risk Groups (Vaccine
indicated)
·
Asplenia
·
Sickle cell disease
·
Immunosuppression
·
Diabetes
·
Cardiopulmonary disease
·
Day care and long term care facilities
·
Health care workers
Polysaccharide Vaccine
· 23-valent preferred
· Reduces bacteremia by up to 80%
· Indicated for adults >65 yr. and those with risk factors.
· Indicated for age >2 yr. with risk factors.
· Ineffective < 2 yr. old.
· 7 serotypes
· Covers 81% of isolates causing invasive disease and 95% of resistant bacteria
· Modest reduction in otitis media, greater reduction in recurrent otitis media.
· Reduces invasive disease by 94%, pneumonia by 89%.
· Reduced nasopharyngeal carriage of vaccine-specific types in kids and sibs.
· Recommendations for Prevnar
All children </= 23 mo.
Children 24-59 mo. with risk factors for invasive disease.
· Prevnar Dosage
Age 2-6 mo. 3 doses, 8 wk apart, booster 12-15 mo.
Age 7-11 mo. 2 doses, 8 wk. apart, booster 12-15 mo.
Age 12-23 mo. 2 doses, 8 wk apart, no booster
Age => 24 mo. 1 dose
Age > 24 mo. 2 doses, 8wk. apart, booster 23 valent
Risk Factors for Severe Disease
·
Age > 65
·
Comorbid
illness
·
Respiratory
rate > 30
·
BP diastolic
< 60 systolic < 90
·
Heart rate >
125
·
Temp < 35 or
> 40
·
Altered mental
status
·
WBC < 4000
or > 30000
·
Pa02 <60 or
PaCO2 > 50
·
PH < 7.35
·
Abnormal renal
function
·
Hct < 30% or
Hb <90
·
DIC
·
Multilobar
disease on CXR
·
Cavitary lesion
on CXR
·
Pleural
effusion
Point Scoring System [2]
Patient Characteristics |
Points |
|
Age (male) |
Age (yr) |
|
Age (female) |
Age (yr) - 10 |
|
LTC resident |
10 |
Comorbidities |
|
|
Neoplastic disease |
30 |
|
Liver disease |
20 |
|
CHF |
10 |
|
Cerebrovascular dis. |
10 |
|
Renal disease |
10 |
Physical Exam |
|
|
Altered mental
status |
20 |
|
Resp. rate > 30 |
20 |
|
Syst. BP < 90 |
20 |
|
Temp < 35 or
> 40 |
15 |
|
Pulse > 125 |
10 |
Laborotory Findings |
|
|
pH < 7.35 |
30 |
|
Creatinine>120 |
20 |
|
Na<130 |
20 |
|
Glucose>13.9 |
10 |
|
Hct < 30% |
10 |
|
PaO2 < 60 |
10 |
|
Pleural effusion |
10 |
Need for Hospitalization
Studies done on need
for hospitalization involved use of respiratory quinolones, and may not be
generallizable for other medications [4,5]
·
Class I : <50 points. <50 years, normal vital signs, temp
<38. Low risk and no need for
hospitalization.
·
Class II: 50-70 points. Low risk and no need for hospitalization
with provisions.
·
Class III: 71 - 90 points. Low risk and no need for hospitalization
with provisions.
·
Class IV: 91 - 130 points. Moderate risk and should be hospitalized.
·
Class V: > 130 points. High risk and should be hospitalized.
Consider consultation.
Provisions to be Met Before Outpatient Treatment
·
SPO2 92% or
more on room air or unchanged from patients normal
·
Able to do all
ADL or adequate supports.
·
On oral meds
·
Followup
arranged.
·
No unstable
comorbidities.
·
No complicated
pleural effusions.
Recommended Empiric Therapy
Hospitalization not required. No cardiopulmonary disease
· Organism likely pneumococcus, mycoplasma, chlamydia
· Treatment second gen. macrolide or doxycycline
· Recent antibiotics (past 3 mo.), choose different antibiotic and add amoxicillin
· Treatment failure choose different agent amoxicillin-clavulanate or cefuroxime axetil PLUS macrolide. Alternative levofloxacin or moxifloxacin
Hospitalization not required with cardiopulmonary disease
·
Organism likely
pneumococcus, moraxella, hemophilus, chlamydia, s.aureus, enterobacter.
·
Treatment
second gen. macrolide or doxycycline.
·
Recent antibiotics (past 3 mo.), choose different
antibiotic and add amoxicillin-clavulanate
·
Treatment failure choose different agent - amoxicillin-clavulanate or cefuroxime
axetil PLUS macrolide. Alternative levofloxacin
or moxifloxacin
Hospitalization required
·
Organism likely
pneumococcus, enterobacter, hemophilus, chlamydia, s.aureus, legionella, Gp A
streptococcus
·
Treatment IV cefuroxime or ceftriaxone or
cefotaxime PLUS macrolide or doxycycline. Alternative
levofloxacin or moxifloxacin
·
Severe disease cefotaxime
IV or ceftriaxone IV PLUS macrolide
or levofloxacin or moxifloxacin
for 10-14 days.
·
Cephalosporin allergy levofloxacin
or moxifloxacin PLUS clindamycin or macrolide or vancomycin.
·
Switch to oral antibiotics when:
Able to tolerate po fluids, meds, no diarrhoea
Cough and respiratory distress improving.
Temp. <38° C for 24 hours
SPO2 improving
WBC improving
Antibiotic Agents
Macrolides
·
Erythromycin
500 mg.
·
Clarithromycin
(Biaxin) 250-500 mg. bid for 7-10 days
·
Azithromycin
(Zithromax) 500 mg. day 1 IV or PO, 250 mg.
Doxycycline
·
Oral 200 mg.
stat, 100 mg. bid for 10 days
·
IV 100 mg. bid
for 10 days
Cefuroxime
·
Oral 500 mg.
bid for 7-10 days
·
IV 750 mg. IV
q8h for 10 days
Cefotaxime
·
IV 1 gram q8h
for 10 days
Ceftriaxone
·
IV 1 gram daily
for 10 days
Levofloxacin
·
Oral 500 mg. daily
for 10 days or 750 mg. daily for 5 days
·
IV 500 mg.
daily for 10 days
Moxifloxacin
·
IV or
Amoxicillin
·
1 gm. tid
Amoxicillin-clavulanate
·
875 mg. bid
References
1.
American
Thoracic Society Guidelines for the management of adults with community
acquired pneumonia. Am J Respir Crit Care Med 2001; 163:1730-54
2.
Fine MJ, Auble
TE, Yealy DM et al: A prediction rule to identify low-risk patients with
community acquired pneumonia. N Engl J Med 1997; 336: 243-50
3. Guideline for the diagnosis and management of community acquired pneumonia: Adult. Alberta Clinical Practice Guidelines revised 2006 [Online]. Available from: http://www.topalbertadoctors.org/. Accessed Jan. 4, 2008.
4. Marrie TJ , et al. A controlled trial of a critical pathway for community acquired pneumonia. JAMA 2000; 283(6): 749-755.
5. Carratala J, et al. Outpatient care compared with hospitalization for community acquired pneumonia. Ann Intern Med 2005; 142: 165-172.