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.