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Management of Community Acquired Pneumonia (CAP) in Adults
(ERS/ESCMID
guidelines1 adapted
for Switzerland)
Appedix 1, Appendix 2, Appendix 3, Appendix References (Appendices from ERS/ESCMID guidelines1)
Gerd
Laifera, Ursula Flückigera, Claude Scheideggerb,
Katia Boggianc, Katrin Mühlemannd, Rainer Webere,
Giorgio Zanettif, Laurent Kaiserg for the Swiss Society
of Infectious Diseases
a Division of Infectious Diseases & Hospital
Epidemiology, University Hospital Basel;
b FMH Infectious Diseases, Greiffengasse 11, 4058
Basel;
c Division of Infectious Diseases, Kantonsspital St. Gallen;
d Insitut of Infectious Diseases and Hospital
Epidemiolgy, Inselspital Bern;
e Division of Infectious Diseases & Hospital
Epidemiology, University Hospital Zürich;
f Division of Hospital Epidemiology, University
Hospital Lausanne;
g Division of Infectious Diseases, University
Hospital Geneva.
Introduction
In
May 2005, the European Respiratory Society (ERS) in collaboration with the
European Society of Clinical Microbiology and Infectious Diseases (ESCMID)
published new guidelines for the management of adult lower respiratory tract
infections (LRTI)1. These guidelines are the result of an
evidence-based review of more than 4’000 publications between 1966 and December
2002.
The
impact of guidelines depends on their incorporation into the daily clinical
practice and on the rapid clinical access at the bedside. In addition to the
published and attached full-text guidelines a group of experts of the Swiss
Society of Infectious Diseases presents a summary which focuses on the
management of community-acquired pneumonia (CAP) outside and inside the
hospital including tables and comments.
In
the Swiss recommendations we considered our local prevalence of antibiotic
resistance and – since the European guidelines only included publications up to
December 2002 – discussed briefly new data available since 2003 addressing a
shortening of the duration of antibiotic therapy.
1.
Management outside hospital (see p. 1144 -1147
of ref. 1)
1.1
Diagnosis
§
Pneumonia should be
suspected, if a patient has an acute cough and one of the following signs:
o
new focal chest signs
o
dyspnoea
o
tachypnoea
o
fever lasting more than 4
days
§
Chest-radiograph is
recommended in this setting.
§
See also table 1 with definitions of upper and lower respiratory tract infections.
§
Aspiration pneumonia should be considered in patients with
difficulties to swallow and who show signs of an acute LRTI. Chest radiograph
is recommended in this setting.
1.2
Microbiological investigations
§
Microbiological
investigations are usually not recommended in primary care.
§
Assessment of the
microbiological aetiology may be useful only in certain subgroups with severe
co-morbidity and a high probability of unusual microorganism or resistance
problems or in immunocompromised patients.
§
The most common causative
organisms of LRTI and CAP in the community are summarized in table 2.
1.3
Treatment
§
Symptomatic treatment:
o
A dry and bothersome acute
cough can be treated with dextrometorphan or codein.
o
Expectorants, mucolytics,
antihistamines and bronchodilators should not be prescribed in acute LRTI in
primary care.
§
Antibiotic treatment in LRTI should be considered in the following
situations:
o
Suspected or definite
pneumonia (see table 1: definitions)
o
Additionally in selected
patients with exacerbation of COPD:
§
All of three “Anthonisen”
criteria: increased dyspnoea; increased sputum volume and increased sputum
purulence
§
Patients with severe COPD (GOLD IV)
o
Age > 75 years and fever
o
Cardiac failure
o
Insulin-dependent diabetes
mellitus
o
Serious neurological disorder
(stroke etc)
§
Recommended empiric
antibiotic treatment in
outpatients with CAP (s. table 3)
o
Empiric antibiotic treatment
should be directed against the most common pathogens, S. pneumoniae and H.
influenzae (see table 2). Epidemiological factors, travel
history and exposure (f.e. to animals) need to be taken into account.
§
Anti-viral treatment
o
The empirical use of
anti-viral treatment in patients suspected of suffering from influenza is
usually not recommended. Anti-viral therapy (f.e. Oseltamivir 2x75 mg x 5 days)
can be considered in the influenza season in high-risk patients (f.e. patients
after transplantations) with influenza symptoms (see table 1: definitions) for < 2
days. Keep in mind that Oseltamivir has not been assessed sufficiently in
immunocompromised hosts.
1.4
Monitoring
§
There are no studies
assessing what would be the best follow up procedure in the primary care
setting
§
Recommendations:
o
Advise patients to return if
fever exceeds 4 days, dyspnoea gets worse, patients stop drinking or
consciousness decreases
o
Plan a second visit in
advance 2 days after the first visit in more seriously ill patients with 2 of
the following characteristics:
high fever; tachypnoea; dyspnoea; relevant
co-morbidity; age > 65 years.
o
In case of antibiotic
treatment: Advise patients to return if clinical signs do not improve within 3
days.
o
Advise patients to return if
symptoms take >3 weeks to disappear.
2.
Decision outpatient versus inpatient treatment (see page
1147-1148 of ref. 1; see also table 1: definitions)
The decision to hospitalise remains a clinical
decision. However, the decision should be validated against at least one
objective tool of risk assessment (Pneumonia
severity index = PSI or CURB65- score). In patients with a PSI of IV and V
or a CURB-score ≥ 2, hospitalisation should be seriously considered.
3.
Management inside hospital (see p. 1147-1158
of ref.1)
3.1
Diagnosis
§
Pneumonia should be
suspected, if a patient has an acute cough and one of the following signs:
o
new focal chest signs
o
dyspnoea
o
tachypnoea
o
fever lasting more than 4
days
§
Chest-radiograph is
recommended in this setting.
3.2
Laboratory Studies recommended for patients with CAP who require hospitalisation (see table 4
for causative organisms).
§
Arterial blood gas or pulse
oximetry determination and basic blood tests (red & differential white
blood cell count, creatinine, urea nitrogen, aminotransferases, sodium,
potassium, C-reactive protein)
§
Blood cultures in all patients who require hospitalisation
§
Sputum gram stain and culture, if a high quality sputum
(≤10 squamous epithelial cells and ≥25 PMN / low power (100x)
field) can be obtained.
§
Urine-antigen-testing for L. pneumophila serogroup 1 in patients with severe CAP or if this infection is
clinically or epidemiologically suspected.
§
Urine-antigen-testing for S. pneumoniae in high-risk patients, if a sputum sample is not
conclusive or not available2 (ERS/ESCMID-guidelines do not recommend
urine-antigen-testing for S. pneumoniae unless
more studies are available).
§
Serological tests are not recommended for an individual patient and are
more useful for epidemiological studies (e.g. Mycoplasma pneumoniae, Chlamydia
pneumoniae and Legionella spp.).
§
Amplification tests for the detection of influenza and respiratory
syncytical virus during the winter season and for atypical pathogens in severe
cases (Legionella spp., Mycoplasma pneumoniae, Chlamydia pneumoniae) may be considered,
if results can be obtained sufficiently rapid to be therapeutically relevant.
§
Diagnostic puncture (see table 5) in case of a significant pleural
effusion (> 10 mm depth in ultrasonography)
§
Bronchoalveolar lavage (BAL)
or bronchoscopic protected specimen brush in nonresolving pneumonia
§
Bronchoscopic sampling in
intubated patients
3.3
Antimicrobial treatment
§
Empiric antimicrobial
treatment should be initiated as
soon as possible.
§
A severity assessment
according to the individual risk of mortality should be performed. The
assessment to mild (ambulant), moderate (hospital ward) and severe pneumonia
(intensive care unit) implies a decision regarding the most appropriate
treatment setting.
§
The empiric therapy should
also consider general and local patterns of resistance of the leading pathogens
and considerations of tolerability and toxicity in the individual patient.
§
Additional risk factors
(epidemiological factors, travel history and exposure) need to be taken into
account (ref 1 p.1155; table 12).
§
Empiric treatment options are
shown in table
3.
§
Recommended treatment options
for specific pathogens are shown in table 6.
3.4
Intensive care unit (ICU) admission
§
ICU admission should be
considered in patients with severe CAP and/or:
o
Respiratory failure: Acute or
severe (PaO2/FiO2 <250; oxygen saturation <90% with 6 l/min O2)
o
Requirement for mechanical
ventilation or vasopressors > 4h
o
Severe sepsis or septic shock
o
Radiographic extension of
infiltrates (i.e. multilobar involvement)
3.5
Duration of treatment
§
The appropriate duration of
antimicrobial treatment has not been settled.
§
The usual duration is 7-10
days, intracellular pathogens (i.e. Legionella
spp.) should be treated for at least 14 days.
§
The trend is to shorten the
duration of antibiotic therapy. Generally we recommend antibiotic treatment
until the patient is afebrile for 3-5 days.
§
Since 2003, several studies
addressing shorter courses of therapy in selected patients were published (five
days levofloxacin 750 mg/d in mild-to severe CAP3; three day regimen
in mild-to-moderate CAP with substantially improvement after three days of
intravenous amoxicillin therapy4). Shorter courses are not discussed
in the ERS / ESCMID guidelines.
3.6
Switch from intravenous to oral treatment
§
In patients with moderate to
severe CAP, treatment should be started intravenously.
§
The optimal time to switch to
oral treatment is unknown. The ERS / ESCMID guidelines suggest to target this
decision according to the resolution of the most prominent clinical features
upon admission (i.e. resolution of fever).
3.7
Additional therapies
§
Low molecular weight heparin
in patients with acute respiratory failure.
§
In patients with severe sepsis
and septic
shock, aggressive volume therapy (“early goal-directed therapy”),
maintainance of glycemic control and low-dose steroids in patients with
relative adrenal insufficiency (f.e. hydrocortone 3x100 mg i.v. after
Synacthen®-test) are recommended.
3.8
Monitoring of CAP
§
Response to therapy should be
monitored by clinical criteria (temperature, respiratory and hemodynamic
parameters). The same parameters should be applied to judge the possibility of
hospital discharge.
§
Complete response, including
radiographic resolution, requires longer time periods.
3.9
Non-responding patients
§
Treatment failures should be
differentiated in non-responding pneumonia and slow resolving pneumonia.
§
In case of non-responding
pneumonia in an unstable patient, full reinvestigation (including BAL) followed
by a second empiric antimicrobial treatment regimen is recommended.
§
Slowly resolving pneumonia
should be reinvestigated according to clinical needs (empyema?, abscess?) in
relation to the condition and individual risk factors of the patient.
4.
Prevention (see page 1164-1169 of ref.1)
4.1
Vaccination against influenza and S. pneumoniae (see annually updated Swiss recommendations)
§
In brief, annual influenza vaccination (inactivated vaccine) is recommended for all adults with ≥ 1 of the following:
o
age ≥ 65y;
institutionalisation; chronic cardiac, pulmonary or renal disease, diabetes, hemoglobinopathies; patients with immunosuppression; health care workers; females who will be in the 2° or 3°
trimester of pregnancy during the influenza season.
§
The 23-valent polysaccharide pneumococcal vaccine is recommended for all adults at risk for pneumococcal disease:
o
age ≥ 65y;
institutionalisation; chronic cardiac, pulmonary, renal or liver disease; diabetes; functional or anatomic asplenia; HIV positive patients; dementia; seizures; chronic cerebrospinal fluid leakage
o
Consider revaccination after
5-10 years.
4.2
Preventive measures in unusual situations
§
Prevention of influenza with anti-virals is only recommended for very high risk patients (e.g. lung transplant), i.e. if vaccination could not be given and can be considered in unusual situations like outbreaks within closed communities.
§
Not recommended preventive
measures are:
o
Oral immunisation with
bacterial extracts or H. influenza
oral vaccine
o
Prophylactic use of antibiotics
or inhaled steroids or long-acting β2-agonists to prevent LRTI in patients
with chronic bronchitis or COPD
o
Treatment of upper
respiratory tract infection with antibiotics will not prevent LRTI.
o
Regular use of oral
mucolytics in patients with chronic bronchitis or COPD to prevent LRTI .
5.
Literature
1.
Woodhead M, Blasi F, Ewig S,
et al. Guidelines for the management of adult lower respiratory tract
infections. Eur Respir J 2005;26:1138-1180.
2.
Roson B, Fernandez-Sabe N,
Carratala J, et al. Contribution of a urinary
antigen assay (Binax NOW) to the early diagnosis of pneumococcal pneumonia.
Clin Infect Dis 2004;38:222-226.
3.
Dunbar LM, Wunderink RG, Habib MP, et al. High-dose, short-course levofloxacin for
community-acquired pneumonia: a new treatment paradigm. Clin Infect Dis
2003;37:752-760.
4.
El Moussaoui R, De Borgie CA,
Van den Broek P, et al. Effectiveness of
discontinuing antibiotic treatment after three days versus eight days in mild
to moderate-severe community acquired pneumonia: randomised, double blind
study. BMJ 2006;332:1355-1361.
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