Pneumonia%20-%20community-acquired Management

• Pneumococcal and influenza vaccines are recommended for the prevention of community-acquired pneumonia (CAP)

Pneumococcal Vaccine¹

• There are 4 different types of pneumococcal vaccines: 13-valent pneumococcal polysaccharide conjugate vaccine (PCV13), 15-valent pneumococcal polysaccharide conjugate vaccine (PCV15)  and 23-valent pneumococcal polysaccharide vaccine (PPSV23) are recommended for adults and 10-valent pneumococcal conjugate vaccine (PCV10), PCV13 and PCV15 are recommended for children
• Pneumococcal vaccination is routinely recommended in adults for the following:
  
  • Persons ≥65 years old
  • Persons aged 19-64 years who smoke cigarettes, with chronic heart disease (including CHF and cardiomyopathy but excluding hypertension), chronic lung disease (including chronic obstructive lung disease, asthma and emphysema), chronic liver disease (including liver cirrhosis), alcoholism and DM
  • People living in nursing homes or other long-term care facility
• Immunocompromised conditions that require pneumococcal vaccination:
  • B- or T-lymphocyte deficiency, complement deficiencies and phagocytic disorders (excluding chronic granulomatous disease)
  • HIV infection (vaccine should be given as soon as possible)
  • Chronic renal failure and nephrotic syndrome
  • Leukemia, Hodgkin lymphoma, generalized malignancy and multiple myeloma
  • Organ transplant (solid)
  • Iatrogenic immunosuppression (including long-term systemic corticosteroid and radiation therapy)
    • Should be given at least 2 weeks before starting immunosuppressive therapy
  • Anatomical or functional asplenia (eg sickle cell disease and other hemoglobinopathies, congenital or acquired  asplenia, splenic dysfunction and splenectomy)
    • Should be given at least 2 weeks before an elective splenectomy
• For ≥19 years old with cochlear implant and CSF leak, PCV20 single dose is recommended 
  • Alternatively, PCV15 may be given 1st followed by PPSV23 given ≥8 weeks
  • For ≥19 years old with cochlear implant and CSF leak and given PPSV23 only, PCV20 or PCV15 should be given ≥1 year after PPSV23 administration
  • For ≥19 years old with cochlear implant and CSF leak and given PCV13 only, PCV20 should be given at least 1 year or PPSV23 should be given ≥8 weeks after PCV13 administration
  • For ≥19 years old with cochlear implant and CSF leak and given PCV13 and 1 dose of PPSV23, PCV20 should be given ≥5 years after PPSV23 administration
• Pneumococcal 13-valent conjugate vaccine can be given to patients age >50 years to prevent pneumonia and other invasive pneumococcal diseases
• Pneumococcal vaccine is not recommended for persons with history of serious allergic reaction to a vaccine component, moderate or severe acute illness, and pregnancy
• Based on the recommendation made by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), for patients ≥65 years with indications for both PCV15 and PPSV23 vaccination with no history of any pneumococcal vaccination, PCV20 should be administered
  
  • Alternatively, PCV15 may be given first followed by the PPSV23 dose ≥1 year after PCV15 administration
  • PCV13 or PCV15 and PPSV23 should not be administered concurrently in the same visit
  • For patients who received PPSV23 vaccination only at any age, PCV15 or PCV20 should be given ≥1 year after the previous PPSV23 dose
  • If patient was previously vaccinated with PCV13 only, PCV20 or PPSV23 should be given ≥1 year after previous PCV13 dose
  • For patients with both PPSV23 and PCV13 doses given before age 65 years, PCV20 or PPSV23 should be given ≥5 years after previous PPSV23 dose
• Revaccination of PPSV23 at age >65 years is recommended 5 years after the last dose of PPSV23 for persons who have received PPSV23 before age 65 years
  • 2nd dose of PPSV23 given 5 years after the 1st dose is advised in persons 19-64 years old with functional or anatomical asplenia and for persons who are immunocompromised

Influenza Vaccine¹

• Influenza vaccine is recommended for any person who is at increased risk for complications from influenza:
  • Persons ≥50 years old
  • Those with chronic illnesses [eg lung diseases, cardiovascular disease (CVD), diabetes mellitus (DM), renal dysfunction, hemoglobinopathies]
  • Immune system disorders [eg human immunodeficiency virus (HIV) infection, malignancies, use of immunosuppressive drugs, radiation therapy, organ or bone marrow transplantation]
  • Residents of nursing homes and other chronic care facilities
  • Healthcare workers and other persons (including household members) in close contact with persons at high-risk should be vaccinated to decrease the risk for transmitting influenza to persons at high-risk
  • Woman who are or may conceive during the influenza season
  • Extremely obese individuals (body mass index ≥40)

Principles of Vaccine Administration

• Both pneumococcal and influenza vaccines can be administered simultaneously at different sites without increasing side effects
• No contraindication for use of either pneumococcal or influenza vaccine immediately after an episode of pneumonia

Smoking Cessation

• Decreases the risk for pneumonia and other invasive pneumococcal diseases (IPD)
• Lowers the risk of IPD by 14% each year after quitting smoking and will return to risk level similar to persons who had never smoked after 13 years

Treatment Failure

• Generally defined as lack of response or worsening of clinical status
  
  • Hemodynamic instability
  • Impairment of respiratory function
  • Need for mechanical ventilation
  • Radiographic progression
  • Appearance of new metastatic infectious foci

Management

• Reassess patient for possible resistance to antibiotics being given
• Consider presence of other pathogens (eg M tuberculosis, viruses, parasites or fungi)
• Remeasure C-reactive protein and repeat chest X-ray if without any clinical improvement 3 days after initiation of therapy
• In addition to microbiological diagnostic procedures, chest computed tomography (CT) scan, thoracentesis, and bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsies, and chest X-ray should be considered
  • Follow up chest X-ray to identify pneumothorax, cavitation and extension to previously uninvolved lobes, pulmonary edema and acute respiratory distress syndrome (ARDS)
• Revise treatment accordingly

Low-risk Pneumonia

• Most patients respond to treatment within 24-72 hours
• Indicators of response to therapy:
  
  • Decline of fever within 72 hours and return of temperature to normal within 5 days
  • Resolution of respiratory signs

Moderate-risk and High-risk Pneumonia

• Streamlining initial empiric broad-spectrum parenteral therapy to a single narrow-spectrum parenteral or oral agent based on available lab data is recommended as early as 72 hours following initiation of empirical treatment
• Indications for streamlining of antibiotic therapy:
  
  • Less cough and normalization of respiratory rate
  • Afebrile for >24 hours
  • Blood cultures are negative or etiology is not a high-risk (virulent/resistant) pathogen
  • No unstable comorbid condition or life-threatening complication [eg myocardial infarction (MI), congestive heart failure (CHF), complete heart block, new atrial fibrillation, supraventricular tachycardia]
  • No obvious reason for continued hospitalization [eg hypotension, acute mental changes, blood urea nitrogen (BUN):creatinine ratio of >10:1, hypoxemia, metabolic acidosis, etc]
  • Able to initiate and maintain oral intake
• Switching therapy to an oral agent will allow discharge from the hospital as early as the 4th day of hospitalization and will lead to cost savings
• In patients given empiric therapy for MRSA or P aeruginosa, blood and sputum culture should be obtained and agents should be de-escalated after 2 days if cultures are negative and with clinical improvement
• Inpatient observation while receiving oral therapy is not necessary

Patients with Poor Treatment Response

• Major causes of antibiotic failure include mismatch between causative organism and agent used, causative agent not covered by usual empirical treatment, presence of nosocomial superinfection pneumonia or complications eg empyema
• May do a follow-up chest X-ray or CT scan
• Reassess for possible resistance to antibiotics being given
• Consider other pathogens (eg M tuberculosis, viruses, parasites or fungi)
• Consider other conditions [eg pneumothorax, cavitation and extension to previously uninvolved lobes, pulmonary edema and acute respiratory distress syndrome (ARDS)]
• Revise treatment based on causative agents and sensitivity test results (pathogen-specific antimicrobial therapy)

Criteria for Discharge

• Review patient status within 24 hours of planned discharge
• Patients should fulfill the following criteria:
  • Temperature of 36-37.5°C
  • Pulse <100 beats/minute
  • Respiratory rate (RR) 16-24 breaths/minute
  • Systolic blood pressure (SBP) >90 mmHg
  • Blood oxygen saturation >90%
  • Ability to eat and take oral antibiotics
  • Absence of active clinical or psychosocial problems requiring hospital stay