| ID | 92 |
|---|---|
| Name | COMMUNITY-ACQUIRED PNEUMONIA (CAP) |
| Cause | |
| Signs Symptoms | |
| Diagnosis | |
| Investigations | Investigations: 1. Blood count: Shows marked leukocytosis; 2. Blood culture: Positive in 25% cases. 3. Sputum for gram-stain: Red cells, white cells & pneumococci may be seen. 4. X-Ray chest: Shows consolidation localised, or patchy in distribution appearing within 12-18 hours of the onset of illness. |
| Management | Management: The important aspects of management include- a. Oxygenation, b. Fluid balance, c. Antibiotic therapy, d. General management. A. Oxygenation: 1. O2 inhalation should be started immediately for all hypoxaemic patients. Concentrations should be used (e.g 35% or more) to maintain PaO2 8 kPa (60 mmHg) or more, or SaO2 92% or more. Assisted ventilation may be considered in cases where patients remain hypoxaemic despite adequate oxygen therapy. 2. Analgesic (e.g paracetamol.) if chest pain. 3. Treatment of pleural pain-Mild analgesic such as paracetamol is rarely adequate and most patients require pethedine 50-100 mg or morphine 10-15 mg by i.m or i.v injection. Opiates, however, must be used with extreme caution. 4. Paraldehyde if delirious. B. Fluid balance: 1. Adequate oral fluid and liquid diet should be started and gradually as the temperature subsides high protein and high calorie diet with plenty of fluid and electrolyte should be given. If the patient is severely ill or vomiting, or in case of very older patient, intravenous fluid should be considered. C. Specific antimicrobial therapy:1-2 In cases of uncomplicated CAP: 1. Penicillin is the drug of choice: Amoxycillin 500mg orally 8 hourly for 7-10 days. 2. For penicillin-allergic patients: Erythromycin 500mg orally 6-hourly for 7-10 days. Or, Clarithromycin 500mg orally 12-hourly for 7-10 days. Or, Azithromycin one 500mg dose on the first day followed by 250mg once a day for the next 4 days or 500mg daily for 3 days. Or, Doxycycline 100mg orally twice daily for 7-10 days. Or, Levofloxacin 500mg orally once daily; or moxifloxacin 400mg orally once daily for 7-10 days. 3. In case of suspected aspiration pneumonia: Co-amoxiclav 875mg orally 12-hourly for 7-10 days. Or, Cefuroxime axetil 250-500mg orally; or, cefpodoxime proxetil 100-200mg orally; or, cefprozil 250-500mg orally 12-hourly for 7-10 days. 4. In case of staphylococcal infection (suspected or cultured): Flucloxacillin l-2gm by i.v injection 6-hourly for 7-10 days. Plus, Clarithromycin 500mg by i.v injection 12-hourly for 7-10 days. In severe infections, treatment for longer period (14 days or more) may be required. 5. In case of mycoplasma or legionella infection: Clarithromycin 500mg orally or by i.v injection 12-hourly for 7-10 days. Or Erythromycin 500mg orally or by i.v injection 6-hourly for 7-10 days. Plus, Rifampicin 600mg by i.v injection 12-hourly for 7-10 days. Treatment for longer period may be required. In cases of complicated or severe CAP: If there is no clinical response with above medication, or the patient is seriously ill, or those with other medical problems should be admitted in the hospital and treated parenterally: Clarithromycin 500mg by i.v injection 12-hourly for 7-10 days or more. Or, Erythromycin 500mg by i.v injection 6-hourly for 7-10 days or more. Plus, Co-amoxiclav 1.2gm by i.v injection 8-hourly for 7-10 days or more. Or, Ceftriaxone l-2gm by i.v/i.m injection daily. Or, Cefuroxime l.5gm by i.v injection 8-hourly. Or, Amoxicillin Igm by i.v injection 6-hourly, plus flucloxacillin 2gm by i.v injection 6-hourly for 7-10 days or more. In case of immunocompromised patients: Antibiotics recommended: In immunocompromised patients- i. pneumonia infections are more profound and more virulent; ii. non-pathogenic or non-virulent organisms may also become ‘opportunistic’ pathogens; iii. infections are often due to more than one agent i.e mixed infections, such as gram-positive bacteria, gram-negative bacteria (specially pseudomonas aeruginosa), viruses, fungi, mycobacteria and less commonly nocardia asteroides. But in practice, in most cases causative agents remain unknown and broad-spectrum antibiotics are given imperically. 1. A third-generation cephalosporin, such as- Ceftriaxone 2gm i.v once daily; or, Cefotaxime 3gm i.v 6-hourly. Or, A quinolone derivative, such as-Levofloxacin 750mg i.v once or twice daily. Plus, An antistaphylococcal antibiotic, such as-Flucloxacillin l-2gm i.v 6-hourly. 2. In cases of suspected or cultured pseudomonal infection- An antipseudomonal penicillin, such as- piperacillin (dosage- see in the text). Plus, An aminoglycoside, such as- amikacin maximum 500mg i.v/i.m every 8-hours, not more than 10 days |
| Introduction | Community-acquired pneumonia (CAP) is the commonst variety of pneumonia, occurs mostly in previously healthy individuals (so called primary pneumonia). Strep, pneumoniae is the most common infecting agent, also other organisms may be involved depending on the age of the patient and the clinical context. Viral infections are an important cause of CAP in children. Pneumonia is a deadly infectious disease and a leading cause of mortality in children and old age. The pneumonia infection is spread mainly by droplet and the incidence is much higher in winter. |
| History | |
| Etiology | |
| Clinical Features | Clinical feature: 1. Acute onset with chill and rigor or vomiting or convulsion in children. 2. High continuous fever upto 105°F (39-40°C) 3. Breathlessness and short painful cough, dry first then productive tenaceous sputum, often rusty coloured, occasionally blood stained. 4. Pain in the chest commonly on the right side associated with pleurisy; pain may be referred to the shoulder or abdomen. 5. Headache and loss of appetite is common. 6. Malaise, weakness, aching pain in the body & limbs. 7. The patient looks very ill with hurried respiration, Herpes labialis is usually found. On physical examination- 8. Pulse rapid; skin hot, dry & face is flushed. 9. Respiration shallow and painful. 10. Central cyanosis may be present. 11. Movement of chest reduced; percussion note dull. 12. Vocal resonance increased with fine or coarse crepitation, pleural rub on the affected side. |
| Preventions | |
| Treatment | |
| Complications | Treatment of complications: 1. If para-pneumonic pleural effusion- thoracentesis should be performed. Chest tube drainage may be required if pneumococci are identified by culture or gram stain. 2. If shock- it should be corrected immediately. 3. If abdominal distension- gastric decompression by ryles tube should be done. 4. If empyema or pericarditis- proper antibiotic therapy and surgical drainage should be done. Echocardiography should be done if pericardial effusion is suspected. |
| Prognosis | |
| Types | |
| Classification | |
| Observation | |
| Pathology |
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