PulmonaryPC2

Community-Acquired Pneumonia (CAP) Diagnosis and Management

• Involves assessing patient history, symptoms, physical exam findings, and diagnostic tests
• Symptoms may include cough, fever, dyspnea, pleuritic chest pain, fatigue, myalgias, or sputum production
• Physical exam may reveal crackles or rales upon lung auscultation and dullness on percussion with decreased breath sounds indicative of consolidation
• Diagnostic tests: Chest X-rays confirm the diagnosis and identify lobar consolidation, Pulse oximetry assesses oxygen saturation and Sputum cultures can identify the causative pathogen, if available

CAP Risk Factors

• Age: Older adults (≥65 years) and young children (<2 years) are at higher risk
• COPD, asthma, heart disease (e.g., congestive heart failure), diabetes mellitus, chronic kidney disease, or liver disease increases risk
• Immunosuppression: HIV/AIDS, immunosuppressive therapy (e.g., corticosteroids, chemotherapy), and organ transplant recipients increases risk
• Lifestyle: Smoking, excessive alcohol use, and poor nutrition increases risk
• Environmental factors: Recent exposure to respiratory pathogens (e.g., influenza) or living in crowded settings (e.g., nursing homes, shelters) increases risk
• Recent Illness: Recent viral infection can predispose to bacterial pneumonia and Recent hospitalization or antibiotic use also increase risk
• Functional status: Impaired airway, difficulty swallowing, or impaired gag reflex, leading to aspiration, bedridden or reduced mobility increases risk

Outpatient Treatment - No Comorbidities

• First-line antibiotic options:
  • High-dose amoxicillin: 1g TID for 5-7 days
  • Doxycycline: 100 mg BID for 5-7 days
  • Macrolides (e.g., azithromycin): 500 mg on day 1, then 250 mg daily
• Antibiotics should be tailored based on local resistance patterns

Outpatient Treatment - With Comorbidities or Risk Factors

• Combination therapy: Beta-Lactam (e.g., Amoxicillin-Clavulanate) + Macrolide or Doxycycline
• Monotherapy: Respiratory Fluoroquinolones (e.g., Levofloxacin 750 mg daily for 5 days)

Pneumonia Severity Assessment (CURB-65)

• CURB-65 helps evaluate pneumonia severity and guide decisions about hospitalization
• CURB-65 Criteria: Score based on five criteria:
  • Confusion
  • Urea level >7 mmol/L (19 mg/dL)
  • Respiratory rate ≥30 breaths per minute
  • Blood pressure: Systolic <90 mmHg or diastolic ≤60 mmHg
  • Age ≥65 years
• Scoring:
  • 0-1 points: Low risk i.e. outpatient treatment
  • 2 points: Moderate risk i.e. short hospital stay or close outpatient monitoring
  • 3-5 points: High risk i.e. hospitalization and possible ICU care

Pneumonia Severity Index (PSI)

• PSI predicts mortality risk and guides treatment decisions for CAP patients
• PSI is more detailed than CURB-65 involving multiple clinical, laboratory, and demographic factors
• PSI is highly predictive

Pneumonia Prevention

• Pneumococcal Vaccines:
  • PPSV23 is recommended for adults 65+, high-risk younger adults, and those with certain chronic conditions
  • PCV20: provides broad protection, covering additional pneumococcal strains, approved for adults
• Annual Flu Vaccine helps to reduce the risk of viral pneumonia and secondary bacterial pneumonia
• COVID-19 Vaccine helps prevent pneumonia by protecting against severe respiratory complications from SARS-CoV-2

Influenza Diagnosis and Management

• The cause is influenza A and B viruses
• Transmission occurs through airborne respiratory droplets
• The incubation period is 1-4 days and peaks are in winter months
• Symptoms of the flue include Fever, chills, muscle aches, and headache, Sore throat, cough, and nasal congestion, and Fatigue and malaise

Patient History and Physical Examination

• Recent exposure and rapid symptom onset informs history
• Fever, pharyngitis, and mild lung exam abnormalities informs the physical exam

Influenza Diagnosis and Treatment

• Diagnostic testing for Influenza includes
  • Rapid Influenza Diagnostic Tests (RIDTs): Results in 15 minutes but can have false negatives
  • RT-PCR: High sensitivity, but longer turnaround time and is Preferred in cases of high clinical suspicion with negative RIDT
  • Clinical Diagnosis: Can be made without testing during peak flu season

Management of Influenza in Primary Care

• Antiviral Medications:
  • Oseltamivir (Tamiflu): Oral, effective within 48 hours of symptom onset
  • Zanamivir (Relenza): Inhaled, alternative for Tamiflu intolerance
  • Baloxavir (Xofluza): Single-dose oral medication
• Managing symptoms involves Rest, fluids, acetaminophen, or ibuprofen for fever and pain
• Annual vaccine is prevention for everyone aged 6 months and older

COVID-19 Assessment and Management

• Symptoms include Fever, cough, shortness of breath, Fatigue, body aches, headache, loss of taste or smell and Sore throat, congestion, nausea, diarrhea
• Testing Methods:
  • PCR Test - Gold standard with high sensitivity and specificity
  • Antigen Test - Quick with Results and useful in symptomatic individuals
  • Rapid At-Home Tests - Convenient but may have lower sensitivity
• Isolation Precautions: Follow CDC guidelines on duration based on symptom resolution and test results

COVID-19 Treatment in Primary Care

• Mild to Moderate cases are best to treat symptomatically with Acetaminophen/NSAIDs for fever and pain, fluids, rest and Antivirals

Treatment Options

• PAXLOVID: Given to eligible high-risk patients within 5 days of symptom onset
  • Interacts with many common medications and is Contraindicated for those with severe kidney or liver disease
  • Side effects include Gastrointestinal symptoms, altered taste, or liver enzyme changes
  • Age and Pregnancy: Generally recommended for adults and older children at high risk and not typically used during pregnancy without careful assessment
• MOLNUPIRAVIR:
  • Alternative if Paxlovid is contraindicated and is Not recommended during pregnancy due to potential risk of fetal harm
  • Patients of reproductive age may be advised on contraception during treatment
  • Side Effects: Potential for mild side effects like diarrhea, nausea, and dizziness, long-term safety data is still limited

COVID-19 Prevention

• Vaccination is the primary method of prevention
  • Current vaccines include mRNA vaccines (Pfizer, Moderna) and protein subunit vaccines (Novavax)
  • It is recommended for everyone aged 6 months and older, with boosters for eligible groups
  • It reduces risk of severe illness, hospitalization, and death
  • Boosters recommended to maintain immunity as it wanes over time and new boosters are updated to target recent COVID-19 variants