Management of Community-Acquired Pneumonia

American Journal of Respiratory Medicine - Tập 2 - Trang 385-394 - 2012
James S. Tan1, Thomas M. File1
1Infectious Disease Section, Department of Internal Medicine, Northeastern Ohio Universities College of Medicine and Summa Health System, Akron, USA

Tóm tắt

Patients with community-acquired pneumonia (CAP) are treated in hospital or in the ambulatory care setting depending on the severity of illness. Despite numerous guidelines proposed, there is no agreement on specific criteria for hospitalization other than the clinicians’ experience. The purpose of this review is to discuss the importance of the appropriate choice and timely administration of antibacterial agents, either in the hospital or in the outpatient setting. Since a high proportion of CAP patients will not have an etiologic agent identified at the time of initiation of treatment, the choice of antibacterial therapy is usually empiric. Antibacterial agents with activity against pneumococci and atypical pathogens causing pneumonia are the preferred choices. Macrolides, doxycycline, or respiratory fluoroquinolones have been recommended by various guidelines committees in North America for the treatment of pneumonia in patients with or without underlying comorbidities. Because of the increasing resistance to β-lactams as well other antibacterial agents such as macrolides, doxycycline, and sulfamethoxazole/trimethoprim (cotrimoxazole), it is important that clinicians are aware of local statistics on resistance to Streptococcus pneumoniae, as infection with this bacterium is associated with high rates of morbidity and mortality. More recently, fluoroquinolone resistance has been reported, but the percentage of pneumococcal strains resistant to this agent is relatively low compared with the other antibacterial agents. Switch (intravenous to oral) therapy is recommended for hospitalized patients with CAP to facilitate early discharge, which has been shown to improve patient satisfaction and reduce hospital costs. Early conversion to oral therapy has not been shown to be associated with increased complications or higher mortality. Following prompt intravenous therapy and stabilization, patients with CAP should be treated with oral therapy in the ambulatory setting.

Tài liệu tham khảo

Bartlett JG, Breiman RF, Mandell LA, et al. Community-acquired pneumonia in adults: guidelines for management. Clin Infect Dis 1998; 26: 811–38 Marston BJ, Plouffe JE, File TM, et al. Incidence of community-acquired pneumonia requiring hospitalization: results of a population-based active surveillance study in Ohio. Arch Intern Med 1997; 157: 1709–18 Halm E, Switzer G, Mittman B, et al. What factors influence physicians’ decisions to switch from intravenous to oral antibiotics for community-acquired pneumonia?. J Gen Intern Med 2001; 16(9): 599–605 Lave JR, Lin CC, Hughes-Cromick P. The cost of treating patients with community-acquired pneumonia. Semin Respir Crit Care Med 1999; 20: 189–97 McCormick D, Fine MJ, Coley CM, et al. Variation in length of hospital stay in patients with community-acquired pneumonia: are shorter stays associated with worse medical outcomes? Am J Med 1999; 107: 5–12 Lim AF, Tan JS, Murphy DM. Factors influencing length of stay, time to resolution of morbidity, and cost of patient care: a comparative retrospective study of short-stay and long-stay patients hospitalized for simple pneumonia (DRG 89 and 90). Infect Dis Clin Pract 2001; 10: 375–83 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 Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-acquired pneumonia in adults. Clin Infect Dis 2000; 31: 347–82 Atlas SJ, Benzer TI, Borowsky LH, et al. Safely increasing the proportion of patients with community-acquired pneumonia treated as outpatients: an interventional trial. Arch Intern Med 1998; 158: 1350–6 Marrie TJ, Lau CY, Wheeler SL, et al. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. JAMA 2000; 283: 749–55 Halm EA, Fine MJ, Marrie TJ, et al. Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines. JAMA 1998; 279(18): 1452–7 Ewig S, Schafer H, Torres A. Severity assessment in community-acquired pneumonia. Eur Respir J 2000; 16(6): 1193–201 Dean N, Suchyta M, Bateman K, et al. Implementation of admission decision support for community-acquired pneumonia. Chest 2000; 117(5): 1368–77 Fantin B, Aubert J, Unger P, et al. Clinical evaluation of the management of community-acquired pneumonia by general practitioners in France. Chest 2001; 120(1): 185–92 Fine MJ, Hough LJ, Medsger AR, et al. The hospital admission decision for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study. Arch Intern Med 1997; 157: 36–44 Mandell LA, Marrie TJ, Grossman RF, et al. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. Clin Infect Dis 2000; 31: 383–421 Macfarlane J, Boswell T, Douglas G, et al. BTS Guidelines for the management of community acquired pneumonia in adults. Thorax 2001; 56Suppl. IV: iv1–iv56 Niederman M. Guidelines for the management of community-acquired pneumonia: current recommendations and antibiotic selection issues. Med Clin North Am 2001; 85(6): 1493–509 Coley CM, Li Y-H, Medsger AR, et al. Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia. Arch Intern Med 1996; 156: 1565–71 Grasela TH, Welage LS, Walawander CA, et al. A nationwide survey of antibiotic prescribing patterns and clinical outcomes in patients with bacterial pneumonia. DICP 1990; 24: 1220–5 Ramirez J. Switch therapy in community-acquired pneumonia. Diagn Microbiol Infect Dis 1995; 22(1–2): 219–23 Niederman MS, Bass Jr JB, Campbell GD, et al. Guidelines for the initial management of adults with community acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. Am Rev Respir Dis 1993; 148: 1418–26 Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process, and outcomes in elderly patients with pneumonia. JAMA 1997; 278(23): 2080–4 Battleman DS, Callahan M, Thaler HT. Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community-acquired penumonia: link between quality of care and resource utilization. Arch Intern Med 2002; 162: 682–8 Leroy O, Santre C, Beuscart C. A 5-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an ICU. Intensive Care Med 1995; 21: 24–31 Niederman M, Mandell L, Anzueto A, et al. Guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001; 163(7): 1730–54 Fang GD, Fine M, Orloff J, et al. New and emerging etiologies for community acquired pneumonia with implications for therapy. Medicine 1990; 69: 307–16 Bochud P-V, Moser F, Erard P, et al. Community-acquired pneumonia: a prospective outpatient study. Medicine 2001; 80: 75–87 Falguera M, Sacristan O, Nogues A, et al. Nonsevere community-acquired pneumonia: correlation between cause and severity or comorbidity. Arch Intern Med 2001; 161: 1866–72 Hansman D, Glasgow H, Surt J, et al. Increased resistance to penicillin of pneumococci isolated from man. N Engl J Med 1971; 284: 175–7 Hansman D, Bullen MM. A resistant pneumococcus. Lancet 1967; II: 264–5 Heffelfinger JD, Dowell SF, Jorgensen JH, et al. Management of community-acquired pneumonia in the era of pneumococcal resistance: a report from the drug-resistant Streptococcus pneumoniae therapeutic working group. Arch Intern Med 2000; 160: 1399–408 Thornsberry C, Sahm DF, Kelly LJ, et al. Regional trends in antimicrobial resistance among clinical isolates of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in the United States: results from the TRUST Surveillance Program, 1999–2000. Clin Infect Dis 2002; 34Suppl. 1: S4–S16 Song JH, Lee NY, Ichiyama S, et al. Spread of drug resistant Streptococcus pneumoniae in Asia countries: Asian Network for Surveillance of Resistant Pathogens (ANSORP) study. Clin Infect Dis 1999; 28: 1206–11 Appelbaum PC. Antimicrobial resistance in Streptococcus pneumoniae: an overview. Clin Infect Dis 1992; 15: 77–83 Munoz R, Coffey TJ, Daniels M, et al. Intercontinental spread of a multiresistant clone of serotype 23F Streptococcus pneumoniae. J Infect Dis 1991; 164: 302–6 Soares S, Kristinsson KG, Musser JM, et al. Evidence for the introduction of a multiresistant clone of 6B Streptococcus pneumoniae from Spain to Iceland in the late 1980s. J Infect Dis 1993; 168: 158–63 Jabes D, Nachman S, Tomasz A. A penicillin-binding protein families: evidence for clonal nature of penicillin resistance in clinical isolates of pneumococci. J Infect Dis 1989; 159: 16–25 Kalin M, Ortqvist A, Almela M, et al. Prospective study of prognostic factors in community-acquired bacteremic pneumococcal disease in 5 countries. J Infect Dis 2000; 182: 840–7 Nasrin D, Collignon PJ, Roberts L, et al. Effect of β lactam antibiotic use in children on pneumococcal resistance to penicillin: prospective cohort study. BMJ 2002; 324: 28–30 Bauer T, Ewig S, Marcos MA, et al. Streptococcus pneumoniae in community-acquired pneumonia: how important is drug resistance? Med Clin North Am 2001; 85: 1367–79 Shortridge VD, Doern GV, Bruggemann AB, et al. Prevalence of macrolide resistance mechanisms in Streptococcus pneumoniae isolates from a multicenter antibiotic resistance surveillance study conducted in the United States in 1994–1994. Clin Infect Dis 1999; 29: 1186–8 Lynch JP, Martinez FJ. Clinical relevance of macrolide-resistant Streptococcus pneumoniae for community-acquired pneumonia. Clin Infect Dis 2002; 34Suppl. 1: S27–46 Ho PL, Que TL, Tsang DNC, et al. Emergence of fluoroquinolone resistance among multiply resistant strains of Streptococcus pneumoniae in Hong Kong. Antimicrob Agents Chemother 1999; 43: 1310–3 Ailani RK, Agastya G, Ailani RK, et al. Doxycycline is a cost-effective therapy for hospitalized patients with community-acquired pneumonia. Arch Intern Med 1999; 159: 266–70 Cunha B. Doxycyline re-revisited. Arch Intern Med 1999; 159: 1006–7 Doern GV, Heilmann KP, Huynh HK, et al. Antimicrobial resistance among clinical isolates of Streptococcus pneumoniae in the United States during 1999–2000, including a comparison of resistance rates since 1994–1995. Antimicrob Agents Chemother 2001; 45: 1721–9 Chen DK, McGeer A, de Azavedo JC, et al. Decreased susceptibility of Streptococcus pneumoniae to fluoroquinolones in Canada. N Engl J Med 1999; 341: 233–9 Davidson R, Cavalcanti R, Brunton JL, et al. Resistance to levofloxacin and failure of treatment of pneumococcal pneumonia. N Engl J Med 2002; 346: 747–50 Hooper DC. Mechanisms of action of antimicrobials: focus on fluoroquinolones. Clin Infect Dis 2001; 32Suppl. 1: S9–S15 Marrie TJ, Peeling RW, Fine MJ, et al. Ambulatory patients with community-acquired pneumonia: the frequency of atypical agents and clinical course. Am J Med 1996; 101: 508–15 Gupta SK, Sarosi GA. The role of atypical pathogens in community-acquired pneumonia. Med Clin North Am 2001; 85: 1349–65 Gleason PP. The emerging role of atypical pathogens in community-acquired pneumonia. Pharmacotherapy 2002; 22(1 Pt 2): 2S–11S Weingarten SR, Riedinger MS, Hobson P, et al. Evaluation of a pneumonia practice guideline in an interventional trial. Am J Respir Crit Care Med 1996; 153: 1110–5 Van den Brande P, Vondra V, Vogel F, et al. Sequential therapy with cefuroxime followed by cefuroxime axetil in community-acquired pneumonia. Chest 1997; 112(2): 406–15 Ramirez J, Srinath L, Ahkee S, et al. Early switch from intravenous to oral cephalosporins in the treatment of hospitalized patients with community-acquired pneumonia. Arch Intern Med 1995; 155(12): 1273–6 Hendrickson J, North D. Pharmacoeconomic benefit of antibiotic step-down therapy: converting patients from intravenous ceftriaxone to oral cefpodoxime proxetil. Ann Pharmacother 1995; 29: 561–5 Rhew D, Tu G, Ofman J, et al. Early switch and early discharge strategies in patients with community-acquired pneumonia: a meta-analysis. Arch Intern Med 2001; 161(5): 722–7 Andaya MRP, Raab TA. Is one day of in-hospital observation after switching from intravenous to oral antibiotic therapy in the treatment of community acquired pneumonia necessary. Infect Dis Clin Pract 2000; 9(9): 372–5 Rhew D, Hackner D, Henderson L, et al. The clinical benefit of in-hospital observation in ‘low-risk’ pneumonia patients after conversion from parenteral to oral antimicrobial therapy. Chest 1998; 113(1): 142–6 Dunn AS, Peterson KL, Schechter CB, et al. The utility of an in-hospital observation period after discontinuing intravenous antibiotics. Am J Med 1999; 106: 6–10 Fine MJ, Pratt IIM, Obrosky DS, et al. Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia. Am J Med 2000; 109: 378–85 Halm E, Fine JM, Kapoor WN, et al. Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia. Arch Intern Med 2002; 162: 1278–84 Ramirez J, Vargas S, Ritter G, et al. Early switch from intravenous to oral antibiotics and early hospital discharge: a prospective observational study of 200 consecutive patients with community-acquired pneumonia. Arch Intern Med 1999; 159(20): 2449–54 Ramirez J, Bordon J. Early switch from intravenous to oral antibiotics in hospitalized patients with bacteremic community-acquired Streptococcus pneumoniae pneumonia. Arch Intern Med 2001; 161(6): 848–50 Plouffe J, Schwartz DB, Kolokathis A, et al. Clinical efficacy of intravenous followed by oral azithromycin monotherapy in hospitalized patients with community-acquired pneumonia. Antimicrob Agents Chemother 2000; 44: 1796–802 Vergis EN, Indorf A, File Jr TM, et al. Azithromycin vs cefuroxime plus erythromycin for empirical treatment of community-acquired pneumonia in hospitalized patients: a prospective, randomized, multicenter trial. Arch Intern Med 2000; 160: 1294–300 File Jr TM. Appropriate use of antimicrobials for drug-resistance pneumonia: focus on the significance of β-lactam-resistant Streptococcus pneumoniae. Clin Infect Dis 2002; 34Suppl. 1: S17–26 Waterer GW, Wunderink RG. Fatal pneumococcal pneumonia attributed to macrolide resistance and azithromycin monotherapy. Chest 2000; 118: 1839–40 Fogarty C, Goldschmidt R, Bush K. Bacteremic pneumonia due to multidrugresistant pneumococci in 3 patients treated unsuccessfully with azithromycin and successfully with levofloxacin. Clin Infect Dis 2000; 31: 613–5 Kelley MA, Weber DJ, Gilligan P, et al. Breakthrough pneumococcal bacteremia in patients being treated with azithromycin and clarithromycin. Clin Infect Dis 2000; 31: 1008–11 Waterer G, Somes G, Wunderink R. Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia. Arch Intern Med 2001; 161(15): 1837–42 Castro-Guardiola A, Viejo-Rodriguez A, Soler-Simon S, et al. Efficacy and safety of oral and early-switch therapy for community-acquired pneumonia: a randomized controlled trial. Am J Med 2001; 111(5): 367–74 Cassiere H, Fein A. Duration and route of antibiotic therapy in community-acquired pneumonia: switch and step-down therapy. Semin Respir Infect 1998; 13(1): 36–42 Cunha B. Oral or intravenous-to-oral antibiotic switch therapy for treating patients with community-acquired pneumonia. Am J Med 2001; 111(5): 412–3 Krumpe P, Cohn S, Garreltes J, et al. Intravenous and oral mono- or combination-therapy in the treatment of severe infections: ciprofloxacin versus standard antibiotic therapy. Ciprofloxacin Study Group. J Antimicrob Chemother 1999; 43Suppl. A: 117–28 Nathwani D, Boyter A, Fegan P, et al. Switch therapy in community-acquired pneumonia [letter]. Arch Intern Med 1996; 156(11): 1235 Omidvari K, de Boisblanc BP, Karam G, et al. Early transition to oral antibiotic therapy for community-acquired pneumonia: duration of therapy, clinical outcomes, and cost analysis. Respir Med 1998; 92(8): 1032–9 Press R. The use of fluoroquinolones as antiinfective transition-therapy agents in community-acquired pneumonia. Pharmacotherapy 2001; 21(7 Pt 2): 100S–4S Ramirez J. Switch therapy with beta-lactam/beta-lactamase inhibitors in patients with community-acquired pneumonia. Ann Pharmacother 1998; 32(1): S22–6 Ramirez J. Managing antiinfective therapy of community-acquired pneumonia in the hospital setting: focus on switch therapy. Pharmacotherapy 2001; 21(7 Pt 2): 79S–82S Siegel R. Strategies for early discharge of the hospitalized patient with community-acquired pneumonia. Clin Chest Med 1999; 20(3): 599–605