Managing community-acquired pneumonia during flu season
ABSTRACTThe clinical findings of influenza overlap those of community-acquired bacterial pneumonia (CABP), and influenza infection can be complicated by bacterial infections. Reviewed here are the epidemiology, pathophysiology, diagnosis, and management of community-acquired pneumonia (CAP) with special emphasis on considerations during influenza season.
KEY POINTS
- Especially during flu season, clinicians should consider influenza in patients with respiratory symptoms.
- The diagnosis of CAP is based primarily on clinical factors: a combination of signs and symptoms such as cough, fever, chills, sputum production, dyspnea, pleuritic pain, tachypnea, tachycardia, hypoxemia, consolidation or rales on auscultation, and a new infiltrate on chest imaging.
- Empiric outpatient treatment of a previously healthy patient with CABP should include either a macrolide or doxycycline. A fluoroquinolone or beta-lactam plus a macrolide should be used for patients with comorbid conditions.
- Several indices have been validated for use in deciding on inpatient vs outpatient treatment and whether a patient with pneumonia should be admitted to an intensive care unit.
FOLLOW-UP AND PREVENTION
Patients with CAP can generally be expected to improve within 3 to 7 days.91 However, it may be several weeks before they return to baseline.92
Follow-up plans may be guided by the time to clinical stability. For patients who do not achieve clinical stability until more than 72 hours after admission, more aggressive follow-up on discharge is indicated, since they are more likely to experience early readmission and death.93
Pneumococcal vaccination. Because S pneumoniae remains the most common cause of CAP, efforts should be made to vaccinate patients appropriately. The Advisory Committee on Immunization Practices (ACIP) and the US Centers for Disease Control and Prevention recommend that the pneumococcal polysaccharide vaccine (Pneumovax 23; PPSV23) be given to those over age 65. Those who were vaccinated before age 65 should receive another dose at age 65 or later if at least 5 years have passed since their previous dose. Those who receive it at or after age 65 should receive only a single dose. A second dose is recommended 5 years after the first dose for people age 19 to 64 years with functional or anatomic asplenia and for those who are immunocompromised.
Influenza vaccination for all. Of note, the ACIP updated its guidelines on influenza vaccination beginning with the 2010–2011 influenza season. It no longer advocates a risk-stratified approach. Instead, it recommends universal influenza vaccination for everybody more than 6 months old.94
Smoking cessation should be addressed. Smoking cessation is a Medicare and Medicaid quality measure and should be encouraged after an episode of CAP because quitting smoking reduces the risk of pneumococcal disease by approximately 14% each year thereafter.95
