Today we
discussed our approach to CAP, however; I wanted to include a few more points
that we didn’t have a chance to cover.
Always consider Complications of
CAP:
· Pulmonary: ARDS, parapneumonic effusion,
lung abscess +/-cavity +/- necrotizing pneumonia, empyema, pleuritis,
hemorrhage
· Extra-Pulmonary/Systemic: hyponatremia, sepsis, purulent
pericarditis
Always consider reasons why the
CAP is not resolving:
· Non-infectious:
malignancy—bronchoalveolar carcinoma/lymphoma, COP, hemorrhage
· Non-bacterial: viral, fungal
· Immune-compromised host: atypical
bugs not covered;
· Wrong Antibiotic Coverage: Antibiotic
resistance
· Pneumonia complications (abscess,
empyema, ARDS)
Non-Pharmacological Management
After discharge from hospital, be
sure to consider the following for your patient:
1) Follow-up CXR (PA and Lateral): used to assess for radiographic resolution of the CAP.
Some authorities recommend a follow-up CXR, 6 weeks after treatment for
patients >40 years who are smokers, to document radiographic resolution and
exclude underlying sinister disease (i.e. malignancy). Note that the duration
required before radiographic resolution varies based on the individual patient.
In the young, otherwise healthy patient with normal cilia, expect radiographic
resolution in 3-4 weeks. In older adults, particularly smokers or those with
known ciliary dysfunction, radiographic resolution may take 6-8 weeks.
2) Vaccination:
recommend the annual influenza vaccine and the pneumococcal vaccine (if over
the age of 65; or poor immune status, smoker, pre-existing lung disease). A
booster is required for the pneumococcal vaccine q5 years.
3) Optimize lung disease management: if the patient has Asthma or COPD, they should
have regular follow-up in place, optimization of their medications, education
surrounding exacerbations and Asthma Action Plans.
4) Smoking Cessation: bring it up, assess their readiness and propose ways to cut down or
quit!
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