Lesson 2 of 1
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Pneumonia Lesson #2

November 24, 2014

 

Pneumonia Treatment

Most cases of pneumonia can be treated without hospitalization with oral antibiotics, rest, and fluids for hydration. However, people with pneumonia who are having trouble breathing, people with other medical problems, and the elderly or infants may need more advanced treatment and need to be hospitalized.

Bacterial Pneumonia Treatments

Pneumonia was lethal and difficult to treat prior to the development of the antibiotic penicillin which became available in 1942. Penicillin was widely regarded as a miracle drug which literally changed the face of infectious disease treatment. Since then, modern medicine has seen many forms of antibiotics enter the market which safely eradicate these bacterial infections. Antibiotics are used to treat bacterial pneumonia. Patients must take a full course of antibiotics to prevent recurrence and development of drug-resistant bacterial infections. In contrast, antibiotics are not useful for viral pneumonia, although they sometimes are used to treat or prevent bacterial infections that can occur in lungs damaged by a viral pneumonia.

The antibiotic choice depends on the nature of the pneumonia, the most common microorganisms causing pneumonia in the local geographic area, and the immune status and underlying health of the individual. Treatment for pneumonia should ideally be based on the causative microorganism and its known antibiotic sensitivity. However, a specific cause for pneumonia is identified in only 50% of people, even after extensive evaluation. Because treatment should generally not be delayed in any person with a serious pneumonia, empiric treatment is usually started well before laboratory reports of sputum specimens become available. The most common antibiotics are amoxicillin, clarithromycin or erythromycin and levaquin are the antibiotics selected for most patients with community-acquired pneumonia. Antibiotics for hospital-acquired pneumonia include third- and fourth-generation cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, and vancomycin. These antibiotics are usually given intravenously. Multiple antibiotics may be administered in combination in an attempt to treat all of the possible causative microorganisms. People who have difficulty breathing due to pneumonia may require extra oxygen. Extremely sick individuals may require intensive care, often including endotracheal intubation and artificial ventilation.

Viral Pneumonia Treatments

As stated before, viral pneumonia is treated with antivirals. However, antibiotics may be used to prevent or treat suprainfection. Viral pneumonia caused by influenza A may be treated with rimantadine or amantadine, while viral pneumonia caused by influenza A or B may be treated with oseltamivir or zanamivir. These treatments are beneficial only if they are started within 48 hours of the onset of symptoms. Many strains of H5N1 influenza A, also known as avian influenza or “bird flu,” have shown resistance to rimantadine and amantadine. There are no known effective treatments for viral pneumonias caused by the SARS coronavirus, adenovirus, hantavirus, or parainfluenza virus.

Bacterial Resistance

Bacterial resistance to antibiotics can take two forms: intrinsic and acquired. Intrinsic resistance is present when bacteria are naturally resistant to an antibiotics mechanism of action. For example, gram-negative bacteria are intrinsically resistant to vancomycin. Of particular interest now is the development of bacterial resistance to antibiotics to which they were previously susceptible. This resistance is generally acquired either by the mutation of existing genes or by the acquisition of new genes (e.g., by exchange of plasmids among bacteria). Resistant bacteria tend to grow prolifically in the presence of antibiotics to which they are resistant, due to the elimination of nonresistant bacteria. Mechanisms of resistance include inactivation, overproduction of the antimicrobial’s target, genetic alteration of the antimicrobial’s target, decreased permeability in relation to the antimicrobial, and active elimination of the antimicrobial from the target cell.

Vancomycin resistance in enterococci was first identified in 1988. Since then, vancomycin-resistant enterococci (VRE) have become widely spread and now ranks as one of the leading nosocomial infections. Enterococci develop vancomycin resistance by the transfer of plasmids from cell to cell and from transposons that can jump from plasmids to chromosomes. Resistance leads to the elimination of the vancomycin binding site on resistant bacteria. Originally, only enterococci were able to demonstrate this acquired resistance, but beginning in the 2000s, S. aureus highly resistant to vancomycin was isolated in the United States. 

Multidrug-Resistant Organism Development (MRDO)

While resistance of bacteria to one antibiotic or class of antibiotics is of clinical importance and affects how clinicians treat patients, the development of resistance to multiple drugs is a major public health concern. MRSA, vancomycin-resistant MRSA, and multidrug-resistant and extremely drug-resistant M. tuberculosis are the subject of much investigation. Strains of bacteria resistant to all available antibiotics have been identified and threaten to allow pneumonia to once again be a major source of morbidity and mortality.

Multidrug resistance can be the result of sequential mutations, acquisition of multiple unrelated genes, or acquisition of a single gene that confers resistance to multiple drugs. Sequential acquisition of genes tends to occur in environments with high levels of antimicrobials (e.g., in an intensive care setting), but acquisition of a single mutation that confers multiple resistance may occur in any setting. Bacteria with multidrug resistance can include enterococci, staphylococci, Salmonella, gonococci, and pneumococci. Gram-negative bacteria often acquire multidrug resistance via genes that allow for the elimination of antimicrobials from the cell as well as genes that encode for the outer membranes of cells.

Symptomatology by type of pneumonia:

Bacterial pneumonia from klebsiella: pleuritic chest pain, fever, recurrent chills, excessive and purulent sputum (green or bloody, viscous, jellylike), hypoxemia, vomiting, diarrhea, jaundice, shallow breathing or difficulty breathing (dyspnea), cyanosis of the lips and nail beds.

Bacterial pneumonia from Staphylococcus: pleuritic chest pain, shortness of breath, rapid respirations, high fever, recurrent shaking chills, bloody sputum,

Bacterial Streptococcus pneumonia: pleuritic chest pain, dyspnea, bloody or rust-colored sputum, sustained fever, shaking chills, distended abdomen or abdominal pain.

Other streptococcus: rapid onset of symptoms following upper respiratory tract infection, sustained high fever, shaking chills, severe cough.

Bacterial Pneumonia from Mycoplasma: cough and sore throat, headache, malaise, anorexia, N/V, diarrhea, joint pain, fever, chills, persistent hacking, nonproductive cough.

Pneumonia from Haemophilus influenza: pleuritic chest pain, productive cough, chills, fever often present with severe sore throat and drooling due to painful swallowing related to acute epiglottitis.

Viral Pneumonia Rubeola: cough with limited sputum production, swollen glands, generalized skin rash, dyspnea, fever.

Viral Pneumonia from Respiratory syncytial virus (RSV): cough with small sputum production, swollen glands, runny nose, sore throat, fever, malaise, anorexia. The clinical course is significantly different from other pneumonias.

Viral Pneumonia from Influenza: initial nonproductive cough followed by purulent sputum, headache, muscle ache, leg pain, chest ache, fever, chills, severe

 

Prevention

Although pneumonia cannot be completely prevented, a variety of strategies can be employed to reduce its incidence. Adequate nutrition, dental hygiene, regular physical exercise, practicing good hand hygiene, and not smoking are elements of a healthy lifestyle that reduce a person’s risk of getting pneumonia.

Vaccination

Vaccination is one of the most important health promotion interventions for patients at risk for developing pneumonia. Pneumovax and influenza vaccines are recommended for high risk population (e.g., elderly, persons with chronic respiratory disease). According to the Infectious Diseases Society of America/American Thoracic Society, pneumococcal polysaccharide vaccine is recommended for persons 65 years of age and older and for those with selected high-risk concurrent diseases, according to current Advisory Committee on Immunization Practices guidelines. The vaccines should not be given in presence of acute fever. The vaccines may be given at the same time in different arms if there is no fever. The 13-valent pneumococcal conjugate vaccine (PCV13) is recommended for all children between two months and 59 months of age (minimum age: 2 months).

Revaccination: One-time revaccination after five years for persons with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease, splenectomy) or immunosuppressive conditions. For persons aged greater than or equal to 65 years, one-time revaccination if they were vaccinated greater than or equal to 5 years previously and were aged less than 65 years at the time of primary vaccination.

Handwashing

Good handwashing is rarely practiced but it is one of the single most effective ways to prevent transmission of many diseases, including many pneumonias and influenzas. Everyone knows to wash their hands before eating and after using the restroom. However, few do little more than remove obvious dirt. Good handwashing involves removing the skin oils where organisms can remain even when the hands look clean. A quick pass under the water faucet and fast dry with a towel removes visible dirt, but the oils and organisms remain.

To effectively remove the oils and organisms, the process should take at least 20 seconds—the amount of time it takes to sing “Twinkle, Twinkle Little Star.” The hands should be soaped and rubbed vigorously for 15 seconds to create a good lather and to assure that all parts of each hand are scrubbed well. Then, the hands should be rinsed thoroughly and dried, preferably with a paper towel. The towel should be used to turn off the water and then properly thrown away. If there is no visible dirt or contamination, a waterless hand sanitizer with at least 60% alcohol can be used. However, nothing is as good as a good scrub wash with soap and water.

Some mistakenly believe that hot water must be used to kill the organisms. Water hot enough to kill organisms would be too hot to touch. Warm water mainly adds to comfort and hopefully encourages better washing technique. Careful attention to handwashing and cleansing may result in chapped skin, especially to caregivers who have to wash their hands frequently, so lotions and moisturizers may be used to care for one’s hands.

Additional prevention precautions

Health education should be done especially to immunocompromised individuals to avoid close contact with persons who are experiencing respiratory symptoms. They should avoid crowds, especially during fall and winter; and avoid known irritants. Infected patients should use proper respiratory hygiene and cough etiquette.

 

Management of patients with pneumonia

Patients with pneumonia should have a treatment plan that includes;

  • Medications: antibiotics, analgesics as needed
  • intravenous fluids; fluid management corrects hypovolemia and improves ventilation/perfusion ratio and thin secretions
  • Diet: a healthy diet as tolerated and encourage fluids;
  • Activity: promote rest and positioning to decrease work of breathing; frequent turning may prevent pooling of secretions in the lungs
  • Treatments: oxygen therapy should be provided to patients having trouble breathing, pulmonary hygiene should be encouraged (coughing, deep breathing, incentive spirometry, suctioning),  humidifier. Oxygen is given to correct hypoxemia. Humidification can be added to enhance mobilization of secretions.

 

Nursing Assistant Interventions

  • Assess respiratory status
  • Maintain bronchial hygiene and use of incentive spirometry
  • Chest physiotherapy if indicated
  • Monitor oxygen saturation and respiratory status
  • Educate patient on postural drainage techniques, chest physiotherapy and positioning
  • Encourage patient to express feelings when distressed over breathing difficulties
  • Encourage activity as tolerated
  • Enforce restrictions based upon severity of illness and tolerance to activity as ordered
  • Encourage healthy diet and a well-balanced nutrition
  • Encourage adequate fluid intake
  • Monitor vital signs closely
  • Monitor intake and output
  • Encourage bedridden or non-active patients to cough and deep breathe

 

Complications of pneumonia

Hypoxia/Hypoxemia: Hypoxia occurs when oxygenation of the body is inadequate to meet the metabolic demands of the tissues. Hypoxemia is a failure of the respiratory system to oxygenate arterial blood. Hypoxia is a life-threatening condition.

Hypoxemia: is caused by low inspired O2, increased diffusion barriers, hypoventilation, ventilation-perfusion mismatch (e.g., pulmonary emboli, pneumonia)

Infection leading to Sepsis: Infection is viewed as a continuum of injury, from local infection to bacteremia leading to sepsis, then severe sepsis-induced hypotension leading finally to multiple organ dysfunction syndrome. Euglycemic control is imperative for infection prevention.

Other complications associated with bacterial pneumonia include abscess formation, necrotizing pneumonia, pneumatocele formation, pleural effusion, and empyema, abscess, pericardial effusion, pneumothorax and bacterial meningitis among others.

 

 

 

 

 

References:

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