Community Acquired Pneumonia: Intro

Community-acquired pneumonia (CAP) is a common group of infectious diseases that are responsible for significant global health and economic burden. CAP affects approximately 5.5/1000 people annually, and is a leading cause of hospital admissions, morbidity, and mortality in developed countries (especially for older people). Among all patients with CAP, those aged 65 or older account for about one-third, but they account for more than half of all health costs due to this disease. COPD is one of the most common comorbidities in patients with CAP, characterized by persistent respiratory symptoms.  COPD was the third-most common cause of death in 2008, and the morbidity from COPD is projected to increase by 2020 (Liu, Han, & Liu, 2018).

Brief Summary of Client Case

            Client HH is a 68 year-old male admitted with a diagnosis of community-acquired pneumonia for the past 3 days. This client’s medical HX includes COPD, HTN, hyperlipidemia, and diabetes. Mr. HH is on day three of two empiric antibiotics (ceftriaxone 1 g IV daily and azithromycin 500 mg IV daily). The client’s clinical status has improved since admission, with decreased oxygen requirements. However, he is not tolerating anything PO at this time and complains of nausea and vomiting. The client’s height is 5’8” and he weighs 89 kg. The only known drug allergy is PCN which results in a rash.

Analysis

 The client in this scenario is responding well to the current antibiotic therapy, as evidence by a drop in WBC count from 18.2 upon admission to 14.6 currently (normal range is between 5.0 and 10). It is also pleasing that the client’s O2 saturation is now 92% on room air alone, compared to 90% while requiring 4L of supplemental oxygen upon admission. Overall, the client’s lab results are not significantly concerning. Neutrophil (normal range 40-60%) and band (normal range 0.0-03%) percentages are slightly elevated as expected given the infectious process (NIH, 2020). Aside from an elevated WBC count that is trending down, a marginally elevated blood glucose, and a HCO3 elevated eight points above the normal limit, the other lab results are within the normal ranges of a healthy adult male (Farinde, 2019). The issues of concern in this client case are the client’s inability to tolerate a diet due to nausea and vomiting, elevated temperature, and continuing antibiotics to treat the pneumonia.

Treatment Considerations

 According to Donovan (2019), the client’s empiric antibiotic regime is consistent with what is recommended by the Infectious Diseases Society of America (IDSA). Initial empiric antimicrobial treatment should be initiated until laboratory results can be obtained to guide more specific therapy. Also, a combination of a beta-lactam (ceftriaxone 1 g IV q24h or cefotaxime 1 g IV q8h or ceftaroline 600 mg IV q12h) plus azithromycin 500 mg IV q24h is consistent with IDSA guidelines for a client with comorbidities such as COPD and diabetes. This therapy should be continued for minimum of 5 days, the client should be afebrile for 48-72 hours, have a stable blood pressure, an adequate oral intake, and have a room air oxygen saturation of greater than 90%; longer treatment duration may be required in some cases (Donovan, 2019). In addition to these criteria, the client’s temperature should be below 100.9º F before switching to oral antibiotics. Zofran or another antiemetic medication will be considered if the client is still unable to tolerate meals at the 5 day mark. However, we expect that the nausea will resolve as the antibiotics work to treat the lung infection. If this client meets all criteria and maintains it for 24 hours, the antibiotic therapy will be switched from IV to oral (Kaysin & Viera, 2016). According to the National Clinical Guideline Centre (2019), inpatient stay remains appropriate for patients with pneumonia only as long as hospital care is delivering management that cannot safely be delivered at home. Thus, once the client is able to tolerate oral antibiotics and his temperature drops below 100.9, discharge should be considered. Ultimately, the client would be discharged and sent home with a course of oral antibiotics. Since the client has a PCN allergy, the client would be started on an oral fluoroquinolone. According to Noreddin and Elkhatib (2010), the efficacy and tolerability of levofloxacin 500mg daily for 10 days in patients with CAP are well established.

            The client in this case has COPD, which is an important comorbidity to consider. Furthermore, COPD increases the risk of developing CAP, which is thought to be associated with a poorer prognosis. Therefore, the association between CAP and COPD is important for providers to pay close attention to. Patients with COPD are more often older, male, and more likely to suffer from respiratory failure, severe pneumonia, or comorbidities. However, COPD is a common and important predisposing comorbidity in patients who develop CAP, and often intensifies the clinical symptoms of patients with CAP. While it may complicate treatment, it generally does not tend to affect prognosis (Liu, Han, & Liu, 2018).

 Possible Patient Education Strategy

 An appropriate patent education strategy for this client would be for the disease management nurse to meet with this client prior to discharge and provide the client with handouts as well as conduct an educational session on community acquired pneumonia. The information disseminated should include an explanation of what pneumonia is, how it’s diagnosed, and how it is treated. Tips to facilitate a quicker recovery should also be discussed. These pointers include: getting plenty of rest, deep breathing exercises, hand washing, coughing/sneezing etiquette, drinking plenty of water, and eating a balanced diet. Strategies to avoid developing pneumonia should also be included, such as; getting a flu vaccine, avoiding smoking, properly managing preexisting respiratory conditions (e.g., asthma or COPD), receiving a pneumonia vaccine, and staying active (Nursing2020, 2010).

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