Guidelines for CAP treatment in the ER

Paul was not overly concerned about the cough that had developed over the last few days.  When Sarah insisted that he show himself to the doctor, Paul brushed it aside stating that the cough was due to the change in weather and nothing more.  However, since yesterday, Paul started feeling a shortness of breath and was producing sputum when coughing.  He told Sarah that they would go to the doctor the next day.  However, this morning Paul work up feeling feverish – a quick check revealed that his temperature was nearly 3 degrees higher than normal.  He was also complaining of sharp chest pain and breathlessness.  An alarmed Sarah called for an ambulance and rushed Paul to the nearby hospital.

Paul was rushed into the emergency room and after a quick but thorough initial check up, taken for an X-Ray and some other tests.  The results of these tests indicated that Paul was suffering from Community-acquired pneumonia (CAP).  Seeing a rather distraught Sarah, the doctor, who had started the treatment process on Paul, asked one of the healthcare workers to explain Paul’s problem and the treatment process to Sarah.

Community-acquired pneumonia    

Pneumonia is caused when the alveoli (the oxygen absorbing areas of the lungs) fill up with fluids.  This creates problems in the functioning of the lungs and manifests itself through fever, coughing, chest pains and dyspnea.  Community-acquired pneumonia refers to pneumonia that is contracted by someone who has very little or no contact with the healthcare system.  Hospital-acquired pneumonia (HAP) is contracted through either a stay at the hospital or through a visit to one.  Healthcare associated pneumonia (HCAP) gets contracted at nursing homes, healthcare centers, outpatient clinics, dialysis centers etc.

Community-acquired pneumonia is the most common out of these three and is a leading cause of illness and death all over the world.  CAP is caused by viruses, parasites, bacteria or fungi.  Doctors diagnose CAP through a physical examination, by assessing the symptoms and through an X-Ray of the chest.  In some cases, additional tests such as sputum and blood cultures are required, although these are for generally for patients with severe illness.  Patients with CAP are treated primarily with antibiotics, antipyretics and cough medicine at the ER or outpatient department.  However, patients with severe illness require hospitalization and the treatment here differs from that at the ER.  In order to maximize the care provided to patients in terms of the diagnosis, tests and treatment, there are a set of guidelines provided for the same.

The guidelines   

A number of medical societies have issued guidelines for the treatment of community-acquired pneumonia (CAP).  Two of the most widely referenced guidelines are those of the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA).  To remove any confusion regarding differences between their respective guidelines, the IDSA and the ATS developed a unified CAP guideline document.  Although, intended to be used by emergency medicine physicians, primary care practitioners and hospitals, these guidelines are also an appropriate starting point for specialists.  These guidelines cover the following recommendations:

  1. Implementation of Guidelines and recommendations
  2. Documented benefits
  3. Site-of-care decisions
  4. Hospital admission decision
  5. ICU admission decision
  6. Diagnostic Testing
  7. Recommended diagnostic tests for etiology
  8. Antibiotic treatment
  9. Out-patient treatment
  10. In-patient non ICU treatment
  11. Pathogen directed therapy
  12. Pandemic influenza
  13. Time to first antibiotic dose
  14. Duration of antibiotic therapy
  15. Other treatment considerations
  16. Management of Non-responding pneumonia definitions and classification
  17. Prevention

Recommendation and implementation

The strength of each recommendation is graded as “strong,” “moderate,” or “weak” on the basis of not only the supporting evidence but also expert interpretation and clinical applicability.

A strong recommendation implies that most patients should receive that particular intervention.   However, significant variability in the management of patients with CAP is well documented.  But, the rationale for variation from a strongly recommended guideline should be apparent from the medical record.

Moderate or weak recommendations suggest that, even if a majority would follow the recommended management, many practitioners may not.  Deviation from guidelines may occur for a variety of reasons.  One set of guidelines cannot cover all the variable settings, unique hosts, or epidemiologic patterns, which may dictate alternative management strategies; and the judgment of the physician, should always supersede guidelines.

These guidelines may be used as a measure of quality of care for hospitals and individual practitioners. Although these guidelines are evidence based, deviations from them should not necessarily be considered substandard care, unless they are accompanied by evidence for worse outcomes in a studied population.


References:

  1. Burke A Cunha, M., & Chief Editor: Michael Stuart Bronze, M. (2015, August 13). Community-Acquired Pneumonia. Retrieved November 02, 2015, from Medscape.com: http://emedicine.medscape.com/article/234240-overview
  2. Devorah J. Nazarian, M., Orin L. Eddy, M., Thomas W. Lukens, M. P., Scott D. Weingart, M., & Wyatt W. Decker, M. (2015). Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia. Retrieved November 02, 2015, from AMERICAN COLLEGE OF EMERGENCY PHYSICIANS: http://www.acep.org/workarea/DownloadAsset.aspx?id=45809
  3. Lionel A. Mandell, R. G. (2015). Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Retrieved November 02, 2015, from Oxford Journals: http://cid.oxfordjournals.org/content/44/Supplement_2/S27.full
  4. Pneumonia – adults (community acquired). (2014, April 26). Retrieved November 02, 2015, from U.S. National Library of Medicine: https://www.nlm.nih.gov/medlineplus/ency/article/000145.htm
  5. RICHARD R. WATKINS, M. M. (2011, June 01). Diagnosis and Management of Community-Acquired Pneumonia in Adults. Retrieved November 02, 2015, from American Family Physician: http://www.aafp.org/afp/2011/0601/p1299.html
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