Treatment Of The Community Acquired In The Community

Treatment of the community acquired in the community

Introduction

The pneumonia acquired in the community (NAC) or community pneumonia is defined as the acute inflammation of the pulmonary parenchyma that has an infectious and extrahospital origin. The main etiological agent of the NAC in the adult human being is the Streptococcus pneumoniae;However, it can also be caused by mycoplasma pneumoniae, Legionella pneumophila and even a variety of respiratory viruses, fungi, parasites among other microorganisms.

The NAC is associated with high rates of morbidity and mortality in the world, which causes an increase in hospital income and mainly affects elderly patients. This pathology is present in approximately five million people in the United States every year, it generates around ten million consultations, one million hospitalizations and 45,000 deaths. 

In countries of South America such as Colombia, the NAC corresponds to the sixth cause of death, the first due to infectious disease and occupies the fifth place between the causes of hospitalizations.  In Ecuador, during the last decade, pneumonia has remained among the ten main causes of general morbidity, some studies mention that in 2011 it became the first, with an incidence of 22.8 for every 10,000 inhabitants. 

The clinical manifestations of this pathology include respiratory symptoms such as coughing with expectoration, dyspnea, side tip pain;and general symptoms of infection such as fever and discomfort, in some cases they can even cause alteration of consciousness.

The usual physical findings include tachypnea, tachycardia, arterial hypotension and auscultatory focal abnormality. For the diagnosis, in addition to evaluating the clinic, it usually performs a simple posttero -ask chest or other imageological and microbiological exams. 

The treatment of NAC depends on age and comorbidities, as well as local epidemiology and the severity of the disease. Current guidelines for NAC management classify patients in: health. Antibiotic treatment begins, in most cases, empirically, this occurs despite the continuous scientific and technological advances in the complementary techniques of microbiological and imaging diagnosis, which are not available in all health establishments in the health of thecountry. 

The doctor currently has several tools to intervene in the evolution of this pathology;If we adequately identify the various etiologies, the severity immunological characteristics of the patient and that of the case is possiblecontributing to reducing complications and mortality.

Therefore, due to the great prevalence of this disease in the world and in our country, and the serious consequences for health and even the lives of patients in case of not making a timely diagnosis and treatment, the need to investigate arisesin depth the proper management of these patients to guide and facilitate the work of both doctors and medical students in the fight against this disease. The objective of this bibliographic review is to present the treatment of pneumonia acquired in the community through the investigation of various sources of bibliographic information to specify the most relevant aspects of the subject and inform both doctors and medical students about the correct management of thispathology.

Methodology

This work corresponds to a non -systematic bibliographic review, which was based on the thorough search for information to know the current state of the topic to be investigated. The selected sources of information are primary and secondary sources;same that include books, scientific journals, clinical guides, medical databases, thesis and web pages. All selected sources meet the quality, reliability and update requirements.

The databases consulted were Cochrane, Elsevier, Dialnet, Medigraphic, Pubmed, Scielo, Web of Science, Medes and Medline. The Google Academic search engine was used on some occasions for the search for scientific articles. The terms used in the search for information were pneumonia acquired in the community, antibiotic therapy in communal pneumonia and pneumonia management. The inclusion criteria were studies in Spanish or English, published on the Internet from 2015 to 2020, with medical or scientific approach and that addressed the issue of the management or treatment of pneumonia acquired in the community. The articles that deal only with nosocomial pneumonia were excluded.

Results

In the research carried out both in books and in the databases around 61 articles related to community pneumonia were collected. Of the 61 articles and chapters of books that were analyzed, 16 articles were excluded because access to the original source of information was not obtained, 8 articles were excluded by low quality of evidence and 37 articles were chosen since they met the inclusion and criteria of inclusion andThey make theoretical contribution for this bibliographic review.

Discussion

The initial treatment of the NAC is done empirically taking into account that most etiological agents responsible for this pathology are gram -positive bacteria;For the proper management of these patients, epidemiological aspects, local microbial resistance profiles, local availability and pharmacological costs should also be considered.

The general measures that must be required in all patients with NAC include hydration, avoid the consumption of tobacco, oxygen administration to maintain a saturation greater than 90%, monitor adequate electrolytic balance, prophylaxis of thromboembolic events, respiratory therapy,Concomitant disease control, non -invasive hemodynamic and respiratory function monitor. It is important to emphasize the importance of respiratory therapy since it provides a placebo effect that helps the patient to detach.

The CURB-65 scale is a predictive instrument that allows classifying the degree of severity of the NAC based on clinical aspects and the patient laboratory analysis results;It is very useful since it directs the need for hospitalization and the treatment of choice in each case;In addition, it facilitates the prediction of mortality at 30 days after diagnosis. This tool classifies NAC patients in three gravity levels: group I or low -risk patients, group II or patients with moderate risk and group III or high -risk patients.

Empirical NAC treatment according to the CURB-65 scale score

Group I patients have a score on the CURB – 65 scale from zero to one;The indicated treatment is outpatient for a time of five to seven days. Within this category, for patients without associated risk factors, amoxicillin is prescribed a gram (g), oral (vo) every eight hours, clarithromycin 500 milligrams (mg) vo every 12 hours, as first -line drugs. As a secondary alternative you can send doxycycline 100 mg vo every 12 hours, moxifloxacin 400 mg vo once a day or levofloxacin 750 mg vo once a day. On the other hand, for patients of group I with concomitant diseases or associated risk factors, amoxicillin / clavulanate is administered one g vo every 12 hours, clarithromycin 500 mg vo every 12 hours, as the first line;As a secondary alternative, 500 mg vo can be used every 12 hours, clarithromycin 500 mg vo every 12 hours, moxifloxacin 400 mg vo once a day or levofloxacin 750 mg vo once a day.

Group II is made up of patients with a two-scale score on the Curb-65 scale. The duration of patient treatment in this group goes from ten to maximum 12 days in general room hospitalization. In turn, group II is subdivided into four categories for greater specificity. In the first category, patients are without concomitant diseases or risk factors, in these patients the treatment is hospitalization in the general room, the following can be used as first -line drugs: Ampicillin / sulbactam three grams intravenously (IV) every sixhours, clarithromycin 500 mg IV every 12 hours, the latter can be administered vo in case of being tolerated;As a secondary treatment alternative we find cefuroxime 750 mg IV every eight hours together or not to clarithromycin 500 mg IV every 12 hours based on medical criteria;Moxifloxacin 400 mg IV once a day or levofloxacin 500 mg IV once a day.

In patients with risk factors for gram -negative, the first -line treatment in hospitalization in the general room is ampicillin / sulbactam three g iv every six hours together or not to clarithromycin based on medical criteria and as an alternative line of treatment it can be administered cefuroxima 750mg IV every eight hours, clarithromycin 500 mg IV every 12 hours;Moxifloxacin 400 mg IV every day or levofloxacin 500 mg IV once a day. In patients with risk factors for S infection. Pneumoniae resistant to penicillin;The first -line treatment in hospitalization in the General Sala is Ceftriaxone three G IV once a day together or not to clarithromycin 500 mg IV every 12 hours, as an alternative of treatment is the administration of moxifloxacin 400 mg IV every day and levofloxacin 500 mg IVevery day.

On the other hand, hospitalizations for socioeconomic reasons, where the treatment position is hospitalization in the General Chamber, are handled with the same prescriptions of group I without associated risk factors. Where the treatment position is hospitalization in the General Chamber, they are handled with the same prescriptions of Group I without associated risk factors. Where the treatment position is hospitalization in the General Chamber, they are handled with the same prescriptions of Group I without associated risk factors.

In Group III there are patients with a Curb-65 score greater than three. The treatment for this group lasts for 12 to 21 days of mandatory hospitalization. This group is in turn subdivided into three categories for more specificity in patient management. In the first place, in patients without risk factors for an aeruginous pseudomcate infection, the first -line treatment corresponds to a combined antibiotic therapy of the following drugs: ampicillin / sulbactam three g iv every six hours, clarithromycin 500 mg IV every 12 hours, oseltamivir75 mg every 12 hours and vancomycin. The second -line treatment consists of an antibiotic therapy in the set of the following drugs: Cefuroxime 750 mg IV every eight hours, clarithromycin 500 mg IV every 12 hours, oseltamivir 75 mg every 12 hours and vancomycin.  

On the other hand, for patients with risk factors for P. Aeruginosa, can be used as a first -line treatment in combined antibiotic therapy.5 g IV every six hours, clarithromycin 500 mg IV every 12 hours and oseltamivir 75 mg every 12 hours;As an alternative or secondary prescription, Cefepime is used. However, for patients who have risk factors by staphylococcus aureus meticillin (SARM) where the first choice treatment is ampicillin / sulbactam three g iv every 6 hours next to clarithromycin 500mg IV every 12 hours, oseltamivir 75 mg every 12 hoursand vancomycin, the latter in loading dose of 25 mg / kg and maintenance 15 mg / kg every 12 hours;As a second treatment option for this group we find combined antibiotic therapy of the following drugs: Piperacillin / Tazobactam 4.5 G IV every 6 hours, clarithromycin 500 mg IV every 12 hours, oseltamivir 75 mg every 12 hours and vancomycin, or in turn you can use the following drugs together: Cefepime two g iv every 8 hours, clarithromycin 500 mg IV every 12hours, oseltamivir 75 mg every 12 hours and vancomycin. oseltamivir 75 mg every 12 hours and vancomycin. oseltamivir 75 mg every 12 hours and vancomycin.

oral anti -infectious with high bioavailability when possible. Oral treatment with amoxicillin or amoxicillin – clavulanic acid is recommended. For young patients without underlying diseases, oral doxylin can be considered if Chlamydia pneumoniae infection is suspected. pneumoniae and m. pneumoniae, since they are highly resistant to macrolides. The empirical treatment of macrolides can only be used in regions with lower resistance rates. Respiratory quinolones can be used in regions with higher rates of macroll resistance or in hypersensitive or intolerant patients to the medications mentioned above.

4.2 Specific antimicrobial treatment according to the Causal Agent of the NAC.

Because the main etiological agents responsible for the NAC are the S. Pneumoniae, m. Pneumoniae, c. Pneumoniae and l. pneumoniae is mentioned below the specific antimicrobial treatment for these pathogens.

conclusion

The blood oxygen level of hospitalized patients should be evaluated in a timely manner. Oxygen therapy through a nasal catheter or a facial mask is recommended for hypoxemia patients with the aim of maintaining blood oxygen over 90%. In addition, for patients with a risk of hypercapnia, oxygen saturation should be maintained at an interval of 88% – 92% before obtaining the results of gasometry. The results of recent studies that high and humidified high flow oxygen therapy through a nasal catheter in a dose of 40 – 60 l per minute could also be used in clinical practice.

For patients with severe NAC and concomitant acute expiratory difficulty syndrome, oxygenation by extracorporeal membrane (ECMO) can be used if regular mechanical ventilation cannot lead to an improvement. ECMO indications include reversible respiratory failure associated with severe hypoxemia