The management of severe community acquired pneumonia in the intensive care unit

Abstract

Severe CAP (SCAP), accounting for 6% of admissions to intensive care units (ICUs) needs early diagnosis and aggressive interventions at the most proximal point of disease presentation. The prognostic scores as the ATS/IDSA rule, the systolic blood pressure, multilobar infiltrates, albumin, respiratory rate, tachycardia, confusion, oxygen and pH or SCAP system are appropriate in early identification of eligible patients requiring admission to ICU. Then the recommended initial resuscitation in SCAP in the ICU consists of fluid volume intake titrated to specific goals after a fluid challenge and hemodynamic optimization. The first selection of antimicrobial therapy should be started in the first hour and would be broad enough to cover all likely pathogens. Combination therapy may be useful in patients with non refractory septic shock and severe sepsis pneumococcal bacteremia as well. After 6 hours the patient would be reevaluated in terms of hemodynamic stability and antibiotic and therapy. Future developments will focus on sepsis biomarkers, molecular diagnostic techniques and the development of novel therapeutic immunomodulaty agents.

Keywords::

• ICU
• management
• resuscitation
• septic shock
• severe community acquired pneumonia

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Severe community-acquired pneumonia, usually admitted in the ICU, reaches a mortality of 50% and requires a rapid and effective management.

• The evaluation of community-acquired pneumonia severity with the help of severity scores is fundamental, because delayed ICU admission is associated with higher mortality.

• Early goal directed therapy consists of a resuscitation bundle which emphasizes aggressive, early reversal of shock via titration of intravenous fluid therapy, optimization of cardiac output with inotropic support and blood transfusion to predefined resuscitation endpoints in the first 6 h.

• Initial antibiotic treatment should be administered in the first hour of presentation and consists of an extended-spectrum antibiotic regimen, particularly a combination antibiotic therapy in septic shock.

• Addition of hydrocortisone in low doses recommended in non-refractory septic shock

Notes

PaO₂/FIO₂: Ratio of arterial partial pressure of oxygen (PaO₂) to fraction of inspired oxygen (FiO₂); SIRS: Systemic inflammatory response syndrome; WBC: White blood cells.

Data taken from [9].

^†PaO₂/FIO₂: Ratio of arterial partial pressure of oxygen (PaO₂) to fraction of inspired oxygen (FiO₂).

SBP: Systolic blood pressure.

Data taken from [2].

^†A portion of this may be albumin equivalent.

Data taken from [9].

^†Levofloxacin 750 mg/24 h or 500 mg twice a day is an alternative.

Data taken from [17].