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COMMUNITY

ACQUIRED
PNEUMONIA
Mary Joy DH Oros
FAMILY MEDICINE CLERK
JUNE 2014
COMMUNITY ACQUIRED
PNEUMONIA
CAP is a lower respiratory tract infection
acquired in the community within 24 hours
to less than 2 weeks

Is one of the leading cause of morbidity and
mortality in the world.

Pneumonia can affect anyone. But the two
age groups at highest risk are:
Infants and children younger than age 2
years, because their immune systems
are still developing
People older than age 65

PNEUMONIA


PNEUMONIA


Risk factors
Exposure to person with CAP
Advance Age
Certain chronic diseases
Weakened or suppressed immune system
Smoking
SIGNS AND SYMPTOMS
Shortness of breath (dyspnea)
Productive Cough
Fever
Sharp or stabbing chest pain
Rapid, shallow breathing

CLINICAL
PRACTICE
GUIDELINES
CLINICAL DIAGNOSIS

Can CAP be diagnosed accurately by
history and PE?

Clinical prediction rules combining history and
physical examination findings may be utilized to
presumptively identify patients with pneumonia
CLINICAL DIAGNOSIS
Can CAP be diagnosed accurately by
history and PE?
Presumptive diagnosis:
Acute cough
Abnormal VS
tachypnea (RR>20breaths/min)
tachycardia (CR>100/min)
fever (temp>37.8C)
With at least 1 abnormal chest findings
diminished BS
rhonchi crackles wheeze
CLINICAL DIAGNOSIS

Diagnosis of CAP by history & PE

No clinical finding is sufficiently sensitive
or specific to confirm or exclude CAP
Accuracy of predicting CAP by these
clinical findings (6-76%)
Reason: uncommon presentation of CAP
(minimal signs & extrapulmonary
symptoms)
CLINICAL DIAGNOSIS
Is there any clinical feature that can predict
CAP caused by an atypical pathogen?

(Typical) Pneumonia
Pathogens:
Streptococcus
pneumoniae
Hemophilus Infleunzae
Moraxella catarrhalis

Clinical manifestations:
fever, cough, & pleural
chest pains
Atypical Pneumonia
Pathogens:
Mycoplasma
pneumoniae
Chlamydophila
pneumoniae
Legionella
pneumophilia

Clinical manifestations:
extrapulmonary
Chest x-ray
What is the value of CXR in the diagnosis of
CAP?
Chest x-ray essential for diagnosis of
CAP assessing severity and complications

Diagnostic standard New parenchymal
infiltrate in the CXR (old & new CXR films)

CXR done to confirm diagnosis in patients
suspected to have CAP

Chest x-ray
What is the value of CXR in the diagnosis of
CAP?
CXR useful for suggesting the etiologic
agent, prognosis, alternative diagnosis and
associated conditions

Poor prognosis:
Bilateral of multilobar involvement
Progression of infiltrates w/in 24 hrs
Presence of pleural effusion and lung
abscess

Chest x-ray
What is the specific view of CXR should be
requested?

Best radiologic evaluationStanding PA
and lateral views of the chest in full
inspiration

Minimizing the magnification of heart and
mediastinum

Chest x-ray
Are there characteristic radiographic features
that can predict the likely etiologic agent from
CXR?
No characteristic radiographic features that can
predict the likely etiologic agent in CAP

Nonspecific CXR
Interstitial or reticulonodular pattern to patchy
consolidations w/c may be segmental or lobular
Pleural effusion and lymphadenopathy
uncommon
Most do not respond to conventional
antimicrobials
Chest x-ray
What is the significance of an initial normal CXR
in a patient suspected to have CAP?

An initial normal CXR may connote a radiologic lag
phase
normal CXR (absence of overt parenchymal lesion) in
a background of symptomatology specific to initial
phase of CAP
May treat patient condition presumptively w/ antibiotics
and repeat CXR in 24-48 hours
Chest x-ray
Should a CXR be repeated routinely?

Patient with low-risk CAP who are recovering
repeat CXR not needed

Patient with CAP who is not improving or shows
progression of disease repeat CXR is needed

Patient who achieved clinical improvement can be
discharge w/o repeat CXR but a repeat CXR is
recommended during follow-up visit 4-6 weeks after
discharge

Chest x-ray
What is the role of Chest CT scan in CAP?

Chest CT scan has no role in the evaluation of
CAP
CT scan is helpful:
To exclude other pathologies (neoplastic,
interstitial disease or granulomatous)
Further evaluation of nonresolving or
progressive pneumonia seen on follow-up
CXR
Chest x-ray
Which patients will need hospital admission?
A management-oriented risk stratification of CAP based
on the patients clinical presentation/condition, status of any
co-morbid condition and CXR findings
used to determined site-of-care
prognosis
management
Based on:
clinical presentation/condition
state of co-morbid conditions &
CXR findings
Chest x-ray

Which patients will need hospital admission?
3 risk categories:
Low-risk CAP outpatient
Moderate-risk CAP ward
High-risk CAP ICU

Chest x-ray
Site of care
Which patients will need hospital admission?
A management-oriented risk stratification of CAP based
on the patients clinical presentation/condition, status of
any co-morbid condition and chest x-ray findings should
be utilized in the decision to determine the site of care
for patients. (Grade A)
3 risk categories:
Low-risk CAP - outpatient
Moderate-risk CAP - ward
High-risk CAP - ICU

Site of care
Site of care
MICROBIOLOGIC STUDIES
What microbiologic studies are necessary in
CAP?
In low-risk CAP, microbiologic studies are optional.
In moderate- and high-risk CAP, blood cultures and
Gram stain and culture with antibiotic sensitivity tests of
respiratory specimens should be done in laboratories
with quality assurance.
When possible, tests to document the presence of
Legionella pneumophila are recommended for
hospitalized CAP.

MICROBIOLOGIC STUDIES
What microbiologic studies are necessary in
CAP?
Invasive procedures (i.e., transtracheal, transthoracic
biopsy, bronchoalveolar lavage, protected brush
specimen) to obtain specimens for special microbiologic
studies for atypical pathogens (e.g., mycobacteria and
other microorganisms that will not grow on routine
culture) are options for non-resolving pneumonia,
immunocompromised patients, and patients in whom no
adequate respiratory specimens can be sent despite
sputum induction and routine diagnostic testing.
TREATMENT
When should antibiotics be initiated for the
empiric treatment of community-acquired
pneumonia (CAP)?
For patients requiring hospitalization, empiric
therapy should be initiated as soon as possible after
diagnosis of CAP is made.
For low-risk CAP, treatment may be delayed
TREATMENT
TREATMENT
TREATMENT
How can response to initial therapy be assessed?
Temperature, respiratory rate, heart rate, blood
pressure, sensorium, oxygen saturation and inspired
oxygen concentration should be monitored to assess
response to therapy.

Response to therapy is expected within 24-72 hours of
initiating treatment. Failure to improve afer 72 hours of
treatment is an indication to repeat the chest radiograph.

Follow-up cultures of blood and sputum are not
indicated for patients who are responding to treatment.
TREATMENT
When should de-escalation of empiric antibiotic
therapy be done?

De-escalation of initial empiric broad-spectrum
antibiotic or combination parenteral therapy to a single
narrow spectrum parenteral or oral agent based on
available laboratory data is recommended once the
patient is clinically improving, is hemodynamically stable
and has a functioning gastrointestinal tract.
TREATMENT

TREATMENT
Which oral antibiotics are recommended for de-
escalation or switch therapy from parenteral
antibiotics?

The choice of oral antibiotics following initial parenteral
therapy is based on available culture results,
antimicrobial spectrum, efficacy, safety and cost. In
general, when switching to oral antibiotics, either the
same agent as the parenteral antibiotic or an antibiotic
from the same drug class should be used.
TREATMENT
How long is the duration of treatment for CAP?
Duration of treatment is 5 to 7 days for low risk
uncomplicated bacterial pneumonia.
For moderate-risk and high-risk CAP or for those with
suspected or confi rmed Gram-negative, S. aureus or P.
aeruginosa pneumonia, treatment should be prolonged
to 14 to 21 days.
A treatment regimen of 10 to 14 days is recommended
for Mycoplasma and Chlamydophila pneumonia while
Legionella pneumonia is treated for 14 to 21 days.
Patients should be afebrile for 48 to 72 hours with no
signs of clinical instability before discontinuation of
treatment.
TREATMENT
TREATMENT
What should be done for patients who are not improving
after 72 hours of empiric antibiotic therapy?
The clinical history, physical examination and the results of all
available investigations should be reviewed. The patient should be
reassessed for possible resistance to the antibiotics being given or
for the presence of other pathogens such as M. tuberculosis,
viruses, parasites or fungi. Treatment should then be revised
accordingly.

Follow-up chest radiograph is recommended to investigate for
other conditions such as pneumothorax, cavitation and extension to
previously uninvolved lobes, pulmonary edema and ARDS.

Obtaining additional specimens for microbiologic testing should be
considered.
TREATMENT
TREATMENT
When can a hospitalized patient with CAP be
discharged?
In the absence of any unstable coexisting illness or
other lifethreatening complication, the patient may be
discharged once clinical stability occurs and oral therapy
is initiated.
A repeat chest radiograph prior to hospital discharge is
not needed in a patient who is clinically improving.
A repeat chest radiograph is recommended during a
follow-up visit, approximately 4 to 6 weeks after hospital
discharge to establish a new radiographic baseline and
to exclude the possibility of malignancy associated with
CAP, particularly in older smokers.
TREATMENT
PREVENTION
How can CAP be prevented?

Influenza vaccination is recommended for the
prevention of CAP.

Pneumococcal vaccination is recommended for the
prevention of invasive pneumococcal disease (IPD) in
adults.

Smoking cessation is recommended for all persons
with CAP who smoke.