Community Acquired Pneumonia (CAP)

- 7th leading cause of death in U.S.
- Most deadly infectious disease

- 5.6 million cases in U.S. each year
- 10 million visits annually
- 1 million hospitalized

An acute infection of the pulmonary parenchyma.
- Associated with symptoms of acute infection
- Presence of acute infiltrate on CXR OR
-Ausculatory findings consistent with pneumonia
- In a patient not hospitalized or residing in LTC facility >14 days

30%

3%

- Elderly and nursing homes
- Alcoholism, drug abuse
- Co-morbid medical conditions
- Altered mental status
- COPD/Smokers
- Immunosuppression

1. Bacterial
2. Atypical
3. Viruses

- S. pneumoniae
- H. influenza
- Morazella catarrhalis
- Group A Strep
- Staph aureus

- Mycoplasma pneumoniae
- Chlamydophilia pneumoniae
- Legionella pneumoniae

- Influenza A & B
- Adenovirus
- RSV
-Hantavirus
- Parainfluenza rhinovirus

- Age
-Typical: very young & elderly
- Atypical: Young adults

Fall Winter Pathogen = Mycoplasma

- S. pneumoniae
- H. influenxa
- Influenza - Post influenza; S. pneumoniae

- Legionnaire's

C. pneumophilia

Klebsiella and anaerobes

Haemophilius influenzae, Moraxella catarrhalis

- Streptococcus pneumoniae
- Gram- negative bacilli
- Haemophilis influenza
- Staphylococcus aureus
- Anaerobes
- Chlamydia pneumoniae

- Anaerobes

- Coccidiodes species

- Legionella

- S. aureus, M. tuberculosis

- Anaerobes

1. S. pneumoniae
2. H. influenza
3. viral

Pertussis

Respiratory syncytial virus (RSV)

Mycoplasma

Streptococcus pneumoniae

- Fever or hypothermia 80%
-Chills 40-50%
-Chest pain 30%
-Rigors 15%
-Sweats
-New cough with or without sputum
-Change in color of sputum if chronic cough
-Onset of dyspnea

- Fatigue
- Myalgia (muscle pain)
- Abdominal pain
- Anorexia
- H/A

- Fever and cough

- Tachypnea (rapid breathing)

- Fever 80%
- Altered breath sounds; Crackles >50% & Diminished breath sounds 33%
- Tachypnea 45-70%
- Tachycardia
- Dullness percussion
- Fremitus
- Egophony

- S. pneumoniae
- Accounts for 66% of bacteremic cases

Streptococcus pneumoniae (pneumococcus)
- Sudden onset
- Cough with "rusty" sputum may be purulent
- Fever, rigors (temo > 102)
- SOB
- Pleuritic chest pain

- Looks sick --> acute
- Cough with sputum
- Febrile
- Crackles (rales)
- Dyspnea, tachypnea, splinting
- Wheeze
-CXR - lobar infiltrate

Walking pneumonia atypical caused by : Mycoplasma pneumoniae

- General presentation does not fit physical findings
- Looks mildly ill --> significant crackles, scarrtered
- Cough, dry
- URI symptoms
- Headache
- GI symptoms
- CXR- patchy or scattered infitrates

Viral

- Chest XRay because it is sensitive- detection pneumonia.
- Standard postero-anterior and lateral views.

False negative CXR:
- Severe dehydration
- Too early in course illness

Treated and follow closely

- All patients over 40
- All smokers or former smokers

1) Lobar consolidation (typical pathogens)
2) Interstitial infiltrates (Viral or atypical pathogens)
3) Cavitation

1) Lobar consolidation (typical pathogens)

2) Interstitial infiltrates (Viral or atypical pathogens)

- Microbiological studies
- Gram stain and culture of sputum

Gram- Stain morphology

Urinary antigen assay - for S. pneumoniae which is the primary bacterial CAP pathogen

PCR

PCR; four fold Increases IgG titer

Urinary antigen assay; PCR

Acid-fast stain; PCR

- Respiratory distress
- Dyspnea at rest
- Tachypnea
- Multilobular infiltrate or pleural effusion - CXR
- Underlying cardiac or pulmonary disease

- When considering hospitalization
- Age > 65
- Co-existing illness

- Clinical presentation
- Definitive Diagnosis --> CXR pulmonary infiltrate
- WBC > 15,000 (L shift increased neutrophils, bands)
- Decreased O2 sat < 94%
Pertinent labs: Hgb/Hct, BUN, electrolytes, glucose.
Cultures: Sputum, blood if hospitalized

Means increased neutrophils, bands

- Age over 65 years
- Presence of co-existing illness
COPD
bronchiectasis
malignancy
DM
CHF
chronic renal failure
chronic alcohol abuse
chronic liver disease
malnutrition
cerebrovascular disease
post splenectomy
hx hospitalization in past year

- Respiratory rate > 30
- Diastolic blood pressure < 60 mm Hg or systolic blood pressure < 90 mm Hg
- Pulse > 125
- Temp < 35 degrees or > 40 degrees C (< 95 degrees or > 104 degrees F)
- Confusion or decreased LOC

COPD
bronchiectasis
malignancy
DM
CHF
chronic renal failure
chronic alcohol abuse
chronic liver disease
malnutrition
cerebrovascular disease
post splenectomy
hx hospitalization in past year

- WBC < 4 or > 30 x 10 (9)
- PaO2 < 60 or PaCO2 > 50 room air
- Creatinine > 1.2, BUN > 20
- Chest x-ray: multi lobular, pleural effusion, presence of a cavity
- HCT < 30 or Hgb < 9
- Arterial ph < 7.35
- Evidence of sepsis

Gram negative bacilli
S. Aureus
Post obstructive pneumonia
Aspiration pneumonia (anerobe)

How can blood borne cause pneumonia- think about similar IV, embolism. Goes to lungs first and bacterial in arms goes to lungs first and lungs first place to get hit with blood borne infection and that is why when someone with infection somewhere that is because lungs are taking the hit of the infection.

Hospitalize or outpatient?

- Assessment pre-existing conditions
- Calculation of risk of severity/mortality
- Clinical judgment

- Pneumonia Severity Index
- PORT (Pneumonia Patient Outcome Research Team)
- CURB 65

- Identify patients with higher risk of complications
- Benefit from hospitalization
- Better studied and validated vs/ other models
- Complicated

Demographics
Co-morbid illness
Physical exam findings
Lab and radiographic findings
Assigns point value
Assigns to 5 risk classifications

PORT- Pneumonia Patient Outcome Research Team
Sound clinical prediction rule
Quantifies short term mortality for patients with CAP
Guideline to use to determine need for hospitalization
Validated as a mortality prediction rule
Prediction rules meant to contribute not supersede clinician’s judgement

Confusion
Urea Nitrogen > 20 mg/dL
Resp rate > 30
BP systolic < 90, diastolic < 60 mmHg
Age > 65 years

Identifying pathogen difficult at time of diagnosis
Base treatment decisions on patient evaluation, epidemiologic setting
Majority treated empirically based on most common pathogen

60-70% of all bacterial CAP

ATS
ISDA
Canadian Guidelines
CDC, Therapeutic Working Group

1) Eradicate pathogen
2) Resolve clinical signs and symptoms
3) Minimize hospitalization
4) Prevent re-infection and complications

1) Treat empirically
2) Based on most likely pathogen
3) Pharmacokinetic profile
4) Adverse reactions
5) Drug interactions
6) Cost

1) Severity of illness
2) Age
3) Co-morbidities
4) Clinical presentation
5) Epidemiologic setting
6) Previous exposure

Macrolide (azithromycin, clarithromycin, e-mycin)
Doxycycline (Vibramycin)
*Fluoroquinolones
CDC cautions resistance concerns

Augmentin
Beta-lactams
Cefpodoxime (Vantin)
Cefprozil (Cefzil)
Cefuroxime (Ceftin)

Fluoroquinolone alone
Levofloxacin (Levoquin)
Gatifloxacin (Tequin)
Moxifloxacin (Avelox) OR
Advanced macrolide*
+ high dose amoxicillin (1 GM TID) OR
Advanced macrolide* + high dose amox-clavulanate (2 GM BID) (Augmentin)

*azithromycin, clarithromycin

Respiratory fluoroquinolone or advanced macrolide

Fluoroquinolone alone or advanced macrolide + beta lactam

Beta lactam (High dose Amox 90 mg/kg, Augmentin) or respiratory fluoroquinolone (Levoflozacin, Gatifloxacin)

Amox-clavulanate or clindamycin

Erythromycin, Doxycycline

Zithromax, Biaxin

Levofloxacin, Gatifloxacin

High dose Amox (90 mg/kf, Augmentin)

- Start as early as possible after diagnosis made
- Shortest course appropriate

- Strep pneumo- until afebrile x 72 hours
7-10 days
- Mycoplasma and chlamydia 10-14 days for most patients
- Legionnella 10-21 days
- Staph aureus > 14 days

Fever and tachypnea

- Atypical pathogen unlikely 2 months- 5 years
- High dose Amoxicillin (80-90 mg/kg/day) for 7-10 days. Cephalosporin or macrolide if allergic.
- Age > 5 years --> macrolides

Rest
Hydration
Cool mist humidification
Avoid resp. irritants
Smoking cessation
High calorie nutrition
Note for school, work
Infection control
Treat fever, cough meds at night
Treat wheeze if present
Cough may last 6 weeks - reassure

Worse
Fever persisting > 2 days on abx
Cough no improving
CP, SOB, wheezing
Vomiting, dehydration
Ped: tachypnea, retractions, poor feeding
Elders: confusion

24-72 hours
1-4 weeks recheck
F/U CXR for any abnormality especially in all smokers after 4-6 weeks

Respiratory distress
Decreased O2 sat, fatigue from resp. effort
GI dysfunction
Vomiting, dehydration
WBC < 5,000 > 25,000
Co-morbidity especially if unstable
Age > 65
Confusion
Failing outpatient treatment after 48-72 hours
PSI class IV, V

1) Cigarette smoking is a risk factor for pneumonia --> Smoking cessation important preventive strategy
2) Influenza vaccine
- Annual, trialent vaccine
- Live, attenuated
- Everyone
3) Polyvalent pneumococcal vaccines
- Prevents 2/3 cases of pneumonia
- Everyone > age 65
- Also patients with underlying disease

- All adults > 65 years old
- High risk concurrent disease
- LTC facilities
- Second dose after 5 years for immunosuppressed or if first dose was received before age 65
- Peds: protein-polysaccharide conjugate vaccine (Prevnar); series of 4 doses

True

CAP is the 7th leading cause of death

- Consult wiht MD if any concern
- Hospitalize early if this is likely
- Use caution with co-morbidities
- Watch for abx resistance
- Cough worse at night
- Treat wheeze aggressively, caution with steroids
No tetracycline in peds w/incomplete dentition or pregnant women
- Follow-up CXR on all pneumonia

Cough Worse at Night- Check reactive airways, post nasal drip, paroxysmal noctural dyspnea

1) American Thoracic Society
2) Guidelines from the Infectious Disease Society of America IDSA
3) American Family Physician; Feb 1, 2006, CAP