بسم الله الرحمن الرحیم با سلام. C OMMUNITY A CQUIRED P NEUMONIA Dr asadian

الرحیم الرحمن الله بسم

سالم با

COMMUNITY ACQUIRED PNEUMONIA

Dr asadian

PNEUMONIA – DEFINITION

An acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, accompanied by an acute infiltrate on CXR or auscultatory findings consistent with pneumonia

PNEUMONIA

The major cause of death in the world The 6th most common cause of death in the

U.S. Annually in U.S.: 2-3 million cases, ~10

million physician visits, 500,000 hospitalizations, 45,000 deaths, with average mortality ~14% inpatient and <1% outpatient

PNEUMONIA - SYMPTOMS

Cough (productive or non-productive)

Dyspnea Pleuritic chest pain Fever or

hypothermia Myalgias

Chills/Sweats Fatigue Headache Diarrhea

(Legionella) URI, sinusitis

(Mycoplasma)

FINDINGS ON EXAM

Physical: Vitals: Fever or hypothermia Lung Exam: Crackles, rhonchi, dullness to percussion

or egophany.

Labs: Elevated WBC Hyponatremia – Legionella pneumonia Positive Cold-Agglutinin – Mycoplasma pneumonia

CHEST X-RAY – PNEUMONIA

CHEST X-RAY -- PNEUMONIA

CHEST X-RAY - PNEUMONIA

TYPES OF PNEUMONIA Community-Acquired (CAP) Health-Care Associated Pneumonia (HCAP)

Hospitalization for > 2 days in the last 90 days Residence in nursing home or long-term care facility Home Infusion Therapy Long-term dialysis within 30 days Home Wound Care Exposure to family members infected with MDR bacteria

Hospital-Acquired Pneumonia (HAP) Pneumonia that develops after 5 days of hospitalization Includes:

Ventilator-Associated Pneumonia (VAP) Aspiration Pneumonia

COMMON BUGS FOR PNEUMONIA

Community-Acquired Streptococcus pneumoniae Mycoplasma pneumoniae Chlamydophila psittaci or

pneumoniae Legionella pneumophila Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus Nocardia Mycobacterium tuberculosis Influenza RSV CMV Histoplasma, Coccidioides,

Blastomycosis

HCAP or HAP Pseudomonas aeruginosa Staphylococcus aureus (Including MRSA) Klebsiella pneumoniae Serratia marcescens Acinetobacter baumanii

ETIOLOGY OF C.A.P

No etiology in ~ 50 % > 2 etiologies in 2-5% S. Pneumonia in : 2/3 of bacterial

cases or 20 % of all cases H. Influenzae ( non typeable) Mycoplasma pneumonia Chlamydia p ~12% Influenza Legionella ~ 5%

ATYPICAL PNEUMONIA

Age (years)- less than 40 Onset- Gradual, coryzal prodrome Cough- Paroxysmal, hacking non productive Sputum- Minimal, mucoid Rigors- Absent Fever- Usually less than 39.5 °C

ATYPICAL PNEUMONIA CTD

Consolidation- Usually absent Leucocytosis - usually absent Chest x-ray- Initially interstitial, may progress

to air space involvement

ACUTE BACTERIAL PNEUMONIA Age ( in yrs) : less than 5, over 40 Onset : Abrupt Cough : Productive Sputum : Rusty & Purulent Rigors : Frequently present Fevers : > 39.5° c Consolidation: present Leucocytosis : 15- 25,000 with

neutrophilia Chest X-ray : alveolar with air

bronchograms.

CAUSES & SIGN & SYMPTOMS

S pneumonia – episodes of rigor, pleurisy, elderly , alcoholic H. Influenzae -- COPD M. catarhalis – COPD Anaerobic -- Putrid Sputum Influenza -- Winter epidemic Chlamydia P -- S.T, HA, hoarseness

CAUSES , SIGN & SYMPTOMS

PCP -- Immunocompromised patients

Legionella – Severe illness, compromised host, Neg G.S.,organ transplant, outbreaks related with water source.

Mycoplasma P – 2-4 wks of prodrome, dry cough

ADMIT OR NOT

2 step decision rules

STEP 1

Assign to risk class I

OR

Risk classes II- IV

RISK CLASS I < 50 years of age have none of five co- morbid conditions

that increase mortality1. Neoplasm2. CHF3. Renal disease4. Cerebrovascular disease5. Liver disease

STEP APPROACH

If not in class I

Go on to Step 2

( assign to one of classes II- V )

STEP 2

Assess patient’s severity index and assign a score

Demographics Co- morbidities P. E. findings Lab findings

DEMOGRAPHICS

Characteristics PointsAgeMale age( in years)Female age ( in years)-

10Nursing home age ( in years) +

10Residents

CO- MORBIDITIESDiseases PointsNeoplasm + 30Liver disease + 20CHF + 10CVD + 10Renal disease + 10

PHYSICAL EXAM

Finding Points

AMS + 20RR> 30 + 20SBP<90mm + 20T<35 or > 40 + 15P> 125 + 10

LABORATORY Findings Points

Ph<7.35 + 30Na< 130 + 20Hct < 30% + 10PO2< 60 + 10Pleural effusion + 10

THE" WHOLE ‘ SHOOTIN’ MATCH "

Patient Assigned pointsDemographics Co- morbiditiesP. E. findingLab finding

Total pointsTotal points

STRATIFICATION OF RISK SCORE

Risk Initial Treatment Risk class Based on

Low Outpatient I Algorithm Outpatient II < 70 pointsMedium Observation III 71-90 points Inpatient IV 91- 130 point

High Inpatient (ICU) V > 130

P. S. I.

Pneumonia severity index can serve as general guideline for management , clinical judgment should always supersede the prognostic scores.

RISK CLASS MORTALITY

Risk class Mortality I 0. 1 % - outpatient II 0. 6 % - outpatient III 2.8 % - inpatient IV 8.2 % - inpatient V 29.2 % - inpatient

Assignment to risk class based on the pneumonia severity index.

Aujesky D , Fine M J Clin Infect Dis. 2008;47:S133-S139

© 2008 by the Infectious Diseases Society of America

COMMUNITY AQUAIRED PNEUMONIA

Severe Pneumonia)ICU(1. Respiratory rate > 30 bpm.2. PaO2 / FiO2 ratio < 250.3. Mechanical ventilation.4. Bilateral or multi-lobar infiltrates on CXR.5. Shock (systolic B.P. < 90 mmHg and / ordiastolic B. P. < 60 mmHg).6. Requirement for vasopressors > 4 hours.7. Urine output < 20 cc/hr or acute renal failure.

SEVERITY ASSESSMENT

CURB-65Confusion

Urea >7mmol/L

Respiratory rate >30

Blood pressure diastolic <60mmHg or systolic <90 ≥65 years old

0-1-may be suitable for outpatient Rx 2 Hospital Rx, consider other features too (e.g.

PaO2) ≥3 Severe disease

BLOOD CULTURE

Positive blood cultures had no correlations with severity of disease and outcome

Current ATS guidelines recommend that patient hospitalized for suspected CAP receive two sets of blood cultures.

However are not necessary for outpatient diagnosis

WHAT TO USE

Outpatient

1. Macrolides2. Fluroquinolones3. Doxycycline

WHAT TO USE

Inpatient-1. Fluroquinolones alone2. Extended spectrum cephalosporins +

macrolidesLevel II evidence

WHAT TO USE

ICU patients1. One of Cefotaxime, Ceftraixone, amp-

sulbactum or pipercillin – tazobactum Plus1. One of macrolides or fluroquinolones

RECOVERY

Symtoms Time periodSubjective Response 1-3 days

Fever without bacteremia - 2.5 days with bacteremia – 6-7 days

RECOVERY

sign Time period

CXR non elderly 30 days older patients 6-8 wks Legionella 12 wksFatigue non elderly 30- 45 days elderly 90 days

A 65-year-old man with hypertension and degenerative joint disease presents to the emergency department with a three-day history of a productive cough and fever. He has a temperature of 38.3°C (101°F), a blood pressure of 144/92 mm Hg, a respiratory rate of 22 breaths per minute, a heart rate of 90 beats per minute, and oxygen saturation of 92 percent while breathing room air. Physical examination reveals only crackles and egophony in the right lower lung field. The white-cell count is 14,000 per cubic millimeter, and the results of routine chemical tests are normal. A chest radiograph shows an infiltrate in the right lower lobe. How should this patient be treated