Community Acquired Pneumonia Dr Ellahi Bakhsh

Community Acquired PneumoniaDR. ELLAHI BAKHSH

PGR PULMONOLOGY

FATIMA JINNAH CHEST HOSPITAL QUETTA

References

Clinical Respiratory Medicine by Stephen G. Spiro

BTS Guideline for Management of Community Acquired Pneumonia in Adults

updated 2009

NICE Guideline for Diagnosis and Management of Community Acquired Pneumonia in Adults ( Published in December 2014 )

Davidson’s Principles & Practice of Medicine

Objectives

To Briefly Review of Pneumonia

Management of Community Acquired Pneumonia in Adults

according to recently published NICE Guideline

Case Scenario

82 year old male , living in a Nursing Care, presented with Fever,

Breathlessness, purulent sputum with alter level of consciousness for the last 3

days. He has COPD and history of Smoking and Mild Dementia.

His Chest Xray shows new right lower lobe infiltrates

CBC shows Raised WBC count 18000/mm3

Initial Gram Staining report shows Prominent Stains of Gram +ve Organism

Case Scenario

What is your Diagnosis

Health Care Associated Pneumonia

What is most probable Causative Pathogen

Staphylococcus Aureus

What should be done next

Vancomycin 1 gram IV every 12 hours

Piperacillin and Tazobactam and intravenous levofloxacin incase of MRSA

Community Acquired Pneumonia

Acc. to BTS Guidelines CAP is defined as

Acute Lower Respiratory Tract Infection

Accompanied by New Infiltrates on Chest Radiograph

Or Ascultatory Findings Consistent with Pneumonia

in a patient Not Hospitalized or residing in a Long Term Care Facility

for More than 2 weeks

before onset of symptoms

What is An Acute Lower Respiratory Tract Infection

Acc. To NICE Guideline

An acute Illness (present for 21 days or less)

usually with Cough as main symptom

and with at least 1 other Lower respiratory tract symptoms such as

Fever

Sputum Production

Breathlessness

Wheeze

Chest Discomfort or Chest Pain

with No alternative explanation

Pneumonia, Acute Bronchitis and Exacerbation of COPD

Hospital Acquired Pneumonia

Pneumonia that develops in a Non-Incubating patient, 48 hours or

more after Hospital Admission

Ventilator Associated Pneumonia

Pneumonia that develops in a patient receiving Invasive Mechanical

Ventilation for at least 48 hours or more

Health Care Associated Pneumonia

Pneumonia that develops in a patient with recent contact with the

Health Care System, that include

Hospitalization for 2 days or more in the preceding 90 days

Residence in Nursing Care

Home Infusion Therapy including Antibiotics

Chronic Dialysis within 30 days

Home Wound Care

Family member with MDR Pathogen

Why it is important to differentiate CAP from

other Pneumonia

Timely Diagnosis and Treatment is the key in Successful

Management of Pneumonia

Early Pathogen detection and Choice of appropriate Antibiotic

will not only result in better outcome of Pneumonia, But also

reduces problems related to Antibiotic Resistant

Burden of Disease

Pneumonia remains common cause of Death

Globally Pneumonia ranked 6th

CAP is most common cause of Severe Sepsis

Despite introduction of Antibiotics, Imaging modalities and

Biomarker testing, mortalities related to CAP has not changed

significantly.

Risk Factors

Age

Altered Immunity

Malnutrition

Environmental Factors

Airway Colonization

Alcoholism

Smoking

Risk Factors

Age

With the increase in Age , Immunity of body weakens

Every Year over 65, increases risk for Pneumonia

Risk Factors

Altered Immunity

Patients with Immunocompromised state such as

HIV

AIDS

Chemotherapy Treatment

Lymphopoliferative Diseases

Cancer

Diabetes

CLD

Heart Failure

are at increased risk for development of CAP

Risk Factors

Malnutrition

whatever the cause may be

Malnutrition leads to alterations in Immunity

Increasing the chance for Airway colonization and infection with Gram –ve Bacilli

Risk Factors

Environmental Factors

Overcrowding

Occupations associated with exposure to Dust, Fumes, various Chemicals,

Contaminated Water Supply and Cooling Towers of Air-Conditioning Units

Contact with Animals

Risk Factors

Airway Colonization

Results in Impairment of Innate Lung Defense

Common in Patients with Chronic Obstructive Pulmonary Disease

Risk Factors

Alcoholism

Leads to Impaired Level of Consciousness, Cough Reflex and Muco-cilliary Movement

Also impairs function of Lymphocytes, Monocytes and alveolar Macrophages

Risk Factors

Smoking

Smoking, itself is not a Risk Factor for Pneumonia

But it alters Muco-cilliary Transport

And increases adhesion of Pathogens to Orophyrangial epithelium

Pathogens

Virus , Bacteria and Fungi are pathogens of Pneumonia

Common Pathogens are

Streptococcus Pneumoniae

Staphylococcus Aureus

H. Influenza

Mycoplasma Pneumoniae

Ligeonalla Pneumophila

Pseudomonas

Clamydia

Ecoli

Klebsella Pneumoniae

MRSA

Anaerobes

Common Pathogens in CAP

Streptococcus Pneumoniae

Staphylococcus Aureus

H. Influenza

Mycoplasma Pneumoniae

Ligeonalla Pneumophila

Clamydia

Klebsella Pneumoniae

Common Pathogens in HAP

•E. Coli

•Pseudomonas

•Klebsella

Gram –ve are Most Common

•Staphylococus Aureus

•MRSAGram +ve

Bacteriods

Common Pathogens in VAP

Pseudomonas aeruginosa

E.coli

Klebsiella pneumoniae

Acinetobacter

Staphylococcus Pneumoiae

Common Pathogens in HCAP

Staphylococcus aureus

Pseudomonas aeruginosa

Streptococcus pneumoniae

Haemophilus influenzae.

Streptococus Pneumoniae

Most Common Pathogen of CAP

If left untreated , it will eventually result in Production of Rust

colored Sputum

Pneumonia caused by Streptococus Pneumoniae is a

Medical emergency

Because of

•Rapid multiplication

•High Risk for Secondary Complications

Staphylococus Pneumoniae

Most Severe form of CAP

Because of

Resistant to Multiple Antibiotics

Leads to formation of Bullae which may repute to Cause Pneumothorax,

Pneumo-Pyothorax and Septicemia

Mycoplasma Pneumoniae

Most Common Pathogen in Atypical Pneumonia

Usually occurs in small epidemics in Overcrowded Population

Clinical Presentation CAP

Classical Symptoms of CAP are

Fever

Intense Chills

Cough

Sputum Production

Dyspnea

Pleuritic Chest Pain

Generalized Fatigue

Hemoptysis

Clinical Presentation

On Chest X ray

Clinical Presentation

On General Physical Examination

Hyperthermia

Tachycardia

Tachypnea

Use of Accessory Muscles

Central Cyanosis

Altered Mental Status

Clinical Presentation

On Chest Examination

Wheezes

Coarse Crackes

Tracheal Deviation

Dull Percussion

Reduced Breath Sounds

Decrease Chest Movements on Effected Side

Bronchial Breathing

Clinical Presentation

On Arterial Blood Gases

Decreased PaO2

Decreased PaCo2

Type 1 Respiratory Failure with Respiratory Alkalosis

Classification of CAP

Typical

Caused by Typical Pathogens

Streptococus Pneumoniae

H. Influenze

Klebsella

Morexella Cataralis

Classical Syptoms are Dominant

Sudden in Onset

High Grade Fever

Intense Chills

Productive Cough

Pleuritic Chest Pain ( Occasionally)

CBC Shows Leukocytosis with Neutrophillic

Predominance

Atypical

Also Called Walking Pneumonia

Caused by Atypical Pathogens

Mycoplasma Pneumoniae

Clamydia Pneumophila

Ligionella

Systemic Menifestations are Dominant

Generalized Myalgea

Muscle Ache

Arthralgia

Diarhhea

Nausea

Vomiting

Abdominal Pain

Gradual in Onset

Low Grade Fever

Dry Cough

CBC Shows Absent Leukocytosis

Do not respond to common Antibiotics

Do not form Lobar Consolidations rather restricted to Small

Areas

Investigations

Baseline

Chest X ray

Complete Blood Count

Serum Electrolytes

Urea Creatinine

Liver Functioning Test

Specific

Arterial Blood Gases

Gram Staining

Sputum Culture

C – reactive Protein

Pneumococcal and Legionella

Urinary Antigen Test

C – reactive Protein

C-reactive protein is an acute phase reactant,

a protein made by the liver and released into the bloodstream within a few hours

after tissue injury,

start of an infection,

or other cause of inflammation

Abbreviated Mental Test

Quick and Easy to Use Test to Assess Elderly patients for

Dementia

Confusion

Impaired Cognitive Functions

10 simple questions are asked from patient

1 Point is given for every Correct Answer and 0 Point for Incorrect Answers

Abbreviated Mental Test

Name

Time

Give the patient an address and ask for recall at end of test

Year

Name of the place

Identification of any two person ( Doctor, Nurse , Home Help etc)

Date of Birth

Any Historical Event

Name of President/ Prime Minister

Count backward from 20-1

Recall Adress

Differential Diagnosis of CAPAcute bronchitis

Acute Exacerbation of COPD

Pulmonary T.B

Pulmonary Edema

Pulmonary Infarction

Pulmonary eosinophilia

Pulmonary fibrosis

Bronciolitis Oblitrans Organising Pneumonia

Bronchoalveolar Cell Carcinoma

Drug-induced pulmonary disease

Myocardial infarction

Congestive heart failure and pulmonary edema

Management Of Community Acquired Pneumonia

Lower Respiratory Tract Infection

For people presenting with symptoms of Lower Respiratory Tract Infection

in Primary Care,

Consider C-reactive protein test

if after clinical assessment a diagnosis of Pneumonia has not been

made

and it is not clear whether Antibiotics should be prescribed

Lower Respiratory Tract Infection

Use the results of the C-reactive protein test to guide Antibiotic prescribing in people without a clinical diagnosis of pneumonia as follows,

Do not routinely offer antibiotic therapy if the C-reactive protein concentration is less than 20 mg/litre

Consider a Delayed Antibiotic Prescription (a prescription for use at a later date if symptoms worsen) if the C-reactive protein concentration is between 20 mg/litre and 100 mg/litre

Offer Antibiotic Therapy if the C-reactive protein concentration is greater than 100 mg/litre

Community Acquired Pneumonia

When a clinical diagnosis of Community Acquired Pneumonia is made in

Primary Care

Severity is assessed

To determine whether patients are at Low, Intermediate or High risk of Death

using the CRB65 Score

CRB65 score

CRB65 Score is calculated by giving 1 Point for each of the following

prognostic features

Confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)

Raised Respiratory Rate (30 breaths per minute or more)

Low Blood Pressure (Diastolic 60 mmHg or less, or Systolic less than 90

mmHg)

Age 65 Years or more

Mortality Risk

Patients are stratified for Risk of Death as follows

0 Low risk (less than 1% mortality)

1 or 2 Intermediate risk (1-10% mortality risk)

3 or 4 High risk (more than 10% mortality risk)

Decision For Site Of Care

Use Clinical Judgment in conjunction with the CRB65 Score to inform

decisions about whether patients need Hospital assessment as

follows

Consider Home-Based Care for patients with a CRB65 score of 0

Consider Hospital Assessment for all other patients, particularly those

with a CRB65 Score of 2 or more

Community Acquired Pneumonia

When a clinical diagnosis of Community Acquired Pneumonia is made in

Hospital

Severity is assessed

To determine whether patients are at Low, Intermediate or High risk of

Death

using the CURB65 Score

CURB65 score

CURB65 Score is calculated by giving 1 Point for each of the

following prognostic features

Confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)

Raised Blood Urea Nitrogen (over 7 mmol/litre)

Raised Respiratory Rate (30 breaths per minute or more)

Low Blood Pressure (Diastolic 60 mmHg or less, or Systolic less than 90 mmHg)

Age 65 years or more

Mortality Risk

Patients are stratified for risk of death as follows

0 or 1 Low risk (less than 3% mortality risk)

2 Intermediate Risk (3-15% mortality risk)

3 to 5 High Risk (more than 15% mortality risk)

Management Of CAP

Use Clinical Judgment in conjunction with the CURB65 Score to Guide

Management of Community Acquired Pneumonia as follows

Consider Home-Based Care for patients with a CURB65 Score of 0 -1

Consider Hospital-Based Care for patients with a CURB65 Score of 2 or more

Consider Intensive Care assessment for patients with a CURB65 Score of 3 or more

Microbiological Test

Do not routinely offer Microbiological Tests to patients with Low-severity

Community Acquired Pneumonia

For patients with Moderate or High-Severity Community Acquired Pneumonia

take Blood and Sputum Cultures and

Consider Pneumococcal and Legionella Urinary Antigen Tests.

Timely Diagnosis And Treatment

Put in place processes to allow diagnosis (including X-rays) and

treatment of Community Acquired Pneumonia within 4 hours of

presentation to Hospital

Offer Antibiotic Therapy as soon as possible after diagnosis, and certainly

within 4 hours to all patients with Community Acquired Pneumonia who

are admitted to hospital

Antibiotic Therapy

Low-severity community-acquired pneumonia

Offer a 5-day course of a Single Antibiotic to patients with Low-Severity

Community Acquired Pneumonia

Consider Amoxicillin in preference to a Macrolide or a Tetracycline for patients

with Low-Severity Community Acquired Pneumonia

Consider a Macrolide or a Tetracycline for patients who are Allergic to Penicillin

Consider Extending the course of the Antibiotic for longer than 5 days as a

possible management strategy for patients with Low-Severity Community

Acquired Pneumonia whose symptoms do not improve as expected after 3 days

Antibiotic Therapy

Explain to patients with Low-Severity Community Acquired Pneumonia

treated in the community, and when appropriate their families or carer, that

they should seek further medical advice if their symptoms do not begin to improve

within 3 days of starting the antibiotic, or earlier if their symptoms are worsening.

Do not routinely offer patients with Low-Severity Community Acquired

Pneumonia

a Fluoroquinolone

Dual Antibiotic Therapy

Antibiotic Therapy

Moderate- and High-Severity Community Acquired Pneumonia

Consider a 7 to10 day course of Antibiotic Therapy for patients with Moderate or High Severity Community Acquired Pneumonia

Consider Dual Antibiotic Therapy with Amoxicillin and a Macrolide for patients with Moderate-Severity Community Acquired Pneumonia

Consider Dual Antibiotic Therapy with a Beta-Lactamase Stable Beta-Lactamand a Macrolide for patients with High-Severity Community Acquired Pneumonia

SiteScoring

SystemSeverity Management

Antibiotic

Therapy

Antibiotic

DurationAntibiotics

Primary

CareCRB-65

Low ( 0 )Home Based

TreatmentSingle 5 Days

Amoxicillin(Preferred)

orMacrolide

OrTetracycline

Moderate

(1-2)Refer to Hospital

High (2-4)

Do not routinely offer Floroquinolone & Dual Antibiotic Therapy to patients with low-severity CAP

Consider Extending the course of the Antibiotic for longer than 5 days for patients with Low-Severity CAP whose

symptoms do not improve as expected after 3 days

Explain to patients with Low-Severity CAP, their families, that they should seek further Medical advice if their symptoms

do not begin to improve within 3 days of starting the antibiotic, or earlier if their symptoms are worsening

SiteScoring

SystemSeverity Management

Antibiotic

Therapy

Antibiotic

DurationAntibiotics

Hospital CURB-65

Low ( 0-1 )Home Based

TreatmentSingle 5 Days

Amoxicillin(Preferred)

orMacrolide

OrTetracycline

Moderate

(2)

Hospital Based CareDual 7-10 Days

Amoxicillin

+Macrolide

Intensive Care UnitHigh (3-5) Dual

7-10 Days

Beta-Lactamase stable

beta-lactam+

Marcrolide

Macrolides include Erythromycin, Clarithromycin, Azithromycin

Beta-Lactamase stable beta-lactam includes Co-Amoxiclave, Cefotaxime, Ceftroline, Fosamil, Ceftriaxone,

Piperacillin with Tazobactam

Antibiotic Dosage

Amoxicillin

Macrolides

Ceftriaxone

Co-Amoxicalve

Piperacillin with Tazobactam

Cefotaxime

• 500mg – 1g 8 Hourly

• 500mg 12 Hourly

• 2g Once Daily

• 1.2g 8 Hourly

• 4.5g 8 Hourly

• 1g 8 Hourly

Glucocorticoid Treatment

Do not routinely offer a Glucocorticosteroid to patients with

Community Acquired Pneumonia unless they have other conditions

for which Glucocorticosteroid treatment is indicated

Monitoring in Hospital

Consider measuring a baseline C-reactive protein concentration in

patients with Community Acquired Pneumonia on admission to Hospital

Repeat the Test if clinical progress is uncertain after 48 to 72 hours

Safe Discharge from Hospital

Do not Routinely Discharge patients with Community Acquired Pneumonia

if in the past 24 hours they have had 2 or more of the following findings

Temperature higher than 37.5°C

Respiratory Rate 24 breaths per minute or more

Heart Rate over 100 beats per minute

Systolic Blood Pressure 90 mmHg or less

Oxygen Saturation under 90% on room air

Abnormal Mental Status

Inability to Eat without Assistance

Consider Delay Discharge

Consider Delaying Discharge for patients with Community Acquired

Pneumonia if their Temperature is higher than 37.5°C

Patient Counseling Explain to patients with Community Acquired Pneumonia that after starting treatment their symptoms

should steadily improve, although the rate of improvement will vary with the severity of the pneumonia, and most people can expect that by

1 week Fever should have resolved

4 weeks Chest Pain and Sputum production should have substantially reduced

6 weeks Cough and Breathlessness should have substantially reduced

3 months most symptoms should have resolved but Fatigue may still be present

6 months most people will feel back to Normal

Patient Counseling

Advise patients with Community Acquired Pneumonia to consult their Healthcare

Professional if they feel that their Condition is Deteriorating or not Improving as

expected

Hospital Acquired Pneumonia

Antibiotic Therapy

Offer Antibiotic Therapy as soon as possible after diagnosis, and certainly within 4 hours, to patients with Hospital Acquired Pneumonia

Choose Antibiotic Therapy in accordance with Local Hospital Policy(which should take into account knowledge of local microbial pathogens) and clinical circumstances for patients with hospital-acquired pneumonia.

Consider a 5 to10 day course of Antibiotic Therapy for patients with Hospital Acquired Pneumonia

Empirical Coverage for Uncommon Pathogens Causing CAP

Pseudomonas MRSA

Vancomycin

Linezolid

Piperacillin with Tazobactam Or Cefepime Or Imepenem plus Either Ciprofloxacin Or Levofloxacin

•Or

Aminoglycoside and Azithromycin

•Or

Beta-Lactam with Aztreonam

Common Causes of Non-Responding Pneumonia

Infective Etiology

Resistant Organism

•Staphylococcus Aureus

•Streptococcus Pneumoniae

Super Infection with Nosocomial Organism

•Pseudomonas

Rare Organisms

•Fungi

•Mycobacteria

Extra Pulmonary Dissemination

• Endocarditis

• Meningitis

• Arthritis

Empyema or Abscess Formation

Common Causes of Non-Responding Pneumonia

Non-Infective Etiology

Pulmonary Embolism

MI

Heart Failure

Pulmonary Edema

Renal Failure

Vasculitis

Malignancy

Pulmonary Hemorrhage

Bronchiolitis Oblitrans with Organizing Pneumonia

Drug Induced Pulmonary Disease

Complications Of CAP

Lung Abscess

Para-pneumonic Effusion

Empyema

Broncho-pleural Fistula

Organizing Pneumonia

Bronchiectasis

Prevention

Vaccination against Streptococcus pneumonia and Influenza Virus

Vaccination status should be assessed at the time of admission

Vaccination should be performed either at Discharge or during Out Patient follow up

if needed

Risk Factor Modifications

Smoking and Alcohol abuse Cessation

Special Thanks

to

Dr. Saeed Ahmed and Dr. Ellahi Bukhsh

Thanks