Community Acquired Pneumonia

Shaher M. Samrah, MBBS, FCCP

Jordan University of Science and Technology

Types of Pneumonias

Community Acquired Pneumonia (CAP) Hospital Acquired Pneumonia Pneumonia in Immune-compromised Host Pneumonia in Patients with HIV

Epidemiology

Common and a serious illness The most common infectious cause of death The sixth leading cause of death

Mortality

< 1% in the outpatient setting 5-12% for patients requiring hospital admission 22-50% for patients requiring ICU admission

Microbiology

Variety of bacterial and viral pathogens Bacteria are the most common cause Streptococcus pneumoniae is the most common organism. Anaerobic infection is more common in patient with dental caries and bad oral hygiene.

Risk factors related to specific pathogens in community-acquired pneumonia

Alcoholism
COPD and/or smoking
Streptococcus pneumoniae, oral anaerobes, Klebsiella pneumoniae, Acinetobacter species, Mycobacterium tuberculosis Haemophilus influenzae, Pseudomonas aeruginosa, Legionella species, S. pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae Gram-negative enteric pathogens, oral anaerobes CA-MRSA, oral anaerobes, endemic fungal pneumonia, M. tuberculosis, atypical mycobacteria Histoplasma capsulatum Chlamydophila psittaci (if poultry: avian influenza) Francisella tularensis Coxiella burnetti (Q fever) Influenza, S. pneumoniae, Staphylococcus aureus, H. influenzae Bordetella pertussis

Aspiration Lung abscess

Exposure to bat or bird droppings Exposure to birds Exposure to rabbits Exposure to farm animals or parturient cats Influenza active in community Cough >2 weeks with whoop or posttussive vomiting Structural lung disease (eg, bronchiectasis) Injection drug use Endobronchial obstruction

Pseudomonas aeruginosa, Burkholderia cepacia, S. aureus

S. aureus, anaerobes, M. tuberculosis, S. pneumoniae Anaerobes, S. pneumoniae, H. influenzae, S. aureus Bacillus anthracis (anthrax), Yersinia pestis (plague), Francisella tularensis (tularemia)

In context of bioterrorism

Typical Vs. Atypical

Typical

Atypical

S. pneumoniae H. influenzae S. aureus Gram ve bacilli

Legionella species Chlamidia pneumoniae Mycoplasma pneumoniae

10-40% Co-infection with one pathogen

Diagnostic Approach to CAP

Clinical Evaluation

History Physical exam Simple laboratory tests

Chest X-Ray CT chest

Radiological Evaluation

Microbiological studies

Clinical Evaluation

Symptoms

Cough Purulent sputum Dyspnea Pleuritic chest pain Fever and chills

90% 66% 66% 50% 30-40%

Clinical Evaluation

Physical Signs

Vital signs:

Tachycardia, tachypnea, fever, hypotension Dullness, egophony, bronchial breath sounds, crepetations

Signs of consolidation:

Signs of pleural effusion:

Stony dullness, diminished breath sound

Investigation
Outpatient vs. Inpatient

Routine tests performed on admission

Chest radiograph Complete blood count Urea, electrolytes and liver function tests

Oxygenation assessment: ABG

SaO2 <92% on admission features of severe pneumonia

Radiological Evaluation

By definition, Pneumonia requires the finding of infiltrate on chest radiograph The presence of infiltrate on CXR is the gold standard for diagnosing pneumonia

Radiological Evaluation

Lobar infiltrate: One lobe or multi-lobar Interstitial infiltrate Pleural effusion: Parapneumonic or empyema Lung abscess

Right Upper Lobe

Right lower + middle Lobes

Pleural Effusion

Lung abscess

Microbiologic Diagnosis

Not sensitive Do not contribute to initial management Microbial cause is not found in 2560% of cases It is not necessary to perform a full range of microbiological investigations on every patient Should be guided by:

The severity of pneumonia Epidemiological risk factors The response to treatment

Microbiological Diagnosis

Sputum culture
~ 30% has unable to produce sputum Adequacy of the sample Finding of a predominant organism Finding of a resistant organism Helps to broaden the empiric antibiotic therapy

Microbiological Diagnosis

Blood Culture

It is recommended for all patients admitted with CAP, preferably before antibiotic treatment Positive in ~10-25% Bacteremia = severity
Gram stain and culture Bronchoscopy (BAL, PB)

Pleural fluid

Invasive Techniques

Microbiological Diagnosis Serology

Legionella urinary antigen

Rapid and easy Sensitivity up to 90%

Pneumococcal urinary antigen

Not routine should be used for patients with severe CAP

Routine serologic testing is not recommended It takes 4-6 weeks to get the results

Treatment

Where to treat?
Outpatient Inpatient Hospital ward ICU Admission

How to decide?
Pneumonia Severity Index (PSI) CURB-65

Pneumonia Severity Index (PSI)

(PSI)
Risk Factors for Increased Risk of Death

COMPLICATED

CURB - 65
C Confusion U Urea > 7 mmol/l R Respiratory rate > 30/min B BP: Systolic < 90 mm Hg Diastolic < 60 mm Hg 65 Age > 65 Years

Thorax 2003

Criteria for Severe CAP ICU Admission

Minor Criteria Major Criteria

Any
Invasive

Respiratory rate > 30/min PaO2 / FIO2 < 250 Multi-lobar infiltrates Confusion Uremia (BUN > 20 mg/dl) Neutropenia Thrombocytopenia Hypothermia

mechanical ventilation

Septic shock requiring vasopressors

CAP - Treatment

Initial therapy is empirical

Microbiological DX unknown in up to 50% Initiate therapy within 8 hours Co-infection (typical and atypical) Clinical/radiological features cannot be reliably used to establish the etiologic diagnosis of CAP

Outpatient Treatment

Previously healthy + No antimicrobials within the previous 3 months

Macrolide: eryhthromycin, Clarithromycin, Azithromycin

Comorbidities or antimicrobials within the previous 3 months:

Respiratory fluoroquinolone: levofloxacin -lactam + macrolide

Inpatient Treatment-Non ICU

IDSA/ATS Guidelines for CAP in Adults

Respiratory fluoroquinolone

Levofloxacin, Moxifloxacin, Gemifloxacin

-lactam + Macrolide

Ceftriaxone, Cefotaxime

CID 2007:44 (Suppl 2)

Dental pneumonia !

In cases of aspiration and lung abscess pneumoniae where anaerobic infection is suspected: Clindamycin (first-line therapy) Amoxicillin-clavulanate Metronidazole + Amoxicillin/Penicillin G

Prevention strategies
Pneumococcal Vaccine

Prevention strategies
Influenza virus Vaccine

Good Luck