Muhammad Ilyas

Pulmonology Division Dept.Of Internal Medicine Faculty Of Medicine Hasanuddin University

Definition: an acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, accompanied by the presence of an acute infiltrate on a chest radiograph, or auscultatory findings consistent with pneumonia, in a patient not hospitalized or residing in a long term care facility for > 14 days before onset of symptoms

CAP is a common illness, with increased mortality in certain population, particularly the elderly and those with severe illness The association between advance age and mortality is well known Sir William Oslers infamous view was that pneumonia was the friend of the aged that often allowed patients with advanced illness to die peacefully

It is more difficult to diagnose pneumonia in the elderly than in young patient because the usual clinical clues for its diagnosis might be absent at the time of onset of the illness Cardinal signs and symptoms, such as cough, fever and dyspnea, may be not present in same older patient with pneumonia

Metlay et al : studied 1812 pneumonia patient and observed that both repiratory and nonrespiratory symptoms were less commonly reported by older patient than by younger patient

Other ways in which advanced age could inderectly increas CAP mortality include a high frequency of comorbid illness as well as a predisposition to more virulent pathogens and pathogenic mechanisms

Pneumonia can also lead to worsening f chronic medical illness, such as COPD and CHF The Coexistence of neurological and GI desease in the elderly may account for their increased risk of aspiration as a common mechanisms of infection Immune dysfunction is common in the elderly, either as a consequence of comorbid illness or directly due to ageing self

 Age Alcoholism Smoking Asthma Immunosuppression Institutionalization COPD PVD Dementia

 Men: age and smoking, weight gain RR 1.5 for age 50-54, 4.17 for > 70 Smoking, current: RR 1.5; heavy: 2.54; Quit <10 yrs: 1.5 Weight gain >40 kg since age 21 Women: smoking, BMI, weight gain BMI 25-26.9, RR 1.53: BMI >30, RR 2.22 Exercise protective: RR 0.66 for most active Alcohol consumption NOT associated with increased risk in men or women

 older, unemployed, unmarried common cold in the previous year asthma, COPD; steroid or bronchodilator use Chronic disease Amount of smoking Alcohol NOT related to increased risk

 Age Bacteremia (for S. pneumoniae) Extent of radiographic changes Degree of immunosuppression Amount of alcohol

 Streptococcus

pneumoniae Haemophilus influenzae Bordetella pertussis Chlamydia pneumoniae Legionella pneumophila Mycoplasma pneumoniae

S. pneumoniae: 20-60% H. influenzae: 3-10% Ch. pneumoniae: 4-6% Myc.pneumonaie: 1-6%

Legionella spp. 2-8% S. aureus: 3-5% Gram negative bacilli: 3-5% Viruses: 2-13%

40-60% - NO CAUSE IDENTIFIED 2-5% - TWO OR MORE CAUSES

Present in nasopharynx of asymtomatic individuals High incidence of colonization in infants under 2 years of age Low incidence in young people High incidence in people in their 70s

Pneumonia develops over several days Cough, sputum , dyspnoea, chest pain and myalgia In healthy young adults: Hyperacute presentation with a dramatic rigor Older people, an insidious presentation, with only confusion and hypothermia Examination: Consolidation, x-ray reveals infiltration

History, PE, CXR

Evaluation for CAP

Infiltrate + clinical evidence of pneumonia

No infiltrate manage/evaluate for alternate diagnosis

evaluate for admission

outpatient: empiric treatment with macrolide, doxycycline, FQ

hospitalize labs

medical ward:abx < 8 hrs

ICU: abx < 8 hrs

no pathogen identified B-lactam + macrolide FQ

no pathogen identified B-lactam + macrolide B-lactam + FQ

Laboratory Tests:
CXR CBC with differential BUN/Cr glucose liver enzymes electrolytes Gram stain/culture of sputum pre-treatment blood cultures oxygen saturation

CXR usually needed to establish diagnosis prognostic indicator rule out other disorders may help in etiological diagnosis Only 3% of outpatients and 28% of ER patients with suggestive signs and symptoms actually have pneumonia

RR > 30 PaO2/FiO2 < 250, or PO2 < 60 on room air Need for mechanical ventilation Mulitlobar involvement Hypotension Need for vasopressors Oliguria Altered mental status

Rational use of microbiology laboratory Pathogen directed antimicrobial therapy whenever possible Prompt initiation of therapy Decision to hospitalize based on prognostic criteria

Outpatient: macrolide doxycycline Fluoroquinolone

NOT IN ANY SPECIFIC ORDER

Patients in ICU: 3GC + macrolide 3GC + FQ B/B-I + macrolide B/B-I + FQ

 Second generation generation cephalosporin plus a macrolide, nonpseudomonal third generation cephalosporin plus a macrolide, or a fluoroquinolone alone were all associated with a lower 30 day mortality in patients with CAP.