Tuesday Conference

Approach to Community
Acquired Pneumonia
Selim Krim, MD
Assistant Professor
TTUHSC
Case 1
A 62-year-old white male presents complaining of cough, fever,
and difficulty breathing, which developed during the night. He
has no symptoms of rhinorrhea, sore throat, or earache. He is
not a smoker and has no history of asthma or recent antibiotic
use. He is a business executive who travels extensively and just
returned from California.

Case 1
On physical examination, he appears flushed but otherwise alert
and oriented. He is 5-11, 180 lbs and has a blood pressure of
110/70 mmHg, a heart rate of 90 beats per minute, a respiratory
rate of 24 breaths per minute, and a body temperature of 39 C.

Lung sounds reveal a mild dullness in right base, no increased
tympany, and coarse breath sounds with mild rales in right
posterior lung base. He is not wheezing. The rest of his exam is
normal.


Based on your history and
physical exam what is your
diagnosis?
Diagnosis of Pneumonia
Signs and symptoms

Fever or hypothermia, cough with or without sputum, dyspnea,
chest discomfort, sweats, or rigors

Atypical pneumonia associated with headaches, diarrhea,
nonexudative pharyngitis, bullous myringitis, slow onset,
myalgias

Physical exam may reveal fever, tachypnea, tachycardia.

Lung exam; increased tactile fremitus, dullness to percussion,
decreased breath sounds, presence of rales or crackles

MCQ 3
What is the next most important step in this patient's care?

Empiric therapy with a fluoroquinolone
Chest x-ray
Sputum culture
Hospitalization
CBC, glucose, BUN, Na tests


Diagnostic tests
Chest x-ray essential (AP and Lateral)
Patchy airspace infiltrates (Mycoplasma)
Lobar or segmental consolidation (w/air bronchogram)
(Pneumococcal)
Diffuse alveolar or interstitial infiltrates (viral or Mycoplasma
and other)



Epidemiology

MCQ 1
Which of the following statements is not true about community-
acquired pneumonia?

More than 4 million cases of community-acquired pneumonia
(CAP) occur each year
Less than 10% of patients with CAP need hospitalization
No causative agent is identified in 30% to 50%of cases
Streptococcus pneumoniae is the most commonly identified
organism
Nursing home-acquired pneumonias are usually caused by the
same organisms as community acquired pneumonias but with
increased numbers of S aureus and gram-negative organisms

MCQ 2
Streptococcus pneumoniae is identified in up to what
percentage of community-acquired pneumonia cases?

40%
50%
60%
70%
80%



Identified Pathogens in Community-acquired
Pneumonia
Pathogen Percentage

Streptococcus pneumoniae 20-60%
Haemophilus influenzae 3-10%
Staphylococcus aureus 3-5%
Gram-negative bacilli 3-10%
Legionella species 2-8%
Mycoplasma pneumoniae 1-6%
Chlamydia pneumoniae 4-6%
Viruses 2-15%
Aspiration 6-10%
Others 3-5%

MCQ 4
What is the most likely pathogenic mechanism in this patient's
pneumonia?

Direct inoculation
Aspiration of oropharyngeal contents
Hematogenous deposition
Reactivation
Inhalation of infectious particles


Pathogenetic mechanisms in
Pneumonia

Inhalation of infectious particles Common
Aspiration of oropharyngeal or gastric content Common
Hematogenous deposition Uncommon
Invasion from infection in contiguous structures Rare
Direct inoculation Less common
Reactivation More common in
Immunocompromised hosts




Case 1
A 62-year-old white male presents complaining of cough, fever,
and difficulty breathing, which developed during the night. He
has no symptoms of rhinorrhea, sore throat, or earache. He is
not a smoker and has no history of asthma or recent antibiotic
use. He is a business executive who travels extensively and just
returned from California.

Case 1
On physical examination, he appears flushed but otherwise alert
and oriented. He is 5-11, 180 lbs and has a blood pressure of
110/70 mmHg, a heart rate of 90 beats per minute, a respiratory
rate of 24 breaths per minute, and a body temperature of 39 C.

Lung sounds reveal a mild dullness in right base, no increased
tympany, and coarse breath sounds with mild rales in right
posterior lung base. He is not wheezing. The rest of his exam is
normal.



Should this patient be admitted?
RISK STRATIFICATION


Pneumonia Severity Index Calculator
Risk of 30 d Mortality By Point
Total
Risk Class Point score Mortality%

I 0.1
II < 70 0.6
III 71-90 2.8
IV 91-130 8.2
V > 130 29.2
Case 1 (Part 2)
Empiric therapy with an oral macrolide was prescribed, and the
patient was sent home. Two days later, he presents at the
emergency room with shaking chills and fever, increasingly
productive cough, and difficulty breathing.

His vital signs are as follow: BP 110/60 mmHg, body
temperature 40.5 C, pulse rate 126 beats/min, and respiration
rate 28 breaths/min. He is alert and oriented. His exam again
reveals rales and dullness in the right lower posterior lung fields
without wheezing. Chest x-ray shows a focal infiltrate in the right
lower lung and a small pleural effusion.


MCQ 5
After recalculating your PSI , what is this patient's 30-day
mortality risk factor classification and should he be admitted?

I
II
III
IV
V


RISK STRATIFICATION


Pneumonia Severity Index Calculator
Risk of 30 d Mortality By Point
Total
Risk Class Point score Mortality%

I 0.1
II < 70 0.6
III 71-90 2.8
IV 91-130 8.2
V > 130 29.2
MCQ 6
Which of the following findings would NOT further raise his risk
factor score (and increase his 30-day mortality risk)?

Serum urea nitrogen > 30 mg/dL
Confusion
Arterial blood pH below 7.35
Elevated white blood cell count (>15,000)
Na below 130 mEq/L


MCQ 7
Which statement is NOT correct concerning this patient?

Because initial empiric outpatient therapy failed, the possibility
of pulmonary emboli or malignancy constitutes a majority

He should be hospitalized and given empiric intravenous
antibiotic therapy with fluoroquinolone alone

Extensive serology testing should be conducted for HIV,
Mycoplasma and Chlamydia species, SARS, and influenza A
and B on specimens obtained by bronchoscopy

Sputum gram-stain and cultures as well as blood cultures need
to be obtained after hospital admission


Which test to order?
MCQ 8
Pathogen-specific treatment with a macrolide or doxycycline in
community-acquired pneumonia is recommended with which
organism?

Staphylococcus aureus
Mycoplasma pneumoniae
Pseudomonas aeruginosa
Influenza A
Streptococcus pneumoniae




How would you treat this patient?
Case 1 (Part 3)
Patient is admitted to the hospital and treated with IV
ciprofloxacin. After 3 days, he is still febrile and in need of
oxygen supplementation, but he is alert and eating on his own.
Blood and sputum cultures are negative.
MCQ 9
Which of the following would be the next best step?

Change to oral antibiotics based on presumed S pneumoniae
Add zanamivir for possible influenza A or B
Direct fluorescent antibody staining by nasal swab for viruses or
sputum for Legionella
Fiberoptic bronchoscopy with lavage and transbronchial biopsy
Add vancomycin with or without rifampin



Would you consider discharging
your patient at this point?
Discharge Criteria


Candidates for discharge should have no more than one of the
following poor prognostic indicators:

Temperature > 37.8 degrees Celsius
Pulse > 100 beats per minute
Respiratory rate > 24 per minute
Systolic blood pressure < 90 mmHg
Oxygen saturation < 90 percent
Inability to maintain oral intake
Key Points
Community-acquired pneumonia can be treated empirically
with oral antibiotics in the outpatient setting in patients with
class I or II PORT category risk factor stratification.

Patients younger than age 50 who have no comorbid health
problems and who present with minimal signs and symptoms
of possible pneumonia can safely be treated without the need
for further testing.

A macrolide or doxycycline is the treatment of choice for
healthy patients younger than age 60 who have presumed
pneumonia. Fluoroquinolones are not recommended in these
patients because of increasing problems with antibiotic
resistance.



Key Points
In all patients in whom pneumonia is suspected, a chest x-ray
should be ordered to provide diagnostic evidence with which to
distinguish different patterns of infiltrates.

The need for in-patient care can be determined by professional
judgment, based on the patient's signs and symptoms; however,
a risk factor calculation can be helpful in determining those with
high predicted mortality.

Obtaining blood cultures within 24 hours of admission and
starting antibiotics within 4 hours of admission have been shown
to reduce 30-day mortality and are considered quality indicators.





Key Points
Because 30% to 50% of patients with community-acquired
pneumonia never have a pathogen identified, it is recommended
that empiric therapy selection be based on presumed organisms
and their sensitivities, history of exposure, other comorbid health
conditions, and x-ray findings.

Aggressive testing including cultures, serology testing, and other
rapid assays to determine the causative pathogen are
appropriate for most inpatients. More invasive testing, including
bronchoscopy, should be reserved for deteriorating patients in
whom no etiology has been determined.



Thank You