1. Community Acquired Pneumonia Peter Valenzuela, MD, MBA, FAAFP Assistant Dean for Clinical Affairs Assistant Professor/Dept. of Family Medicine

2. Objectives Identify the pathogens common to CAP Describe the signs and symptoms of CAP Describe the diagnostic criteria for CAP Discuss treatment options for CAP

3. Background Total annual cost of health care for CAP in U.S. is $8.4 billion 5.6 million cases of CAP in U.S. each year J Respir Dis 2002; 23:10-7 J Respir Dis 2002; 23:10-7 Pneumonia and influenza combined are 7 th leading cause of death in U.S. –21.8 deaths per 100,000 Natl Vital Stat Rep 2003; 52:1-115 Natl Vital Stat Rep 2003; 52:1-115

4. Definition Community-Acquired Pneumonia (CAP)- lower respiratory tract infection in a non- hospitalized person associated with symptoms of acute infection with or without new infiltrate on chest radiograph

5. Types-Pathogens Typical CAP (60-70%) –Streptococcus pneumoniae Atypical CAP (30-40%) –Influenza virus –Mycoplasma –Chlamydia –Legionella

6. Signs & Symptoms Clinical symptoms –Cough (productive or non-productive) –Fever (>100.4) –Chills/Rigors –Dyspnea –Fatigue/Myalgia –Gastrointestinal (Legionella)

7. Signs & Symptoms Physical exam –Dullness to percussion of chest –Crackles or rales on auscultation –Bronchial breath sounds –Egophony (“E” to “A” changes)

8. Diagnosis- Labs All patients with suspected CAP should have chest radiograph Leukocyte count Sputum Gram stain Blood cultures x 2 Serum/urine antigens

9. Radiograph findings Lobar consolidation is common in typical pneumonia This image can be accessed at http://www.emedicine. com/med/images/187 614_2228CONSOLID.JPG http://www.emedicine. com/med/images/187 614_2228CONSOLID.JPG http://www.emedicine. com/med/images/187 614_2228CONSOLID.JPG

10. Radiograph findings Diffuse or patchy infiltrates are more common in atypical pneumonia This image can be accessed at http://www.mevis.de/~ hhj/Lunge/ima/InfOrni ThA54.JPG http://www.mevis.de/~ hhj/Lunge/ima/InfOrni ThA54.JPG http://www.mevis.de/~ hhj/Lunge/ima/InfOrni ThA54.JPG

11. Management Inpatient cost for CAP is $7,500 Outpatient cost for CAP is $150-$350 Pneumonia Severity Index- assesses need for hospitalization This index can be accessed at http://www.medscape. com/content/2004/00/ 49/50/495094/art- jags495094.app.gif http://www.medscape. com/content/2004/00/ 49/50/495094/art- jags495094.app.gif http://www.medscape. com/content/2004/00/ 49/50/495094/art- jags495094.app.gif

12. Management Algorithm This algorithm can be accessed at http://www.aafp.org/afp/20060201/442_f1. gif http://www.aafp.org/afp/20060201/442_f1. gif http://www.aafp.org/afp/20060201/442_f1. gif

13. Treatment Preferred outpatient management is single therapy with one of the following –Macrolide –Fluoroqunolone –Doxycycline Preferred inpatient management –Beta-lactam + macrolide –Fluoroquinolone

14. Summary Identify the pathogens common to CAP Describe the signs and symptoms of CAP Describe the diagnostic labs for CAP Discuss treatment options for CAP

15. Questions?

16. References Lutfiyya N, et al, Diagnosis and treatment of community-acquired pneumonia Am Fam Physician 2006;73:442-50 Niederman MS. Community-acquired pneumonia: management controversies, part 1; practical recommendations from the latest guidelines. J Respir Dis 2002;23:10-7. Arias E, Anderson RN, Kung HC, Murphy SL, Kochanek KD. Deaths: final data for 2001. Natl Vital Stat Rep 2003;52:1-115. Fish D. Pneumonia. PSAP, Pharmacotherapy Self-Assessment Program. Kansas City, Mo.: American College of Clinical Pharmacy, 2002:202. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-50.