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Community-Acquired Pneumonia (CAP)

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1 Community-Acquired Pneumonia (CAP)

2 Introduction Pneumonia is the 6th leading cause of death in the U.S.
90% of the deaths occur in persons over 65 years of age. The etiology is 50% idiopathic Only 20% with specific organism in clinical practice

3 Introduction According to the National Institutes of Health: “at any given time, the noses and throats of up to 70% of healthy people contain pneumococcus” (the most common cause of bacterial pneumonia). The paradigm for any type of pneumonia is the balance between the patient's host defenses, the virulence of the potential pathogen, and the size of the exposure to the pathogen.

4 Definition Pneumonia defined as inflammation of the lung parenchyma; pneumonia is characterized by consolidation of the affected part and a filling of the alveolar air spaces with exudate, inflammatory cells, and fibrin.

5 Classification and categorization of bacterial pneumonia
Anatomic/radiographic patterns of pneumonia Lobar pneumonia Bronchopneumonia Interstitial pneumonia Setting of infection Community-acquired pneumonia CAP Health care–associated pneumonia HCAP Nursing home–associated pneumonia NHAP Hospital-acquired pneumonia HAP Ventilator-associated pneumonia VAP Aspiration pneumonia

6 Pneumonia types The 2005 ATS/IDSA guidelines distinguish the following types of pneumonia : Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma in a patient who has acquired the infection in the community. Hospital-acquired (or nosocomial) pneumonia (HAP) is pneumonia that occurs 48 hours or more after admission and did not appear to be incubating at the time of admission. Ventilator-associated pneumonia (VAP) is a type of HAP that develops more than 48 to 72 hours after endotracheal intubation.

7 Pneumonia types Healthcare-associated pneumonia (HCAP) is defined as pneumonia that occurs in a non-hospitalized patient with extensive healthcare contact, as defined by one or more of the following:       - Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days       - Residence in a nursing home or other long-term care facility       - Hospitalization in an acute care hospital for two or more days within the prior 90 days       - Attendance at a hospital or hemodialysis clinic within the prior days

8 Bacterial pathogens of pneumonia
Atypical organisms: Mycoplasma pneumonia, Chlamydophila species (Chlamydophila psittaci, Chlamydophila pneumoniae) Legionella species,Coxiella burnetii , Bordetella pertussis Gram-positive bacteria: S pneumoniae , S aureus ,Enterococcus (Enterococcus faecalis, Enterococcus faecium) Actinomyces israelii ,Nocardia asteroides Gram-negative bacteria: Pseudomonas aeruginosa Klebsiella pneumoniae Haemophilus influenzae Escherichia coli Moraxella catarrhalis, Acinetobacter baumannii, Francisella tularensis ,Bacillus anthracis ,Yersinia pestis Anaerobic organisms: Klebsiella, Peptostreptococcus, Bacteroides, Fusobacterium, and Prevotella

9 Frequency Inpatient, non-ICU Inpatient, ICU Outpatient S pneumoniae
The most common etiologies of community-acquired pneumonia (CAP), listed in descending order of frequency are as follows : Outpatient S pneumoniae M pneumoniae H influenzae C pneumoniae Respiratory viruses Inpatient, non-ICU Legionella species Aspiration Inpatient, ICU S aureus Gram-negative bacilli

10 Histopathology Lobar pneumonia: Four stages of inflammatory response are classically described, as follows: Congestion Red hepatization Gray hepatization Resolution

11 Mortality/Morbidity The average length of hospital stay for a patient diagnosed with pneumonia was 5 days Pneumonia and influenza together were the sixth-eighth leading cause of death in the United States

12 History / Symptoms Chest pain, dyspnea, hemoptysis (when clearly delineated from hematemesis), decreased exercise tolerance, and abdominal pain from pleuritis are also highly indicative of a pulmonary process Rust-colored sputum - Frequently associated with infection by S pneumoniae Currant-jelly sputum - Frequently associated with infection by Klebsiella species Foul-smelling or bad-tasting sputum - Often produced by anaerobic infections

13 History / Symptoms Nonspecific symptoms such as rigors or shaking chills, and malaise are common. Other nonspecific symptoms that may be seen with pneumonia include myalgias, headache, nausea, vomiting, diarrhea, and altered sensorium

14 Potential exposures - Travel, pets, occupation, environment
History of various exposures can be helpful in determining possible etiologies and the likelihood of bacterial pneumonia, as follows: Exposure to contaminated air-conditioning or water systems -Legionella species Exposure to overcrowded institutions (eg, jails, homeless shelters) -S pneumoniae, Mycobacteria, Mycoplasma, Chlamydophila Exposure to various types of animals Cats, cattle, sheep, goats -C burnetii, B anthracis (cattle hide) Turkeys, chickens, ducks, or other birds -C psittaci Rabbits, rodents -F tularensis, Y pestis

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16 Aspiration risks Patients at increased risk of aspiration with:
Alcoholism Altered mental status Anatomic abnormalities, congenital or acquired Dysphagia GERD Seizure disorder

17 Physical examination Approximately 80 % are febrile - frequently absent in older patients A respiratory rate above 24 breaths/minute is noted in 45 to 70 % of patients Most sensitive sign in elderly patients Tachycardia is common

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19 Pneumonia Approach The following 3 aspects of disease are important in the management of pneumonia, in which diagnostic testing can play a pivotal role: Determining the presence of pneumonia Assessing disease severity at the time of presentation Identifying the causative agent Differentiation between community-acquired pneumonia (CAP), health care–associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), and other pulmonary pathology

20 Diagnosis Outpatients  Testing for a microbial diagnosis is usually not performed in outpatients. This is appropriate since empiric treatment is almost always successful. In one study of over 700 ambulatory patients treated for CAP, empiric antibiotics (a macrolide or fluoroquinolone in >95 percent) were almost universally effective; only 1 percent required hospitalization due to failure of the outpatient regimen The 2007 IDSA/ATS consensus guidelines suggest that routine tests to identify an etiology for CAP are optional for patients who do not require hospitalization An exception is in clinical or epidemiologic settings suggesting a critical microbe is the etiologic agent, in which tests for a microbial diagnosis are important

21 Diagnosis Critical microbes — Some microbes are critical to detect because they represent important epidemiologic challenges and/or serious conditions that require treatment different from standard empiric regimens. These organisms include: Legionella species Influenza A and B Avian influenza Community-associated methicillin-resistant Staphylococcus aureus MRSA

22 Diagnosis The incidence of S. aureus in the HCAP and HAP groups were comparable (47 %) and significantly higher than in the CAP group (26 %). The rate of MRSA infection was also higher in HCAP and HAP patients compared to CAP (27 and 23 versus 9 % for CAP).

23 MDR pathogens Host risk factors for infection with MDR pathogens include : Receipt of antibiotics within the preceding 90 days Current hospitalization of ≥5 days High frequency of antibiotic resistance in the community or in the specific hospital unit Immunosuppressive disease and/or therapy Presence of risk factors for HCAP

24 Laboratory studies Diagnostic testing in patients with suspected pneumonia is driven mostly by the possibility that the results would significantly alter empiric therapy and management decisions and whether the test is likely to have a high yield. The following initial tests are indicated with suspected pneumonia: Blood culture, prior to antibiotic therapy Sputum Gram stain and culture, prior to antibiotic therapy (if a good-quality, contaminant-sparse specimen containing <10 squamous epithelial cells per low-power field can be obtained) Sputum, serum, and/or urinary antigen test for Streptococcus pneumoniae Sputum and/or urinary antigen test for Legionella pneumophila Endotracheal aspirate for culture in intubated patients Culture and study of pleural fluid if effusion present Immune serologies for Mycoplasma pneumoniae, Chlamydophila pneumoniae, L pneumophila, and Coxiella burnetii - Results usually not available until several weeks after infection

25 Severity of Pneumonia Various systems to assess the severity of disease and risk of death exist and are in wide use, including : PSI/PORT (ie, Pneumonia Severity Index/Patient Outcomes Research Team score) CURB-65 system (ie, confusion, urea of 7 mmol/L, respiratory rate of 30 breaths/min, and low systolic [90 mm Hg] or diastolic [60 mm Hg] blood pressure)

26 Imaging Studies Lobar pneumonias Bronchopneumonias
S pneumoniae: homogenous parenchymal lobar opacities with air bronchograms; round opacity stimulating a pulmonary mass, called round pneumonia. K pneumoniae: lobar expansion with bulging of interlobular fissures as well as cavitations. L pneumophila: Radiologic resolution tends to lag far behind clinical improvement (8 wk to clear). Bronchopneumonias S aureus: Lobar enlargement with bulging of interlobular fissures can be seen in severe cases; abscesses, cavitations (with air-fluid levels), and pneumatoceles are commonly seen; 30-50% of patients develop pleural effusions, half of which are empyemas. P aeruginosa: usually all lobes are involved, with a predilection for the lower lobes; necrosis and cavitation occur frequently; pulmonary vasculitis can produce areas of pulmonary infarction that radiographically resembles invasive aspergillosis H influenzae: Pleural effusion is present in approximately half of infected individuals.

27 Imaging Studies Aspiration pneumonias:
Gravity-dependent portions of the lungs (affected by patient positioning) The right lung is affected twice as often as the left lung

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33 Chest X-ray

34 Procedures Bronchoscopy with or without bronchoalveolar lavage (BAL): Lung tissue can be visually evaluated and bronchial washing specimens Nonbronchoscopic bronchoalveolar lavage, mini-BAL: BAL can be performed without the use of a bronchoscope. Transtracheal aspiration for culture Thoracentesis: Essential procedure in patients with a parapneumonic pleural effusion.

35 MORTALITY The mortality rate ranged from:
5.1 % for combined ambulatory and hospitalized patients 13 % in hospitalized patients 36 % in patients admitted to the ICU.

36 PREDICTORS OF MORTALITY
Risk factors at presentation  British Thoracic Society BTS found a 21-fold increase in mortality in patients who had two or more of the following findings : Blood urea nitrogen greater than 20 mg/dL (7 mmol/L) Diastolic blood pressure less than 60 mmHg Respiratory rate above 30 per minute The presence of all three variables predicted a nine-fold greater risk for death with 70 % sensitivity and 84 % specificity

37 PREDICTORS OF MORTALITY
CURB-65 score These findings plus confusion (based upon a specific mental test or new disorientation to person, place, or time) and age greater than 65 years Prediction rule for prognosis to determine whether a patient should be admitted to the hospital

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39 Pneumonia Severity Index

40 Pneumonia Severity Index

41 Pneumonia Severity Index
Classes I and II - Outpatient management Class III - Admission to an observation unit or for short hospital stay Classes IV and V - Treatment in inpatient setting Class I is 0-50 points - 0.1% mortality Class II is points - 0.6% mortality Class III is points - 0.9% mortality Class IV is points - 9.3% mortality Class V is greater than 130 points - 27% mortality

42 Severe CAP Additional criteria that can help determine the need for ICU admission are the presence of 3 minor criteria that compose the definition of severe CAP. Minor criteria are as follows: Respiratory rate greater than or equal to 30 breaths per minute Ratio of PaO2 to fraction of inspired oxygen (ie, PaO2/FiO 2 ) of less than or equal to 250 Need for noninvasive ventilation (bilevel positive airway pressure [BiPAP] or continuous positive airway pressure [CPAP]) Multilobar infiltrates Confusion/disorientation Uremia (BUN greater than or equal to 20 mg/dL) Leukopenia (WBC count <4000 cells/µL) Thrombocytopenia (platelet count <100,000/µL) Hypothermia (core temperature <36°C) Hypotension requiring aggressive fluid resuscitation

43 Medication The goals of pharmacotherapy for bacteria pneumonia are to eradicate the infection, reduce morbidity, and prevent complications.

44 Treatment- CAP The regimens chosen by the IDSA/ATS guidelines mainly rely on macrolides (with or without a beta-lactam) or newer fluoroquinolones for outpatient therapy The guidelines promote the use of macrolides to provide coverage for both S. pneumoniae and atypical pathogens (particularly, M. pneumoniae and C. pneumoniae), which account for the majority of cases of CAP in ambulatory patients

45 Treatment- CAP In studies from different regions of the world, atypical pathogens account for 20 to 30 % of cases of CAP Recent use of macrolide antibiotics is considered a risk factor for resistant S pneumoniae Monotherapy with a macrolide is not recommended for persons who received a macrolide antibiotic in the preceding three months.

46 Treatment Recommend one of the following oral regimens for HIGH RISK patients: A respiratory fluoroquinolone Combination therapy with a beta-lactam effective against S. pneumoniae PLUS either a macrolide or Doxycycline Comorbidities or recent antibiotic use:  The presence of significant comorbidities (ie, chronic obstructive pulmonary disease [COPD], liver or renal disease, cancer, diabetes, chronic heart disease, alcoholism, asplenia, or immunosuppression). Use of antibiotics within the prior three months, increases the risk of infection with more resistant pathogens.

47 Treatment In previously healthy patients with no exposure to antibiotics within the previous 90 days, use the following:  Macrolide or doxycycline In patients with comorbidities such as chronic disease of the heart, lung, liver, or kidneys; diabetes mellitus; alcoholism; malignancy; immunosuppression (drug- or disease-induced); or use of antimicrobials within the last 90 days, use the following: Respiratory fluoroquinolone or beta-lactam plus macrolide

48 Inpatient Treatment Inpatient empiric antibiotic therapy   Inpatient treatment of pneumonia, according to 2009 Joint Commission and the Centers for Medicare and Medicaid Services consensus guidelines, should be given within 6 hours of hospital admission (or in the emergency department if this is where the patient initially presented) and should consist of the following antibiotic regimens : Non-ICU patients (choice of one option) Beta-lactam (IV or IM) plus macrolide (IV or PO) Antipneumococcal quinolone monotherapy (IV or IM)  Beta-lactam (IV or IM) plus doxycycline (IV or oral) If patient younger than 65 years with no risk factors for drug-resistant pneumococcus - Macrolide monotherapy (IV or oral) ICU Patients (choice of one option) Beta-lactam (IV) plus macrolide (IV) Beta-lactam (IV) plus antipneumococcal quinolone (IV) If patient has documented beta-lactam allergy - Antipneumococcal quinolone (IV) plus aztreonam (IV)

49 Inpatient Treatment Patients at increased risk of infection with Pseudomonas (acceptable for both ICU and non-ICU patients) (choice of one option) Antipseudomonal beta-lactam (IV) plus antipseudomonal quinolone (IV; PO in non-ICU only) Antipseudomonal beta-lactam (IV) plus aminoglycoside (IV) plus one of the following: Macrolide (IV) Antipneumococcal quinolone (IV; PO in non-ICU only) If patient has documented beta-lactam allergy - Aztreonam (IV) plus aminoglycoside (IV) plus antipneumococcal quinolone (IV; PO in non-ICU only)

50 MRSA For suspected infection with methicillin-resistant S aureus (MRSA): Vancomycin or linezolid may be added to the antibiotic regimen until the organism's identity and antibiotic sensitivities are known, at which point the medications can be adjusted accordingly

51 Aspiration pneumonia Aspiration pneumonia empiric therapy
The causative organisms in aspiration pneumonia have been noted to be similar to those of CAP or HCAP Patients with severe periodontal disease, putrid sputum, or a history of alcoholism with suspected aspiration pneumonia may be at greater risk of anaerobic infection. One of the following antibiotic regimens is suggested for such patients: Piperacillin-tazobactam Imipenem Clindamycin or metronidazole plus a respiratory fluoroquinolone plus ceftriaxone

52 Clinical response Clinical response to antibiotic therapy should be evaluated within hours of initiation. With appropriate antibiotic therapy, improvement in the clinical manifestations of pneumonia should be observed in hours. Because of the time required for antibiotics to act, antibiotics should not be changed within the first 72 hours unless marked clinical deterioration occurs.

53 Clinical response With pneumococcal pneumonia, the cough usually resolves within 8 days and crackles heard on auscultation clear within 3 weeks. The timing of radiologic resolution of pneumococcal pneumonia varies with patient age and the presence or absence of an underlying lung disease. The chest radiograph usually clears within 4 weeks in patients younger than 50 years without underlying pulmonary disease. Resolution may be delayed for 12 weeks or longer in older individuals and those with underlying lung disease.

54 Clinical response/Failure
If patients do not improve within 72 hours, an organism that is not susceptible or is resistant to the initial empiric antibiotic regimen should be considered. Secondary to a complication such as empyema or abscess formation. Broadening the differential diagnosis to include noninfectious etiologies such as malignancies, inflammatory conditions, or congestive heart failure

55 Further Outpatient Care
Patients should have a follow-up chest radiograph in approximately 6 weeks to ensure resolution of consolidation. Chest radiograph findings indicating nonresolution of symptoms should raise the consideration of an endobronchial obstruction as a cause of postobstructive pneumonia.

56 Pneumonia in Immunocompromised Pts
Smokers, alcoholics, bedridden, immuno-compromised, elderly Common still common S. pneumo Mycoplasma Pneumocystis Carinii Pneumonia P. jirovecii Fever, dyspnea, non-prod cough (triad 50%), insidious onset in AIDS, acute in other immunocompromised Pts CXR: bilateral interstitial infiltrates Steroids for hypoxia TMP-SMZ still first line

57 Prevention Smoking cessation Vaccination per ACIP recommendations
Influenza Inactivated vaccine for people >50 yo, those at risk for influenza compolications, household contacts of high-risk persons and healthcare workers Intranasal live, attenuated vaccine: 5-49yo without chronic underlying dz Pneumococcal Immunocompetent ≥ 65 yo, chronic illness and immunocompromised ≤ 64 yo

58 Complications Potential complications include the following:
Destruction and fibrosis/organization of lung parenchyma Bronchiectasis Necrotizing pneumonia Empyema Pulmonary abscess Respiratory failure Acute respiratory distress syndrome ARDS Ventilator dependence Death

59 THANKS


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