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

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

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 Pneumonia and influenza combined are 7th leading cause of death in U.S. 21.8 deaths per 100,000 Natl Vital Stat Rep 2003; 52:1-115

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 Community Acquired Pneumonia is pneumonia not acquired in a hospital or long-term care facility.

Types-Pathogens Typical CAP (60-70%) Atypical CAP (30-40%) Streptococcus pneumoniae Atypical CAP (30-40%) Influenza virus Mycoplasma Chlamydia Legionella Mycoplasma (most common atypical pneumonia), 1.4% mortality, person-to-person contact within closed populations (households, schools, businesses) Chlamydia- 9% mortality due to secondary infection or co-morbid diseases, contact with respiratory secretions, incubation period of weeks, cough can last for months Legionella (most severe of atypicals)- 14% mortality, spread via environment in freshwater or man-made water systems (condensers, RT equipment, showers and faucets, whirlpools)

Signs & Symptoms Clinical symptoms Cough (productive or non-productive) Fever (>100.4) Chills/Rigors Dyspnea Fatigue/Myalgia Gastrointestinal (Legionella) Typical pneumonia presents with dyspnea and bronchial breath sounds

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

Diagnosis- Labs All patients with suspected CAP should have chest radiograph Leukocyte count Sputum Gram stain Blood cultures x 2 Serum/urine antigens According to the American Thoracic Society (ATS), chest x-ray can help establish diagnosis and identify complications Remember that CXR may be normal early in course of disease The ATS discourages the use of the sputum gram-stain to help guide initial therapy, preferring that initial therapy be empiric. The ATS also recommends that a sputum culture only be obtained when an unusual or drug-resistant pathogen is suspected. The utility of obtaining blood cultures from patients with suspected CAP is somewhat doubtful. In a study of CAP cases in 19 Canadian hospitals over a six-month period, positive blood cultures were obtained in only 5.2 to 6.2 percent of patients, including those with the most severe disease. Another prospective study showed that blood cultures were positive in only 10.5 percent of patients with pneumonia. Campbell SG, et. Al. Chest 2003;123:1142-50. Feagan BG. Pharmacotherapy 2001;21(pt 2):S89-94. Sopena N, et. al, Eur J Clin Microbiol Infect Dis 1999;18:852-8.

Radiograph findings Lobar consolidation is common in typical pneumonia This image can be accessed at http://www.emedicine.com/med/images/187614_2228CONSOLID.JPG

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/InfOrniThA54.JPG Always keep in mind that chronic diseases such as congestive heart failure, chronic obstructive pulmonary disease (COPD), and malignancy may obscure the infiltrate of pneumonia

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

Management Algorithm This algorithm can be accessed at http://www.aafp.org/afp/20060201/442_f1.gif Timing of antibiotics is important-4 hours of hospitalization in Medicare patients, They add that early administration can reduce in-hospital mortality in the Medicare population and reduce costs, and should be feasible in most patients. A randomized, double-blind, placebo-controlled trial consisting of patients 18 years or older admitted to nine Dutch hospitals because of clinical symptoms and signs of CAP with a severity index of 110 or less found that three-day antibiotic therapy provides outcomes comparable to eight-day therapy in patients with mild to moderate-severe CAP who show substantial improvement after three days of therapy. This may show the potential for substantial savings in antibiotic treatment of CAP in the primary care setting. These reductions in antibiotic use could impact the development of bacterial resistance to antibiotics and contribute to savings in health care costs. BMJ June 10, 2006;332:1355-8.

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

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

Questions?

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.