Pneumonia Salutations: I am going to talk mainly about the work-up of CAP and the IDSA guidelines for the treatment of CAP.

Community Acquired Pneumonia 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 in 2 days (48 hrs) after gospitalization or 28 days after been discharged Adeel A. Butt, MD Bartlett. Clin Infect Dis 2000;31:347-82.

Community Acquired Pneumonia Epidemiology: 4-5 million cases annually ~500,000 hospitalizations ~45,000 deaths Mortality 2-30% <1% for those not requiring hospitalization Bartlett. CID 1998;26:811-38. Adeel A. Butt, MD

Community Acquired Pneumonia Epidemiology: (contd) fewest cases in 18-24 yr group probably highest incidence in <5 and >65 yrs mortality disproportionately high in >65 yrs Adeel A. Butt, MD

Community Acquired Pneumonia Incidence # in 1000s NCHS Data: www.cdc.gov/nchswww/data/nvsr47_9.pdf Adeel A. Butt, MD

Community Acquired Pneumonia Mortality # in 1000s NCHS Data: www.cdc.gov/nchswww/data/nvsr47_9.pdf Adeel A. Butt, MD

Community Acquired Pneumonia Risk Factors for pneumonia age chronic alcohol intox smoking asthma immunosuppression institutionalization COPD PVD dementia ID Clinics 1998;12:723. Am J Med 1994;96:313 Adeel A. Butt, MD

Community Acquired Pneumonia Risk Factors (contd.) 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 lbs 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 Baik et al. Arch Int Med 2000;160:3082-8. Adeel A. Butt, MD

Community Acquired Pneumonia Risk Factors in Patients Requiring Hospitalization 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 Farr BM. Respir Med 2000;94:954-63 Adeel A. Butt, MD

Pneumonia Risk Factors for Mortality Adeel A. Butt, MD Fine. JAMA 1996;275:134-41. Adeel A. Butt, MD

Community Acquired Pneumonia Microbiology Legionella spp. 2-8% S. aureus: 3-5% Gram negative bacilli: 3-5% Viruses: 2-13% S. pneumoniae: 20-60% H. influenzae: 3-10% Chlamydia pneumoniae: 4-6% Mycoplasma pneumonaie: 1-6% Bartlett. NEJM 1995;333:1618-24. 40-60% - NO CAUSE IDENTIFIED 2-5% - TWO OR MORE CAUSES Adeel A. Butt, MD

Community Acquired Pneumonia Adeel A. Butt, MD

Community Acquired Pneumonia Laboratory Tests: CXR CBC with differential BUN/Cr glucose liver enzymes electrolytes Gram stain/culture of sputum pre-treatment blood cultures oxygen saturation Adeel A. Butt, MD

Community Acquired Pneumonia Diagnostic Evaluation CXR or CT usually needed to establish diagnosis prognostic indicator rule out other disorders may help in etiological diagnosis CXR – screening CT - standard Adeel A. Butt, MD J Chr Dis 1984;37:215-25

Community Acquired Pneumonia Who should be hospitalized? Adeel A. Butt, MD

Community Acquired Pneumonia Who should be hospitalized? Adeel A. Butt, MD

Who should be hospitalized? Adeel A. Butt, MD

Community Acquired Pneumonia Severity of CAP 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 Adeel A. Butt, MD

Community Acquired Pneumonia Management Rational use of microbiology laboratory Pathogen directed antimicrobial therapy whenever possible Prompt initiation of therapy Decision to hospitalize based on prognostic criteria Adeel A. Butt, MD

Community Acquired Pneumonia Empiric Treatment Outpatient: PPC Macrolide Fluoroquinolone NOT IN ANY SPECIFIC ORDER Adeel A. Butt, MD

Community Acquired Pneumonia Empiric Treatment Patients in General Medical Ward: PPC + macrolide 3GC (ctxn or ctxm)+ macrolide FQ Adeel A. Butt, MD

Community Acquired Pneumonia Empiric Treatment Patients in ICU: 3GC + FQ PPC + FQ IDSA guidelines: Clin Infect Dis 2000;31:347-82 Adeel A. Butt, MD

Community Acquired Pneumonia Concerns about multiply resistant pneumococcus: 25-40% overall penicillin resistance intermediate resistance of questionable significance high level resistance associated with in vitro macrolide and 3GC resistance clinical failures not really documented Adeel A. Butt, MD IDSA guidelines: Clin Infect Dis 2000;31:347-82

Community Acquired Pneumonia Macrolide Resistance Increased drug efflux coded by mefE susceptible to clindamycin most cases in US may be overcome by achievable levels of macrolides Ribosomal methylase coded by ermAM resistant to clindamycin mostly in Europe not overcome by standard doses Amsden GW. J Antimicrob Chemother 1999;44:1-6. Adeel A. Butt, MD

Community Acquired Pneumonia RESPIRATORY Fluoroquinolones (MXFC @ LVFC) Active against 98% of resistant pneumococcus Resistance has begun to increase Adeel A. Butt, MD