1. Acute Community Acquired Pneumonia Babak Sayad Associate Professor of Infectious Diseases Department of Infectious Diseases Kermanshah University of Medical Science (KUMS)

2. Introduction In 1901, Sir William Osler' noted in the fourth edition of his book, The Principles and Practice of Medicine, that "the most widespread and fatal of all acute diseases, pneumonia, is now Captain of the Men of Death“ In 1901, Sir William Osler' noted in the fourth edition of his book, The Principles and Practice of Medicine, that "the most widespread and fatal of all acute diseases, pneumonia, is now Captain of the Men of Death“ Over a century later, the prominence of pneumonia a same clinical entity remains Over a century later, the prominence of pneumonia a same clinical entity remains

3. Introduction It remains among the top 10 most common causes of death among all age groups in the United States It remains among the top 10 most common causes of death among all age groups in the United States It is the single most common cause of infection-related mortality It is the single most common cause of infection-related mortality

4. When we think about pneumonia ? Respiratory finding: Cough Sputum Dyspnea Takypnea Positive chest physical exam Non-Respiratory finding: Fever Fatigue Sweating Headache Nausea Myalgia

5. Clinical evaluation History History The history should attempt to define: The history should attempt to define: (1) symptoms consistent with the diagnosis of pneumonia (1) symptoms consistent with the diagnosis of pneumonia (2) the clinical setting in which the pneumonia takes place (2) the clinical setting in which the pneumonia takes place (3) defects in host defense that could predispose to the development of pneumonia (3) defects in host defense that could predispose to the development of pneumonia (4) possible exposures to specific pathogens (4) possible exposures to specific pathogens

6. Clinical evaluation History History Age Age Site of acquisition Site of acquisition Season Season Geographic location Geographic location Contact history Contact history Animal contact Animal contact Travel history Travel history Occupational history Occupational history Habits Habits Drug history Drug history Socioeconomic status Socioeconomic status Concomitant diseases Concomitant diseases Rice Rice Presentation of disease Presentation of disease

7. Clinical evaluation Physical Examination Physical Examination Vital signs Vital signs Respiratory distress Respiratory distress Cyanosis Cyanosis Rapid respiratory rate Rapid respiratory rate Use of accessory muscles Use of accessory muscles Sternal retraction Sternal retraction Nasal flaring Nasal flaring Chest exam Chest exam Splinting Splinting Rales Rales Evidence of consolidation (dullness on percussion, bronchial breath sounds, and E to A changes) Evidence of consolidation (dullness on percussion, bronchial breath sounds, and E to A changes)

8. Clinical evaluation Physical Examination Physical Examination Specific keys: Specific keys: Furuncle Furuncle Herpes labialis Herpes labialis Bullous myringitis Bullous myringitis Splenomegaly Splenomegaly Track marks Track marks Poor dentition Poor dentition

9. Pneumonia syndromes Acute Community Acquired Pneumonia Nasocomial Pneumonia Aspiration Pneumonia …

10. Acute Community Acquired Pneumonia Typical presentation: Typical presentation: Sudden fever Sudden fever Productive cough Productive cough Chest pain Chest pain Consolidation Consolidation Atypical presentation: Atypical presentation: Slow manifestation Slow manifestation Non-Productive cough Non-Productive cough Extrapulmonary manifestation Extrapulmonary manifestation CXR abnormality CXR abnormality

11. Differential diagnosis Acute tracheobronchitis Acute tracheobronchitis Exacerbation of COPD Exacerbation of COPD Pleurisy Pleurisy Lung abscess Lung abscess Malignancy Malignancy Pulmonary emboli & infarction Pulmonary emboli & infarction Systemic diseases: Systemic diseases: Wegner Wegner PAN PAN SLE SLE …

12. Diagnostic Testing Radiologic Examination Radiologic Examination Sputum Examination Sputum Examination Blood Culture Blood Culture Examination of Pleural Effusions Examination of Pleural Effusions Serologic Studies Serologic Studies Urine Studies, Including Antigen Detection Urine Studies, Including Antigen Detection Fiberoptic Bronchoscopy Fiberoptic Bronchoscopy Lung Biopsy Lung Biopsy

13. Normal chest radiograph

14. Patchy infiltrate representing bronchopneumonia in a patient with Streptococcus pneumoniae

15. Chest radiograph showing dense left lower consolidation consistent with bacterial pneumonia, in this case caused by Streptococcus pneumoniae

16. Lateral radiograph of a patient with left lower lobe pneumococcal pneumonia

17. Chest radiographs showing a large left pleural effusion in a patient with Klebsiella pneumoniae pneumonia

19. Pneumatocele formation in the left upper lobe of a patient with staphylococcal pneumonia

20. Bilateral involvement with a mixed interstitialalveolar pattern in a patient with viral pneumonia

21. “Currant-jelly” sputum associated with Klebsiella pneumoniae pneumonia

22. Expectorated sputum with gram-positive, lancetshaped diplococci from a patient with pneumococcal pneumonia

23. Expectorated sputum demonstrating a positive quellung reaction in a patient with pneumococcal pneumonia

24. Expectorated sputum with gram-negative coccobacillary forms (arrows) from a patient with Haemophilus influenzae pneumonia

25. Expectorated sputum with clusters of gram-positive cocci in a patient with Staphylococcus aureus pneumonia

26. Expectorated sputum with gram-negative rods in a patient with Klebsiella pneumoniae pneumonia

27. Expectorated sputum with acid-fast bacilli in a patient infected with Mycobacterium tuberculosis

28. Management 1-The first decision confronting the clinician is whether the patient presenting with respiratory symptoms in fact has pneumonia. 1-The first decision confronting the clinician is whether the patient presenting with respiratory symptoms in fact has pneumonia. 2-The next decision is whether the patient is to be hospitalized or out patient treatment 2-The next decision is whether the patient is to be hospitalized or out patient treatment 3-The next problem is determining the most likely cause of pneumonia. 3-The next problem is determining the most likely cause of pneumonia. 4-Empirical Antibiotic Therapy 4-Empirical Antibiotic Therapy

29. Management The patient in fact has pneumonia: The patient in fact has pneumonia: Clinical evaluation Clinical evaluation History History Physical Examination Physical Examination

30. Management The patient is to be hospitalized or out patient treatment: The patient is to be hospitalized or out patient treatment: PORT score (Patient Outcome ResearchTeam) or Pneumonia Severity Index (PSI) PORT score (Patient Outcome ResearchTeam) or Pneumonia Severity Index (PSI) CURB,CURB-65,CRB-65 CURB,CURB-65,CRB-65 C: Confusion C: Confusion U: Urea> 7mmol/L U: Urea> 7mmol/L R: RR>30/min R: RR>30/min B: BPs<90mm Hg or BPd<60mm Hg B: BPs<90mm Hg or BPd<60mm Hg 65: Age>65Y 65: Age>65Y

31. Management The most likely cause of pneumonia: The most likely cause of pneumonia: Diagnostic Testing Diagnostic Testing Radiologic Examination Radiologic Examination Sputum Examination Sputum Examination Blood Culture Blood Culture Examination of Pleural Effusions Examination of Pleural Effusions Serologic Studies Serologic Studies Urine Studies, Including Antigen Detection Urine Studies, Including Antigen Detection Fiberoptic Bronchoscopy Fiberoptic Bronchoscopy Lung Biopsy Lung Biopsy

32. Management Empirical Antibiotic Therapy Empirical Antibiotic Therapy For most patients, a specific diagnosis cannot be established with certainty before the onset of therapy. Selecting an empirical antibiotic regimen is a continuing clinical challenge For most patients, a specific diagnosis cannot be established with certainty before the onset of therapy. Selecting an empirical antibiotic regimen is a continuing clinical challenge Recent controversies and questions have included when antibiotics should be started, how to determine the most appropriate antibiotics to use, and how long therapy should continue Recent controversies and questions have included when antibiotics should be started, how to determine the most appropriate antibiotics to use, and how long therapy should continue

33. Management Empirical Antibiotic Therapy Empirical Antibiotic Therapy When antibiotics should be started? When antibiotics should be started? In 2007, the Joint Commission suggested that antibiotics be started within 6 hours, even though no other data had been presented. The joint IDSA & ATS guidelines have suggested a more common sense approach that antibiotic treatment for pneumonia be started “as soon as possible” after the diagnosis is considered likely In 2007, the Joint Commission suggested that antibiotics be started within 6 hours, even though no other data had been presented. The joint IDSA & ATS guidelines have suggested a more common sense approach that antibiotic treatment for pneumonia be started “as soon as possible” after the diagnosis is considered likely

34. Management Empirical Antibiotic Therapy Empirical Antibiotic Therapy How to determine the most appropriate antibiotics to use? How to determine the most appropriate antibiotics to use? Outpatient Therapy Outpatient Therapy Previously Healthy Previously Healthy Comorbidities Comorbidities Inpatient Therapy Inpatient Therapy Medical Ward Medical Ward Intensive Care Unit (ICU) Intensive Care Unit (ICU) Health Care–Associated Pneumonia Health Care–Associated Pneumonia

35. Management Empirical Antibiotic Therapy Empirical Antibiotic Therapy Outpatient Therapy Outpatient Therapy Previously Healthy Previously Healthy No recent antibiotic therapy No recent antibiotic therapy Macrolide or doxycycline Macrolide or doxycycline Recent antibiotic therapy Recent antibiotic therapy A respiratory fluoroquinolone alone, an advanced macrolide plus oral β-lactam A respiratory fluoroquinolone alone, an advanced macrolide plus oral β-lactam

36. Management Empirical Antibiotic Therapy Empirical Antibiotic Therapy Outpatient Therapy Outpatient Therapy Comorbidities Comorbidities No recent antibiotic therapy No recent antibiotic therapy An advanced macrolide plus oral β-lactam or a respiratory fluoroquinolone An advanced macrolide plus oral β-lactam or a respiratory fluoroquinolone Recent antibiotic therapy Recent antibiotic therapy A respiratory fluoroquinolone alone or an advanced macrolide plus a β -lactam A respiratory fluoroquinolone alone or an advanced macrolide plus a β -lactam Suspected aspiration with infection Suspected aspiration with infection Amoxicillin-clavulanate or clindamycin Amoxicillin-clavulanate or clindamycin Influenza with bacterial superinfection Influenza with bacterial superinfection Vancomycin,linezolid, or other coverage for MRSA or CA-MRSA Vancomycin,linezolid, or other coverage for MRSA or CA-MRSA

37. Management Empirical Antibiotic Therapy Empirical Antibiotic Therapy Inpatient Therapy Inpatient Therapy Medical Ward Medical Ward No recent antibiotic therapy No recent antibiotic therapy A respiratory fluoroquinolone alone or an advanced macrolide plus an IV β -lactam A respiratory fluoroquinolone alone or an advanced macrolide plus an IV β -lactam Recent antibiotic therapy Recent antibiotic therapy An advanced macrolide plus an IV β -lactam, or a respiratory fluoroquinolone alone (regimen selected will depend on nature of recent antibiotic therapy) An advanced macrolide plus an IV β -lactam, or a respiratory fluoroquinolone alone (regimen selected will depend on nature of recent antibiotic therapy)

38. Management Empirical Antibiotic Therapy Empirical Antibiotic Therapy Inpatient Therapy Inpatient Therapy Intensive Care Unit (ICU) Intensive Care Unit (ICU) Pseudomonas infection is not a concern Pseudomonas infection is not a concern A β -lactam plus either an advanced macrolide or a respiratory fluoroquinolone A β -lactam plus either an advanced macrolide or a respiratory fluoroquinolone Pseudomonas infection is not a concern but patient has a β-lactam allergy Pseudomonas infection is not a concern but patient has a β-lactam allergy A respiratory fluoroquinolone, with or without clindamycin A respiratory fluoroquinolone, with or without clindamycin

39. Management Empirical Antibiotic Therapy Empirical Antibiotic Therapy Inpatient Therapy Inpatient Therapy Intensive Care Unit (ICU) Intensive Care Unit (ICU) … Pseudomonas infection is a concern(cystic fibrosis, impaired host defenses) Pseudomonas infection is a concern(cystic fibrosis, impaired host defenses) Either (1) an antipseudomonal β -lactam plus ciprolloxacin, or (2) an antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide Either (1) an antipseudomonal β -lactam plus ciprolloxacin, or (2) an antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide Pseudomonas infection is a concern but the patient has a β -lactam allergy Pseudomonas infection is a concern but the patient has a β -lactam allergy Aztreonam plus aminoglycoside plus a respiratory fluoroquinolone Aztreonam plus aminoglycoside plus a respiratory fluoroquinolone

40. Management Empirical Antibiotic Therapy Empirical Antibiotic Therapy Inpatient Therapy Inpatient Therapy Health carc-associated pneumonia Health carc-associated pneumonia Either (1) an antipseudomonal β-lactam plus ciprofloxacin or levofloxacin or (2) an antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide plus vancomycin or linezolid (for MRSA coverage) Either (1) an antipseudomonal β-lactam plus ciprofloxacin or levofloxacin or (2) an antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide plus vancomycin or linezolid (for MRSA coverage)

41. Management Empirical Antibiotic Therapy Empirical Antibiotic Therapy How long therapy should continue? How long therapy should continue? The classic 10 to 14days of care is unsupported by evidence The classic 10 to 14days of care is unsupported by evidence Recent data suggest that clinical stability occurs more quickly, and therefore antibiotic therapy may be safely discontinued earlier Recent data suggest that clinical stability occurs more quickly, and therefore antibiotic therapy may be safely discontinued earlier Less than 7 days and as short as 3 days are just as effective as any longer durations of therapy for mild to moderate pneumonia. Less than 7 days and as short as 3 days are just as effective as any longer durations of therapy for mild to moderate pneumonia. Oral antibiotic therapy is safe after clinical stability has been reached Oral antibiotic therapy is safe after clinical stability has been reached

42. Management Empirical Antibiotic Therapy Empirical Antibiotic Therapy Adjunctive Therapy Adjunctive Therapy Critical illness-related corticosteroid insufficiency (CIRCI) has been associated with community- acquired pneumonia Critical illness-related corticosteroid insufficiency (CIRCI) has been associated with community- acquired pneumonia Statins also possess anti-inflammatory properties Statins also possess anti-inflammatory properties