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

2. 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:

3. 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:
Adeel A. Butt, MD

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

5. Community Acquired Pneumonia
Incidence
# in 1000s
NCHS Data:
Adeel A. Butt, MD

6. Community Acquired Pneumonia
Mortality
# in 1000s
NCHS Data:
Adeel A. Butt, MD

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

8. 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 , 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:
Adeel A. Butt, MD

9. 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

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

11. Community Acquired Pneumonia
Microbiology
Legionella spp %
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:
40-60% - NO CAUSE IDENTIFIED
2-5% - TWO OR MORE CAUSES
Adeel A. Butt, MD

12. Community Acquired Pneumonia
Adeel A. Butt, MD

13. 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

14. 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

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

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

17. Who should be hospitalized?
Adeel A. Butt, MD

18. 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

19. 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

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

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

22. 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

23. 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

24. 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

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