1. CAP
Irfan Shafi 
PGY 1 
1885,  Dr. Holtzapple administered oxygen to 16-year-old Pt with pneumonia

2. Epidemiology 
CAP is the 8th m/c cause of death in the United States (500,000 hospitalizations and 57,000 deaths annually.
M/C cause of death among infectious diseases.
Mortality rate in hospitalized Patients is 12-14%
HCAP includes any patient who was hospitalized in an acute care hospital for two or more days within 90 days of the infection; resided in a nursing home or long-term care facility; received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection; or attended a hospital or hemodialysis clinic.

3. Risk factors for increased mortality in CAP
5th leading cause of death among those greater than 65 years of age, and moves to 4th  for those 85 and above.
 Less pronounced symptoms 
 Age is among the most important predictors of mortality from CAP.
 Pneumococcal vaccine; influenza vaccine in the elderly are critical
IDSA recommends HIV screening should be performed for any patient between the ages of in a medical setting presenting with CAP.

4. etiology

5. D.D
INFECTIOUS CAUSES 
NON-INFECTIOUS 

6. IDSA/ATS
Blood cultures are found to be positive in 5-14% of patients admitted to the hospital. 
Blood cultures are rarely helpful in the ambulatory setting and are not recommended for the outpatient management of CAP.
Sputum gram stain and culture has a highly variable diagnostic yield. In outpatients, sputum provides diagnostic information in roughly 20% of those tested

7. 54-year-old man with coronary artery disease, hypertension and obesity
54-year-old man with coronary artery disease, hypertension and obesity. He comes to clinic and explains that he has felt more tired than usual. He describes a new cough that is non-productive and occasional pleuritic chest pain that he notes is becoming more frequent. Further history reveals myalgias and headaches, but no recent sick contacts.​
He is febrile to 38.5, though other vital signs are normal. Careful auscultation reveals some decreased breath sounds over the lower lobes. A chest x-ray is obtained and shows no new infiltrate or effusion. ​
Which of the following statements regarding the diagnosis of community acquired pneumonia is true?​ ​
a) Sensitivity and specificity of sputum gram staining in the diagnosis of CAP are greater than 90%. ​
b) A negative chest x-ray should prompt consideration of diagnoses other than CAP. ​
c) Mycoplasma pneumonia and Chlamydophila pneumonia are frequently identified by sputum culture in outpatients with CAP. ​
d) Sputum culture growing organisms originally classified as Gram positive diplococci should prompt treatment for S. aureus. ​
e) Blood cultures should be obtained in outpatients being treated for CAP

8. Diagnostic Criterion
The diagnosis of CAP requires two or more acute respiratory complaints and a new chest x-ray infiltrate.  ​
M/C complains  cough (86%), followed by dyspnea (72%) and sputum production (64%).
 CXR is strongly recommended by the ATS/IDSA guidelines in order to diagnose CAP.​
 CXR is not 100% sensitive, and a negative chest x-ray in a clinical setting that is highly suggestive of CAP does not exclude pneumonia​.
 Pneumocystis jiroveci pneumonia has been shown to have negative initial x-rays in up to 30% of patients​
 False negative readings can also occur in the patient with CAP due to early stage of disease, dehydration, or confounding/artifactual features on chest x-ray​
 CT Chest is significantly more sensitive for acute parenchymal infection; however IDSA does not recommend CT for Dx Pneumonia ​

9. Can you purely Dx Pneumonia by clinical exam without CXR ?

10. Diagnosing Pneumonia by Physical Examination Relevant or Relic?
Twenty-four patients had pneumonia confirmed by chest x-ray films. Twenty-eight patients did not have pneumonia. Abnormal lung sounds were common in both groups; the most frequently detected were rales in the upright seated position and bronchial breath sounds. Relatively high agreement among examiners (κ ≈ 0.5) occurred for rales in the lateral decubitus position and for wheezes. The 3 examiners' clinical diagnosis of pneumonia had a sensitivity of 47% to 69% and specificity of 58% to 75%.
Conclusion:  The traditional chest physical examination is not sufficiently accurate on its own to confirm or exclude the diagnosis of pneumonia.

11. IDSA/ATS Recommendations for Diagnostic Testing in CAP

12. Patient who is able to expectorate with a deep cough. ​
Sputum gram stain:​
(sensitivity between 50 and 60% and specificity of greater than 80%) ​
From whom: ​                                                                           
Patient who is able to expectorate with a deep cough. ​
When is the sample good:​
IDSA recommends a ratio of polymorphonuclear cells (PMN) to squamous epithelial cells (SEC) viewed under low-power microscopy to determine the adequacy of a sample. Sputum shown to have 25 or greater PMN and less than 10 SEC per low-power field is deemed adequate.​
Other tests:​
Blood and sputum Cx​
Legionella and pneumococcal urine antigens​(Strep antigen sensitivity 70-90% and specificity 99%)
IDSA also recommends HIV testing for inpatients and tuberculosis screening for at-risk patients. ​
Procalcitonin has been studied as a tool to distinguish between acute bronchitis, which is almost always viral in etiology, and community acquired pneumonia.​
"Procalcitonin less than 0.10 mcg/L is highly predictive of acute bronchitis and does not merit antibiotics, while a procalcitonin of greater than 0.50 mcg/L is consistent with community acquired pneumonia."

13. PSI Score 
The Pneumonia Severity Index, described as part of the PORT cohort study, allows for risk stratification among patients with CAP and helps determine optimal site of care.
PSI<70: Risk class II
PSI 71 to 90: Risk class III
PSI 91 to 130: Risk class IV
PSI>130: Risk class V
 risk classes III-V warrant admission to the hospital. 
Impact of age on management: any male patient 70 and older and any female patient 80 or older will be at best intermediate risk, and according to PSI scoring should be hospitalized.

14. Risk Stratification
CURB-65 criteria or PSI can be used to identify patients with CAP who may be candidates for out- patient treatment. (Strong recommendation; level I evidence.)
CURB 65 score 
Score 0-1   = 1.5% mortality = outpatient Mx
Scores of 2 = 9.2% mortality = brief inpatient admission. 
Scores of 3 or higher = 22% mortality and represent the group at highest risk. 
The estimated sensitivity and specificity is approximately 80% for this prediction model. CURB-65 is endorsed by IDSA/ATS guidelines.

15. A 72-year-old patient with coronary artery disease presents to clinic with progressive shortness of breath, cough productive of whitish sputum, lower extremity edema, and fatigue. He denies chest pain, but does report poor appetite and insomnia. Based on these symptoms his son is certain he has pneumonia and wants you to prescribe an antibiotic. You obtain the CXR shown here. What is the next best step in management?
 a) Prescribe doxycycline for CAP. 
 b) Prescribe moxifloxacin for CAP. 
 c) Admit the patient for IV antibiotics. 
 d) Admit the patient for diuresis.

16. Management  2007 IDSA/ATS guidelines for empiric outpatient treatment of CAP.

17. Duration of treatment
Duration of antibiotics ranges from 5 to 14 days and depends upon the patient's clinical improvement.
Most of studies suggest that patients have similar outcomes when using higher doses of antibiotics for a shorter time when compared to standard dosing and duration.
 IDSA/ATS  minimum of five days of antibiotic  for uncomplicated CAP.
    (Level I evidence)
Patients should be afebrile for hours with resolution or marked improvement in symptoms prior to antibiotic discontinuation.
Typically macrolides such as azithromycin are used for five days, while doxycycline and the quinolones are prescribed for 5 to 7 days. 
A longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infection, such as meningitis or endocarditis. (Weak recommendation; level III evidence.)

18. Thank You