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COMMUNITY ACQUIRED
PNEUMONIA
Dr
asadian
PNEUMONIA – DEFINITION

An acute infection of the pulmonary parenchyma
that is associated with at least some symptoms of
acute infection, accompanied by an acute
infiltrate on CXR or auscultatory findings
consistent with pneumonia
PNEUMONIA
The major cause of death in the world
 The 6th most common cause of death in the U.S.
 Annually in U.S.: 2-3 million cases, ~10 million
physician visits, 500,000 hospitalizations, 45,000
deaths, with average mortality ~14% inpatient
and <1% outpatient

PNEUMONIA
- SYMPTOMS
Cough (productive or
non-productive)
 Dyspnea
 Pleuritic chest pain
 Fever or hypothermia
 Myalgias

Chills/Sweats
 Fatigue
 Headache
 Diarrhea (Legionella)
 URI, sinusitis
(Mycoplasma)

FINDINGS ON EXAM

Physical:
Vitals: Fever or hypothermia
 Lung Exam: Crackles, rhonchi, dullness to percussion or
egophany.


Labs:
Elevated WBC
 Hyponatremia – Legionella pneumonia
 Positive Cold-Agglutinin – Mycoplasma pneumonia

CHEST X-RAY – PNEUMONIA
CHEST X-RAY -- PNEUMONIA
CHEST X-RAY - PNEUMONIA
TYPES OF PNEUMONIA


Community-Acquired (CAP)
Health-Care Associated Pneumonia (HCAP)







Hospitalization for > 2 days in the last 90 days
Residence in nursing home or long-term care facility
Home Infusion Therapy
Long-term dialysis within 30 days
Home Wound Care
Exposure to family members infected with MDR bacteria
Hospital-Acquired Pneumonia (HAP)


Pneumonia that develops after 5 days of hospitalization
Includes:


Ventilator-Associated Pneumonia (VAP)
Aspiration Pneumonia
COMMON BUGS FOR PNEUMONIA
Community-Acquired
 Streptococcus pneumoniae
 Mycoplasma pneumoniae
 Chlamydophila psittaci or
pneumoniae
 Legionella pneumophila
 Haemophilus influenzae
 Moraxella catarrhalis
 Staphylococcus aureus
 Nocardia
 Mycobacterium tuberculosis
 Influenza
 RSV
 CMV
 Histoplasma, Coccidioides,
Blastomycosis
HCAP or HAP
 Pseudomonas aeruginosa
 Staphylococcus aureus
(Including MRSA)
 Klebsiella pneumoniae
 Serratia marcescens
 Acinetobacter baumanii
ETIOLOGY OF C.A.P
 No
etiology in ~ 50 %
 > 2 etiologies in 2-5%
 S. Pneumonia in : 2/3 of bacterial cases
or 20 % of all cases
 H. Influenzae ( non typeable)
 Mycoplasma pneumonia
 Chlamydia p ~12%
 Influenza
 Legionella ~ 5%
ATYPICAL PNEUMONIA
Age (years)- less than 40
 Onset- Gradual, coryzal prodrome
 Cough- Paroxysmal, hacking non productive
 Sputum- Minimal, mucoid
 Rigors- Absent
 Fever- Usually less than 39.5 °C

ATYPICAL PNEUMONIA CTD
Consolidation- Usually absent
 Leucocytosis - usually absent
 Chest x-ray- Initially interstitial, may progress to
air space involvement

ACUTE BACTERIAL PNEUMONIA
 Age
( in yrs) : less than 5, over 40
 Onset : Abrupt
 Cough : Productive
 Sputum : Rusty & Purulent
 Rigors : Frequently present
 Fevers : > 39.5° c
 Consolidation: present
 Leucocytosis : 15- 25,000 with
neutrophilia
 Chest X-ray : alveolar with air
bronchograms.
CAUSES & SIGN & SYMPTOMS
S pneumonia – episodes of rigor, pleurisy,
elderly , alcoholic
 H. Influenzae -- COPD
 M. catarhalis – COPD
 Anaerobic
-- Putrid Sputum
 Influenza
-- Winter epidemic
 Chlamydia P -- S.T, HA, hoarseness

CAUSES , SIGN & SYMPTOMS



PCP -- Immunocompromised patients
Legionella – Severe illness, compromised host,
Neg G.S.,organ transplant, outbreaks related
with water source.
Mycoplasma P – 2-4 wks of prodrome, dry cough
ADMIT OR NOT
2 step decision rules
STEP 1
Assign
to risk class I
OR
Risk
classes II-
IV
RISK CLASS I


1.
2.
3.
4.
5.
< 50 years of age
have none of five co- morbid conditions that
increase mortality
Neoplasm
CHF
Renal disease
Cerebrovascular disease
Liver disease
STEP APPROACH

If not in class I
Go on to Step 2
( assign to one of classes II- V )
STEP 2
 Assess
patient’s severity index and assign
a score
Demographics
 Co- morbidities
 P. E. findings
 Lab findings

DEMOGRAPHICS
Characteristics
Age
Male
Female
Nursing home
Residents
Points
age( in years)
age ( in years)- 10
age ( in years) + 10
CO- MORBIDITIES
Diseases
Neoplasm
Liver disease
CHF
CVD
Renal disease
Points
+ 30
+ 20
+ 10
+ 10
+ 10
PHYSICAL EXAM
Finding
AMS
RR> 30
SBP<90mm
T<35 or > 40
P> 125
Points
+ 20
+ 20
+ 20
+ 15
+ 10
LABORATORY
Findings
Points
Ph<7.35
Na< 130
Hct < 30%
PO2< 60
Pleural effusion
+ 30
+ 20
+ 10
+ 10
+ 10
THE" WHOLE ‘ SHOOTIN’ MATCH "
Patient
Demographics
Co- morbidities
P. E. finding
Lab finding
Total points
Assigned points
STRATIFICATION OF RISK SCORE
Risk
Low
Initial Treatment
Outpatient
Outpatient
Medium Observation
Inpatient
High
> 130
Risk class Based on
I
Algorithm
II
< 70 points
III
71-90 points
IV 91- 130 point
Inpatient (ICU)
V
P. S. I.
Pneumonia
severity
index can serve as
general guideline for
management , clinical
judgment should
always supersede the
prognostic scores.
RISK CLASS MORTALITY
Risk class
I
II
III
IV
V
Mortality
0. 1 % - outpatient
0. 6 % - outpatient
2.8 % - inpatient
8.2 % - inpatient
29.2 % - inpatient
Assignment to risk class based on the pneumonia severity index.
Aujesky D , Fine M J Clin Infect Dis. 2008;47:S133-S139
© 2008 by the Infectious Diseases Society of America
COMMUNITY AQUAIRED PNEUMONIA
Severe Pneumonia)ICU(
1. Respiratory rate > 30 bpm.
2. PaO / FiO ratio < 250.
3. Mechanical ventilation.
4. Bilateral or multi-lobar infiltrates on CXR.
5. Shock (systolic B.P. < 90 mmHg and / or
diastolic B. P. < 60 mmHg).
6. Requirement for vasopressors > 4 hours.
7. Urine output < 20 cc/hr or acute renal
failure.
2
2
SEVERITY ASSESSMENT
 CURB-65
 Confusion
 Urea >7mmol/L
 Respiratory rate >30
 Blood pressure diastolic <60mmHg or systolic <90

≥65 years old
 0-1-may
be suitable for outpatient Rx
 2 Hospital Rx, consider other features too (e.g.
PaO2)
 ≥3 Severe disease
BLOOD CULTURE
Positive blood cultures had no correlations with
severity of disease and outcome
 Current ATS guidelines recommend that patient
hospitalized for suspected CAP receive two sets of
blood cultures.
 However are not necessary for outpatient
diagnosis

WHAT TO USE

1.
2.
3.
Outpatient
Macrolides
Fluroquinolones
Doxycycline
WHAT TO USE
Inpatient1.
Fluroquinolones alone
2.
Extended spectrum cephalosporins +
macrolides
Level II evidence

WHAT TO USE

1.
1.
ICU patients
One of Cefotaxime, Ceftraixone, ampsulbactum or pipercillin – tazobactum
Plus
One of macrolides or fluroquinolones
RECOVERY
Symtoms
Subjective Response
Fever
Time period
1-3 days
without bacteremia - 2.5 days
with bacteremia – 6-7 days
RECOVERY
sign
CXR
non elderly
older patients
Legionella
Fatigue non elderly
elderly
Time period
30 days
6-8 wks
12 wks
30- 45 days
90 days
A 65-year-old man with hypertension and degenerative joint
disease presents to the emergency department with a threeday history of a productive cough and fever. He has a
temperature of 38.3°C (101°F), a blood pressure of 144/92
mm Hg, a respiratory rate of 22 breaths per minute, a heart
rate of 90 beats per minute, and oxygen saturation of 92
percent while breathing room air. Physical examination
reveals only crackles and egophony in the right lower lung
field. The white-cell count is 14,000 per cubic millimeter,
and the results of routine chemical tests are normal. A chest
radiograph shows an infiltrate in the right lower lobe. How
should this patient be treated