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Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
Community acquired pneumonia
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Community acquired pneumonia

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CAP BASIC

CAP BASIC

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  • 1. COMMUNITY ACQUIRED PNEUMONIA DR. ABHAY MANGE
  • 2.  70 year old female patient  r/o Badegaon district Nagpur was admitted in MICU, on 12/12/2013 with c/o  Dry cough since 1 month  Fever since 1 month  Breathlessness since 15 days, increased since 4days  h/o arthralgia +  No h/o bronchial Asthma, PTB/contact in past  No h/o HTN/DM/IHD past,  No h/o recent hospitalization
  • 3. 0n examination  Confused  Febrile  Pulse -140/min, ire. irregular  RR-44/min  SpO2 – 78 % in room air, 92 % with O2( 5 L/min)  BP- 120/80 mmHg  Pallor +  JVP- nr  Edema feet absent  No lymphadenopathy  No s/o arthritis  RS – AE decreased on lt side crackles were present Lt.MA, IAA,ISA .  CVS- S I changing, no murmur  PA- Soft, S/L np  CNS – Confused ,no menningeal signs  CRB-65 =4
  • 4. Investigations  Hb – 9.9 gm%  TLC-14000/cumm  P-88% , L-10%,E-1%,M-1%  BUL-95 mg%, SC-1.9mg%  Na -147 meq/l, K-3.8 meq/l  LFT- WNL,Except S.Alb=2.8gm%  ECG s/o Atrial fibrillation  CXR S/O Consolidation Left Lung with Synpneumonic effusion
  • 5. Provisional diagnosis  Consolidation Left Lung  Synpneumonic Effusion  Atrial fibrillation
  • 6. Severity indices  CURB 65 = 4  Confusion +  Urea>19mgm/dl 95mg/dl  Respiratory Rate >30/min 44/min  Blood Pressure SP<90/ DP< 60 120/80  Age>65 years +
  • 7. Severity indices CURB 30 DAYS SCORE MORTALITY 0-1 1.5% 2 9.2% 3-5 22% Sensitivity - 66% Specificity - 73%
  • 8. Severity indices PSI SCORE =150 (CLASS-V) CLINICAL PARAMETER SCORE  AGE 70 YR , FEMALE 60  ALTERED SENSORIUM 20  RR >20 20  BUN >30 20  PULSE >125 10  PLEURAL EFFUSION 10  TOTAL 150
  • 9. Severity indices
  • 10. Severity indices
  • 11. Severity indices SMART-COP score =7  Multilobar chest radiography involvement 1 point  Low Albumin level 1 point  High Respiratory rate(25/min) 1 point  Tachycardia (>125) 1point  Confusion 1 point  Poor Oxygenation 2 points
  • 12. Severity indices SMART-COP  Derived from the Australian CAP Study (ACAPS)  Identifies patients who received invasive respiratory and vasopressor support (IRVS). Interpretation of SMART-COP score  0 to 2 points—low risk of needing IRVS  3 to 4 points—moderate risk (1 in 8) of needing IRVS  5 to 6 points—high risk (1 in 3) of needing IRVS  7 or more points—very high risk (2 in 3) of needing IRVS  Severe CAP = a SMART-COP score of 5 or more points.
  • 13. PARAMETER AGE <50 AGE >50 POINTS SBP < 90 mmhg <90 mmhg 2 Multilobular CXR involvement + + 1 Albumin <35gm/l <35gm/l 1 Resp.rate >25 /min >25 /min 1 Tachycardia >125/min >125/min 1 Confusion(acute) + + 1 Low Oxygen PaO2 <70 or SpO2<93 or PaO2/FIO2 < 333 PaO2 <60 or SpO2<90 or PaO2/FIO2 < 250 2 PH < 7.35 <7.35 2
  • 14. Treatment  PUP, O2 5/L min IVF  Inj. Piperacillin + tazobactum 4.5 gm bd  Inj. Azithromycin 500 mg od  Inj . Metrogyl 500 mg tds  Inj . Diltiazem 12.5 mg stat  Tab Diltiazem sr 60 mg od  Nebulisation with duolin
  • 15. Treatment and course on Day 3 ON EXAM TREATMENT  No Clinical Improvement  Febrile  Pulse – 120/min  RR – 40/min  SpO2 – 95 % with O2  BP 120/70  Crackles persistent Also on right Side (IC)  Inj. Meropenam 1 gm tds  Inj. Vancomycin I gm bd  Inj. Levofloxacin 500 mg od Blood Urea- 103mgm% Serum Creat- 1.3mgm%
  • 16. Treatment & Course on Day 6 ON EXAM TREATMENT  Febrile  Pulse -98/min,regular  RR – 44/min  SpO2 -91% with o2  BP – 120/70  Crackles persistent  Present all over the right side as well  TLC 13800/cumm  P79%, Platelets 1.10,000/cumm  Tobramycin repsules 300mg (5ml) bd  Cap Tamiflu 75mg bd added
  • 17. Day 9 – No Improvement in Cl Condt  Inj. Colistin 2 MU bd,  Inj . Linezolid 600 mg bd,  Inj. Lasix 40 mg od, •Sputum AFB- NEG •H1N1 -ve •Pleural fluid •Exudative, •TLC=380/cmm,N-28%,L-70%, •ADA-Neg CT Thorax planned
  • 18. Day 15  Clinically stable  Inj antibiotics stopped  Tab Cefixime 200 + azithromycin 250 bd
  • 19. CT -THORAX B/L patchy inter- lobular and intra- lobular septal thicknening with associated ground glass opacities predomintly in sub pleural location Ground glass and reticular opacities in b/l upper lobes FSO- Non specific interstitial pneumonia
  • 20.  PULMONOLOGIST OPINION-  Non specific Interstitial Pneumonia  ? Collagen Tissue Disorder  RA factor – positive  CRP- Negative  ANA- Negative  LE CELL –Negative  E-NA - Negative
  • 21. Final diagnosis  Non specific Interstitial Pneumonia with  MDR-Community acquired pneumonia
  • 22. DISCUSSION
  • 23. Definition  IDSA define CAP as an acute infection of the pulmonary parenchyma, accompanied by the presence of an acute infiltrate on a chest radiograph (or altered auscultatory findings consistent with pneumonia) in a patient not hospitalized or residing in a long-term care facility for >14 days before onset of symptoms .
  • 24. Microbial Causes of CAP, by Site of Care  Outpatients Non-ICU ICU  S. pneumoniae S. pneumoniae S.pneumoniae  Mycoplasma pneumoniae M. pneumoniae Staphylococcus aureus  H. influenzae Chlamydia pneumoniae Legionella spp.  C. pneumoniae H. influenzae Gram-negative bacilli  Respiratory virusesa Legionella spp. H. influenzae Respiratory virusesa  a=Influenza A and B, adenovirus, respiratory syncytial virus, and parainfluenza
  • 25. Clinical Features  Systemic complaints include malaise, and high fever  Pulmonary symptoms include any combination of  Dyspnea  Chest discomfort  Pleuritic pain  Chest splinting  Cough productive of purulent or blood-tinged sputum  Tachypnea  Tachycardia  In advanced cases you may see:  Cyanosis  Confusion  Chest sounds include:  Early on in disease a fine crepitant rales over the involved portion of the lung(s).  Progression to lobar consolidation results in:  Dullness to percussion  Vocal fremitus  Whispered pectoriloquy  Bronchial breathing  Pleural effusions can occur with the following symptoms:  Pleural friction rub  Dullness to percussion  Decreased breathing sounds  Egophony  If necrosis of the lung occurs, cavities in the lung develop resulting in cavernous or amphoric breathing directly over the cavitary lesion..
  • 26. Site-of-Care Decisions (ATS) Hospital admission decision.  For patients with CURB-65 scores 2, o more-intensive treatment—that is, hospitalization or, where appropriate and available, intensive in-home health care services—is usually warranted.  Objective criteria or scores should always be supplemented with o Physician determination of subjective factors, including the ability to safely and Reliably take oral medication and the availability of outpatient support resources
  • 27. Site-of-Care Decisions – ATS Guidelines ICU admission decision  Direct admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation.  Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed . Minor criteria  Respiratory rate > 30 breaths/min  PaO2/FiO2 ratio <250  Multilobar infiltrates  Confusion/disorientation  Uremia (BUN >20 mg/dL)  Leukopenia (WBC count, <4000 cells/mm3)  Thrombocytopenia (platelet count, <100,000 cells/mm3)  Hypothermia (core temperature, <36C)  Hypotension Major criteria  Invasive mechanical ventilation  Septic shock with the need for vasopressors
  • 28. Diagnostic Testing Recommended diagnostic tests for etiology Patients with CAP should be investigated for specific pathogens  That would significantly alter standard (empirical) management decisions,  When presence of such pathogens is suspected on the basis of clinical and epidemiologic clues
  • 29. Diagnostic Testing  Routine diagnostic tests to identify etiologic diagnosis are optional for outpatients with CAP.  Pretreatment blood samples for culture and an expectorated sputum sample for stain and culture should be obtained from hospitalized patients with the clinical indications listed below but are  optional for patients without these conditions.  Intensive care unit admission  Failure of outpatient antibiotic therapy  Cavitary infiltrates  Leukopenia  Active alcohol abuse  Chronic severe liver diseas  Severe obstructive/structural lung disease  Asplenia (anatomic or functional)  Recent travel (within past 2 weeks)  Positive Legionella UAT  Positive pneumococcal UAT result  Pleural effusion
  • 30. Diagnostic Testing  Pretreatment Gram stain and culture of expectorated sputum should be performed only if,  a good-quality specimen can be obtained and  quality performance measures for collection, transport, and processing of samples can be met.  Patients with severe CAP, should at least have blood samples drawn for culture, urinary antigen tests for Legionella pneumophila and Streptococcus pneumoniae performed, and expectorated sputum samples collected for culture.  For intubated patients, an endotracheal aspirate sample should be obtained
  • 31. Empirical antimicrobial therapy Outpatient treatment  Previously healthy and no antibiotics in past 3 months  A macrolide Clarithromycin (500 mg PO bid) or Azithromycin (500 mg PO once, then 250 mg qd) or  Doxycycline (100 mg PO bid)  Comorbidities or antibiotics in past 3 months:  select an alternative from a different class A respiratory fluoroquinolone Moxifloxacin (400 mg PO qd), Gemifloxacin (320 mg PO qd), Levofloxacin (750 mg PO qd)] or  A -lactam [preferred: high- dose amoxicillin (1 g tid) or amoxicillin/clavulanate (2 g bid); or  ceftriaxone (1–2 g IV qd), cefpodoxime (200 mg PO bid), cefuroxime (500 mg PO bid)] plus  a macrolide
  • 32. Empirical antimicrobial therapy Inpatients, Non-ICU  A respiratory fluoroquinolone moxifloxacin (400 mg PO or IV qd), gemifloxacin (320 mg PO qd), levofloxacin (750 mg PO or IV qd) or  A -lactam [cefotaxime (1–2 g IV q8h), ceftriaxone (1–2 g IV qd), ampicillin (1–2 g IV q4–6h), ertapenem (1 g IV qd in selected patients)] plus  A macrolide [oral clarithromycin or azithromycin (as listed above for previously healthy patients) or IV azithromycin (1 g once, then 500 mg qd)] Inpatients, ICU  A -lactam [cefotaxime (1–2 g IV q8h), ceftriaxone (2 g IV qd), ampicillin-sulbactam (2 g IV q8h)] plus  Azithromycin or a fluoroquinolone (as listed above for inpatients, non-ICU
  • 33. Empirical antimicrobial therapy Special Concerns If Pseudomonas is a consideration  An antipneumococcal, antipseudomonal –lactam [piperacillin/tazobactam (4.5 g IV q6h), cefepime (1–2 g IV q12h), imipenem (500 mg IV q6h), meropenem (1 g IV q8h)] plus either ciprofloxacin (400 mg IV q12h) or levofloxacin (750 mg IV qd)  The above –lactams plus an aminoglycoside [amikacin (15 mg/kg qd) or tobramycin (1.7 mg/kg qd) and azithromycin]  The above –lactams plus an aminoglycoside plus an antipneumococcal fluoroquinolone If CA-MRSA is a consideration  Add linezolid (600 mg IV q12h) or vancomycin (1 g IV q12h).
  • 34. Empirical antimicrobial therapy Duration of antibiotic therapy  Patients with CAP should be treated for a minimum of 5 days ,  should be afebrile for 48–72 h, and should have no more than 1 CAP-associated sign of clinical instability before discontinuation of therapy  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.
  • 35. Multidrug-Resistant CAP COMMON PATHOGENS  Pseudomonas Aeruginosa  Acinetobacter baumanii  Staphylococcus aureus  Klebsiella pneumoniae  Streptococcus pneumoniae
  • 36. Multidrug-Resistant CAP Pseudomonas Aeruginosa  Most worrisome characteristics of P. aeruginosa is its low antibiotic susceptibility, which is attributable to a concerted action of multidrug efflux pumps and the low permeability of the bacterial cellular envelopes.  Adjunctive antibiotic therapy with inhaled antibiotics has been proposed in the management of MDR Pseudomonas; however, there is no clear evidence for its use.  The intrinsic susceptibility of P. aeruginosa is already limited to only several antimicrobial classes, but  Emergence of multidrug resistance compromises most of the antipseudomonals except colistin and polymyxin B therapies.
  • 37. Multidrug-Resistant CAP Acinetobacter  Acinetobacter baumanii is a Gram-negative coccobacillus that is normally a commensal pathogen but can be a nosocomial pathogen.  In 2004, the CDC reported an increasing number of Acinetobacter baumannii infections in military ‘Operation Iraqi Freedom’ and in Afghanistan during ‘Operation Enduring Freedom’.  Most of these showed multidrug resistance , with a few isolates resistant to all drugs tested  Treatment options for MDR Acinetobacter include carbapenems, polymyxins [polymyxin B and polymyxin E (colistin)], tigecycline, and combination therapy with sulbactam or rifampicin, or combination of carbapenem with colistin.
  • 38. Multidrug-Resistant CAP Acinetobacter  Colistin is as safe and as efficacious as the standard antibiotics for the treatment . Although the recommended dose of colistin is 2 MU intravenously thrice a day, some studies suggest using higher doses of colistin (9 MU/day) .  Sulbactam is a relatively new agent for the treatment of MDR Acinetobacter. The recommended dose for sulbactam is 40-80 mg/kg (at least 6 g/day in divided doses).  Rifampicin in combination with colistin has also been shown to be beneficial in observational studies.  Tigecycline is approved by the FDA for treatment of complicated CAP
  • 39. Multidrug-Resistant CAP Staphylococcus aureus  Community-acquired MRSA (CA-MRSA) has now emerged as an epidemic that is responsible for rapidly progressive, fatal diseases, including necrotizing pneumonia, severe sepsis.  The first documented strain with complete (>16 μg/ml) resistance to vancomycin, termed vancomycin-resistant Staphylococcus aureus(VRSA) appeared in the United States in 2002.  Linezolid-resistance in S. aureus was reported in 2001.  Drugs approved for the treatment of MRSA pneumonia include vancomycin, teicoplanin, and linezolid.  Newer investigational drugs include lipoglycopeptides (telavancin, dalbavancin), cephalosporins (ceftobiprole and ceftaroline), and dihydrofolate reductase inhibitors (iclaprim)
  • 40. Multidrug-Resistant CAP Streptococcus pneumoniae  Antibacterial resistance in Streptococcus pneumoniae is increasing worldwide, affecting principally beta-lactams and macrolides (prevalence ranging between 1% and 90% depending on the geographical area).  The major mechanism - mutations in genes encoding penicillin- binding proteins.  A large number of drugs with activity against these multi-drug resistant strains (cephalosporins, carbapenems, glycopeptides, ketolides, lincosamides, oxazolidinones, quinolones, deformylase inhibitors).
  • 41. Multidrug-Resistant CAP Klebsiella pneumoniae  Klebsiella pneumoniae is a facultative anaerobic, Gram-negative, rod-shaped bacterium in the Enterobacteriaceae family.  Klebsiella pneumoniae carbapenemase (KPC)-producing bacteria are a group of emerging highly in a variety of clinical settings around the world.  Parenteral therapeutic options for infections with ESBLproducing and carbapenem-resistant isolatesTigecycline, Colistin, Fosfomycin.
  • 42. THANKS !

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