The document discusses the management of community acquired pneumonia. It defines community acquired pneumonia and outlines its typical clinical features. Several severity assessment scores for pneumonia are described, including CURB-65 and Pneumonia Severity Index. Common causative agents are noted. Investigations and treatment principles are outlined, with betalactam antibiotics, macrolides, and fluoroquinolones discussed in detail regarding their mechanisms of action, resistance, indications, and adverse effects. Prevention methods like influenza and pneumococcal vaccines are also mentioned.

1. 9/18/2023 Dr Fizzah Ali
COMMUNITY ACQUIRED
PNEUMONIA
Dr Fizzah Ali

2. 9/18/2023 Dr Fizzah Ali
Objectives
 Discuss the management of community acquired pneumonia
 Betalactam antibiotics in detail
 Macrolides in detail
 Fluoroquinolones in detail

3. 9/18/2023 Dr Fizzah Ali
Definition
 An acute respiratory illness characterized by clinical and/or
radiological signs of consolidation of a part or parts of one
or both lungs.

4. 9/18/2023 Dr Fizzah Ali
Clinical Definition
 Symptoms of acute LRT infection
a) Cough, sputum,chest pain
b) Fever,sweating,shiver, aches and pains
 New focal chest signs on examination
OR
 New radiographic pulmonary infiltrates

5. 9/18/2023 Dr Fizzah Ali

6. 9/18/2023 Dr Fizzah Ali
Types of pneumonia
 Community acquired pneumonia
 Hospital acquired pneumonia
 Supprative or aspirational pneumonia
 Pnemonia in Immunocompromised patients

7. 9/18/2023 Dr Fizzah Ali
Typical or Atypical CAP ?
 Difficult to differentiate on clinical grounds alone
 The term ‘atypical’ is used to refer to a group of organisms
rather than a clinical picture

8. 9/18/2023 Dr Fizzah Ali
Causative Agents
 Streptococcus pneumoniae :
commonest
 Haemophilus influenza
 Staphylococcus Aureus
 Legionella, Moraxella catarrhalis
& chlyamdia
 Coxiella burnetii & anaerobes very
rare

9. 9/18/2023 Dr Fizzah Ali
Investigations (CAP)
 CXR
 Sputum –Direct ,D/r
 Blood culture
 Serology: Mycoplasma , chlamydia legionella & viral
infections .
 FOR SEVERE CAP
 Tracheal aspirate ,bronchoalveolar lavage
 Serology
 Cold agglutinins :mycoplasma
For immunocompromised patients
 Bronchoscopy & bronchoalveolar lavage

10. 9/18/2023 Dr Fizzah Ali
Clinical Features
Signs
 Fever 90%
 Tachypnoea 80-90%
 Tachycardia 80-90%
 Crackles & 80-90%
 Bronchial breathing 80-90%
 Hypotension 20%
 Confusion 15%
 Herpes labialis 10%

11. 9/18/2023 Dr Fizzah Ali

12. 9/18/2023 Dr Fizzah Ali
CURB 65
 CURB-65,, is a clinical prediction rule that has been validated
for predicting mortality in community-acquired pneumonia
Core’ clinical adverse prognostic features
(CURB)
• Confusion mental test ≤ 8
• Urea > 7 mM (>19.1 mg/dL)
• Resp.rate >30 /min
• Blood Pressure: Systolic BP < 90 mm Hg and/or diastolic BP
≤ 60 mmHg
• Age < 65
NOTE: Patients with 2 or more CURB are at high risk of death

13. 9/18/2023 Dr Fizzah Ali
Severity assessment in CAP in the
community (CRB-65 score)
 1-2 suitable for home
treatment
 3-4 Needs hospital referral

14. 9/18/2023 Dr Fizzah Ali
Pneumonia Severity Index (PSI)
Class I is determined by absence of the following risk factors:
• Age > 50 or temperature > 40°C
Class II - V is determined by a patient’s total risk score, which
in addition to the risk factors above, include
Demographic factors (male sex and nursing home residence)
and seven laboratory or radiographic findings:
• BUN concentration >30 mg/dL
• Glucose concentration >250 mg/dL
• Hematocrit <30%
• Sodium concentration <130 mmol/L
• Partial pressure of oxygen <60 mmHg
• Arterial pH <7.35
• Pleural effusion
Class IV/V suggests severe/life-threatening CAP.

15. 9/18/2023 Dr Fizzah Ali

16. Infectious Diseases Society of America/American Thoracic Society
Criteria for Defining Severe Community-acquired Pneumonia
Validated definition includes either one major criterion or three or more minor criteria
Minor criteria
Respiratory rate ≥ 30 breaths/min
PaO2/FIO2 ratio ≤ 250
Multilobar infiltrates
Confusion/disorientation
Uremia (blood urea nitrogen level ≥ 20 mg/dl)
Leukopenia* (white blood cell count < 4,000 cells/μl)
Thrombocytopenia (platelet count < 100,000/μl)
Hypothermia (core temperature < 36°C)
Hypotension requiring aggressive fluid resuscitation
Major criteria
Septic shock with need for vasopressors
Respiratory failure requiring mechanical ventilation
9/18/2023 https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST

17. Infectious Diseases Society of America/American Thoracic Society Criteria for Defining Severe Community-acquired
Pneumonia
Validated definition includes either one major criterion or three or more minor criteria
Minor criteria
Respiratory rate ≥ 30 breaths/min
PaO2/FIO2 ratio ≤ 250
Multilobar infiltrates
Confusion/disorientation
Uremia (blood urea nitrogen level ≥ 20 mg/dl)
Leukopenia* (white blood cell count < 4,000 cells/μl)
Thrombocytopenia (platelet count < 100,000/μl)
Hypothermia (core temperature < 36°C)
Hypotension requiring aggressive fluid resuscitation
Major criteria
Septic shock with need for vasopressors
Respiratory failure requiring mechanical ventilation
9/18/2023 https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST

18. 9/18/2023
https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST

19. 9/18/2023 Dr Fizzah Ali

20. 9/18/2023 Dr Fizzah Ali
Management

21. 9/18/2023 Dr Fizzah Ali
Therapy Principles
 All admitted patients should receive first antibiotic
dose within 8 hours of arrival to the hospital
 All populations should be treated for the possibility of
atypical pathogens
 Upto 10% of all CAP patients will not respond to
initial therapy. A diagnostic evaluation is mandatory

22. 9/18/2023 Dr Fizzah Ali
Antibiotics to be used

23. JAMA. 2020;323(9):885-886. doi:10.1001/jama.2019.21118

24. Beta lactam Antibiotics
 These are antibiotics that contain a beta-
lactam ring in their molecular structure.
9/18/2023 Dr Fizzah Ali

25. 9/18/2023 Dr Fizzah Ali

26. 9/18/2023 Dr Fizzah Ali
Mechanism of Action
Inhibit cell wall synthesis by binding of the drug to specific
enzymes (penicillin-binding proteins [PBPs]) located in the
bacterial cytoplasmic membrane;
 Inhibition of the transpeptidation reaction that cross-links
the linear peptidoglycan chain constituents of the cell wall;
 Activation of autolytic enzymes that cause lesions in the
bacterial cell wall.
 Enzymatic hydrolysis of the beta-lactam ring results in loss of
antibacterial activity ..

27. 9/18/2023 Dr Fizzah Ali

28. 9/18/2023 Dr Fizzah Ali

29. 9/18/2023 Dr Fizzah Ali
Resistance
 Inactivation of antibiotic by beta lactamases
 Modification of target PBPs.
 Impaired penetration of drug to target PBPs.
 Efflux

30. 9/18/2023 Dr Fizzah Ali
Penicillins indication
The indications for penicillins vary depending on penicillins group.
Natural penicillins are used in:
 Infections caused by S.pyogenes, and their consequences:
 tonsilopharyngitis
 scarlet fever
 erysipelas
 year-round rheumatism prevention.
 Infections caused by S.pneumoniae:
 community-acquired pneumonia
 meningitis
 sepsis
 Infections caused by other streptococci:
 Infective endocarditis (in combination with gentamicin or
streptomycin);
 Meningococcal infections (meningitis)
 Syphilis
 Leptospirosis
 Tick-borne borreliosis (Lyme disease)
 Gangrenous emphysema
 Actinomycosis

31. 9/18/2023 Dr Fizzah Ali
PHARMAKOKINETICS
 Except for oral amoxicillin
 Penicillin should be given 1-2 hrs before meal.
 Amoxicillin is well absorbed orally
 Penicillin is xcreated by kidneys
 Naficillin is cleared by biliary excretion

32. 9/18/2023 Dr Fizzah Ali
 SIDE EFFECTS

33. 9/18/2023 Dr Fizzah Ali
 Remarkably nontoxic .
 A/E are due to hypersenitivity.
 All penicillin is cross sensitizing & cross reacting

34. 9/18/2023 Dr Fizzah Ali
 ALLERGIC REACTIONS: Anaphylactic
shock,serum sicknessUrticaria,fever,joint swelling
,angioneurotic edema, intense pruritis skin rashes
 Oral lesions fever,interstitial nephritis eosinophilia
,hemolytic anemia ,vasculits
 In renal failure- Seizure
 Naficillin - neutropenia
 Oxacillin - hepatitis
 Methicilin – Interstitial nephritis
 Ampicillin – pseudomembranous Colitis

35. 9/18/2023 Dr Fizzah Ali

36. 9/18/2023 Dr Fizzah Ali

37. 9/18/2023 Dr Fizzah Ali
Cephalosporin
 They are beta lactam antibiotics
 Chemically similar to penicillin, so it shares the mechanism of
action and adverse effects with that

38. 9/18/2023 Dr Fizzah Ali

39. 9/18/2023 Dr Fizzah Ali

40. 9/18/2023 Dr Fizzah Ali
Macrolides
 Azithromycin
 Clarithromycin
 Erythromycin
Mechanism of action:
 Macrolides bind irreversibly to a site on the 50S subunit of the
bacterial ribosome thus inhibiting translocation steps of protein
synthesis.
 They also interefere with transpeptidation

41. 9/18/2023 Dr Fizzah Ali

42. 9/18/2023 Dr Fizzah Ali
 Resistance:
 by post-transcriptional methylation of the 23S bacterial
ribosomal RNA
 production of drug-inactivating enzymes (esterases or kinases)
 production of active ATP-dependent efflux proteins that
transport the drug outside of the cell.

43. 9/18/2023 Dr Fizzah Ali
Adverse Effects
 Gastric distress
 May prolong the QT interval
 Ototoxicity
 Cholestatic jaundice
Combination of some macrolides and statins is not advisable and
can lead to debilitating myopathy.
 This is because some macrolides (clarithromycin and
erythromycin, not azithromycin) are potent inhibitors of the
cytochrome P450 system, particularly of CYP3A4.

44. 9/18/2023 Dr Fizzah Ali

45. Fluoroquinolones
 Fluoroquinolones are a class
of antibiotics approved to treat bacterial
infection.
 The fluoroquinolone antibiotics
include ciprofloxacin, gemifloxacin, levofloxac
in, moxifloxacin, and ofloxacin
9/18/2023 Dr Fizzah Ali

46. Mechanism of action
 Fluoroquinolones act by inhibiting two
enzymes involved in bacterial DNA synthesis,
both of which are DNA topoisomerases that
human cells lack and that are essential for
bacterial DNA replication, thereby enabling
these agents to be both specific and
bactericidal.
9/18/2023 Dr Fizzah Ali

47. 9/18/2023 Dr Fizzah Ali

48. 9/18/2023 Dr Fizzah Ali

49. 9/18/2023 Dr Fizzah Ali
Prevention
 Influenza vaccine
 Younger patients at risk
- Chronic cardiovascular and pulmonary diseases
- Renal and metabolic disease
- Immune deficiency
- Nursing home residents and health care workers

50. 9/18/2023 Dr Fizzah Ali

51. 9/18/2023 Dr Fizzah Ali
Prevention
 23-valent polysaccharide pneumococcal vaccine
 90 percent of the serotypes are included in the 23
valent vaccine
 70 % response in the general population
 Lower in immunocompromised patients and those
on maintenance dialysis

52.  https://www.youtube.com/watch?v=EjI1YQrb
XgM
 https://www.youtube.com/watch?v=PKRQFr0
T5MY
9/18/2023 Dr Fizzah Ali

53. 9/18/2023 Dr Fizzah Ali
Thank You!