7. Infiltrates on plain chest x-ray – gold standard
for diagnosing pneumonia
Radiological appearances CAP :
lobar consolidation(typical bacteria)
interstitial infiltrates(pneumocystis carinii
& viruses)
CT scan – higher sensitivity for CAP
8.
9.
10. Treatment is best when it is pathogen-directed
Includes:- blood - culture & sensitivity.
sputum – Gram staining & culture.
urinary antigen tests (legionella &
pneumococcus)
Newer tests :- PCR
11. Based on severity of disease
Other features – ability to maintain oral intake
likelihood of compliance
h/o substance abuse
cognitive impairement
living situation
functional status of pt.
12. Commonly used prediction rules
i)PSI (pneumonia severity index)
ii) CURB 65
Confusion (based on specific mental test,
disorientation to time place or person)
blood urea > 7mmol/lit (20 mg/dl)
respiratory rate > 30cpm
blood pressure (systolic < 90mm hg
diastolic <60mm hg)
age >= 65 yrs
Score : 0-1 – treated on outpatient basis
2-3 – admitted in hospital
>3 – admitted in icu
13. Choice of initial treatment complicated by
emergence of antibiotic resistance of S. pneumoniae
Antibiotic therapy started on empiric basis since
causative organism is not identified in proportinate
no. of pts.
14. In pts without risk factors or microbiological
eveidence of pseudomonas aeruginosa or MRSA :
Combination of I.V. beta lactam { ceftrioxone
:1-2 gms daily cefotaxim : 1-2 gms every 8th hrly or
ampicillin :1.5-3 gms 6th hrly.}
PLUS
Either Macrolide {azithromycin 500mg daily} or
fluoroquinolone {levofloxicin 750 mg daily or
moxifloxicin 400mg daily}
15. In pts who may be infected with pseudomonas
aeruginosa or other resistant pathogens ( those with
COPD or Bronchiectasis or frequent antimicrobial or
glucocorticoid use) combination therapy with beta
lactam and fluoroquinolones is used :
Piperacillin-Tazobactam(4.5 gms every 6 hrs) or
Imipenem (500mg every 6 hours) or
Meropenam (1 gm every 8 hrs) or
Cefipime ( 2gms every 8 hrs) or
Ceftazidime (2gms every 8 hrs)
PLUS
Ciprofloxacin (400mg every 8 hrs) or
Levofloxacin( 750 mg daily)
16. In pts allergic to penicillin by skin testing
cephalosporins can be continued ( 3rd generation)
In cases of mild reaction ( not IgE mediated)
initially 1/10 of dose is given observed for 1 hr, then
remaining 9/10 dose is given & observed for
another hr.
In pts with past allergic reaction to cephalosporins,
Aztreonam (2mg I.V every 6-8 hrs) can be
given.(exception to those allergic to ceftazidime)
17. Empirical treatment to CA-MRSA should be given to
hospitalised pts with severe CAP.
It includes addition of vancomycin (15mg/kg I.V
every 12 hrs). In severly ill pts loading dose of 25-
30 mg/kg is given .
OR
Linezolid (600mg I.V every 12 hrs)
Clindamycin (600mg I.V/oral 3 times daily) can be
given if pathogen is susceptable.
If sputum culture reveals meticillin suscptible
staphylococcus therapy can be changed to nafcillin
(2gm I.V every 4hrs) or oxacillin (2gm I.V every 4
hrs)
18. Switch to oral therapy – initially hospitalized pts
are treated intravenously. Oral treatment can be
syarted once pt is hemodynamically stable,improving
clinically,able to take oral medicines & have
normally functioning GIT.
19. Pts treated with intravenous betalactam &
macrolides have high risk of developing drug
resistant s. pneumoniae(DRSP).
High dose of amoxicillin ( 1gm orally 3 times daily)
is given instead of I.V beta lactams
An alternative to pts without risk of DRSP, is to
give macrolide or doxycyclin alone to complete
course.
Doses for macrolides and doxycyclin is:
Azithromycin : 500mg once daily
Clarithromycin :500mg once daily
Clarithromycin XL :500mg two tablets once daily
Doxycyclin : 100mg twice daily
20. Duration of therapy :- recommended duration for pts
with good response in first 2-3 days is 5-7 days.
Before stopping therapy- pt should be afebrile for 48-
72 hrs , breathing without supplement oxygen ,and have
no more than one clinical instability factor (i.e PR >
100bpm RR > 24cpm , systolic BP < 90mmhg)
Longer treatment is required in cases of :
initial treatment not efficient against subsequent
isolated pathogen
in extrapulmonary infection (meningitis or
endocarditis)
if pt has empyema or lung abscess
pneumonia caused by P.aeruginosa S.aureus legionella
or other unusual pathogens
21. Procalcitonin can be evaluated for guiding decision
of stopping antibiotic treatment as its level
correlate with likelihood of bacterial infection.
Follow up chest radiography- x-ray findings clear
more slowly than clinical features.pts responding
clinically do not require follow up x-ray.
Follow up x-ray is adviced for pts > 50 yrs , males ,
smokers. 7- 12 wks following treatment
22. Treatment failure:-may be due to
delayed host response despite appropiate
treatment
infection with organism not covered in initial
antibiotic regimen
drug resistant organisms
pt related factors – neoplasia ,aspiration
pneumonia severity of illness, neurologic disease
etc.
infectious complications – lung abscess, empyema
