Although there are no large epidemiological studies from India, mortality data on total number of deaths from lower respiratory tract infection are available. Whereas the world wide mortality of CAP in hospitalised patients varies from 14%–50%, the reported mortality in India varies from 3.3% to 40% with higher rates in elderly & in those requiring intensive care unit (ICU) care. Use of clinical scores like CURB-65, & CRB 65 help to stratify risk of severe disease & need for hospitalisation & ICU care. Early initiation of appropriate antibiotic based upon the knowledge of local resistant patterns of existing pathogens is the key for successful treatment.

1. Severe Community Acquired Pneumonia (SCAP)

2. Review Article
Severe Community Acquired Pneumonia (SCAP)
Ajit Vigg a,b,c,d,e,*
a
Head Dept. of Respiratory Medicine, Apollo Hospitals, Hyderabad, India
b
Former Governor, American College of Chest Physicians (ACCP), South India Chapter, India
c
Former President, Indian Association of Bronchology, India
d
Member, Steering Committee, Sleep Network, ACCP, India
e
Member, American Academy of Sleep Medicine, India
a r t i c l e i n f o
Article history:
Received 28 January 2015
Accepted 6 February 2015
Available online xxx
Keywords:
Severe community acquired
Pneumonia
Streptococcus pneumoniae
Clinical scores
Initial early appropriate antibiotic
a b s t r a c t
Although there are no large epidemiological studies from India, mortality data on total
number of deaths from lower respiratory tract infection are available. Whereas the world
wide mortality of CAP in hospitalised patients varies from 14%e50%, the reported mortality
in India varies from 3.3% to 40% with higher rates in elderly & in those requiring intensive
care unit (ICU) care. Use of clinical scores like CURB-65, & CRB 65 help to stratify risk of
severe disease & need for hospitalisation & ICU care. Early initiation of appropriate anti-
biotic based upon the knowledge of local resistant patterns of existing pathogens is the key
for successful treatment.
Pneumonia is the seventh leading cause of death in United States.1
It is estimated that
there are 4 million cases of community-acquired pneumonia (CAP)/yr in the United States
which result in approximately 10 million physician visits, 1 million hospitalizations, and
45,000 deaths.2
There are no large studies from India on incidence of CAP3
; however,
mortality data on total number of deaths are available related to lower respiratory tract
infection (LRTI).4
Number of deaths due to LRTI was 35.1/100,000 population in 2008
compared to 35.8/100,000 population for tuberculosis & deaths related to gastro intestinal
infections & parasitic diseases was 194.9/100,000 population. As per the WHO data overall
mortality due to LRTI is around 20% in our country.4
Worldwide mortality of CAP in hospitalised patients is 14% but increases to 20%e50% in
those requiring Intensive Care Unit (ICU)care. The reported mortality from CAP in India is
similar to that reported elsewhere in the world. In one Indian series of admitted patients
with CAP, 8% had hospital mortality & 2.7% had 30 day mortality.5
In a recent study
decrease in mortality in Severe Community-Acquired Pneumococcal Pneumonia was seen
with early antibiotic and combined therapeutic intervention.6
Another study of 72 Indian
patients with CAP showed mortality of 35% in elderly & 14% in young Indian patients.7
Mortality has varied from 3.3% to 11% in several other Indian studies.8,9
Pneumonia is characterized by the presence of fever, altered general well-being, and
respiratory symptoms such as cough (90%), expectoration (66%), dyspnoea (66%), pleuritic
pain (50%), and haemoptysis (15%).3
Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.
* Vigg Villa 553, Rd No 3, Banjara Hills, Hyderabad 500034, India.
E-mail address: drajitvigg@gmail.com.
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
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Please cite this article in press as: Vigg A, Severe Community Acquired Pneumonia (SCAP), Apollo Medicine (2015), http://
dx.doi.org/10.1016/j.apme.2015.02.010
http://dx.doi.org/10.1016/j.apme.2015.02.010
0976-0016/Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.

3. Community Acquired Pneumonia presents with mild to se-
vere symptoms which can be treated in outpatient or inpa-
tient (ward or ICU) depending on the severity. The common
pathogens which cause CAP are:
Outpatient setting: Streptococcus pneumonia, Myco-
plasma pneumonia, Haemophilus influenza, Chlamydia
pneumoniae and Respiratory viruses.
Inpatient (non-ICU) Streptococcus Pneumonia, M. Pneu-
moniae, C. Pneumoniae, H. Influenzae, Legionella species, and
Respiratory viruses.
Inpatient (ICU) Streptococcus Pneumonia, Staphylococcus
aureus, Legionella species, Gram-negative bacilli, H.
Influenza.2
There are very few Indian reports on aetiological agents of
CAP. In a study of Blood cultures performed in CAP, Strepto-
coccal Pneumoniae was the most common isolate (35.3%),
followed by staphylococcus aureus (23.5%), klebseilla pneu-
monia (20.5%) & Hemophilus influenzae (8.8%).8
Another In-
dian study published a decade ago found Mycoplasma
Pneumoniae in 15% of their cases with CAP.7,9
Legionella
pneumophilia was detected with high serological titres in 27%
of patients with CAP in one more Indian study.10
Severe Community Acquired Pneumonia is one which re-
quires ICU admission The severity of CAP can be assessed
with the help of different scores like Pneumonia severity
index (PSI), CURB-65 Score & CRB 65 score in primary settings.
All the Scores help in making decision on site of care and
indicate the risk of mortality.11
PSI score consists of 20 variables, Patients who have a PSI
score of 70 or less (class I or II) risk of death of less than 1% and
require outpatient treatment. Patients with a PSI score of
71e90 (class III) have a risk of mortality of 2.8% and may benefit
from brief hospitalization. Hospital care is appropriate for pa-
tients with scores of 91e130 (class IV), who have a 30-day risk of
death of 8.2%e9.3%, and for patients with a score of more than
130 (class V), who have a 30-day risk of death of 27.0%e31.1%.12
CURB-65 Score- 1 point for each of the criteria present:- (1)
confusion; (2) urea higher than 7 mmol/L; (3) respiratory rate
of 30/min or more; (4) low systolic (<90 mm Hg) or low diastolic
(60 mm Hg) blood pressure; and (5) age 65 years or older.
CURB- 65 score of 0e1 be treated as outpatients; those with a
score of 2 be admitted to the wards, and those patients with a
score of 3 often require ICU care.13,14
The IDSA and the ATS ICU admission criteria for patients
with CAP: According to this criteria patient with 3 minor criteria
or one major criterion qualifies for ICU admission.15
Many guidelines have been formed for the management of
community acquired pneumonia. The widely used guidelines
are the ones from American Thoracic Society (ATS)/Infectious
disease society of America (IDSA), British thoracic society
(BTS), National institute for health and care excellence (NICE).
Recently Indian guidelines have been formed by ICS/NCCP.9
They are in line with the international guidelines.
The diagnosis of severe community acquired is based on
the clinical features like fever, cough, sputum production and
pleuritic chest pain with chest radiography and physical ex-
amination of rales or bronchial breath sounds. In elderly pa-
tient clinical features or physical finding might be less or
altered. Chest radiography helps in knowing etiological agent,
alternative diagnosis, prognosis of the patient etc. Pulse ox-
imetry helps in identifying hypoxemia in a diagnosed patient.
1. Management of Severe Community
Acquired Pneumonia15e18
Microbiological investigation of severe community acquired
pneumonia (CAP)
1. Blood cultures (minimum 20 ml)
2. Sputum or other respiratory sample for routine culture and
sensitivity tests
3. Pleural fluid, if present, for microscopy, culture and pneu-
mococcal antigen detection.
4. Pneumococcal urine antigen test
5. Investigations for legionella pneumonia:
(a) Urine for legionella antigen
(b) Sputum or other respiratory sample for legionella cul-
ture and direct immunofluorescence (if available)
6. Investigations for atypical and viral pathogens:
(a) Ifavailable,sputumorotherrespiratorysampleforPCR or
direct immunoflourescence (or other antigen detection
test) for Mycoplasma pneumonia, Chlamydia species,
Influenza A and B, Parainfluenza 1e3, adenovirus, respi-
ratory syncytial virus, Pneumocystis jirovecii (if at risk)
7. (b) Consider initial and follow-up viral and “atypical path-
ogen” serology
Appropriate antimicrobials are the main stay of treatment;
it helps in eradicating the infecting agent and resolution of
clinical disease. Antibiotics should be started as soon as
possible once admitted to Hospital. (within one hour ideally).
Local knowledge of drug resistant patterns in the community
Minor criteriaa
Respiratory rateb
30 breaths/min
PaO2/FiO2 ratiob
250
Multilobar infiltrates
Confusion/disorientation
Uremia (BUN level, 20 mg/dL)
Leukopeniac
(WBC count, 4000 cells/mm3
)
Thrombocytopenia (platelet count, 100,000 cells/mm3
)
Hypothermia (core temperature, 36
C)
Hypotension requiring aggressive fluid resuscitation
Major criteria
Invasive mechanical ventilation
Septic shock with the need for vasopressors
Note. BUN, blood urea nitrogen; PaO2/FiO2, arterial oxygen pres-
sure/fraction of inspired oxygen; WBC, white blood cell.
a
Other criteria to consider include hypoglycemia (in nondiabetic
patients), acute alcoholism/alcoholic withdrawal, hyponatremia,
unexplained metabolic acidosis or elevated lactate level, cirrhosis,
and asplenia.
b
A need for noninvasive ventilation can substitute for a respira-
tory rate 30 breaths/min or a PaO2/FiO2 ratio 250.
c
As a result of infection alone.
Adapted Mandell LA, Wunderink RG, Anzueto A, et al.: Infectious
Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneu-
monia in adults. Clin Infect Dis 44(Suppl 2):S27eS72, 2007.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1 e32
Please cite this article in press as: Vigg A, Severe Community Acquired Pneumonia (SCAP), Apollo Medicine (2015), http://
dx.doi.org/10.1016/j.apme.2015.02.010

4. hospital play an important role in selecting empircal anti-
biotic initially.
1) Empirical Antibiotic therapy in Severe Community Ac-
quired Pneumonia
b-lactam (cefotaxime, ceftriaxone, or ampicillin-
sulbactam) plus either azithromycin or a fluo-
roquinolone (For penicillin-allergic patients, a respira-
tory fluoroquinolone and aztreonam are recommended.)
For Pseudomonas infection, use an antipneumococcal,
antipseudomonal b-lactam (piperacillin-tazobactam,
cefepime, imipenem, or meropenem) plus either cipro-
floxacin or levofloxacin (750-mg dose) or
the above b-lactam plus an aminoglycoside and azi-
thromycin or
the above b-lactam plus an aminoglycoside and an anti-
pneumococcal fluoroquinolone. (For penicillin-allergic
patients, substitute aztreonam for the above b-lactam.)
2) Shift to Specific antibiotic once the culture and sensitivity
report is available.
3) If there is no improvement in 48e72 h the patient should be
evaluated for non responsive pneumonia e atypical path-
ogen and drug resistant pathogen.
4) Switch from intravenous to oral therapy once the patient is
heamodynamically stable and clinically improving and
able to take medication orally.
5) Steroids are not recommended routinely for treatment of
severe CAP.
6) CAP with ARDS and CAP leading to severe sepsis and septic
shock should be treated with ARDS net trial protocol and
surviving sepsis campaign protocol respectively.
7) Preventive measures
i. Smoking Cessation in smokers
ii. Influenza vaccination
iii. Pneumococcal vaccination for the people at risk of
developing invasive pneumococcal pneumonia.
Conflicts of interest
The author has none to declare.
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