2. Community Acquired Pneumonia(CAP)
Gamal Rabie Agmy, MD,FCCP
Professor of Chest Diseases, Assiut university

3. 3
Pneumonias – Classification •Community Acquired CAP •Health Care Associated HCAP •Hospital Acquired HAP •ICU Acquired ICUAP •Ventilator Acquired VAP Nosocomial Pneumonias

4. *HCAP: diagnosis made < 48h after hospitalization with any of the following risk factors:
(1)hospitalized in an acute care hospital for > 48h within 90d of the diagnosis; (2) resided in a nursing home or long-term care facility; (3) received recent IV antibiotic therapy, chemotherapy, or wound care within the 30d preceding the current diagnosis; and (4) attended a hospital or hemodialysis clinic
HCAP

5. Infection of the lung parenchyma in a person who is not hospitalized or living in a long-term care facility for ≥ 2 weeks. This pneumonia develops in the outpatient setting or within 48 hours of admission to a hospital.
Definition of CAP

6. Symptoms:
• Respiratory: Cough dry or productive, mucopurulent sputum , sometimes rusty, dyspnea, sometimes pleuritic chest pain
• Non-respiratory: Fever, body aches, altered mental state, vomiting or diarrhea.
The clinical diagnosis of CAP

7. Signs:
Generally: Fever, sometimes hypothermia, tachycardia, tachypnea.
Local: signs of consolidation
The clinical diagnosis of CAP

8. 8 CAP – The Two Types of Presentations Classical
•Sudden onset of CAP
•High fever, shaking chills
•Pleuritic chest pain, SOB
•Productive cough
•Rusty sputum, blood tinge
•Poor general condition
•High mortality up to 20% in patients with bacteremia
•S.pneumoniae causative
•Gradual & insidious onset
•Low grade fever
•Dry cough, No blood tinge
•Good GC – Walking CAP
•Low mortality 1-2%; except in cases of Legionellosis
•Mycoplasma, Chlamydiae, Legionella, Ricketessiae, Viruses are causative Atypical

9. Sputum Gram stain:
is a rapid and inexpensive test that can help a lot:
• Differentiate Gm –ve from Gm +ve bacteria.
• Excess pus cells without organism suspect atypical infection.
The Bacteriological Diagnosis of CAP

10. Cultures to identify the causative organism:
Sputum cultures are not recommended in cases of CAP except in certain occasions:
• Patients admitted in hospital or ICU.
• Patients who do not respond to empirical antibiotic therapy.
• Suspection of resistant strains of S.pneumoniae.
The Bacteriological Diagnosis of CAP

11. Blood Culture:
Recommended for all patients with moderate and high severity CAP, preferably before antibiotic therapy is commenced.
Examination of sputum for Mycobacterium TB
The Bacteriological Diagnosis of CAP

12. 12
CAP – Pathogenesis Inhalation Aspiration Hematogenous

14. 14 PORT Scoring – PSI
Clinical Parameter
Scoring
Age in years
Example
For Men (Age in yrs)
50
For Women (Age -10)
(50-10)
NH Resident
10 points
Co-morbid Illnesses
Neoplasia
30 points
Liver Disease
20 points
CHF
10 points
CVD
10 points
Renal Disease (CKD)
10 points
Clinical Parameter
Scoring
Clinical Findings
Altered Sensorium
20 points
Respiratory Rate > 30
20 points
SBP < 90 mm
20 points
Temp < 350 C or > 400 C
15 points
Pulse > 125 per min
10 points
Investigation Findings
Arterial pH < 7.35
30 points
BUN > 30
20 points
Serum Na < 130
20 points
Hematocrit < 30%
10 points
Blood Glucose > 250
10 points
Pa O2
10 points
X Ray e/o Pleural Effusion
10 points Pneumonia Patient Outcomes Research Team (PORT)

15. 15 Classification of Severity - PORT Predictors Absent Class I  70 Class II 71 – 90 Class III 91 - 130 Class IV > 130 Class V

16. 16
CAP – Management based on PSI Score
PORT Class
PSI Score
Mortality %
Treatment Strategy
Class I
No RF
0.1 – 0.4
Out patient
Class II
 70
0.6 – 0.7
Out patient
Class III
71 - 90
0.9 – 2.8
Brief hospitalization
Class IV
91 - 130
8.5 – 9.3
Inpatient
Class V
> 130
27 – 31.1
IP - ICU

17. 17
CURB 65 Rule – Management of CAP CURB 65 Confusion BUN > 30 RR > 30 BP SBP <90 DBP <60 Age > 65 CURB 0 or 1 Home Rx CURB 2 Short Hosp CURB 3 Medical Ward CURB 4 or 5 ICU care

19. 19
CAP – Criteria for ICU Admission
Major criteria
Invasive mechanical ventilation required
Septic shock with the need of vasopressors
Minor criteria (least 3)
Confusion/disorientation
Blood urea nitrogen ≥ 20 mg%
Respiratory rate ≥ 30 / min;
Core temperature < 36ºC
Severe hypotension;
 PaO2/FiO2 ratio ≤ 250
Multi-lobar infiltrates
WBC < 4000 cells;
Platelets <100,000

20. The Radiological Diagnosis of CAP

21. 21
CAP – Value of Chest Radiograph •Usually needed to establish diagnosis •It is a prognostic indicator •To rule out other disorders •May help in etiological diagnosis
J Chr Dis 1984;37:215-25

22. 22 Infiltrate Patterns and Pathogens
CXR Pattern
Possible Pathogens
Lobar
S.pneumo, Kleb, H. influ, Gram Neg
Patchy
Atypicals, Viral, Legionella
Interstitial
Viral, PCP, Legionella
Cavitatory
Anerobes, Kleb, TB, S.aureus, Fungi
Large effusion
Staph, Anaerobes, Klebsiella

23. 23
Normal CXR & Pneumonic Consolidation

24. 24
Lobar Pneumonia – S.pneumoniae

25. 25 CXR – PA and Lateral Views

26. 26
Lobar versus Segmental - Right Side

27. 27
Lobar Pneumonia

28. 28
Special forms of Consolidation

29. 29 Round Pneumonic Consolidation

30. 30 Special Forms of Pneumonia

31. 31
Special Forms of Pneumonia

32. 32
Complications of Pneumonia

33. 33
Empyema

34. 34 Mycoplasma Pneumonia

35. 35
Mycoplasma Pneumonia

36. 36 Chlamydia Trachomatis

37. 37
Rare Types of Pneumonia

38. S Curve of Golden
When there is a mass adjacent to a fissure, the fissure takes the shape of an "S". The proximal convexity is due to a mass, and the distal concavity is due to atelectasis. Note the shape of the transverse fissure.
This example represents a RUL mass with atelectasis

39. THE BAT VIEW Chest wall
Pleural line

40. THE BAT VIEW
Chest wall
Pleural line

41. 41

45. Pneumonia
Posterior intercostal scan shows a hypoechoic consolidated area that contains multiple echogenic lines that represent an air bronchogram.

46. Post-stenotic pneumonia
Posterior intercostal scan shows a hypoechoic consolidated area that contains anechoic, branched tubular structures in the bronchial tree (fluid bronchogram).

47. Contrast-enhanced ultrasonography of pneumonia
A: Baseline scan shows a hypoechoic consolidated area
B: Seven seconds after iv bolus of contrast agent, the lesion shows marked and homogeneous enhancement
C: The lesion remains substantially unmodified after 90 s.

48. The Treatment of CAP

49. ANTIMICROBIAL DRUGS

50. MECHANISMS OF ACTION OF ANTIBACTERIAL DRUGS
Mechanism of action include:
Inhibition of cell wall synthesis
Inhibition of protein synthesis
Inhibition of nucleic acid synthesis
Inhibition of metabolic pathways
Interference with cell membrane integrity

51. EFFECTS OF COMBINATIONS OF DRUGS
Sometimes the chemotherapeutic effects of two drugs given simultaneously is greater than the effect of either given alone.
 This is called synergism. For example, penicillin and streptomycin in the treatment of bacterial endocarditis. Damage to bacterial cell walls by penicillin makes it easier for streptomycin to enter.

52. EFFECTS OF COMBINATIONS OF DRUGS
Other combinations of drugs can be antagonistic.
For example, the simultaneous use of penicillin and tetracycline is often less effective than when wither drugs is used alone. By stopping the growth of the bacteria, the bacteriostatic drug tetracycline interferes with the action of penicillin, which requires bacterial growth.

53. EFFECTS OF COMBINATIONS OF DRUGS
Combinations of antimicrobial drugs should be used only for:
1.To prevent or minimize the emergence of resistant strains.
2.To take advantage of the synergistic effect.
3.To lessen the toxicity of individual drugs.

54. Patterns of Microbial Killing Concentration dependent
–Higher concentration greater killing Aminoglycosides, Flouroquinolones, Ketolides, metronidazole, Ampho B. Time-dependent killing
–Minimal concentration-dependent killing (4x MIC)
–More exposure more killing Beta lactams, glycopeptides, clindamycin, macrolides, tetracyclines, bactrim

55. The Ideal Drug*
1.Selective toxicity: against target pathogen but not against host
 LD50 (high) vs. MIC and/or MBC (low)
2.Bactericidal vs. bacteriostatic
3.Favorable pharmacokinetics: reach target site in body with effective concentration
4.Spectrum of activity: broad vs. narrow
5.Lack of “side effects”
 Therapeutic index: effective to toxic dose ratio
6.Little resistance development

56. Resistance Physiological Mechanisms
1. Lack of entry – tet, fosfomycin
2. Greater exit
 efflux pumps
 tet (R factors)
3. Enzymatic inactivation
 bla (penase) – hydrolysis
 CAT – chloramphenicol acetyl transferase
 Aminogylcosides transferases
REVIEW

57. Resistance Physiological Mechanisms
4. Altered target
 RIF – altered RNA polymerase (mutants)
 NAL – altered DNA gyrase
 STR – altered ribosomal proteins
 ERY – methylation of 23S rRNA
5. Synthesis of resistant pathway
 TMPr plasmid has gene for DHF reductase; insensitive to TMP
(cont’d) REVIEW

58. Empirical Treatment is the recommended strategy in treatment of CAP and shouldn’t be delayed.

59. 59 CAP – Special Features – Pathogen wise
Typical – S.pneumoniae, H.influenza, M.catarrhalis
Blood tinged sputum - Pneumococcal, Klebsiella, Legionella
H.influenzae
CAP has associated of pleural effusion:S.Pneumoniae – commonest – penicillin resistance problem
S.aureus, K.pneumoniae, P.aeruginosa
S.aureus causes CAP in post-viral influenza; Serious CAP
K.pneumoniae primarily in patients of chronic alcoholism
P.Aeruginosa causes CAP in pts with CSLD or CF, Nosocom
Aspiration CAP only is caused by multiple pathogens
Extra pulmonary manifestations only in Atypical CAP

60. Outpatient treatment: Oral Respiratory Fluroquinolones OR Oral B-Lactam/ B-Lactamase + Oral New Macrolide OR IM 3rd Generation Cefalosporines + New Macrolide Recommendations for the Empirical Treatment:

61. In-patient treatment: Non-ICU:
Intravenous ( IV )Respiratory fluoro- quinolone OR IV B-Lactam/ B-Lactamase + IV New Macrolide OR IV 3rd Generation Cephalosporin + IV New Macrolide Recommendations for the Empirical Treatment:

62. In-patient treatment: ICU:
No Monotherapy.
IV Respiratory fluoroquinolone + 3rd or 4th generation cephalosporin
OR IV Imipenem + IV New Macrolide
Recommendations for the Empirical Treatment:

63. Special entities in ICU:
Aspiration:
As Before + i.v. Clindamycin OR Metronidazole
Risk of Pseudomonas Infection:
Antipseudomonal beta-lactam (3rd or 4th generation cephalosporin OR Piperacillin-tazobactam OR carbapenem) Plus (aminoglycoside OR antipseudomonal fluoroquinolone) For community-acquired methicillin-resistant Staphylococcus aureus infection (MRSA): Add Teicoplanin OR linezolid Alternative: Vancomycin (considering its renal side effects) Recommendations for the Empirical Treatment:

64. 64 Duration of Therapy
•Minimum of 5 days
•Afebrile for at least 48 to 72 h
•Longer duration of therapy
If initial therapy was not active against the identified pathogen or complicated by extra pulmonary infection

65. 65
Strategies for Prevention of CAP
•Cessation smoking
•Influenza Vaccine It offers 90% protection and reduces mortality by 80%
•Pneumococcal Vaccine (Pneumonia shot)
It protects against 23 types of Pneumococci
70% of us have Pneumococci in our RT
It is not 100% protective but reduces mortality
Age 19-64 with co morbidity of high for pneumonia
Above 65 all must get it even without high risk
•Starting first dose of antibiotic within 4 h & O2 status

66. 66 Switch to Oral Therapy
Four criteria
Improvement in cough, dyspnea & clinical signs
Afebrile on two occasions 8 h apart
WBC decreasing towards normal
Functioning GI tract with adequate oral intake
If overall clinical picture is otherwise favorable, hemodynamically stable; can switch to oral therapy while still febrile.

67. 67 Management of Poor Responders
Consider non-infectious illnesses
Consider less common pathogens
Consider serologic testing
Broaden antibiotic therapy
Consider bronchoscopy

68. 68 CAP – Complications
Hypotension and septic shock
3-5% Pleural effusion; Clear fluid + pus cells
1% Empyema thoracis pus in the pleural space
Lung abscess – destruction of lung - CSLD
Single (aspiration) anaerobes, Pseudomonas
Multiple (metastatic) Staphylococcus aureus
Septicemia – Brain abscess, Liver Abscess
Multiple Pyemic Abscesses

69. 69 CAP – So How Best to Win the War?
Early antibiotic administration within 4-6 hours
Empiric antibiotic Rx. as per guidelines (IDSA / ATS)
PORT – PSI scoring and Classification of cases
Early hospitalization in Class IV and V
Change Abx. as per pathogen & sensitivity pattern
Decrease smoking cessation - advice / counseling
Arterial oxygenation assessment in the first 24 h
Blood culture collection in the first 24 h prior to Abx.
Pneumococcal & Influenza vaccination; Smoking cessation

70. Broncho-Vaxom is an extract of different bacterial species frequently responsible of respiratory infections. It stimulates the immune system in order to increase the body’s natural defences against a wide spectrum of respiratory pathogens. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .

71. Broncho-Vaxom prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular sinusitis, rhinopharyngitis and middle ear infection, in adults and children. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .

72. Immunostimulating agent In animals, an increased resistance towards experimental infections, a stimulation of macrophages and B lymphocytes as well as an increase in immunoglobulins secreted by the respiratory mucosal cells have been reported. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .

73. Immunostimulating agent In humans, an increase in the rate of circulating T lymphocytes, in salivary IgA, in the non-specific response to polyclonal mitogens and in the mixed lymphocyte reaction have been observed. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .

74. Safety Extensive toxicity studies have not revealed any toxic effect. Effects on ability to drive and use machines:
Broncho-Vaxom is presumed to be safe and unlikely to produce an effect.
BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .

75. Safety Reproduction studies in animals have not demonstrated any risk to the fetus, but controlled studies in pregnant women are not available. As regards breast-feeding, no specific studies have been performed and no data have been reported up to now. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .

76. Side effects The overall incidence of adverse effects in clinical trials lies between 3 and 4%. Gastrointestinal troubles (nausea, abdominal pain, vomiting), dermatologic reactions (rash, urticaria), and respiratory disorders (coughing, dyspnea, asthma), as well as generalized problems (fever, fatigue, allergic reactions) are the most frequent complaints reported. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .

77. Interaction No drug interaction is known up to now.. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .