Community acquired pneumonia

1. COMMUNITY ACQUIRED
PNEUMONIA
PRESENTED BY :
DR VINCENT JAYAKUMAR A
DNB RESIDENT
DEPARTMENT OF GENERAL MEDICINE
IGGGH AND PGI

2. TABLE OF CONTENTS
• INTRODUCTION
• EPIDEMIOLOGY
• RISK FACTOR
• CLINICAL PRESENTATION
• CAUSES
• DIAGNOSTIC AND MICROLOGICAL INVESTIGATIONS
• IMAGING
• TREATMENT

3. INTRODUCTION
• Community-acquired pneumonia is an acute disease caused by an
infection of the lung parenchyma acquired outside of a hospital
setting.
• It is one of the leading global causes of morbidity and mortality in
patients who are immunocompetent and patients who are
immunocompromised.
• Unfortunately, community-acquired pneumonia is a neglected, but
common, medical event; the lack of a sense of emergency within the
general public, little economic investment at a public and private
level, and absence of advocacy and disease awareness are worrisome

4. EPIDEMIOLOGY
• In a 2-year study done in the USA, the annual age-adjusted incidence
was 649 patients hospitalised (admitted to hospital and treated there)
with community-acquired pneumonia per 100 000 adults,
corresponding to more than 1·5 million annual adult community-
acquired pneumonia hospitalisations in the USA.1
• Mortality during hospitalisation was 6·5%; its rate at 30 days was
13·0%, 6 months was 23·4%, and 1 year 6%
• Community-acquired pneumonia (CAP) is the prominent cause of
mortality and morbidity with important clinical impact across the
globe.
• India accounts for 23 per cent of global pneumonia burden with
case fatality rates between 14 and 30 per cent, and Streptococcus
pneumoniae is considered a major bacterial aetiology.

5. RISK FACTORS
• Chronic cardiovascular conditions
• Neurological conditions like stroke and psychiatric conditions.
• Chronic respiratory diseases including COPD,BRONCHITIS AND
ASTHMA
• Diabetes
• Chronic liver diseases.
• Lifestlye factors like – alcoholism and smoking.

6. CLINICAL PRESENTATION
• LOWER RESPIRATORY INFECTIONS include cough , fever, sputum
production, dyspnoea, chest pain, and new focal signs.
• Fever > or equal to 37.8 C
• Crackles on auscultation
• Oxygen saturation less than 95 %
• Tachycardia
• Tachpnyea
• Lethargy
• Altered mental status.

7. •Fever
•Cough
•Expectoration
MILD
PNEUMONIA
•Sepsis
•Respiratoy failure
SEVERE
PENUMONIA

8. ATYPICAL ORGANISM CAUSING CAP
• Legionella organism is frequently associated with hyponatremia,dry
cough and elevated LDH/
• Mycoplasma is associated with extrapulmonary manifestations such
as encephalitis,acute psychosis, or stroke.

9. CAUSES

11. DIAGNOSIS
• Common blood investigations include the complete blood count,renal
profile and the serum electrolytes and the liver function test.
• Among these test WBC, C reactive protein and the procalcitonin are the
measure of the SYSTEMIC INFLAMMATION.
• Other tests, such as lactate ,arterial blood gas analysis or coagulation
tests, are useful in evaluating the associated organ damage, as seen in
SEVERE SEPSIS AND MULTIORGAN FAILURE.
• Viral markers are obtained in view of the IMMUNOSUPRESSION

12. PROCALCITONIN
Much discussion over the past 20 years has focused on the use of
procalcitonin as a biomarker to initiate empiric antibiotic therapy in
patients with community-acquired pneumonia.
0·25 μg/L - BACTERIAL PNEUMONIA
0·1 μg/L OR less - LIKELIHOOD OF VIRAL INFECTION.
The controversy is also documented by a study showing an inability of
procalcitonin to discriminate between viral and bacterial infection.

13. SPUTUM EXAMINATION YES OR NO?
The latest guidelines from the American Thoracic Society and the
Infectious Diseases Society of America (ATS and IDSA) neither
recommend nor discourage routinely obtaining sputum Gram stain and
culture in all adults with community-acquired pneumonia managed in
the hospital setting.
Gramstain and the sputum culture is ordered in patients with risk
factors for MRSA or P aeruginosa caused community-acquired
pneumonia and in patients being considered for coverage for MRSA or
Pseudomonas.
The 2019 ATS and IDSA guidelines identified previous infection and
hospitalisation and treatment with parenteral antibiotics in the past 90
days as the two most important risk factors for MRSA or Pseudomonas
leading physicians to order sputum culture.

14. BLOOD CULTURE
• The effect of blood cultures on the outcomes of hospitalised patients
with community-acquired pneu-monia has not been fully evaluated,
with studies showing mixed results.
• It has been suggested that blood culture should be obtained before
treatment in hospitalised patients with severe community-acquired
pneumonia (because a delay in targeting less common pathogens
might harm patients), and
• In hospitalized patients undergoing empiric antibiotic therapy against
MRSA or P aeruginosa, or patients previously infected with MRSA or P
aeruginosa, or who were hospitalized and received parenteral
antibiotics, in the past 90 days.

15. IMAGING
• The diagnosis of community acquired pneumonia requires evidence
of an INFILTRATE on a chest xray , CT chest ,lung ultrasonography or
all three, in a patient with a clinical compatible syndrome.
• POSTEROANTERIOR CHEST XRAY
• LATERAL CHEST XRAY , these both x ray can give us definitive
diagnosis of community acquired pneumonia.
In cases of focal non-segmental
or lobar pneumonia, multifocal bronchopneumonia
or lobular pneumonia, or focal or diffuse interstitial pneumonia
With or without pleural effusion.

16. Several diseases might mimic community- acquired pneumonia, and
infiltrates that might be absent at the initial chest x-ray evaluation
might become apparent after 24–72 h.
Chest CT is usually the next line of investigation if a discrepancy
exists between the clinical suspicion of pneumonia and a negative
chest x-ray.

17. DIGNOSTIC DIFFICULTIES
Up to 30% of patients of patients with pneumonia in chest
xray diagnosis do not show up on CT imgaing
But upto 1/3rd of the patients with a negative chest xray might
have a CT changes consistent with penumonia

18. STRENTHS VS LIMITATIONS

19. NEWER TESTS
• Urinary antigen testing for S pneumoniae and Legionella
Pneumophila are rapid and readily available; they are algorithms.
DRAWBACKS:
• These test have high specificity, the low sensitivity does not rule out a
pneumonia caused by S pneumoniae and L pneumophila.
• No benefit of a pathogen-directed treatment based on these tests
versus guideline-based treatment has been identified in terms of
clinical outcomes or length of antibiotic treatment.
• Both tests are recommended for severe community- acquired
pneumonia, and a Legionella test is also recom- mended for
epidemiological reasons (eg, outbreaks).

20. NEWER TEST CONT.
• Although serology is currently available for Chlamydophila,
Mycoplasma, and Legionella, its clinical usefulness is controversial,
especially given the delay in results. The specificity of the serology for
M pneumoniae is not sufficiently high; furthermore, the test typically
becomes positive about 7 days after the onset of the disease.
• Real-time and multiplex panel PCR, currently available for bacteria
and viruses, can provide results in a few hours, and are promising
methods for fast causal diagnosis of community-acquired pneumonia.
•

21. • Testing for influenza with a rapid molecular assay is recommended
during influenza season, although no studies evaluating the effect of
influenza testing on outcomes of patients with community-acquired
pneumonia have been published, Finally, the sensitivity of both
influenza rapid antigen tests and viral culture is low when the tests
are done in older hospitalized adults.

22. DISEASE SEVERITY AND SITE OF CARE
DECISION
• Different severity assessment tools have been developed to predict
the mortality and other clinical outcomes .it includes
• Pneumonia Severity index(PSI) and CURB 65 are frequently used
severity scores.
• CURB 65 is simpler to use than PSI but less effective in guiding the site
of care decision.
• The latest ATS and IDSA guidelines state a preference for the use of
PSI over CURB-65 to decide the site of care.

23. CURB 65

24. PORT/
PSI
SCORING

25. SMART COP SCORING FOR ICU ADMISSION

26. TREATMENT
• Empiric antibiotic treatment
• Anti influenza treatment
• Recognition and management of sepsis and respiratory failure
• Adjuctive therapy
• Early and late clinical outcomes
• Clinical stability and switch to oral therapy
• Duration of therapy.
• Prevention

28. OUTPATIENT TREATMENT STRATAGIES

29. ANTI INFLUENZA TREATMENT
• Influenza therapy is recommended for inpatients and outpatients
with community-acquired pneumonia and a positive influenza test,
independent from the duration of signs and symptoms before the
diagnosis of pneu-monia. Uncomplicated influenza usually improves
with or without antiviral treatment.
• There are four US FDA-approved influenza antiviral drugs
recommended by the US Centers for Disease Control and Prevention
(CDC): peramivir, zanamivir, oseltamivir phosphate, and baloxavir
marboxil.

30. MANAGEMENT OF SEPSIS AND FAILURE
• Sepsis, respiratory failure, and acute respiratory distress syndrome
are the most severe complications of community-acquired
pneumonia and mortality can be 50% in pateints who require ICU
admission and therefore the early recognition and management of
community acquired pneumonia.

31. • These measures include correct diagnosis and treatment of the
infections
• Fluid management
• Vasopressor use
• ICU supportive care such as nutrition,early mobilizations and
prevention of secondary infection .
• Acute respiratory failure in patients in community acquired
pneumonia may require ventilatory and non ventilatory management
but recent days use of the continuous positive airway pressure and
non invasive ventilation as first line ventilatory support of CAP.

32. ADJUNCTIVE THERAPY
Even after extensive targeted therapy , it is important to know about
controlling excessive systemic inflammatory reponse is very important
in management of CAP.
So usage of administration of corticosteroids as coadjunct treatment in
hospitalized patients with community acquired pneumonia.
However it showed promising benefits , it also has coexisting
complications like hyperglycemia, higher secondary infections and
mortality in case of influenza.

33. Both the 2011 European Respiratory Society and 2019 ATS and IDSA
guidelines do not recommend routine use of steroids in non-severe
community-acquired pneumonia, severe community-acquired
pneumonia, or severe influenza pneumonia

34. CLINICAL STABILITY AND SWITCH TO ORAL
THERAPY
• The identification of clinical stability is a crucial step for physicians
once patients have started antibiotic therapy for community-acquired
pneumonia.
• In patients with community-acquired pneumonia who are
immunocompetent and respond to treatment, clinical improvement is
usually expected to be reached around day 3 or 4 after the initiation
of antibiotic therapy.

36. • Time to clinical stability is the most important early outcome in
community-acquired pneumonia and has been widely accepted as a
tool to guide the switch from intravenous to oral antibiotic therapy
during hospitalisation, as well as to establish duration of antibiotic
therapy and to judge appropriateness for hospital discharge.

37. DURATION OF THERAPY
• Patients with community acquired pneumonia have been treated
with a realatively standard prolonged antibiotic course of 7 to 14
days.
• The duration of the antibiotic therapy should balance the
risk of illness
progression of the disease
address the antibiotic treatment
adverse drug events associated with the treatment.

38. • But with the recent studies , the Short-course treatment was
associated with fewer serious adverse events and lower mortality
than long-course treatment.
• A 2016 multicentre, non-inferiority, randomised, clinical trial showed
that the 2007 ATS and IDSA recom- mendations for duration of
antibiotic treatment, based on clinical stability criteria, can be safely
implemented in hospitalised patients with community-acquired pneu-
monia.
• Patients with extrapulmonary complications, or empyema and
pneumonia due to specific pathogens (eg, Legionella and MRSA),
might benefit from prolonged treatment.

39. • Individualising duration of antibiotic therapy in community-acquired
pneumonia with clinical stability criteria, biomarkers, or
pharmacological properties of antibiotics is supported by several
observations.
• Current scientific evidence shows that procalcitonin-guided
antimicrobial stewardship reduces the antibiotic expo- sure without
increasing mortality in patients with pneumonia.

40. NON RESOLVING PNEMONIA
• Non-resolving pneumonia is considered to be a clinical syndrome
characterised by signs and symptoms compatible with respiratory
infection and infiltrates on chest x-ray, which persist after antibiotic
initiation, with a patient’s clinical status that neither improves nor
deteriorates.
• The inceidence of the clinical failure in community acquired
pneumonia ranges form 6% to 31%.
• Early clinical failure – within 1 to 3 days.
• Late clinical failure – between 4 to 7 days of hospitalization.

41. PREVENTION
• Influenza vaccine can reduce infleunza infection and pneumonia
ranges from 56 to 60 percentage.
• S pneumoniae infections can be prevented after the administration of
two types of vaccines:
Unconjugated pneumococcal Polysaccharide vaccine (PPSV)-
Polysaccharide vaccines - produce an independent T-cell response
without the activation of memory B cells.
Pneumococcal conjugate vaccines (PCV) - T-cell dependent
response through an immunogenic protein with a B-cell memory and
long-term immunization.

42. THANKING YOU