This document discusses the diagnosis and management of community acquired pneumonia. It outlines the clinical features required for diagnosis, including cough, fever, sputum production and chest pain along with imaging findings of lung infiltrates. Investigations like chest x-rays are important to confirm pneumonia and assess severity. Common pathogens are discussed. Treatment involves antibiotics, with duration and site of care (outpatient vs hospitalization) determined by severity scores. Prognosis depends on patient factors and comorbidities. Prevention involves vaccination and smoking cessation.
Pneumonia - Community Acquired Pneumonia (CAP)Arshia Nozari
An overview to Community Acquired Pneumonia; It's Pathophysiology, Etiology, Epidemiology, Diagnosis and Treatment according to Harrison's Internal Medicine, 20th Edition (2018).
Pneumonia - Community Acquired Pneumonia (CAP)Arshia Nozari
An overview to Community Acquired Pneumonia; It's Pathophysiology, Etiology, Epidemiology, Diagnosis and Treatment according to Harrison's Internal Medicine, 20th Edition (2018).
ATYPICAL PNEUMONIA BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE SOPORE...Prof Dr Bashir Ahmed Dar
DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR PRESENTLY WORKING IN MALAYSIA TEACHING MEDICAL STUDENTS THE ART OF TREATING PATIENTS SPEAKS ABOUT THE IMPORTANCE OF HISTORY TAKING.MEDICAL STUDENTS AND DOCTORS should probe more deeply WHILE TAKING HISTORY OF A PATIENT as it gives the useful information in formulating a diagnosis and providing medical care to the patient.
Otitis is one of the most frequent diseases in early childhood and one of the reasons for first prescription of antibiotics.
Most frequently reported pediatric bacterial infection, with up to 85% of children experiencing an episode by the age of 3 years and many of them have to treat with medicine and surgical management is restricted
ATYPICAL PNEUMONIA BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE SOPORE...Prof Dr Bashir Ahmed Dar
DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR PRESENTLY WORKING IN MALAYSIA TEACHING MEDICAL STUDENTS THE ART OF TREATING PATIENTS SPEAKS ABOUT THE IMPORTANCE OF HISTORY TAKING.MEDICAL STUDENTS AND DOCTORS should probe more deeply WHILE TAKING HISTORY OF A PATIENT as it gives the useful information in formulating a diagnosis and providing medical care to the patient.
Otitis is one of the most frequent diseases in early childhood and one of the reasons for first prescription of antibiotics.
Most frequently reported pediatric bacterial infection, with up to 85% of children experiencing an episode by the age of 3 years and many of them have to treat with medicine and surgical management is restricted
Diagnosis & Mangement of Community-Acquired Pneumonia, Hospital Acquired Pneu...Riaz Rahman
Clinical overview of Community Acquired Pneumonia, Hospital Acquired Pneumonia, Aspiration Pneumonia. Covers pathophysiology, clinical management, prevention, risk stratification (pneumonia severity index), prognostic factors, complications. Includes case studies, comprehension questions. Given at Jackson Park Medical Center on 12/1/2013. Includes references.
These lecture notes were prepared by Dr. Hamdi Turkey- Pulmonologist- Department of internal medicine - Taiz university
Do Not Forget To Visit Our Pages On Facebook on the following Links:
https://www.facebook.com/groups/569435236444761/
AND
https://www.facebook.com/groups/690331650977113/
Pathology of Pneumonia:
Broncho- pneumonia,
Lobar Pneumonia,
Lung Abscess,
Lung Fungal Absces,
Normal Lung
Please leave a comment after downloading.
THANK YOU ^^
respiratory inspections are common in elderly people and often times,that tickles into the lungs.More often than not they have comorbiidites,like Diabetes,hypertension etc.Hence,the treatment has to be different and some times the prognosis is guarded
Newly Approved Agents: Lefamulin, the first systemic pleuromutilin antibiotic, was approved by the FDA in August 2019 (after the societies’ approval of the guidelines) for the treatment of adults with CAP caused by S pneumoniae, methicillin-susceptible S aureus (MSSA), H influenzae, Legionella pneumophila, M pneumoniae, and C pneumoniae.11,12 Lefamulin acts as a bacterial protein synthesis inhibitor by targeting the peptidyl transferase center of the 50S bacterial ribosomal subunit. It may be given either IV or orally at a dosage of 150 mg IV every 12 hours or 600 mg orally every 12 hours, with dosage adjustment required for patients with hepatic impairment. Lefamulin may prolong the QT interval, and its use should be avoided in patients who have known QT prolongation or are taking other QT-prolonging agents. Lefamulin has several other drug interactions. Its use should be avoided (because of potential for reduced efficacy) with strong or moderate CYP3A inducers or P-glycoprotein (Pgp) inducers. The oral formulation of lefamulin should not be used with agents that are that are strong CYP3A inhibitors or Pgp inhibitors or with CYP3A4 substrates that prolong the QT interval. Lefamulin may cause fetal harm, and females should be counseled to use effective contraception during treatment and for 2 days after completion of therapy.11-13
Delafloxacin, a fluoroquinolone antibiotic, was approved in October 2019 (after the guidelines were published) for treatment of adults with CAP caused by S pneumoniae, MSSA, selected gram-negative pathogens (Klebsiella pneumoniae, Escherichia coli, P aeruginosa, H influenzae, Haemophilus parainfluenzae), and atypical microorganisms (C pneumoniae, L pneumophila, M pneumoniae).14 It may be given either IV or orally at a dosage of 300 mg IV every 12 hours or 450 mg orally every 12 hours, with adjustment required for patients with severe renal impairment. Delafloxacin has the same warnings and precautions as other agents in the fluoroquinolone antimicrobial class.14,15
Directed Treatment
The patient’s clinical response should be evaluated after initiation of antimicrobial therapy. In cases where blood and/or sputum cultures are recommended, once microbiology culture and sensitivity results are available, antibiotic coverage should be deescalated and therapy should be directed at the pathogen(s) causing disease.4,9
Duration of Therapy
The recommended duration of antibiotic therapy has not changed from previously published guidelines. Patients with CAP should be treated for a minimum of 5 days, with antibiotic therapy continued until the patient achieves clinical stability. Validated measures of clinical stability include resolution of vital sign abnormalities (heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature); ability to eat; and normal mental status. Given that most patients achieve clinical stability within 48 to 72 hours after therapy initiation, a 5-day course typically is sufficient
2. DIAGNOSIS AND MANAGEMENT
DIAGNOSIS
In addition to a constellation of suggestive clinical features, a
demonstrable infiltrate by chest radiograph or other imaging
technique, with or without supporting microbiological data, is required for
the diagnosis of pneumonia.
The diagnosis of CAP is based on the presence of select clinical features :
cough,
fever,
sputum production,
pleuritic chest pain
And this is supported by imaging of the lung, usually by chest radiography.
•SIGNS –
• Tachypnea
• Rales
• Bronchial breath sounds
3. INVESTIGATIONS
CHEST X RAY :
All patients admitted to hospital with suspected CAP should have
a chest radiograph performed as soon as possible to confirm or
refute the diagnosis. The objective of any service should be for
the chest radiograph to be performed in time for antibiotics to be
administrated within 4 h of presentation to hospital should the
diagnosis of CAP be confirmed.
4. CHEST X RAY IN PNEUMONIA
Radiologically Pneumonias present as :
Areas of increased opacities, which is confined to a
segment or a lobe.
Rarely it may involve one or more lobes also.
Broadly defined into :
Lobar Pneumonia
Bronchopneumonia
5. INVESTIGATIONS - CHEST X RAY
There are no characteristic features on the chest radiograph in CAP that
allow confident prediction of the causative organism.
Multilobe involvement at presentation and pleural effusions were more
likely at presentation in Bacteraemic Pneumococcal pneumonia than in
non-bacteraemic pneumococcal pneumonia or legionella pneumonia.
Homogenous shadowing was less common in Mycoplasma pneumonia
than in the other types.
Lymphadenopathy was noted in some cases of Mycoplasma infections
but not in the other types of infection.
CAP due to S aureus appears to be more likely to present with
multilobar shadowing, cavitation, pneumatoceles or spontaneous
pneumothorax.
K pneumoniae has a predilection for upper lobes (especially the right). A
bulging interlobar fissure and abscess formation with cavitation have also
been reported.
6. INVESTIGATIONS - CHEST X RAY
Radiographic changes resolve relatively slowly after CAP and lag
behind clinical recovery.
In one study complete clearance were seen duration after initial
presentation are by
2 weeks in 51%
4 weeks in 64%
6 weeks in 73%
Clearance rates are slower in
Elderly (Major factor { 35%,60%,84% at 3,6,12 weeks respectively})
More than one lobe involvement at presentation
Smokers
Inpatients rather than outpatients
C-Reactive Protein Level >200 mg/L
Pneumonia caused by atypical pathogens clear quickly.
7. INVESTIGATIONS - CHEST X RAY
The chest radiograph need not be repeated prior to hospital discharge in
those who have made a satisfactory clinical recovery from CAP.
A chest radiograph should be arranged after about 6 weeks for all those
patients
who have persistence of symptoms or physical signs
who are at higher risk of underlying malignancy (especially smokers and those aged
>50 years)
Further investigations which may include bronchoscopy should be
considered in patients with persisting signs, symptoms and radiological
abnormalities at around 6 weeks after completing treatment.
8. ROUTINE INVESTIGATIONS
General investigations are not necessary for the majority of patients with
CAP who are managed in the community.
Pulse oximeters allow for simple assessment of oxygenation.
The only other simple non-microbiological tests that influence
immediate management are the UREA, which informs severity
assessment, and OXYGEN SATURATION.
The need for an inspired oxygen of 35% or more to maintain the
oxygen saturation above 90% implies severe pneumonia.
So does a PaO2 of 60mmHg or less or a PaCO2 of 50mmHg or more.
These findings warn that assisted ventilation may become necessary.
9. ROUTINE INVESTIGATIONS
A white cell count of >15 x109 /l strongly implicates a bacterial
(particularly pneumococcal) aetiology.
A white cell count of >20 x 109/l or, is an indicator of severity.
All patients with CAP had CRP levels >50 mg/l and 75% of
patients had levels >100 mg/l.
CRP level of >100 mg/l helped to distinguish CAP from acute
exacerbations of COPD
10. MICROBIOLOGICAL INVESTIGATIONS
For patients managed in the community, microbiological
investigations are not recommended routinely.
Examination of sputum should be considered for patients who do
not respond to empirical antibiotic therapy.
More extensive microbiological investigations are recommended
only for patients with moderate or high severity CAP.
14. MICROBIOLOGICAL INVESTIGATIONS
SPUTUM STAINING :
Advantages
1. Quick and relatively inexpensive.
2. Can assess quality of samples (cytological content) with rejection of
poor quality samples.
3. Can aid the interpretation of culture results and occasionally give an
early indication of possible aetiology.
Disadvantages
1. Strict criteria for interpretation require appropriate operator training.
2. Validity of results is directly related to the experience of the interpreter
15. MICROBIOLOGICAL INVESTIGATIONS
SPUTUM CULTURES :
Routine sputum cultures are neither very sensitive nor specific.
Problems include:
1. Of patients to produce good specimens.
2. Prior exposure to antibiotics.
3. Delays in transport and processing.
4. Difficulty in interpretation due to contamination of the
sample by upper respiratory tract flora. (especially in patients
already given antibiotics).
16. MICROBIOLOGICAL INVESTIGATIONS
BLOOD CULTURES
Blood cultures are recommended for all patients with moderate
and high severity CAP, preferably before antibiotic therapy is
commenced.
17. MICROBIOLOGICAL INVESTIGATIONS
Other tests
Streptococci pneumoniae
Pneumococcal antigen detection
Antigen detection is less affected by prior antibiotic therapy.
The detection of antigenaemia has a correlation with clinical
severity.
The test remains positive in 80–90% of patients for up to 7 days
after starting antimicrobial treatment.
May also be applied to other relevant sample types such as
pleural fluid.
Pneumococcal PCR
Pneumococcal PCR has little to offer for the diagnosis of CAP at
this time, being insufficiently sensitive and specific for routine
use.
18. MICROBIOLOGICAL INVESTIGATIONS
LEGIONELLA
Urine antigen detection – EIA, specificity (>95%) & sensitivity
(>80%).
CULTURES :
Culture is 100% specific and is the only reliable method of detecting
infection with non-pneumophila legionella species.
Problems with culture :
The inability of many patients with legionella pneumonia to produce
sputum samples.
Prior antibiotic therapy; laboratory time and cost in processing samples.
Lack of rapid results (legionella cultures need to be incubated for up to
10 days).
19. MICROBIOLOGICAL INVESTIGATIONS
SEROLOGICAL TESTING :
Standard for diagnosing infection with most atypical pathogens.
Relies on Acute and convalescent – phase serological testing.
IgM and IgG ELISA for Mycoplasma – IgM is consistent with acute
infection in70% of patients admitted in hospital.
Cold Agglutinins are present in 50% of Mycoplasma patients.
20. MANAGEMENT
SITE OF CARE :
Depends on the initial assessment of severity.
Many prognostic models have been introduced for severity
assessment.
The two most interesting and widely studied are :
Pulmonary Severity Index
British Thoracic Society Criteria
21. PARAMETER SCORE
AGE 1 POINT / YR
FEMALE -10
NURSING HOME RESIDENT +10
NEOPLASTIC DISEASE HISTORY +30
LIVER DISEASE +20
CHF, CEREBROVASCULAR DISEASE, RENAL DISEASE +10,+10,+10
ALTERED MENTAL STATUS +20
RESPIRATORY RATE > 29 +20
SBP > 90 +20
TEMPERATURE > 39.9 C, < 35 C +15
PULSE > 124 +10
pH < 7.35 +30
Bun > 29, Sr Na < 130 +20, +20
Glucose > 249 mg/dL +10
Hematocrit < 30%, PaO2 < 60 mm Hg +10, +10
PLEURAL EFFUSION ON CHEST X RAY +10
22. PULMONARY SEVERITY INDEX :
CLASS I – 0.1% MORTALITY ( score < 51)
CLASS II – 0.6% (51 – 70)
CLASSIII – 0.9% (71 – 90)
CLASS IV – 9.3% (90 – 130)
CLASS V – 27% ( > 130 )
Class I – III – Low Risk – Suitable for OP management.
23. CURB – 65 :
C – Confusion
U – BUN - > 7mmol / 20 mg/dL
R – Respiratory Rate - >_ 30 / mt
B – Blood Pressure – SBP < 90mm, DBP < 60mm
65 – Age >_ 65 years
One point for each parameter if present
25. REASONS FOR ADMISSION OF LOW –
MORTALITY RISK PATIENTS :
1. Complications of pneumonia itself.
2. Exacerbations of underlying diseases.
3. Inability to reliably take oral medications or receive
outpatient care
4. Multiple risk factors falling just above or below thresholds
for the score.
30. TREATMENT
SWITCHING FROM INTRAVENOUS TO ORAL
THERAPY :
If patients are hemodynamically stable.
Improving clinically.
Able to ingest medications.
Normally functioning GIT.
Patients should be discharged as soon as they are
CLINICALLY STABLE, have no other active medical
problems.
In patient observation while receiving oral therapy is not
necessary.
31.
32. DURATION OF ANTIBIOTIC THERAPY
Patients with CAP should be treated for a minimum of 5 days.
Should be afebrile for 48–72h.
Should have no more than 1 CAP-associated sign of clinical
instability before discontinuation of therapy.
A longer duration of therapy may be needed if :
Initial therapy was not active against the identified pathogen
Or if it was complicated by extrapulmonary infection, such as
meningitis or endocarditis.
37. PROGNOSIS
Depends upon :
Age
Comorbidities
Site of treatment
Young patients without comorbidities recover after 2 weeks.
Older patients with comorbidities may take several weeks for
full recovery.
Mortality for OP < 1%.
Inpatients < 10% (50% deaths direct cause is pneumonia itself)
41. REFERENCES
BRITISH THORACIC SOCIETY - Guidelines for the management
of community acquired pneumonia in adults: update 2009
Infectious Diseases Society of America/American Thoracic Society -
Consensus Guidelines on theManagement of Community-
Acquired Pneumonia in Adults
CROFTON AND DOUGLA’S RESPIRATORY DISEASES 5 e
HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18 e