This document summarizes guidelines for diagnosing and managing community-acquired pneumonia (CAP) from the Philippine Clinical Practice Guidelines published in 2010 and updated in 2016. It discusses CAP definitions, pathogenesis, clinical presentation, diagnostic testing including chest x-rays, typical and atypical bacterial causes, treatment recommendations, and prevention. Key points covered include how CAP can often be diagnosed based on history and exam findings alone, the value of chest x-rays in confirming CAP diagnosis and evaluating severity, and emphasis on initial empiric antibiotic therapy targeting the most common bacterial pathogens depending on severity and patient risk factors.
This presentation gives general overview of all aspects of bowel sounds including its pathophysiology, auscultation techniques and features of normal versus abnormal bowel sounds.
This presentation gives general overview of all aspects of bowel sounds including its pathophysiology, auscultation techniques and features of normal versus abnormal bowel sounds.
In obstetrics, Leopold maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus; they are named after the gynecologist Christian Gerhard Leopold. They are also used to estimate term fetal weight.
The aim of Leopold maneuvers is to determine the fetal presentation and position by systematically palpating the gravid abdomen.
ctto Marie Belen Tamayor - Leopold's Maneuver, Miss Marie's presentation provided the slides that explain Leopold's maneuver.
In obstetrics, Leopold maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus; they are named after the gynecologist Christian Gerhard Leopold. They are also used to estimate term fetal weight.
The aim of Leopold maneuvers is to determine the fetal presentation and position by systematically palpating the gravid abdomen.
ctto Marie Belen Tamayor - Leopold's Maneuver, Miss Marie's presentation provided the slides that explain Leopold's maneuver.
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.
COVID-19 disease is a highly infectious disease caused by a newly (novel) identified coronavirus. COVID-19 infected patients may have mild to
moderate respiratory symptoms and can recover without any specific medical management. But few experience severe symptoms and lead to
mortality. COVID-19 is announced by WHO as a global pandemic. It is very critical to take appropriate decisions and timely management and
prevention of the infection.
Keywords: COVID-19, Diagnostic test, Management of COVID19, Pandemic, Pathophysiology, Signs, Symptoms.
Role of physiotherapy on COVID-19 patient in ICU settingsJavidsultandar
Early physiotherapy, i.e., started during mechanical ventilation, is considered feasible and safe to improve patient performance and long-term quality of life ( kayambu et al., 2013), although this has not yet been proven in COVID-19. Among chest physiotherapy strategies during mechanical ventilation, mucus clearance and alveolar RMs are very commonly applied in clinical practice. Sputum production was reported in about 34 % of COVID-19 patients ( Guan et al., 2020), thus suggesting that, by promoting mucus clearance during mechanical ventilation, early physiotherapy interventions (such as subglottic secretion drainage, postural hygiene, and ventilator hyperinflation) may produce beneficial effects in this new critically ill population (Thomas et al., 2020).
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
NVBDCP.pptx Nation vector borne disease control program
Community acquired pneumonia cpg 2016
1. COMMUNITY-ACQUIRED PNEUMONIA
(Philippine Clinical Practice Guidelines with 2016 updates)
By: Intern Kalpana Sah
Southwestern University School of medicine
Dr. Pablo O. Torre Memorial Hospital-Department of Internal Medicine
12/29/18
2. COMMUNITY ACQUIRED PNEUMONIA
Lower respiratory tract
infection (pulmonary
parenchyma)
Acquired in the Community
within 24 hours to less than 2
weeks.
12/29/18
3. COMMUNITY ACQUIRED PNEUMONIA
CAP remains the leading cause of death from an infectious disease.
Third leading cause of morbidity and mortality (CPG 2010)
Sixth leading cause of death overall and is a major cause of morbidity
and mortality (CPG 2016)
12/29/18
4. PATHOPHYSIOLOGY
o Infection of pulmonary parenchyma acquired in the community within
24 hours to less than 2 weeks.
o Results from the proliferation of microbial pathogens at the alveolar
level and the host’s response to those pathogens.
o Most common access of microorganisms to the lower respiratory tract is
through aspiration from the oropharynx.
Harrison’s Internal medicine-19th
edition
10. CLINICAL MANIFESTATIONS
Vary from indolent to fulminant in presentation and from mild to fatal in
severity.
Manifestations of progression and severity include both constitutional
findings and those limited to the lung and associated structures.
Frequently febrile with tachycardia or may have a history of chills and/or
sweats.
Cough:
may be either nonproductive or productive of mucoid,
purulent, or blood-tinged sputum.
Harrison’s Internal medicine-19th
edition
11. SIGN AND SYMPTOMS
Fever or hypothermia
Cough with or without sputum, hemoptysis
Pleuritic chest pain
Myalgia, malaise, fatigue
GI symptoms
Dyspnea
Rales, rhonchi, wheezing
Egophony, bronchial breath sounds
Dullness to percussion
Atypical Sx’s in older patients
Harrison’s Internal medicine-19th
edition
13. CLINICAL DIAGNOSIS:
1. CXR : Demonstrable infiltrate
Establish Diagnosis and presence of complications
(pleural effusion, multilobar disease)
CXR: classically thought of as the Gold standard
May show hyper-expansion, Atelectasis or Infiltrates
Harrison’s Internal medicine-19th
edition
15. 12/29/18
ETIOLOGIC DIAGNOSIS
2. Gram’s stain and Culture of sputum
Main purpose of the sputum Gram’s stain is to ensure that a sample is
suitable for culture.
May also identify certain pathogens (e.g., S. pneumoniae, S. aureus, and
gram-negative bacteria) by their characteristic appearance.
Sensitivity and Specificity of the sputum Gram’s stain and culture are
highly variable.
Harrison’s Internal medicine-19th
edition
16. 12/29/18
3. Blood Cultures
Only 5–14% of cultures of blood from patients hospitalized with CAP are
positive
The most frequently isolated pathogen is S. pneumoniae.
ETIOLOGIC DIAGNOSIS
Harrison’s Internal medicine-19th
edition
17. 12/29/18
4. Urinary antigen tests
Two commercially available tests detect pneumococcal and Legionella
antigen in urine.
Legionella urine antigen test (serogroup 1)
Sensitivity 90%, Specificity 99%
Pneumococcal urine antigen test
Sensitive 80% , Specific >90%
ETIOLOGIC DIAGNOSIS
Harrison’s Internal medicine-19th
edition
18. 12/29/18
5. polymerase Chain reaction
Test amplify a microorganism’s DNA or RNA, are available for a number of
pathogens.
PCR of nasopharyngeal swabs has become standard for diagnosis of
respiratory viral infection.
In addition, PCR can detect the nucleic acid of Legionella species, M.
pneumoniae, C. pneumoniae, and Mycobacteria.
ETIOLOGIC DIAGNOSIS
Harrison’s Internal medicine-19th
edition
21. PHILIPPINE CLINICAL PRACTICE GUIDELINES
On the diagnosis, empiric management, and prevention of
COMMUNITY-ACQUIRED PNEUMONIA (CAP)
IN IMMUNOCOMPETENT ADULTS
12/29/18
2010 CAP CPG with 2016 updates
22. COMMUNITY-ACQUIRED PNEUMONIA
Lower respiratory tract infection acquired in the community within
24 hours to less than 2 weeks
COMMONLY PRESENTS WITHCOMMONLY PRESENTS WITH
1. An acute cough
2. Abnormal vital signs
Tachypnea (respiratory rate >20 breaths per minute)
Tachycardia (cardiac rate >100/minute), and
Fever (temperature >37.8ºc)
1. At least one abnormal chest finding
diminished breath sounds, rhonchi, crackles, or wheeze
12/29/18Philippine Clinical Practice Guidelines on CAP (2010)
23. Outlines of the 2010 CPG guideline
Part I: Clinical Diagnosis
Part II: Chest Radiography
Part III: Site-of-Care Decisions
Part IV: Microbiologic Studies
Part V: Treatment : 2016 CPG updates focuses on treatment of CAP
Part VI: Prevention
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
24.
25. Part One: Clinical Diagnosis
Philippine Clinical Practice Guidelines on CAP (2010)
26. 1. Can CAP be diagnosed accurately by
history and physical examination?
Philippine Clinical Practice Guidelines on CAP (2010)
27. 2. Is there any clinical feature that can predict
CAP caused by an atypical pathogen?
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
28. Atypical pathogens
Common cause of CAP in all regions of the world with a global
incidence of 22%
Mycoplasma pneumoniae, Chlamydophila pneumoniae, and
Legionella
Main difference: presence of extrapulmonary findings (GI,
cutaneous)
Suspect Legionella in hospitalized CAP because it is the most
important atypical pathogen in terms of severity
12/29/18Philippine Clinical Practice Guidelines on CAP (2010)
29. Part Two: Chest Radiography
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
30. 3. What is the value of the chest
radiograph in the diagnosis of CAP?
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
31. CXR may not be routinely done in:
Healthy individuals or those with stable co-morbid conditions, and
Normal vital signs and physical examination findings, and
Reliable follow-up can be ensured.
12/29/18Philippine Clinical Practice Guidelines on CAP (2010)
32. 4. What specific views of the chest
radiograph should be requested?
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
33. 5. Are there characteristic radiographic
features that can predict the likely
etiologic agent from the chest
radiograph?
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
34. 6. How should a clinician interpret a
radiographic finding of “pneumonitis”?
12/29/18
A radiographic reading of “Pneumonitis” does not always denote an
infectious process.
Philippine Clinical Practice Guidelines on CAP (2010)
35. 7. What is the significance of an initial
“normal” chest radiograph in a patient
suspected to have CAP?
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
36. 8. Should a chest radiograph be
repeated routinely?
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
37. Repeat CXR
Low-risk CAP recovering satisfactorily – not needed
CAP not clinically improving or shows progressive disease – should
be repeated as needed based on clinician’s judgement
4-6 weeks after hospital discharge
New radiographic baseline
Exclude malignancy
12/29/18Philippine Clinical Practice Guidelines on CAP (2010)
38. 9. What is the role of chest CT scan in
CAP?
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
39. Part Three: Site-of-Care Decisions
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
40. 10. Which patients will need hospital
admission?
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
46. Microbiologic Studies
Definite etiology
Pathogen is isolated from normally sterile or uncontaminated
specimens (blood, pleural fluid or secretions obtained from
transtracheal or transthoracic aspiration)
Probable etiology
Pathogens demonstrated by smear or isolated from cultures in
moderate to heavy quantity from respiratory secretions (e.g.,
expectorated sputum, bronchoscopic aspirate, quantitatively
cultured bronchoalveolar lavage fluid or brush catheter
specimen)
12/29/18
Philippine Clinical Practice Guidelines on CAP (2010)
47. Sputum culture
May be contaminated with resident flora of the upper airways,
thus leading to false positive results
Not sensitive in patients who have taken previous antibiotics,
unable to expectorate and in those with delays in the
processing
S. pneumoniae was isolated in 64% (29/45) of patients with
presumed pneumococcal pneumonia based on the finding of
Gram-positive diplococci compared to 6% (2/31) of patients
without Gram-positive diplococci
12/29/18
Microbiologic Studies
Philippine Clinical Practice Guidelines on CAP (2010)
48. ATYPICAL PATHOGENS
Group of pathogens (M. pneumoniae, C. pneumoniae and L.
pneumophila)
Do not grow on routine culture isolation in the laboratory
It is recommended that the presence of L. pneumophila be
documented through
Urine antigen test (UAT) or
Direct fluorescent antigen test (DFA) of respiratory secretions
12/29/18
Microbiologic Studies
Philippine Clinical Practice Guidelines on CAP (2010)
49. Emerging Etiologies (Human Pandemic
Influenza A [H1N1] 2009, SARS)
Rapid influenza diagnostic tests (RIDTs) in respiratory clinical
specimens have low overall sensitivity in detecting H1N1 (40-69%)
If the presence of H1N1 is suspected in patients with moderate
and high risk pneumonia, a definitive determination with rRT-PCR
should be conducted (95.4 – 100%).
12/29/18Philippine Clinical Practice Guidelines on CAP (2010)
51. 12. When should antibiotics be initiated for the
empiric treatment of CAP ?
Patient should receive initial therapy as soon as possible after
the diagnosis is established
Reduced in hospital mortality when antimicrobial therapy was
initiated within the first four hours of admission and diagnosis of
CAP.
Philippine Clinical Practice Guidelines on CAP (2016)
52. 13. What initial antibiotics are recommended for
the empiric treatment of CAP ?
For low risk CAP without comorbid illness AMOXICILLIN remains the
standard choice ( use of extended macrolides may also be considered)
For low risk CAP with stable comorbid illness, B-Lactam with B-
lactamse inhibitor combinations (BLIC) or second generation cephalosporin
with or without extended macrolides are recommended
For patients who have completed first line treament (BLIC or 2nd
generation cephalosporin) with no response , an extensive work up(sputum
Gram stain and culture) should be done to identify the factors for failure of
response
Philippine Clinical Practice Guidelines on CAP (2016)
53. 13. What initial antibiotics are recommended for
the empiric treatment of CAP ?
For moderate risk CAP a combination of
•an IV non-antipseudomonal B-Lactam with
•either an extended macrolide or a repiratory fluoroquinolone
For high risk CAP without risk for P. aeruginosa a combination of
•IV non-antipseudomonal B-lactam (BLIC, cephalosporin or carbapenem) with
• either an IV extended macrolide or an IV respiratory fluoroquinolone
Philippine Clinical Practice Guidelines on CAP (2016)
54. 13. What initial antibiotics are recommended for
the empiric treatment of CAP ?
For high risk CAP with risk for P. aeruginosa , a combination of
•an IV antipneumococcal ,antipseudomonal B-lactam ( BLIC, cephalosporin or
carbapene with
•an extended macrolide and aminoglycoside
OR a combination of
•an IV antipneumococcal, antipseudomonal B-Lactam and
• an IV ciprofloxacin or high dose IV levofloxacin
Philippine Clinical Practice Guidelines on CAP (2016)
55. Empiric antimicrobial therapy for CAP with usual recommended
dosages in 50-60kg adults with normal liver and renal functions
Risk stratification Potentential pathogens Empiric Therapy
Low -risk CAP
Stable vital signs
•RR<30/minute
•PR<125/min
•SBP>90mmhg
•DBP>60mmhg
•Temp>36c or 40c
No altered mental state of acute onset
No suspected aspiration
No or stable comorbid conditions
Chest xray
• localized infiltrates
•No evidence of pleural effusion
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Mycoplasma pneumoniae
Moraxella catarrhalis
Enteric gram negative bacilli (among those
with co-morbid illness)
Without co -morbid illness
Amoxicillin 1gm TID or, extended
macrolides
Azithromycin 500mg OD or clarithromycin
500mg BID
With stable co- morbid illness
B-lactam / B- lactamase inhibitor
combination (BLIC) OR, 2nd gen oral
cephalosporin +/- extended macrolides
Co- amoxiclav 1gm BID OR,
Sultamicillin 750mg BID OR,
Cefuroxime axetil 500mg BID +/-
Azithromycin 500mg OD OR
Clarithromycin 500mg BID
56. MODERATE RISK CAP
Unstable vital sign
•RR > 30/minute
•PR > 125/min
•Temp < 36c or > 40c
•SBP < 90mmhg
•DBP < 60mmhg
Altered mental state of acute onset
Suspected aspiration
Unstable / Decompensated comorbid condition
•Uncontrolled diabetes mellitus
•Active malignancies
•Neurologic disease in evolution
•Congestive heart failure Class (CHF) II-IV
•Unstable coronary artery disease
•Renal failure on dialysis
•Uncompesated COPD
•Decompensated liver disease
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Mycoplasma pneumoniae
Moraxella catarrhalis
Enteric gram- negative bacilli
Legionella pneumophila
Anaerobes (among those with risk of
aspiration)
IV non-antipseudomonal B-lactam (BLIC, cephalosporin) +
extended macrolides or respiratory fluoroquinolones (PO)
Ampicillin-sulbactam 1.5gm q6h IV OR Cefuroxime 1.5gm
q8h IV OR Ceftriaxone 2gm OD +
Azithromycin 500 OD PO OR Clarithromycin 500mg BID PO
OR Levofloxcin 500mg OD PO OR Moxifloxacin 400mg OD
PO
If aspiration pneumonia is suspected and a regimen
containing ampicillin-sulbactam and /or moxifloxacin is used
there is no need to add another antibiotic for additional
anaerobic coverage. If another combination is used may add
clindamycin to the regimen to cover microaerophilic
streptococci
Clindamyicn 600mg q8h IV OR Ampicillin Sulbactam 3g q6hr
IV OR
Moxifloxacin 400mg OD PO
Empiric antimicrobial therapy for CAP
Philippine Clinical Practice Guidelines on CAP (2016)
57. High risk CAP
Any of the clinical feature of moderate risk CAP
plus any of the following
•Severe sepsis and septic shock OR
•need for mechanical ventilation
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Mycoplasma pneumoniae
Moraxella catarrhalis
Enteric gram negative bacilli
Legionella pneumophila
Anaerobes (among those with risk of aspiration)
Staphylococcus aureus
Pseudomas aeruginosa
No risk for P.aeruginosa
IV non- antipseudomonal B-lactam + I V extended
macrolides
or IV respiratory fluoroquinlones
Ceftriaxone 2gm OD OR Ertapenem 1gm OD +
Azithromycin dihydrate 500mg OD IV OR
Levofloxacin 500mg OD IV OR Moxifloxacin 400mg
OD IV
Empiric antimicrobial therapy for CAP
Philippine Clinical Practice Guidelines on CAP (2016)
58. High risk CAP
Any of the clinical feature of moderate risk CAP
plus any of the following
•Severe sepsis and septic shock OR
•need for mechanical ventilation
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Mycoplasma pneumoniae
Moraxella catarrhalis
Enteric gram negative bacilli
Legionella pneumophila
Anaerobes (among those with risk of aspiration)
Staphylococcus aureus
Pseudomas aeruginosa
Risk for P.aeruginosa
IV antipneumococcal antipseudomonal B-latam
(BLIC, Cephalosporin or carbapenem) + IV
extended macrolides + aminoglycoside
Piperacillin-Tazobactam 4.5gm q6hr OR
Cefepime 2 gm q8-12hr OR Meropenem 1gm
q8h + Azithromycin dihydrate 500mg OD IV+
Gentamicin 3mg/kg OD OR amikacin 15mg/kg
OD OR IV antipneumococcal antipseudomonal B-
lactam (BLIC, cephalosporin or carbapenem) +IV
ciprofloxacin /high dose levofloxacin
Piperacillin-tazobactam 4.5gm q6hr OR Cefepime
2gm q8-12hr OR meropenem 1gm q8h+
levofloxain 750mg OD iv or ciprofloxacin 400mg
q8-12hr IV
If MRSA pneumonia is suspected add
Vancomycin 15mg/kg q8-12hr OR Linezolid
600mg q12hr IV OR
Clindamycin 600mg qq8hr IV
Empiric antimicrobial therapy for CAP
59. 12/29/18
Pneumonia Risk ScorePneumonia Risk Score (CURB-65)(CURB-65)
Predicts Mortality In CAPPredicts Mortality In CAP
C Confusion of new onset
U Urea (BUN) > 7mmol/L (19mg/dl)
R Respiratory rate > 30 breaths per minute
B Blood pressure <90/60 mmhg
65 Age > 65 years old
Interpretation:
0-1: Treat as outpatient
2: Admit patient
>3 : Consider ICU admission
Philippine Clinical Practice Guidelines on CAP (2016)
60. 14. How can response to initial therapy be assessed?
Temperature, respiratory rate, heart rate, blood pressure, sensorium, oxygen saturation and
inspired oxygen concentration should be monitored to assess response to therapy.
Response to therapy is expected within 24-72 hrs of initiating treatment .
Failure to improve after 72 hrs of treatment is an indication to repeat chest radiograph
Follow up cultures of blood and sputum are not indicated for patients who are responding to
treatment.
Philippine Clinical Practice Guidelines on CAP (2016)
61. 15. When should de-escalation of empiric antibiotic
therapy be done ?
De-escalation of initial empiric broad spectrm antibiotic or combination
parenteral therapy to a single narrow spectrum parenteral or oral
agents based on avaialble laboratory data is recommended
• Once the patient is clinically improving ,
• Is hemodynamically stable and
• Has a functioning gastrointestinal tract.
Philippine Clinical Practice Guidelines on CAP (2016)
62. Indications for streamlining of antibiotic therapy
1. Resolution of fever for >24hrs
2. Less cough and resolution of respiratory distress (normalization of
respiratory rate)
3. Improving white blood cell count, no bacteremia.
4. Etiologic agent is not a high risk (virulent/ resistant) pathogen e.g. Legionella
S. aureus or Gram-negative enteric bacilli
5. No instable comorbid condition or life threatning complication such as
myocardial infarction, congestive heart failure, complete heart block, new
atrial fibrillation, SVT etc.
6. No sign of organ dysfunction such as hypotension , acute mental changes ,
BUN to creatinine ratio of >10:1 , hypoxemia and metabolic acidosis
7. Patient is clinically hydrated , taking oral fluids and is able to take oral
medications.
Philippine Clinical Practice Guidelines on CAP (2016)
63. 16. Which oral antibiotics are recommended for de-escalation or
switch therapy from parenteral antibiotics?
The choice of oral antibiotics following initial parenteral therapy is
based on available culture results, antimicrobial spectrum ,
efficacy , safety and cost.
In general when switching to oral antibiotics, either the same agent
as the parenteral antibiotic or an antibiotic from the same drug
class should be used
Philippine Clinical Practice Guidelines on CAP (2016)
64. Antibiotic dosage of oral agents for streamlining or
switch therapy
Antibiotic Dosage
Amoxicillin -clavulanic acid 625 mg TID or 1gm BID
Azithromycin 500mg OD
Cefixime 200mg BID
Cefuroxime axetil 500mg BID
Cefpodoxime proxetil 200mgw BID
Levofloxacin 500-750mg OD
Moxifloxacin 400mg OD
Sultamicillin 750mg BID
Philippine Clinical Practice Guidelines on CAP (2016)
65. 17. How long is the duration of treatment for CAP?
Low risk uncomplicated bacterial pneumonia : 5 to 7 days
Moderate risk bacterial pneumonia : 7-10 days
For moderate risk and high risk CAP or for those with suspected or confirmed
Gram- negative, S. aureus or P. aruginosa pneumonia, treatment should be
prolonged to 28 days if with associated bacteremia.
Mycoplasma : 10 to 14 days
Chlamydophila pneumonia and Legionella pneumonia : 4 to 21 days
Philippine Clinical Practice Guidelines on CAP (2016)
66. Duration Of Antibiotics Use Based On Etiology
Etiologic agent Duration of therapy (days)
Most bacterial pneumonias except enteric Gram -negative
pathogens S.aureus (MSSA and MRSA) , and P.aeruginosa
5-7 days
3-5 (azalides) for S.pneumniae
Enteric gram negative pathogens S.aureus (MSSA and
MRSA), and P.aeruginosa
MSSA community acquired pneumonia
a. non bacteremic - 7-14days
b. bacterimic -longer up to 21 days
MRSA community acquired pneumonia
a. non-bacteremic -7-21 days
b. bacterimic -longer up to 28days
Pseudomonas aeruginosa
a. non-bacteremic -14-21days
b. bacetrimic-longer up to 28days
Mycoplasma and Chlamydophila 10-14 days
Legionella 14-21 ; 10 azalides
Philippine Clinical Practice Guidelines on CAP (2016)
67. 18. What should be done for patients who are not
improving after 72hrs of empiric antibiotic therapy?
The lack of response to seemingly appropriate treatment in a patient with CAP should
lead to a complete reappraisal, rather than simply to selection of alternative antibiotics.
The clinical history , physical examination and the results of all available investigations
should be reviewed.the patient should be reassessed for possibl resistance to the
antibitics being given or for the presence of other pathogens such as M. tuberculosis ,
virsuses , parasites or fungi .
Treatment should then be revised according to culture result.
Philippine Clinical Practice Guidelines on CAP (2016)
68. 12/29/18
19. What should be done for patients who are not
improving after 72hrs of empiric antibiotic therapy?
Follow up chest radiograph is recommended
• investigate for other conditions such as pneumothorax, cavitation and extension to previously
univolved lobes , pleural effusion , pulmonary edema and ARDS , for an underlying mass,
bronchiectasis , loculation, pulmonary abscesses
• a CT scan would provide more information
Obtaining additional specimens for microbiologic testing should be considered
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69. 12/29/18
Reasons for lack of response to treatment of CAP
Correct organism but inappropriate antibiotic choices or dose.
Resistance of oraganism to selected antibiotics
Wrong dose (e.g. in apatient whois morbidly obese or has fluid overload)
Antibiotics not administered
Correct organism and correct antibiotic but infection is loculated (e.g. most
commonly empyema)
Obstruction (e.g lung cancer , foreign body)
Incorrect identification of causative organism
No identification of causative organism and empirical therapy directe toward wrong
organism
Non-infectious cause
Drug induced fever
Presence of an unrecognized concurrent infection
Philippine Clinical Practice Guidelines on CAP (2016)
70. 12/29/18
20. When can a hospitalized patient with CAP be
discharged ?
In the absence of any unstable coexisting illness or other life
threatening complication , the patient may be discharged once clinically
stable and oral therapy is initiated.
A repeat chest radiograph prior to hospital discharge is not needed in
a patient who is clinically improving.
A repeat chest radiograph is recommended during a follow up visit
approximately 4 to 6 weeks after hospital discharge to establish a new
radiograph baseline and to exclude the possibility of malignancy
associated with CAP, particularly in older smokers.
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71. 12/29/18
Recommended hospital discharge criteria
During the 24 hours before discharge , the patient should have the following
characteristics (unless this represents the baseline status):
1. Temperature of 36 -37.5c
2. Pulse <100/min
3. Respiratory rate between 16-24/minute
4. Systolic BP>90mmHg
5. Bloodoxygen saturation >90%
6. Functioning gastrointestinal tract
Philippine Clinical Practice Guidelines on CAP (2016)
72. 12/29/18
21. What other information should be explained and
discussed with the patient ?
Explain to patients with CAP that after starting treatment their symptoms are expected to
steadily improve , although the rate of improvement will vary with the severity of the
pneumonia.
Most people can expect that by:
1week :fever should have resolved
4weeks :chest pain and sputum production should have substantailly reduced
6weeks: cough and breathlessness should have substantially reduced
3months : most symptoms should have resolved but fatigue may still be present
6months :most people will feel back to normal.
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73. 12/29/18
PROGNOSIS
Prognosis depends on the
• Patient’s age,
• Comorbidities, and
• Site of treatment (inpatient or outpatient).
Young patients without comorbidity do well and usually recover fully
after ~2 weeks.
Older patients and those with comorbid conditions can take several
weeks longer to recover fully.
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PREVENTION
The main preventive measure is vaccination
• PPV23 contains capsular material from 23 pneumococcal serotypes;
• In PCV13 capsular polysaccharide from 13 of the most frequent
pneumococcal pathogens affecting children is linked to an immunogenic
protein.
• PCV13 produces T cell–dependent antigens that result in long-term
immunologic memory.
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PREVENTION
Administration of PCV13 vaccine to children has
• Led to an overall decrease in the prevalence of antimicrobial-resistant
pneumococci and
• In the incidence of invasive pneumococcal disease among both children and
adults.
PCV13 now is also recommended for the elderly and for younger
immunocompromised patients.
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77. 12/29/18
PREVENTION
Two forms of influenza vaccine are available:
intramuscular inactivated vaccine and
intranasal live-attenuated cold-adapted vaccine.
The latter is contraindicated in immunocompromised patients.
Philippine Clinical Practice Guidelines on CAP (2016)
78. Smoking Cessation
Cigarette smoking, both active and passive, is a recognized
independent risk factor for CAP.
It is the major avoidable risk factor for acute pneumonia in adults.
Smoking cessation is recommended for all patients with CAP who
are current smokers.
12/29/18Philippine Clinical Practice Guidelines on CAP (2010)
An acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, accompanied by the presence of an acute infiltrate on a chest radiograph, or auscultatory findings consistent with pneumonia, in a patient not hospitalized or residing in a long term care facility for &gt; 14 days before onset of symptoms.
Primary inhalation: When organisms bypass normal respiratory defense mechanisms or when the Patient inhales aerobic GN organisms that colonize the upper respiratory tract or respiratory support equipment
Aspiration: occurs when the Patients aspirates colonized upper respiratory tract secretions
Stomach: reservoir of GNR that can ascend, colonizing the respiratory tract.
Hematogenous: originate from a distant source and reach the lungs via the blood stream.
The overall yearly cost associated with CAP is estimated at $12 billion. The incidence rates are highest at the extremes of age. The overall annual rate in the United States is 12 cases/1000 persons, but the figure increases to 12–18/1000 among children &lt;4 years of age and to 20/1000 among persons &gt;60 years of age
In the elderly, factors
such as decreased cough and gag reflexes as well as reduced antibody
and Toll-like receptor responses increase the likelihood of pneumonia.
CA-MRSA pneumonia is more likely in patients with skin colonization or infection with CA-MRSA. Enterobacteriaceae tend to infect patients
who have recently been hospitalized and/or received antibiotic therapy or who have comorbidities such as alcoholism, heart failure, or renal
failure. P. aeruginosa is a particular problem in patients with severe structural lung disease, such as bronchiectasis, cystic fibrosis, or severe
chronic obstructive pulmonary disease. Risk factors for Legionella infection include diabetes, hematologic malignancy, cancer, severe
renal disease, HIV infection, smoking, male gender, and a recent hotel stay or ship cruise. (Many of these risk factors would now reclassify as
HCAP some cases that were previously designated CAP.)
Gross hemoptysis is suggestive of CA-MRSA pneumonia.
If the pleura is involved, the patient may experience pleuritic chest pain. Up to 20% of patients may have gastrointestinal symptoms such as nausea, vomiting, and/or diarrhea. Other
symptoms may include fatigue, headache, myalgias, and arthralgias
What is xray finding ? Right Midlobar infiltrates
To be adequate for culture, a sputum sample must have &gt;25 neutrophils and &lt;10 squamous epithelial cells per low-power field.
To be adequate for culture, a sputum sample must have &gt;25 neutrophils and &lt;10 squamous epithelial cells per low-power field.
Even in cases of proven bacteremic pneumococcal pneumonia, the yield of positive cultures from sputum samples is ≤50%
the greatest benefit
of staining and culturing respiratory secretions is to alert the physician
of unsuspected and/or resistant pathogens and to permit appropriate
modification of therapy. Other stains and cultures (e.g., specific stains
for M. tuberculosis or fungi) may be useful as well.
The yield from blood cultures, even when samples are collected before antibiotic therapy, is disappointingly low.
Since recommended empirical regimens all provide pneumococcal coverage, a blood culture positive for this pathogen has little, if any,effect on clinical outcome.
However, susceptibility data may allow narrowing of antibiotic therapy in appropriate cases.
Because of the low yield and the lack of significant impact on outcome, blood cultures are no longer considered de rigueur for all hospitalized CAP patients.
Certain high-risk patients—including those with neutropenia secondary to pneumonia, asplenia, complement deficiencies, chronic liver disease, or severe CAP—should have blood cultured
Legionella pneumophila test detects only serogroup 1, but this serogroup accounts for most community-acquired cases of Legionnaires’ disease in the United States.
Although false-positive results can be obtained with samples from pneumococcus-colonized children, the test is generally reliable.
Both tests can detect antigen even after the initiation of appropriate antibiotic therapy
Although false-positive results can be obtained with samples from pneumococcus-colonized children, the test is generally reliable.
Both tests can detect antigen even after the initiation of appropriate antibiotic therapy
In patients with pneumococcal pneumonia, an increased bacterial load in whole blood documented by PCR is associated with an increased risk of septic shock, the need for mechanical ventilation, and death.
Clinical availability of such a test could conceivably help identify patients suitable for ICU admission.
In patients with pneumococcal pneumonia, an increased bacterial load in whole blood documented by PCR is associated with an increased risk of septic shock, the need for mechanical ventilation, and death.
Clinical availability of such a test could conceivably help identify patients suitable for ICU admission.
Recently,
however, they have fallen out of favor because of the time required to
obtain a final result for the convalescent-phase sample
Levels of these acute-phase reactants increase in the presence of an inflammatory response, particularly to bacterial pathogens.
These tests should not be used on their own but, when interpreted in conjunction with other findings from the history, physical examination, radiology, and laboratory tests, may help with antibiotic stewardship and appropriate management of seriously ill patients with CAP.
CAP is a lower respiratory tract infection acquired in the community within 24 hours to less than 2 weeks. It commonly presents with an acute cough, abnormal vital signs of tachypnea (respiratory rate &gt;20 breaths per minute), tachycardia (cardiac rate &gt;100/minute), and fever (temperature &gt;37.8ºC) with at least one abnormal chest finding of diminished breath sounds, rhonchi, crackles, or wheeze.
Patients who acquire the infection in hospitals or long-term facilities are typically excluded from the definition.
However, no particular clinical symptom or abnormal finding is sufficiently sensitive or specific to confirm or exclude the diagnosis of CAP from other acute lower respiratory tract infections.
The initial CAP guidelines by the American Thoracic Society have clearly stated that symptoms cannot be reliably used to establish the etiologic diagnosis of pneumonia (typical or atypical pathogen)
The clinical presentation of pneumonia may vary because of three reasons: the virulence factors of the pathogens; the advanced age of the host; and the presence of coexisting illnesses of the host.
Infection with Legionella spp. ranks among the most common causes of severe pneumonia and is isolated in 1-40% of cases of hospital-acquired pneumonia.
Strong suspicion for Legionella should be considered with unexplained confusion, lethargy, loose stools or watery diarrhea, abdominal pain, relative bradycardia, and lack of response to B-lactams.
A new parenchymal infiltrate in the chest radiograph remains the reference diagnostic standard for pneumonia. A chest x-ray should be done in patients suspected to have CAP to confirm the diagnosis. In addition to confirming the diagnosis of pneumonia, an initial chest radiographic examination is essential in assessing the severity of disease and the presence of complications.
However, in settings with limited resources, a chest x-ray may not be routinely done in patients strongly suspected to have CAP with the following conditions:
• Healthy individuals or those with stable co-morbid conditions, and
• Normal vital signs and physical examination findings, and
• Reliable follow-up can be ensured.
A posteroanterior radiograph places the patient with his or her chest against the film, minimizing the magnification of the heart and the mediastinum on the image, thus minimizing the amount of lung obscured by these structures.
On the lateral view, the size of the heart on the image is minimized if the left side is against the film. The left-lateral is therefore the preferred position for the lateral view.
Mycoplasma, Legionella, and Chlamydophila, creates a daunting task of differentiation from those produced by bacterial or viral etiologies due to overriding clinico-radiologic features.
The radiographic presentations in general are non-specific, varying from interstitial or reticulonodular pattern to patchy consolidations which may be seen separately or sequentially, segmental, or lobular.
These pathogens are rarely associated with pleural effusion and lymphadenopathy.
There is a greater weight given to the importance of comparative follow-up studies in arriving at the diagnosis, considering most of said etiologies do not respond to conventional antimicrobials and, hence, remains radiographically stable despite prompt and adequate treatment.
A radiographic reading of “pneumonitis” does not always denote an infectious process.
Non-infectious causes of pneumonitis may include fibrosis (immunologic, occupational lung disease).
If pneumonitis is infectious in nature, it could relate to the first stage in the process of pneumonia. This is the congestive phase, where infection is contained within the interstitial compartment or peribronchial region.
A “normal” chest radiograph connotes an absence of any overt parenchymal lesion.
It is possible to have a “normal chest” in a background of significant symptomatology specifically in an early phase of pneumonia, that is referred to as a “radiographic lag phase”.
For patients who are hospitalized for suspected pneumonia but have initial negative chest radiography findings, it may be reasonable to treat their condition presumptively with antibiotics and repeat the imaging in 24 to 48 hours.
Chest radiographic findings usually clear more slowly than clinical findings and multiple radiographs are generally not required.
In patients with low-risk CAP who are recovering satisfactorily, a repeat chest x-ray is not needed.
However, if the patient with CAP is not clinically improving or shows progressive disease, the chest x-ray should be repeated as needed based on the clinician’s judgment.
In the absence of any unstable coexisting illness or other life-threatening complication, the patient may be discharged once clinical stability occurs and oral therapy is initiated.
There is no need to repeat a chest radiograph prior to hospital discharge in a patient who is clinically improving.
However, a repeat radiograph is recommended during a follow-up office visit, approximately 4 to 6 weeks after hospital discharge. The repeat radiograph will establish a new radiographic baseline and to exclude the possibility of malignancy associated with CAP, particularly in older smokers.
It is, however, helpful in excluding other pathologies (i.e., neoplastic, interstitial disease or granulomatous) masquerading as infectious and for the further evaluation of nonresolving or progressive pneumonia seen on follow-up chest x-ray.
Triage
Patients with CAP can be classified into three risk categories (Table 4) to help determine the need for hospitalization.
Stable or medically controlled co-morbid conditions such as diabetes mellitus, neoplastic disease, neurologic disease, congestive heart failure (CHF) class I, coronary artery disease (CAD), renal insufficiency, chronic obstructive pulmonary disease (COPD) and/or Asthma, chronic liver disease, and chronic alcohol abuse, are also classified under this risk category.
Low morbidity and mortality rate of 1-3% and are thus categorized as low-risk CAP.
Those with suspected aspiration; or those with altered mental status of acute onset have a higher mortality rate of 8-10% and are thus categorized as moderate-risk CAP.
Higher mortality rate of 20-30% and are thus categorized as High-risk CAP warranting admission in the intensive care unit.
Figure 1 shows the algorithm for the management-oriented risk stratification of CAP in immunocompetent adults.
The most common etiologic agents are bacterial (S. pneumoniae, H. influenzae) and atypical pathogens (M. pneumoniae, C. pneumoniae).
Since the bacterial etiology is predictable and the mortality risk is low, sputum Gram stain and culture may not be done except when there is failure of clinical response to previous antibiotics and the patient has clinical conditions in which drug resistance may be an issue.
Moderate- and high-risk CAP: In hospitalized patients, there are more pathogens to consider in addition to the above organisms (enteric Gram negatives,
P. aeruginosa, S. aureus, L. pneumophila).
In these patients, two sites of blood cultures are recommended prior to starting any antibiotic treatment.
A positive blood culture is specific and is considered the gold standard in the etiologic diagnosis of bacterial pneumonia. Gram stain and culture of appropriate respiratory secretions should also be part of the initial work up.
For L. pneumophila, urine antigen test (UAT) to detect serotype 1 and direct fluorescent antibody test (DFA) of respiratory specimens are additional tests that
are recommended.
The main disadvantage of extensive microbiologic testing is the cost effectiveness which is driven by the low yield of blood cultures (5 to 15%) and the poor quality of samples in respiratory specimens.
The etiologic diagnosis is considered definite when the pathogen is isolated from normally sterile or uncontaminated specimens (blood, pleural fluid or secretions obtained from transtracheal or transthoracic aspiration).
Pathogens demonstrated by smear or isolated from cultures in moderate to heavy quantity from respiratory secretions (e.g., expectorated sputum, bronchoscopic aspirate, quantitatively cultured bronchoalveolar lavage fluid or brush catheter specimen).
Cultures of expectorated sputum may be contaminated with resident flora of the upper airways which may be potential pathogens, thus leading to false positive results.
They are not sensitive in patients who have taken previous antibiotics, in those unable to expectorate good-quality sputum and in those with delays in the processing of the specimens.
S. pneumoniae was isolated from the sputum in 64% (29/45) of patients with presumed pneumococcal pneumonia based on the finding of Gram-positive diplococci compared to 6% (2/31) of patients without Gram-positive diplococci.
Among the atypical pathogens, L. pneumophila causes severe pneumonia with the majority of patients requiring intensive care. The associated case
fatality rate is 5 to 30%.
New and emerging causes of pneumonia (Human pandemic influenza A [H1N1], SARS) should be sought during outbreaks or when there are epidemiologic clues that point to their presence.
Rapid influenza diagnostic tests (RIDTs) in respiratory clinical specimens have low overall sensitivity in detecting human pandemic influenza A [H1N1] (40-69%).
If the presence of human pandemic influenza A [H1N1] is suspected in patients with moderate and highrisk pneumonia, a definitive determination with rRT-PCR should be conducted. The sensitivity test for rRT-PCR is 95.4 – 100%
Several studies have shown a direct association between age and mortality for age &gt;65 years as an independent predictor of a complicated course
However, a prediction rule based on the PSI has emphasized that an age of more than 65 years alone is not an indication for admission.
A 5 day course of oral or IV therapy for low -risk CAP and 10 day course of IV for Legionella pneumonia is possible with new agents such as the azalides, which possess a long half -life and achieve high tissue levels that prolong its duration of effect
Patient should be afebrile for 48 to 72 hours with no signs of clinical instability before discontinuation of treatment.
The overall mortality rate for the outpatient group is &lt;1%. For patients requiring hospitalization, the overall mortality rate is estimated at 10%, with ~50% of deaths directly attributable to pneumonia
The overall mortality rate for the outpatient group is &lt;1%. For patients requiring hospitalization, the overall mortality rate is estimated at 10%, with ~50% of deaths directly attributable to pneumonia
However, vaccination can be followed by the replacement of vaccine serotypes with nonvaccine serotypes, as was seen with serotypes 19A and 35B after introduction of the original 7-valent conjugate vaccine.
However, vaccination can be followed by the replacement of vaccine serotypes with nonvaccine serotypes, as was seen with serotypes 19A and 35B after introduction of the original 7-valent conjugate vaccine.
Because of an increased risk of pneumococcal infection, even among patients without obstructive lung disease, smokers should be strongly encouraged to stop smoking.
In the event of an influenza outbreak, unprotected patients at risk from complications should be vaccinated immediately and given chemoprophylaxis with either oseltamivir or zanamivir for 2 weeks—i.e., until vaccine-induced antibody levels are sufficiently high.