2. • Defined as lower respiratory
tract infection acquired in the
community
• Infection of the pulmonary
parenchyma
• Result of the proliferation of
microbial pathogens at the
alveolar level and the host’s
response to those pathogens.
4. PATHOLOGY
• Edema with
proteinaceous
exudate and often
bacteria in the
alveoli
Initial Stage
• Erythrocytes in the
intraalveolar exudate
Red Hepatization
Stage
• No new erythrocytes are
extravasating, and those already
present have been lysed and
degraded
• Corresponds with the successful
containment of the infection and
improvement in gas exchange
Gray Hepatization
Stage
• Macrophage reappears as
the dominant cell in the
alveolar space and debris
of neutrophils, and
bacteria and fibrin have
been cleared, as has the
inflammatory response
Resolution
5.
6. Microbial Causes of Community Acquired
Pneumonia, by Site of Care
HOSPITALIZED PATIENTS
OUTPATIENT NON-ICU ICU
o Streptococcus
pneumoniae
o Mycoplasma
pneumoniae
o Haemophilus
influenzae
o C. pneumoniae
o Respiratory
viruses*
o Streptococcus
pneumoniae
o Mycoplasma
pneumoniae
o Chlamydia
pneumoniae
o H. influenzae
o Legionella spp.
o Respiratory
viruses
o Streptococcus
pneumoniae
o Staphylococcus
aureus
o Legionella spp.
o H. influenzae
o Respiratory
viruses
o Gram-negative
bacilli
MICROORGANISMS AND RISKS
LOW MODERATE HIGH
o Streptococcus
pneumoniae
o Haemophilus
influenzae
o Chlamydophila
pneumoniae
o Mycoplasma
pneumoniae
o Moraxella
catarrhalis
o Enteric Gram-
negative bacilli
(among those with
co- morbid illness)
Same as low-risk
PLUS
o Legionella
pneumophila
o Anaerobes
(among those
with aspiration
risk)
Same as moderate
risk PLUS
o Staphylococcus
aureus
o Pseudomonas
aeruginosa
7. CLINICAL MANIFESTATIONS
Subjective Findings Objective Findings
o febrile
o Tachycardia
o Chills or sweats
o Cough (productive or non-productive –
mucoid, purulent, or blood-tinged)
o May present with shortness of breath
depending on severity
o Pleuritic chest pain
o GI symptoms (nausea, vomiting or
diarrhea)
o Fatigue, headache, myalgias, arthralgias
o Increased respiratory rate and use of
accessory muscles of respiration
o Increased or decreased tactile fremitus
o Dull to flat on percussion (consolidation
or Pleural Effusion)
o Crackles, Bronchial breath sounds,
possible pleural friction rub
8. Risk Stratification for Community
Acquired Pneumonia
LOW RISK MODERATE RISK HIGH RISK
VITAL SIGNS Stable Unstable Unstable
Respiratory Rate < 30/minute > 30/minute
> 125/minute
< 90 mmHg
< 60 mmHg
< 36°C or > 40°C
Pulse Rate < 125/minute
Systolic Blood Pressure > 90 mmHg
Diastolic Blood Pressure > 60 mmHg
Temperature > 36°C or < 40°C
OTHERS
Altered mental state of acute onset Absent Present
Yes
Unstable or decompensated co-morbidities
With suspected aspiration No
Co-morbid condition None or stable co-morbid
Severe sepsis and septic shock Absent Absent Absent/Present
Need for mechanical ventilator No No No/Yes
9. How to risk stratify Community Acquired
Pneumonia?
COMMUNITY ACQUIRED PNEUMONIA
Vital signs
features
Chest
X-Ray
Stable
• RR <30/min
• PR <125 bpm
• Temp 36-40 C
• BP >90/60 mmHg
• No altered sensorium of acute
onset
• No suspected aspiration
• No or stable co-morbids
• Localized infiltrates
• No pleural effusion
• No abscess
Unstable
• RR ≧ 30/min
• PR ≧ 125 bpm
• Temp ≦ 36 C or ≧ 40 C
• BP ≦ 90/60 mmHg
• Altered sensorium of acute onset
• Suspected aspiration
• Decompensated co-morbids*
• Multilobal infiltrates
• Pleural effusion
• Abscess
Any of the criteria under
Moderate-Risk CAP, PLUS
any of the following:
• Severe sepsis and septic
shock, OR
• Need for medical
ventilation
LOW-RISK CAP MODERATE-RISK CAP HIGH-RISK CAP
OUTPATIENT WARD ADMISSION ICU ADMISSION
DISPOSITION
10. CURB - 65
1 POINT EACH
C – ONFUSION
U – REA >7 MMOL/L
R – ESPIRATORY RATE >
30/MIN
B – LOOD PRESSURE LOW,
<90 OR <60
AGE > 65
oPatients who have a CURB-65 score of 3 or
more
• High risk of death and should be managed as having
severe pneumonia (ICU management)
o Patients who have a CURB-65 score of 2
• Increased risk of death
• They should be considered for short stay inpatient
treatment or hospital supervised outpatient treatment
oPatients who have a CURB-65 score of 0 or 1
• Low risk of death
• They can be treated as having non-severe pneumonia
and may be suitable for home treatment
11. Criteria for Severe Community Acquired
Pneumonia
Minor Criteria Major Criteria
Respiratory Rate >30/min
PaO2/Fio2 ratio <250
Multilobar infiltrates
Confusion/disorientation
Uremia (BUN level >20 mg/dL)
Leukopenia (WBC count <4000 cells/uL)
Thrombocytopenia (platelet count <100,000
cells/uL)
Hypothermia
Hypotension requiring aggressive fluid
resuscitation
Respiratory failure requiring invasive mechanical
ventilation
Septic shock requiring vasopressors
12. Summary of Clinical Practice Guideline
Recommendations for the management
of CAP
13. Diagnosis
GSCS
Question 1: among adult patients diagnosed with CAP, when should Gram stain and Culture with Sensitivity
(GS/CS testing of respiratory secretions be performed?
Recommendation 1: We do not recommend gram stain and culture of respiratory secretions for low risk CAP
Recommendation 2: We recommend gram stain and culture of respiratory secretions for patients with
moderate to high risk CAP, or with risk factors for MDRO infection
Blood Culture
Question 2: among adult patients diagnosed with CAP, when should blood cultures be requested?
Recommendation 3: We recommend blood cultures for patients with moderate and high-risk CAP.
14. Influenza Test
Question 3: Among adult patients with CAP, should testing of respiratory secretions for Influenza Virus at the time
of diagnosis be done to minimize morbidity and mortality?
Recommendation 4: We recommend testing of respiratory secretions for influenza through rapid molecular
testing using rapid nucleic acid amplification tests during periods of high influenza activity (July to January) for
patients with high-risk CAP preceded by influenza-like illness symptoms (sore throat, rhinorrhea, body malaise,
joint pains) and any of the following risk factors:
• Aged 60 years and above
• Pregnant
• Asthmatic
• Other co-morbidities: uncontrolled diabetes mellitus, active malignancies, neurologic disease in evolution,
congestive heart failure class II-IV, unstable coronary artery disease, renal failure on dialysis, uncompensated
COPD, decompensated liver disease
15. Legionella Test
Question 4: Among patients with CAP, should Legionella urine antigen test be requested?
Recommendation 5: Legionella urine antigen tests may be considered for patients with high-risk CAP.
Multiplex PCR
Question 5: Among adult patient with CAP, what is the clinical utility of multiplex PCR?
Recommendation 6: We do not recommend the routine use of multiplex polymerase chain reaction among adult
patients with CAP
16. Empiric Treatment: Low-risk CAP
Question 6: What antibiotics are recommended for the empiric treatment of low-risk CAP?
Recommendation 7: The following antibiotics should be started for empiric treatment of patients with low-risk CAP without co-
morbidities: Amoxicillin 1 gram, three times daily
OR
Clarithromycin 500mg, twice daily
OR
Azithromycin 500mg once daily
Recommendation 8: The following antibiotics should be started for empiric treatment of patients with low-risk CAP with stable co-
morbidities:
Beta-lactam
Co-amoxiclav (amoxicillin/clavulanate 500 mg/125 mg three times daily, OR amoxicillin/ clavulanate 875 mg/125 mg twice daily)
OR
Cefuroxime 500mg, twice daily
PLUS OR MINUS (+/-)
Macrolide
Clarithromycin 500mg, twice daily
OR
Azithromycin 500mg once daily
OR
Doxycycline 100mg, twice daily
17. Empiric Treatment: Moderate-risk CAP
Question 7: What antibiotics are recommended for the empiric treatment of moderate risk
CAP?
Recommendation 9: The following antibiotics should be started for empiric treatment of patients with
moderate risk CAP without MDRO infection
Non-pseudomonal Beta-lactam antibiotic
Ampicillin-sulbactam 1.5–3 g every 6 h
OR
Cefotaxime 1–2 g every 8 h
OR
Ceftriaxone 1–2 g daily
PLUS
Macrolide
Azithromycin 500 mg daily
OR
Clarithromycin 500 mg twice daily
18. Empiric Treatment: High-risk CAP
Question 8: What antibiotics are recommended for the empiric treatment of high risk CAP?
Recommendation 10: The following antibiotics should be started for empiric treatment of patients with high risk CAP without MDRO infection:
FIRST LINE THERAPY
Non-pseudomonal Beta-lactam antibiotic
Ampicillin-sulbactam 1.5–3 g IV every 6 h
OR
Cefotaxime 1–2 g IV every 8 h
OR
Ceftriaxone 1–2 g IV daily
PLUS
Macrolide
Azithromycin 500 mg PO/IV daily
OR
Erythromycin 500 mg PO every 6 hours
OR
Clarithromycin 500 mg PO twice daily
ALTERNATIVE THERAPY
Non-pseudomonal Beta-lactam antibiotic
PLUS
Respiratory fluoroquinolone*
Levofloxacin 750 mg PO/IV daily
OR
Moxifloxacin 400 mg PO/IV daily
* given as 1 hour IV infusion
19. Atypical Coverage for Aspiration
Pneumonia
Question 9: Among adults with suspected aspiration pneumonia, should additional anaerobic coverage
beyond empiric treatment for CAP be given?
Recommendation 11: Routine anaerobic coverage for suspected aspiration pneumonia is NOT
recommended, unless lung abscess or empyema is suspected
20. Empiric Treatment: MDROs and their risk
factors
Question 10: Among patients with CAP, who are the patients at risk for MRSA, Pseudomonas aeruginosa, ESBL
producing organisms and should receive empiric antibiotic coverage for these organisms?
Recommendation 12: The following antibiotics should be started for empiric treatment of patients with moderate
to high-risk CAP and with risk factors for MDROs
Risk Factors and Organisms Empiric Antibiotic Recommendations
Risk for Methicillin Resistant Staphylococcus aureus
(MRSA)
• Prior colonization or infection with MRSA within 1
year
• Intravenous antibiotic therapy within 90 days
Non-pseudomonal Beta lactam antibiotic
PLUS Macrolide OR respiratory fluoroquinolone*
PLUS
Vancomycin 15 mg/kg IV every 12 hours^
OR
Linezolid 600 mg IV every 12 hours ^
OR
Clindamycin 600 mg IV every 8 hours^
21. Empiric Treatment: MDROs and their risk
factors
Recommendation 12: The following antibiotics should be started for empiric treatment of patients with moderate
to high-risk CAP and with risk factors for MDROs
Risk Factors and Organisms Empiric Antibiotic Recommendations
Risk for ESBL
• Prior colonization or infection with ESBL-producing
organisms within 1 year
REPLACE Non- pseudomonal Beta lactam antibiotic with:
Ertapenem 1g IV every 24 hours
OR
Meropenem 1 g IV every 8 hours (if Ertapenem is not
available)
PLUS
Macrolide OR respiratory fluoroquinolone*
22. Empiric Treatment: MDROs and their risk
factors
Recommendation 12: The following antibiotics should be started for empiric treatment of patients with moderate
to high-risk CAP and with risk factors for MDROs
Risk Factors and Organisms Empiric Antibiotic Recommendations
Risk for Pseudomonas aeruginosa
• Prior colonization or infection with P aeruginosa
within 1 year
• Severe bronchopulmonary disease (severe COPD,
bronchiectasis, prior tracheostomy)
REPLACE Non- pseudomonal Beta lactam antibiotic with:
Piperacillin- Tazobactam 4.5g IV every 6 hours
OR
Cefepime 2 g IV every 8 hours
OR
Ceftazidime 2 g IV every 8 hours
OR
Aztreonam 2 g IV every 8 hours
OR
Meropenem 1 g IV every 8 hours (especially if with ESBL
risk)
PLUS
Macrolide OR respiratory fluoroquinolone*
23. Antiviral Treatment
Question 12: Among adult patients with CAP who test positive for Influenza virus, should antiviral therapy be started?
Recommendation 13: We recommend antiviral therapy in addition to antibacterial therapy among patients with high
risk CAP and any of the following risk factors (aged 60 years and above, pregnant, asthmatic, other co-morbidities:
uncontrolled diabetes mellitus, active malignancies, neurologic disease in evolution, congestive heart failure class II-
IV, unstable coronary artery disease, renal failure on dialysis, uncompensated COPD, decompensated liver disease)
who test positive for influenza virus.
Recommendation 14: If diagnostic tests are not accessible, empiric antiviral therapy may be considered in addition to
antibacterial therapy during periods of high influenza activity (July to January) among patients with high risk CAP
preceded by influenza-like illness symptoms (sore throat, rhinorrhea, body malaise, joint pains) and any of the
following risk factors:
• Aged 60 years and above
• Pregnant
• Asthmatic
• Other co-morbidities: uncontrolled diabetes mellitus, active malignancies, neurologic disease in evolution,
congestive heart failure class II-IV, unstable coronary artery disease, renal failure on dialysis, uncompensated
COPD, decompensated liver disease
24. Initiation of Treatment
Question 13: Among adults with CAP, how soon should empiric treatment be started?
Recommendation 15: As soon as diagnosis is established, treatment of community acquired pneumonia,
regardless of risk, should be initiated within 4 hours.
25. Duration of Treatment
Question 14: Among adult patients with CAP, what is the appropriate duration of treatment?
Recommendation 16:
Among patients with low to moderate risk CAP, a treatment duration of 5 days is recommended as long as the
patient is clinically stable
Recommendation 17:
Antibiotic therapy may be extended according to clinical consideration such as: (1) pneumonia is not resolving, (2)
pneumonia complicated by sepsis, meningitis, endocarditis and other deep-seated infection, (3) infection with less
common pathogens (i.e. Burkholderia pseudomallei, Mycobacterium tuberculosis, endemic fungi, etc),
(4) infection with a drug resistant pathogens.
26. De-escalation
Question 15: Among patients on empiric antibiotic therapy for CAP, should de-escalation be done?
Recommendation 18: De-escalation of initial empiric broad spectrum or extended spectrum antibiotic
with coverage for MRSA, Pseudomonas or ESBL to targeted or oral antibiotics based on culture results is
recommended once the patient is clinically improving, hemodynamically stable and able to tolerate oral
medications.
27. Monitoring Response with Chest X-ray
Question 16: Among patients with clinical improvements while ongoing treatment, should the following
tests be performed to monitor response to treatment?
a. Chest xray
b. CRP
c. Procalcitonin
Recommendation 19: Among adult patients who are being treated for community-acquired pneumonia
and who are clinically improving, follow up chest x-ray should NOT routinely be performed to monitor
response to treatment.
Recommendation 20: We recommend post- treatment chest x-rays after a minimum of 6 to 8 weeks
among patients with CAP to establish baseline and to exclude other conditions.
28. Monitoring Response with CRP
Recommendation 21: We do not recommend the use of CRP to monitor treatment response among patients
with CAP
29. Monitoring Response with Procalcitonin
Recommendation 22: We do not recommend the use of procalcitonin to monitor treatment response among
patients with moderate or high risk CAP
Recommendation 23: Procalcitonin may be used to guide antibiotic discontinuation among patients with
moderate or high risk CAP.
30. Inadequate Response after 72 hours of
Empiric Antibiotic Therapy
Question 17: What should be done for patients who are not improving after 72 hours of empiric antibiotic
therapy?
Recommendation 24: The clinical history, physical examination, and the results of all available investigations
should be reviewed. The patient should be reassessed for possible resistance to the antibiotics being given or
for the presence of other pathogens such as Mycobacterium tuberculosis, viruses, parasites, or fungi.
Treatment should then be revised accordingly.
Recommendation 25: Follow-up chest radiograph is recommended to investigate for other conditions such as
pneumothorax, cavitation, and extension to previously uninvolved lobes, pulmonary edema, and acute
respiratory distress syndrome.
Recommendation 26: Obtaining additional specimens for microbiologic testing should be considered
31. Prevention: Pneumococcal and Influenza
Vaccine
Recommendation 27: Pneumococcal polysaccharide vaccine (PPSV) or pneumococcal conjugate vaccine (PCV)
are recommended for the prevention of invasive pneumococcal disease in adults 50 years old and older.
Recommendation 28: Pneumococcal polysaccharide vaccine is recommended for adults to prevent (a)
pneumococcal pneumonia, (b) mortality from IPD or pneumonia and (c) pneumonia among high-risk groups
and adults 50 years and above.
Recommendation 29: Influenza vaccine is recommended to prevent influenza, influenza-like illness and
hospitalization in all adults.
Recommendation 30: Administration of both influenza and pneumococcal vaccine is recommended to prevent
pneumonia, hospitalization and mortality in adults 50 years old and above.
33. Thank you!
“We are not what we know but what we are
willing to learn.”
– Mary Catherine Bateson
Editor's Notes
CAP or Community-Acquired Pneumonia is defined as lower respiratory tract infection acquired in the community. It is an infection of the pulmonary parenchyma, that is often misdiagnosed, mistreated, and underestimated.
It is the result of the proliferation of microbial pathogens at the alveolar level and the host’s response to those pathogens.
Most common access of microorganisms to the lower respiratory tract is through aspiration from the oropharynx.
CAP or Community-Acquired Pneumonia is defined as lower respiratory tract infection acquired in the community. It is an infection of the pulmonary parenchyma, that is often misdiagnosed, mistreated, and underestimated.
It is the result of the proliferation of microbial pathogens at the alveolar level and the host’s response to those pathogens.
Most common access of microorganisms to the lower respiratory tract is through aspiration from the oropharynx.
Introduction of pathogen into the lungs via microaspiration in the lower respiratory tract.
Mechanical factors such as hairs, turbinates of the nares, the branching tracheobronchial tree, mucociliary clearance, gag and cough reflex play a role in the host defense however when become Insufficient will not effectively block bacteria access to the lower airways.
Microorganism reach the lower respiratory tract
The body will recognize the entry of foreign organism causing inflammation
Inflammation – epithelial and endothelial injury results in the release of cytokines, chemokines and catecholamines. Interleukin 6 and TNF causes the fever while chemokine such as inteleukin 8 and granulocyte colony stimulating factor increase local neutrophil numbers. ( Some may selectively promote the growth of certain bacteria, such as Strep P and P. Aeruginosa)
- The mediators released by macrophages and neutrophils creates alveolar capillary leak resulting in the impaired oxygenation, hypoxemia and radiograohic infiltrates.
Positive feedback loop (process that occurs in a feedback manner that exacerbates the effects of small disturbance) further accelerates inflammation and growth of bacteria – The pathogens will now become DOMINANT
If body ‘s adaptive immunity and innate immunity fails to contain the potential pathogen – Development of Pneumonia.
Classic pneumonia (lobar pneumococcal pneumonia) evolves through series of changes: EDEMA, RED HEPATIZATION, GRAY HEPATIZATION, RESOLUTION.
The initial stage is edema with a proteinaceous exudate and often bacteria in the alveoli.
Next is a rapid transition to the red hepatization phase. Erythrocytes in the intraalveolar exudate give this stage its name.
In the third phase, gray hepatization, no new erythrocytes are extravasating, and those already present have been lysed and degraded. The neutrophil is the predominant cell, fibrin deposition is abundant, and bacteria have disappeared. This phase corresponds with the successful containment of the infection and improvement in gas exchange.
In the final phase, resolution, the macrophage reappears as the dominant cell in the alveolar space and the debris of neutrophils, and bacteria and fibrin have been cleared, as has the inflammatory response.
this illustration shows the microorganisms that causes CAP
Respiratory viruses:
Influenza A and B
Parainfluenza
Adenovirus
Human metapneumovirus
RSV (respiratory syncytial virus)
Pathogens are listed in descending order of frequency
ACCESSORY MUSCLES:
External intercostals
Scalene
Sternocleidomastoid
Abdominal muscles
PLEURITIC CHEST PAIN
Defined as an intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling
TACTILE FREMITUS
Palpation of the chest wall to detect changes in the intensity of vibrations created with certain words
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 ventilator
Co-morbidities: uncontrolled diabetes mellitus, active malignancies, neurologic disease in evolution, congestive heart failure class II-IV, unstable coronary artery disease, renal failure on dialysis, uncompensated COPD, decompensated liver disease
CURB-65 is a severity score for CAP, comprising 5 variables attributing to 1 point for each item:
C for confusion of new onset
U for urea >7 mmol/L;
R for respiratory rate more than 30/mins
B for blood pressure with a systolic of <90 mmHg and/or diastolic of < / = 60 mmHg
65 for people ageing 65 and older
This summary was taken from the 2020 Philippine Clinical Policy Guidelines on the Diagnosis, Empiric management, and prevention of CAP
There are 17 priority questions identified and 30 corresponding recommendations developed by a group of experts composed of an Oversight Committee, a Guideline Writing Panel and a Technical Review Committee. Based on the best available evidences, the quality and strength of evidence was rated using the Grading of Recommendations, Assessment, Development and evaluation (GRADE) approach. Draft recommendations were finalized after these were presented to and voted on by the members of the Consensus Panel.
MDRO – multiple drug resistant organisms
Multiplex PCR
Amplification of multiple DNA sequences simultaneously
Clarithromycin – macrolide – inhibit protein synthesis in bacteria by binding to subunit 50s of the bacterial ribosome
- Gram neg
Azithromycin – macrolide – inhibition of bacterial protein synthesis, inhibition of proinflammatory cytokine production, inhibition of neutrophil infestation, and macrophage polarization alteration, gives it the ability to act against a wide range of microorganisms
- Gram neg
Co-amox – beta lactamase-producing strains – contains amoxicillin (an antibiotic from the penicillin group of medicines) mixed with clavulanic acid. The clavulanic acid stops bacteria from breaking down amoxicillin, allowing the antibiotic to work better.
- Gram posi and gram neg and gram neg anaerobes
Cefuroxime – cephalosporins – 2nd generation cephalosporin which binds to 1 or more of the penicillin-binding proteins (PBPs) thereby inhibiting the final transpeptidation step of peptidoglycan synthesis in the bacterial cell wall, thus interrupting cell wall biosynthesis, and arresting cell wall assembly
Broad spectrum
Doxycycline is a tetracycline antibiotic that inhibits bacterial growth and is thought to have anti-inflammatory effects.
reversibly binds to the 30S ribosomal subunits and possibly the 50S ribosomal subunit(s), blocking the binding of aminoacyl tRNA to the mRNA and inhibiting bacterial protein synthesis
Reco 16 - (afebrile within 48 hours, able to eat, normal blood pressure, normal heart rate, normal respiratory rate, normal oxygen saturation, and return to baseline sensorium).
