2. Definitions
• Community acquired pneumonia (CAP)
– Infection of the lung parenchyma in a person who is not hospitalized or living in a long-term care
facility for ≥ 2 weeks
• Hospital-acquired pneumonia (HAP)
– Occurs 48 hours or more after admission, which was not incubating at the time of admission
• Healthcare-associated pneumonia (HCAP) is defined as
pneumonia that occurs in a non-hospitalized patient with
extensive healthcare contact, as defined by one or more of
the following:
– Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days.
– Residence in a nursing home or other long-term care facility
– Hospitalization in an acute care hospital for two or more days within the prior 90 days
– Attendance at a hemodialysis clinic within the prior 30 days
• Ventilator-associated pneumonia (VAP)
– Arises more than 48-72 hours after endotracheal intubation
3. Initial Evaluation of Suspected
Pneumonia
• Common clinical features
– Cough
– Fever/Chills
– Pleuritic chest pain
– Dyspnea
– Sputum production
– Some may have GI symptoms including nausea, vomiting and
diarrhea
• Physical Exam
– Fever
– Respiratory Rate >24
– Tachycardia
– Chest examination may reveal audible rales
4. Initial Evaluation of Suspected
Pneumonia
• A chest radiograph should be obtained in patients with
suspected pneumonia when possible; a demonstrable
infiltrate by chest radiograph or other imaging technique is
required for the diagnosis of pneumonia, according to the
2007 consensus guidelines from the Infectious Diseases
Society of America and the American Thoracic Society
(IDSA/ATS)
• The radiographic appearance of Pneumonia may include
lobar consolidation, interstitial infiltrates, and/or
cavitation.
5. Initial Evaluation of Suspected
Pneumonia
• The 2007 IDSA/ATS consensus guidelines
recommend for diagnostic testing:
– For outpatients with CAP routine diagnostic tests
are optional.
– Hospitalized patients should have CBC w/ diff,
blood cultures and sputum Gram stain and culture
– Patients with severe CAP requiring ICU admission
should have blood cultures, urinary antigen tests,
and sputum culture (either expectorated or
endotracheal aspirate)
6. Hospital Admission
• There are a Severity-of-illness scores that can help guide
whether to admit or not but should not be used over
clinical judgment of the patient and situation
• CURB-65 criteria (>2, more-intensive treatment)
– Confusion
– Urea 7 mmol/L (20 mg/dL)
– Increased respiratory rate >30
– low blood pressure (SBP <90 or DBP <60)
• Pneumonia Severity Index (PSI)
– uses demographics, the coexistence of co-morbid
illnesses findings on physical examination, vital signs
and essential laboratory findings
7. ICU Admission
• Minor criteria (need 3)
– Respiratory rate >30 breaths/min
– PaO2/FiO2 ratio <250
– Multilobar infiltrates
– Confusion
– BUN level, >20 mg/dL
– Leukopeniac (WBC count, <4000
cells/mm3
– Thrombocytopenia (platelet count,
< 100,000 cells/mm3
– Hypothermia (core temperature,
<36 degrees C
– Hypotension requiring aggressive
fluid resuscitation
• Major criteria
– Invasive mechanical ventilation
– Septic shock with the need for
vasopressors
8. CAP Pathogens
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic
Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect
Dis 2007; 44 Suppl 2:S27.
9. CAP Treatment Outpatient
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
10. CAP Inpatient
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
