This document discusses community-acquired pneumonia (CAP) in both children and adults. It provides information on the definition, most common causes, symptoms, physical exam findings, diagnostic testing, treatment recommendations, and management of CAP. Specifically, it notes that CAP is a significant cause of morbidity and mortality in children and the elderly. It recommends physical exams, labs, chest x-rays, and severity scores to evaluate patients and determine treatment approach. First-line antibiotic treatment depends on patient factors but usually includes macrolides or doxycycline. Hospitalization is advised if severity criteria are met.

1. By : Dr. ALI ALHAGAWY, R4

2. Objectives
By end of this lecture, you will:
Be able to identify the most common
cause of CAP.
Be familiar with the evaluation and
diagnostic approach to a patient with
CAP.
Be able to identify when refer patient
with CAP.

3. Community-acquired
pneumonia (CAP)
is defined as an acute infection of the
pulmonary parenchyma in a patient who
has acquired the infection in the
community, as distinguished from
hospital-acquired (nosocomial)
pneumonia.

4. Community Acquired
Pneumonia in children
Community acquired pneumonia is a significant cause of
respiratory morbidity and mortality in children, especially
in developing countries.
Worldwide, CAP is the leading cause of death in children
younger than five years.
Factors that increase the incidence and severity of
pneumonia in children include prematurity, malnutrition,
low socioeconomic status, exposure to tobacco smoke,
and child care attendance.

10. Physical Examinations

13. RADIOLOGIC EVALUATION
Plain radiograph
Exclusion of pneumonia in young children (3 to
36 months) with fever >39ºC and leukocytosis
(≥20,000 [WBC]/microL)

14. When does a child or infant with
CAP require hospitalization?

15. Which diagnostic laboratory and imaging
tests should be used in a child with
suspected CAP in an outpatient setting?

16. Management
increase water intake to at least eight 8- to
12-oz glasses per day.
To control systemic symptoms of pneumonia,
paracetamol is recommended.
Patients should be advised to avoid cough
suppressants.
Patients should be advised that fatigue is
common during the acute phase and that
more rest than usual may be necessary.

17. Management

19. Recommendations
 The absence of tachypnea is the most useful clinical finding
for ruling out CAP in children. Grade C
 Chest radiography has not been shown to improve clinical
outcomes or change treatment of CAP in children. Grade B
 Empiric antibiotic choices in children with CAP should be
based on the patient’s age and severity of illness, and local
resistance patterns of pathogens. Grade C
 Oral amoxicillin and intravenous penicillin G are equally
effective in the treatment of hospitalized children with non-
severe CAP. However, amoxicillin is generally more cost-
effective. Grade B
 Macrolides are the empiric antibiotics of choice for children
five to 16 years of age with CAP because of their activity
against Mycoplasma pneumonia and Chlamydophila
pneumonia. Grade C
 Routine childhood immunization with the pneumococcal
conjugate vaccine significantly reduces the incidence of
invasive pneumococcal disease in children. Grade A

21. Community Acquired
Pneumonia in Adult
Community Acquired Pneumonia in Adult is
most significant cause of morbidity and
mortality in adults.
CAP is defined as an infection of the lung
parenchyma that is not acquired in a
hospital, long-term care facility, or other
recent contact with the health care system.
Pneumonia and influenza combined is the
eighth leading cause of death in the United
States and the most common cause of
infection-related mortality.

22. Etiology

24. History
Common symptoms include fever , chills, pleuritic chest pain, and a
cough producing mucopurulent sputum.
Absence of fever and sputum also significantly reduces the likelihood
of pneumonia in outpatients.
High fever (greater than 104° F [40° C]), male sex, multi-lobar
involvement, and gastrointestinal and neurologic abnormalities have
been associated with CAP caused by Legionella infection.
The clinical presentation of CAP is often more subtle in older patients,
and many of these patients do not exhibit classic symptoms.They
often present with weakness and decline in functional and mental
status.
Patients should be asked about occupation, animals exposures, and
sexual history to help identify a specific infectious agent .???????
A recent travel history (within two weeks) may help identify
Legionella pneumonia.

25. Physical Examinations
Temperature in 80% of patients is high==> may
normal in older adult patient.
Respiratory rate more than 24 breath/min in 45-
70% ==> most sensitive sign in older adult patient.
Tachycardia.
Chest examination reveals audible crackles in
most patients and dullness to percussion and
egophony.
Pulse oximetry screening should be performed in
all patients with suspected CAP.

26. Investigations
 Routine laboratory testing to establish an
etiology in outpatients with CAP is usually
unnecessary.
 white blood cell count greater than 10,400
per mm3 and a C-reactive protein level of
5.0 mg per dL (47.62 nmol per L) or greater
are modestly helpful when positive, but it is
important to note that normal values do not
rule out pneumonia.
 Blood and sputum culture in inpatient sitting.

28. Chest Radiography
Chest radiography should be performed in:
Any patient with at least one of the following abnormal
vital signs:
Temperature > 100°F (37.8°C)
Heart rate > 100 beats per minute Respiratory rate >
20 breaths per minute
Any patient with at least two of the following clinical
findings:
Decreased breath sounds Crackles (rales)
Absence of asthma

29. When Refer ?
According to CURB-65 Mortality Prediction Tool for Patients with
Community-Acquired Pneumonia
A simplified version (CRB-65), which does not require testing for blood urea nitrogen, may be
appropriate for decision-making in primary care practitioners' offices
In this version, admission to the hospital is recommended if one or more points are present.
Confusion
Blood Urea nitrogen level > 20 mg per dL (7.14 mmol per L)
Respiratory rate ≥ 30 breaths per minute
Blood pressure (systolic < 90 mm Hg or diastolic ≤ 60 mm Hg)
Age ≥ 65 years

31. Management
 The importance of adherence to medication should be emphasised, even if the patient
is feeling better.
 Patients should be instructed to call their doctor if their symptoms do not improve
within 72 hours.
 Patients should be instructed to increase water intake to at least eight 8- to 12-oz
glasses per day.
 If a patient is a smoker, the importance of smoking cessation during this illness
should be stressed. Patients should be told how smoking impairs natural mechanisms
to eliminate pathogens and debris.
 To control systemic symptoms of pneumonia, paracetamol is recommended.
 Patients should be advised to avoid cough suppressants. There is insufficient
evidence to support the use of either mucolytics or cough suppressants to reduce
cough.
 Patients should be advised that fatigue is common during the acute phase and that
more rest than usual may be necessary. The patient can increase activity as tolerated
after the acute phase.

35. Management
Macrolides are the first-line treatment of choice in patients
with no contraindications who have not had a recent course
of antibiotics and have no risk of drug-resistant
infections)Evidence B1)
azithromycin: 500 mg orally once daily on day one, followed
by 250 mg once daily ????
OR
doxycycline: 100 mg orally twice daily

36. Comorbidities include chronic heart, lung, liver, or renal
disease; diabetes mellitus; alcoholism; malignancies;
asplenia; or immunosuppressing conditions or
medication ==>
levofloxacin :750 mg orally once daily OR
amoxicillin/clavulanate :875 mg orally twice daily
or
amoxicillin :1000 mg orally three times daily

37. Recommendations
In patients with clinically suspected CAP, chest radiography should
be obtained to confirm the diagnosis. Grade C
Evaluation for specific pathogens that would alter standard empiric
therapy should be performed when the presence of such pathogens is
suspected on the basis of clinical and epidemiologic clues; this
testing usually is not required in outpatients. Grade C
Mortality and severity prediction scores should be used to determine
inpatient versus outpatient care for patients with CAP. Grade A
All patients with CAP who are admitted to the intensive care unit
should be treated with dual therapy. Grade A
Prevention of CAP should focus on universal influenza vaccination
and pneumococcal vaccination for patients at high risk of
pneumococcal disease. Grade B