This document discusses community-acquired pneumonia (CAP). It notes that CAP affects 5-6 million people per year in the US, with 20% hospitalized and 10% requiring ICU admission. Mortality rates are 1-5% for outpatients and 12% for inpatients, rising to 50% for those in the ICU. The document reviews common causative respiratory pathogens and risk factors for multi-drug resistant organisms. It also discusses signs and symptoms, diagnostic testing, imaging findings, severity assessment tools, and treatment guidelines for CAP.

2. Lung Parenchymal infection
Or
Clinical and/Or Radiological
Manifestations of Consolidation

3.  Common : 5 to 6 million cases/year
 20% are hospitalized ( 10% in ICU)
 No. 1 cause of death from infectious
disease
 Mortality rates :
 Outpatients = 1-5%
 Inpatients = 12% ( higher in ICU- 50%)

4. • CAP incidence is rising
• Pneumonia is the most common
cause of sepsis
• 10 folds increased rate in age of 85
and more

7. RESPIRATORY PATHOGENS IN CAP
Respiratory Pathogens in CAP

10. RESPIRATORY PATHOGENS IN CAP
Respiratory Pathogens in CAP

11. • Innocent bystander
• Causing CAP
• Promoting secondary bacterial
CAP
• Co-etiology of CAP

13. • About 6% of CAP is due to MDRO
• The most common are
Pseudompnas and Staph Aerius
esp. MRSA

15. • Structural lung disease
• Antibiotics in the last 90 days
• Recent steroid therapy
• Nursing home residents
• Malnutrition
• Low CRP

16. • ESKD
• Contact sports Participants
• Crowded conditions
• Male homosexuality
• Recent influenza
• Prisoners
• IV drug abusers
• Previous antiotics in last 90 days
• Hospital in last 90 days
• Need for ICU admission

17. Signs and Symptoms: Pneumonia
 Fever (may be absent in the elderly or
immunocompromised)
 Cough
 Sputum production
 Dyspnea
 Pleuritic chest pain
 GI Sx: nausea, vomiting, diarrhea
 Mental status changes
 Tachycardia
 Tachypnea
 Leukocytosis or leukopenia
 Infiltrate on CXR - remember that an infiltrate
may not appear in a hypovolemic patient!

19.  Laboratory Tests:
 CXR
 CBC with differential
 BUN/Cr
 glucose
 liver enzymes
 electrolytes
 Gram stain/culture of sputum
 pre-treatment blood cultures
 oxygen saturation

20.  PA and lateral for all patients
 To:
1. Establish the diagnosis
2. Show the disease extent
3. Detect complications
4. Detect other pathologies or DD
5. May guide some diagnostic procedures
6. Not advised to follow response (short
term)

23. RULP, Sagging Fissure: St Pneum,
H influenza, Klebsiella, TB

24. Klebsiella Pneumonia

27. Staph Pneumonia with
pyopneumothorax

28. Tree In-Bud, Atypical pneumonia

29. Lobar Pneumonia

30. Necrotizing Pneumonia

31. Atypical Pneumonia, GGO
to Consolidation

32. Staph Pneumonia

34. Influenza Pneumonia with
ARDS

35. • Variable
• Depends on: causative organism
and host response and occurnce of
complications
• Not required for follow up of CAP
patients unless for other cause

36. • Lymphopenic CAP profile carry higher
mortality
• NLR:
< 11.12 early discharge
11.2-13.4 short term hospital
13.4-28.3 moderate hospital
more than 28.3 ICU

37. BTS guidelines 2009

40. IDSA/ATS Guidelines 2007
• Blood & sputum culture, pneumococcal urine Ag:
severe CAP, chronic disease, immune defects
• Legionella urine Ag: severe CAP, pts with recent
travel

41. (If study performed)
<60mmHg / SO 2 <90%
Pneumonia
Severity Index
(PSI) score

42. CAP – Management based on
PSI Score
PORT
Class
PSI
Score
Mortality
%
Treatment
Strategy
Class I No RF 0.1 – 0.4 Out patient
Class II  70 0.6 – 0.7 Out patient
Class III 71 - 90 0.9 – 2.8
Brief
hospitalization
Class IV 91 - 130 8.5 – 9.3 Inpatient
Class V > 130 27 – 31.1 IP - ICU

43. CURB 65 score
CURB 65
Confusion
BUN ≥ 30
RR ≥ 30
BP SBP
<90
/DBP
<60
Age > 65
CURB 0 or 1 Home Rx
CURB 2 Short Hosp
CURB 3
Medical
Ward
CURB 4 or 5 ICU care
Thorax 2003,58:377

45. CAP: When to start empiric
therapy?
 As soon as possible in ED
 CAP: delay-to-AB> 4h after arrival
 Increased mortality
 Increased LOS
IDSA /ATS Consensus Guidelines on the Management of Community-Acquired
Pneumonia
in Adults. Clinical Infectious Diseases 2007; 44:S27–72
Site of
Care RF
Treatment
1
Treatment
2
Treatment
3
OP No RF AZ CLR ER / Doxy
OP RF FQ  + M  + Doxy
Med
Ward
±RF FQ + AZ 3G + AZ
Carbapenem
+Mac
ICU
±RF
 3G + AZ 3G + FQ FQ+ AZT
Pseud
Extended 
+ Cipro /
Levo
 3G +
AmGly + AZ
 3G +
AmGly + FQ
CA-
MRSA
+ Vanco/Linezo

49. • As early as possible
• 4-8 hours of admission
• Some studies showed even better
outcome if started within 2 hours

50.  5-7 days in patients showing
favorable response in the 1st 2-3
days
 Patients should be:
• Afebrile for 2-3 days
• Breathing his baseline O2
• No more than 2 of:
Bl Pr < 90, HR >100, RR>24

51. Longer duration in:
1. Pseudomonas, MRSA, and
Legionella
2. Complicated Pneumonia (eg
empyema and lung abscess)
3. Extra-pulmonary infection (eg
meningitis)

52. Switch from intravenous to oral
therapy?
 Afebrile for 24 hours or more
 Functioning GIT
 Clinical improvement “RR, Cough,
Dyspnea”
 WBC returning to normal
 No role for CXR here

53. Steroids in CAP:
Among adults, there is an overall advantage to corticosteroid
therapy.
The question remains as to whom this benefit applies: who
are the patients that will gain from corticosteroid therapy
18 patients should be treated to prevent one death in severe
CAP
4 patients should be treated to prevent clinical failure
Good in septic shock
dose 40 mg daily of prednisolone

55. May play a protective role in
• Occurence of CAP
• Progression of CAP
• Complications of CAP
Not recommended to study them