Overview of community acquired pneumonia: Diagnosis, risk stratification and management

1. COMMUNITY
ACQUIRED
PNEUMONIA
Dr. Zia Hashim
MD Internal Medicine (PGI Chandigarh)
DM Pulmonary & Critical Care (PGI
Chandigarh)
FCCP (USA)
Fellow Indian Sleep Disorders
Association
Associate Professor
Consultant in charge Sleep Lab
Department of Pulmonary Medicine
SGPGIMS Lucknow

2. WHAT IS CAP
• CAP is infection of lung parenchyma
• Acquired in community

3. DEFINITIONIn the absence of CXR
Chest symptoms:
Cough with or without expectoration
Pluritic chest pain
Dyspnea
Systemic symptoms:
Fever with or without chills
Severe Malaise
Focal sign on examination:
Bronchial breath sound
Crackles
No other explanation
In presence of CXR
• Along with these
• Presence of new radiologic shadow
which has no other explanation
• Pulmonary edema
• Pulmonary embolism

4. RADIOLOGICAL TYPES
OF PNEUMONIA

5. PATHOLOGY
Normal alveolus
Consolidation: filled with
inflammatory cells, exudate

6. LOBAR PNEUMONIA: AIR BRONCHOGRAM

7. SILHOUTTE SIGN: LOSS OF
NORMAL OUTLINE

8. BULGING FISSURE SIGN

9. BRONCHOPNEUMONIA

10. ROLE OF CT SCAN
• 319 prospectively enrolled patients
underwent HRCT within four hours
• Probability of CAP established clinically
• Parenchymal infiltrate identified in 188
• Because of CT scan antibiotics were
initiated in 51 (16%) and discontinued
in 29 (9%), and hospitalization was
decided in 22 and discharge in 23
Claessens YE et al AJRCCM 2015

11. IMPORTANT
DIFFERENTIAL
DIAGNOSIS
• Tuberculosis
• Viral pneumonia especially H1N1
• Fungal pneumonias
• Pulmonary embolism
• Malignancy
• Acute exacerbation of COPD, Bronchial asthma, ILD
• Fluid overload: CHF, CRF, Anemia

12. A smoker with mild drooping
eyelid, hoarseness of voice
A poorly controlled diabetic
with respiratory distress
Pancoast
tumor
Mucormycosis

13. A young female
photosensitivity, joint pains
with acute onset anemia
Sudden onset dyspnea with
chest pain, hypotension
SLE
Diffuse Alveolar
Hemorrhage
Pulmonary embolism

14. HIV positive
A 65 year smoker with altered
sensorium
PCP
Pneumonia
COPD Acute
Exacerbation
NO CONSOLIDATION

15. CAP PROBLEM: INDIA
• LRTI causes 20 % of death due to infectious diseases
• Mortality due to CAP: 8-11%

16. WHO IS MORE LIKELY TO GET
PNEUMONIA• Smokers
• Age > 60 years
• Immunocompromised
• Chronic conditions: Kidney, heart, lung,
liver
• Antibiotic use/abuse
• Chronic alcohol consumption

17. MICROORGANISM
• Bacteria:
• S. Pneumoniae ~ 35%
• Gram negative
• Community acquired Staph aureus
• Pseudomonas
• Anaerobes
• Atypical:
• Mycoplasma ~ 30%
• Legionella ~ 25%
• Chlamydia ~ 10%
• Viral

18. PHYSICAL FINDINGS IN CAP
• Adventitious breath sounds:
Crackles, BBS, Wheeze
• Decreased intensity of breath
sounds
• Dullness on percussion
• Lymphadenopathy
• Tachycardia
• Bradycardia
• Peridontal disease

19. EXAMINE WHOLE BODY
CAREFULLY
Chlamydia
Skin nodules in
nocardiosis

20. ADMISSION CRITERIAS

21. CURB-65
• C Confusion
• U Uremia > 20 mg/dL
• R Respiratory rate > 30/min (25 in some)
• BP Hypotension: SBP<90
• Age > 65
• Hypoxemia
• SpO2<92 (Age<50)
• SpO2<90 (Age>50)
• Multilobar CXR involvement

22. OUTPATIENT EVALUATION
• Chest X ray is required
• Pulse oximetry is always
desirable
• SpO2/FiO2 ratio can predict
ARDS

23. WHAT MICROBIOLOGIC
INVESTIGATIONS SHOULD
BE PERFORMED IN OPD
• Sputum gram stain & culture: Not recommended
routinely
• If patient does not improve: Sputum for AFB

24. OPD TREATMENT
• Without comorbidities
• Macrolide
or
• Amoxycillin
• With comorbidities
• Chronic heart, lung, kidney, liver disease
• Diabetes mellitus
• Alcoholism
• Malignancy
• Antibiotic use in previous 3 month
• Severe CAP
• Combination: Amoxycillin + Macrolide

25. FLUROQUINOLONE
SHOULD BE AVOIDED
1. Masking of
tuberculosis
2. Development of
resistance

26. WHO SHOULD BE ADMITTED:
CHURB-65
• C Confusion
• U Uremia (BUN > 20 mg/dL)
• R Respiratory rate > 30/min (25 in some)
• BP Hypotension: SBP<90
• Age > 65
• Hypoxemia
• SpO2<92 (Age<50)
• SpO2<90 (Age>50)
• Multilobar CXR involvement

27. INVESTIGATIONS IN ADMITTED
PATIENTS
Required
• CXR PA view
• ABG
• Hemogram
• Urea
• Creatinine
• LFT
• Electrolytes
Not required
• Prolacatin
• CRP

28. MICROBIOLOGIC
INVESTIGATIONS IN ADMITTED
PATIENTS
• Sputum gram stain
and culture
• Sputum AFB
• Blood culture
• Legionella urinary
antigen (In severe
CAP)
• PCR for H1N1 if
rapidly progressing
Not required
• Pneumococcal
antigen
• Pneumococcal PCR
• Mycoplasma
• Chlamydia

29. ADMISSION TO ICU

30. INPATIENT TREATMENT
• Whether risk for Pseudomonas present or not
• Structural lung disease
• Chronic steroid therapy
• Broad spectrum antibiotics in past 3 months
• AIDS CD4<50
• Risk factors for CA-MRSA
• Necrotizing pneumonia
• Post influenza

31. IN PATIENT NO RISK
FACTORS FOR
PSEUDOMONAS
• I/V Amoxiclav
or
• I/V Cefotaxime
or
• I/V Ceftriaxone
+
• Macrolide

32. RISK FACTORS FOR
PSEUDOMONAS
PRESENT
• Cefoperazone Sulbactam
• Piperacillin Tazobactam
• Cefepime
• Meropenem
• Imipenem
±
Aminoglycoside
Or
Fluroquinolone (after ruling out tuberculosis)

33. IF CA-MRSA SUSPECTED
• Multiple patchy consolidation
• Cavitation
• Pneumatoceles
• Pneumothorax
• Effusion
• Vancomycin
or
• Linezolid
or
• Teicoplanin

34. SUPPORTIVE TREATMENT
• Proper monitoring
• Maintenance of oxygenation
• Oxygen
• NIV
• MV
• Fluid and electrolytes
• DVT prophylaxis
• ? Steroids:
• Not indicated
• May be used if septic shock is not responding to fluids and vasopressors

35. WHEN SHOULD CXR BE
REPEATED
• Not before discharge if there is satisfactory recovery
• At 6 weeks for patients:
• Persistence of symptoms or physical signs
• Higher risk of underlying malignancy
• Smokers
• Age >50 years

36. WHEN TO DISCHARGE
• When clinical improvement starts can switch from intravenous to oral
• Duration of treatment
• OPD: 5 d
• IPD: 7 d
• Can be discharged
• If accepting orally
• Afebrile
• Hemodynamically stable for 48 hrs

37. PROLONGED ANTIBIOTIC
COURSE
• Bacteremic pnemococcal pneumonia
• Staph aureus pneumonia
• Legionella pneumonia
• Lung abscess
• Empyema
• Infection with enteric Gram negative
bacilli
• Pseudomonas
• Meningitis
• Endocarditis

38. FAILURE TO IMPROVE IN 48-72
HRS• Repeat CXR
• CT scan
• Bronchoscopy
• Examination
• BAL
• Sputum AFB, GeneXPERT, HIV
• Autoimmune workup: ANA, ANCA, dsDNA
• ECHO

39. COMPLICATIONS
Empyema ARDS

40. AFTER DISCHARGE
• Smoking cessation
• Washing hands
• Cleaning surfaces that are
frequently touched
• Good glycemic control
• Immunization
• Influenza
• Pneumococcal

41. VACCINATION
PCV 13
• Conjugate vaccine
• Recommended after 65 years of age
• Should be followed 1 year later by
PPV-23
PPV-23
• Polysaccharide vaccine
• Recommended in high risk group
• Chronic lung disease
• Post splenectomy
• Does not decrease pneumococcal
pneumonia
• Decreases pneumococcal bacteremia
• Should be repeated every 5 years

42. SUMMARY
• Exclusion of other important conditions is the most important step in diagnosis of
CAP
• Classification severity is the next important step
• CHURB-65: if any point is positive; Admit

43. MANAGEMENT
OPD
• Without comorbidities:
Amoxycillin
Or
Macrolide
• With comorbidity:
Amoxycillin
+
Macrolide
IPD
• No risk for pseudomonas
I/V Amoxiclav/Cefotaxim/Ceftriaxone
+ Clarithromycin
• Risk for pseudomonas
I/V Cefoperazone-Sulbac/Pip-
Taz/Meropenem/Imipenem/Cefepime
+ Aminoglycoside/FLQ
• Risk for CA-Staph aureus:
Vanco/Linezolid/Teicoplanin

44. SUMMARY CONTINUED
• Duration of treatment is 5-7 days, may have to be prolonged in certain cases
• Patient may be switched to oral once patient starts taking orally
• Patient may be discharged when afebrile, hemodyanamically stable for 48 hrs
• Failure to improve in 48-72 hrs should lead to extensive workup
• Should be actively monitored for development of complications: Empyema, ARDS
• Prevention: Quitting smoking, hand wash, sugar control, vaccination