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COMMUNITY-ACQUIRED PNEUMONIA (CAP)
Anju Jain, MS, ATC, PA-C08/03/19
Disclosures
§ I have no disclosures
OBJECTIVES§ Identify Community-Acquired Pneumonia (CAP) ,
microbiology, clinical findings and diagnosis criteria
§ Differentiate between the clinical presentation of
Bacterial CAP and Viral CAP
§ Identify risk stratifying diagnostic tools for mortality
prediction for CAP
§ Identify classes of drugs and drug regimen therapy for
CAP
COMMUNITY ACQUIRED PNEUMONIA (CAP)
§ Community-acquired pneumonia (CAP)1: an infection pulmonary parenchyma that is acute and occurring in non-health care setting
§ Healthcare-associated pneumonia (HCAP)1: pneumonia that occur in settings such as long-term care facilities, dialysis centers or having been recently admitted in the hospital
§ Hospital-acquired pneumonia (HAP)2: pneumonia that occurs > 48 hours after an admission stay in the hospital
COMMUNITY ACQUIRED PNEUMONIA (CAP)
§ Even famous people are diagnosed with it….
MICROBIOLOGYTypical Atypical/Viral
Atypical• Mycoplasma pneumoniae • Legionella pneumophila • Chlamydophila pneumoniae
• Viral• Influenza A and B• Human rhinovirus • Respiratory syncytial virus
• Streptococcus pneumoniae 3• MOST COMMON
• Haemophilus influenzae
• Moraxella catarrhalis
• Staphylococcus aureus
RISK FACTOR/PATHOGENSRISK FACTOR PATHOGEN
-S. pneumoniae, anaerobes,S. aureus
-M. tuberculosis, S. pneumoniae, Anaerobic oral flora
-H. influenzae, M. catarrhalis,P. Aeruginosa
-Anaerobic oral flora
Injection Drug Use1,4
Alcoholism
COPD/Smoking
Aspiration
§ SIGNS AND SYMPTOMS1-4
§ Pleuritic chest pain
§ Tachypnea
§ +/- cough with purulent sputum production
§ Elevated temperature> 100.40F /380C
§ Hypotensive
§ Decreased oxygen saturations
§ Altered mental status (severe)
§ Physical exam findings for consolidation (rales, fine crackles, dullness to percussion, egophany, tactile fremitus, etc.)
CLINICAL FINDINGS FOR CAP
§LABORORATORY DATA1-4
§Leukocytosis with a left shift§Leukopenia (in severe CAP)§Thrombocytopenia§ESR, CRP and +/- Procalcitonin
§RAPID POINT OF CARE DATA5
§Urine antigen tests for Legionella and/or Pneumococcal
§Rapid antigen detection test for Influenza (PCR)§Sputum Gram Stain
DIAGNOSITC FINDINGS FOR CAP
§Rapid antigen detection test for Influenza (PCR)
DIAGNOSITC FINDINGS FOR CAP
§Sputum Gram Stain S. PneumoniaeDIAGNOSTIC FINDINGS FOR CAP
§Sputum Gram Stain M. Catarrhalis
CHEST RADIOGRAPHISTHE STANDARD1,7
IMAGING FOR CAP
§Chest Radiographs for Typical Pathogens1,3
§ Typical Pneumococcal CAP demonstratesa segmental infiltrate at the lobar regions
§Chest X-ray for Atypical/Viral Pathogens1,3
§ Not very well defined, with patchy like appearance and interstitial infiltrates that are generalized
§ Legionella pneumophila presents on radiograph with diffuse infiltrates that do not appear in a typical lobar pattern
IMAGING FOR CAP
IMAGING FOR CAP
Pneumonia suggesting Viral Etiology
IMAGING FOR CAP
Pneumonia suggesting Legionella
IMAGING FOR CAP
Pneumonia suggesting Psuedomonas
IMAGING FOR CAP
CLINICAL PRESENTATIONTypical Bacterial CAP3 Viral CAP3
• Exposure to sick contacts• Presences of upper
respiratory symptoms• WBC will be within
average range or slightly elevated
• Procalcitonin within average range
• Infiltrates are patchy on radiograph
• Sepsis presentation• Lack of upper respiratory
symptoms• WBC> 15,000 with left
shift• Procalcitonin elevated• Lobar or dense
consolidation on radiograph
OUTPATIENT OR ADMISSION?Pneumonia Severity Index (PSI)6
§ https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap
-Risk Class I-V points added based on:
§ Age
§ Gender
§ Co-morbidities (renal or liver dysfunction, CHF, etc.)
§ Vital sings findings (tachycardia, tachypnea, fever, SPB <90mmHg
§ Laboratory findings (hyponatremia, hyperglycemia, anemia, etc.)
OUTPATIENT OR ADMISSION?
CURB-65: Calculated Mortality Rate6
§ http://www.mdcalc.com/curb-65-severity-score-community-acquired-pneumonia/
§ Confusion
§ Uremia (BUN >19 mg/dL)
§ Respiratory rate: RR >30/min
§ Blood pressure: SBP or DBP hypotensive
§ Age > 65
OUTPATIENT OR ADMISSION?SMART-COP: Does not predict mortality6
-MD Calc for SMART-COP-Predicts the risk of admission and the need for intensive respiratory or vasopressor support (IRVS) in community-acquired pneumonia (CAP)
Systolic blood pressure: SBP <90mmHgMultilobar infiltrates: yes or noAlbumin: <3.5 g/dL (35 g/L)Respiratory rate:≥25Tachycardia: ≥125
Confusion: new onsetOxygen: PaO₂ <70 mmHg, SaO₂ ≤93%, or PaO₂/FiO₂ <333pH: < 7.35
OUTPATIENT OR ADMISSION?
6Rider AC, Frazee BW. Community-acquired pneumonia. Emerg Med Clin N Am. 2018;(36): 665–683.
COMPLICATIONS DUE TO CAP
§Complications for Typical/Atypical Bacterial5
§ Bacteremia§ Sepsis§ Empyema§ Increase in Mortality rate§ Infections in distant location (e.g., meningitis)
§Complications for Viral5
§ Increase in Mortality§ Acute Respiratory Distress Syndrome§ Residual functional abnormalities
DIFFERENTIAL DIAGNOSES
§What else could it be other than CAP?§Acute exacerbation of Chronic Bronchitis
§Sarcoidosis
§Neoplasm of the Lung
§Pulmonary Embolism
DRUG CLASS/TREATMENT REGIMEN
1Mandell LA, Wunderink RG, Anzueto A, et. al. Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;(44): S27-S72.
3
DRUG CLASS/TREATMENT REGIMEN
§ Treatment for Bacterial Pathogen1,3,5
§ Start with treating empirically for S. Pneumo§ Patient has not been on antibiotics in the last 90 days§ Macrolides first line therapy (eg Azithromycin or
Clarithromycin)§ Also Tetracycline due to low cost (Doxycycline) or allergies§ Consider a probiotic or antifungal in conjunction
§ Treatment for Bacterial Pathogen with comorbidities (Diabetes, immunosuppressed, works in daycare, etc.)1,3,5
§ Fluoroquinolones: Levofloxacin, Moxifloxacin§ Be mindful of use and risk of tendinopathy
§Treatment for Viral Pathogen1,3,5
§ Treatment for Influenza A or B
§ Osteltamivir (Tamiflu): 75mg twice daily by mouth x 5days (adjust dose for CrCl values)
§ Must start within 48 hours of onset of symptoms
§ For Influenza A can utilize Amantadine or Rimantadine
§ These drugs may help speed recovery
DRUG CLASS/TREATMENT REGIMEN
§For Immunocompetent/Immunocompromised Patients Greater Than 65 Years-old
§PCV13 = 13-valent pneumococcal conjugate vaccine8
§ PCV 13 be administered first and then…..
§PPSV23 = 23-valent pneumococcal polysaccharide vaccine8
§ PPPSV23 to be administered 12 months after the PCV13
PREVENTION OF CAP
References1. 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): S27-S72.
2. Ramirez, JA. Overview of community-acquired pneumonia in adults. UpToDate Online. Waltham, MA; 2019. http://www.uptodateonline.com. Accessed July 1, 2019.
3. Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med. 2014;(371): 1619-1628.
References4. Kaysin A, Viera A. Community-acquired pneumonia in adults: diagnosis and management. Am Fam Physician.2016;(94): 698-706.
5. Chesnutt AN, Chesnutt MS, Prendergast NT, Prendergast TJ. Pulmonary Disorders: Pulmonary infections. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis & Treatment 2019 New York, NY: McGraw-Hill, 2019.
6. Rider, AC, Frazee, BW. Community-acquired pneumonia. Emerg Med Clin N Am. 2018;(36): 665–683.
References
7. Hill AT, Gold PM, El Solh AA et al. Adult outpatients with acute cough due to suspected pneumonia or influenza: CHEST guideline and expert panel report. Chest. 2019; 155(1):155-67.
8. Kobayashi M, Bennett NM, Gierke R, Almendares O, Moore MR, Whitney CG, et al. Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2015;64(34):944-7.
