Diagnosis, Empiric Diagnosis, Empiric Management and Management and

Prevention of CAP Prevention of CAP

PneumoniaPneumonia

Acute infection of the pulmonary Acute infection of the pulmonary parenchyma accompanied by symptoms parenchyma accompanied by symptoms of acute illness accompanied by of acute illness accompanied by abnormal chest findings.abnormal chest findings.

Third leading cause of morbidity (2001) Third leading cause of morbidity (2001) and mortality (1998) in Filipinos based and mortality (1998) in Filipinos based on the Philippine Health Statistics on the Philippine Health Statistics (DOH).(DOH).

CPG is a joint statement from PSMID, CPG is a joint statement from PSMID, PCCP and PAFP. PCCP and PAFP.

CAP definition:CAP definition: Lower respiratory tract infectionLower respiratory tract infection Acute onset of within 24 hrs to 2 wksAcute onset of within 24 hrs to 2 wks Patient with :Patient with :

coughcough Tachypnea (RR>20), tachycardia Tachypnea (RR>20), tachycardia

(HR>100), fever (T>37.8(HR>100), fever (T>37.8˚̊C)C) At least one abnormal chest findings - At least one abnormal chest findings -

breath sounds, rhonchi, crackles, or breath sounds, rhonchi, crackles, or wheezewheeze

2004 CAP Guidelines in 2004 CAP Guidelines in Immunocompetent AdultsImmunocompetent Adults

No particular sx & abnormal P.E. finding No particular sx & abnormal P.E. finding sufficiently sensitive or specific to confirm sufficiently sensitive or specific to confirm or exclude the Dxor exclude the Dx

Chest x- ray is required for definitive DxChest x- ray is required for definitive Dx

Clinical prediction rules may be utilized if Clinical prediction rules may be utilized if CXR is not availableCXR is not available

CAP in Immunocompetent Adults - CAP in Immunocompetent Adults - 20042004 Update Update

Diagnostic standard – Chest Diagnostic standard – Chest radiographradiograph

Assess severityAssess severity Presence of complicationsPresence of complications

pleural effusionpleural effusion multilobar involvementmultilobar involvement abscessabscess

May suggest possible etiologyMay suggest possible etiology Differentiate pneumonia from other Differentiate pneumonia from other

conditionsconditions

CAP in Immunocompetent Adults - CAP in Immunocompetent Adults - 20042004 Update Update

Pts w/ Pts w/ stablestable VS: VS: RR < 30 breaths/min, PR < 125 beats/min RR < 30 breaths/min, PR < 125 beats/min DBP DBP >> 60 mmHg & SBP 60 mmHg & SBP >> 90 mmHg 90 mmHg

No / stable comorbid condition No evidence of extrapulmonary sepsis No evidence of aspiration CXR: localized infiltrates; no evidence

of pleural effusion nor abscess; not progressive within 24 h

LOW Risk C A P LOW Risk C A P ---> Outpatient Care---> Outpatient Care

CAP in Immunocompetent Adults - CAP in Immunocompetent Adults - 20042004 Update Update

Which patient will need hospital admission ?Which patient will need hospital admission ?

* Comorbid conditions * Comorbid conditions include: include:

Diabetes mellitus (DM)Diabetes mellitus (DM) Neoplastic diseaseNeoplastic disease Neurologic diseaseNeurologic disease Congestive heart failure (CHF) Congestive heart failure (CHF) Coronary artery disease (CAD)Coronary artery disease (CAD) Renal failureRenal failure COPDCOPD Chronic liver diseaseChronic liver disease Chronic alcohol abuseChronic alcohol abuse

Pts w/ Pts w/ unstableunstable VS: VS: RR RR >> 30 breaths/min, 30 breaths/min, PR PR >> 125 beats/min, 125 beats/min, Temp Temp >> 40 40ooC or C or <<3535ooC C

unstable comorbid condition extrapulmonary evidence of sepsis * suspected aspiration Chest X-ray: multilobar infiltrates; pleural

effusion or abscess; progression of findings to >50% in 24 hrs

Patients which will need hospital Patients which will need hospital

admission ?admission ?

Moderate CAP: In-patientsModerate CAP: In-patients

**Unstable comorbid conditions Unstable comorbid conditions

include:include: uncontrolled diabetes mellitus uncontrolled diabetes mellitus

(DM)(DM) active malignanciesactive malignancies neurologic disease in evolutionneurologic disease in evolution congestive heart failure (CHF) congestive heart failure (CHF)

Class II-IVClass II-IV unstable coronary artery disease unstable coronary artery disease

(CAD)(CAD) renal failure on dialysisrenal failure on dialysis uncompensated COPDuncompensated COPD decompensated liver diseasedecompensated liver disease

Any criteria under moderate risk categoryAny criteria under moderate risk category

plusplus Hemodynamic alterations and hypoperfusionHemodynamic alterations and hypoperfusion

(i.e. altered mental state, DBP <60 mmHg or (i.e. altered mental state, DBP <60 mmHg or SBP <90 mmHg, urine output <30 ml/hr)SBP <90 mmHg, urine output <30 ml/hr) oror

Impending or frank respiratory failure Impending or frank respiratory failure

(i.e. Hypoxemia of PaO2 <60 mmHg or acute (i.e. Hypoxemia of PaO2 <60 mmHg or acute hypercapnea of PaCO2 >50 mmHg)hypercapnea of PaCO2 >50 mmHg)

Patients which will need hospital Patients which will need hospital

admission ?admission ?

High Risk CAP: ICU CareHigh Risk CAP: ICU Care

*Extrapulmonary evidence of *Extrapulmonary evidence of sepsis:sepsis:

Moderate Risk C A P:• Hepatic • Hematologic • Gastrointestinal • EndocrineHigh Risk C A P:• CNS - altered mental state CNS - altered mental state • CVS - DBP <60 mmHg or SBP CVS - DBP <60 mmHg or SBP

<90 mmHg <90 mmHg • Renal - urine output <30 ml/hrRenal - urine output <30 ml/hr

HIGH RISK CAP

YES

Algorithm: Management-Oriented Risk Stratification of Community-Acquired Pneumonia

in Immunocompetent Adults

Intensive careIntensive care

YES

Any of the ff:1. Shock or signs of

hypoperfusion - hypotension - altered mental state - urine output <30ml/hr2. PaO2<60mmHg or Acute hypercapnea (PaCO2>50mmHg)

CAP

LOW RISK CAP

OutpatientOutpatient

NO MODERATE RISK CAP

NO

In-patientIn-patient

Any of the ff:

1. RR > 30/min2. PR > 125/min3. Temp > 40oC or <35oC4. Extrapulmonary evidence of sepsis5. Suspected aspiration6. Unstable comorbid conditions*7. CXR: multilobar, pleural

effusion abscess, progression of lesion to >50% of initial within 24 hrs

Microbiologic studies are necessary in CAP?Microbiologic studies are necessary in CAP?

Moderate Risk CAP Blood CS Sputum GS CSOptional : PA for M. pneumoniae MIF for C. pneumoniae (for (for

elderly & elderly & immunocompromised)immunocompromised)

Urine Ag Test for L. pneumophila

DFA Test for L. pneumophila

High Risk CAP Blood CS Sputum GS CS (ABG) PA for M. pneumoniae MIF for C. pneumoniae Urine Ag Test for L.

pneumophila DFA Test for L.

pneumophila

PRINCIPLES OF EMPIRICAL PRINCIPLES OF EMPIRICAL THERAPYTHERAPY

Treat early; give antibiotics within 4 h of Treat early; give antibiotics within 4 h of admissionadmission

Cannot reliably differentiate etiology on Cannot reliably differentiate etiology on basis of clinical findingsbasis of clinical findings

Treat most likely pathogensTreat most likely pathogenso S. pneumoniaeS. pneumoniae; ; H. InfluenzaeH. Influenzae

o AtypicalsAtypicals

o Others (local epidemiology)Others (local epidemiology)

*Recent antibiotics, recent hospitalization, etc. *Recent antibiotics, recent hospitalization, etc.

Empiric Antimicrobial Empiric Antimicrobial Therapy in CAPTherapy in CAP

Low risk: Amoxicillin, Co-Low risk: Amoxicillin, Co-trimoxazole, Macrolides trimoxazole, Macrolides (Azithromycin, Clarithromycin, (Azithromycin, Clarithromycin, Roxithromycin)Roxithromycin)

Co-amoxiclav, SultamicillinCo-amoxiclav, Sultamicillin 22ndnd Generation Cephaloporins: Generation Cephaloporins:

Cefuroxime, CefaclorCefuroxime, Cefaclor

Empiric Antimicrobial Empiric Antimicrobial Therapy in CAPTherapy in CAP

Moderate Risk CAP: Macrolides, Moderate Risk CAP: Macrolides, Antipneumococcal fluoroquinolones Antipneumococcal fluoroquinolones (PO or IV), (PO or IV), ββ-lactams with -lactams with ββ--lactamase inhibitor (IV)lactamase inhibitor (IV)

22ndnd Generation Cephalosporins (IV) Generation Cephalosporins (IV) 33rdrd Generation Cephalosporins Generation Cephalosporins

(Ceftriaxone, Cefotaxime, Ceftizoxime (Ceftriaxone, Cefotaxime, Ceftizoxime IV)IV)

Carbapenems (Ertapenem IV)Carbapenems (Ertapenem IV)

cc IV IV bb-lactams-lactams include include 2nd gen 2nd gen cephalosporincephalosporin - cefuroxime - cefuroxime sodiumsodium

3rd gen 3rd gen cephalosporinscephalosporins - ceftriaxone, - ceftriaxone, cefotaxime cefotaxime

those w/ anaerobic those w/ anaerobic activity:activity: cefoxitin, ceftizoxime, cefoxitin, ceftizoxime, ertapenem ertapenem

dd IV IV bb-lactams w/ -lactams w/ bb--lactamase inhibitor lactamase inhibitor include include

ampicillin-sulbactam, ampicillin-sulbactam, amoxicillin-clavulanic amoxicillin-clavulanic acidacid

NonpseudomonalNonpseudomonal

ee IV IV antipneumococcantipneumococcalal fluoroquinolonfluoroquinoloneses include include

levofloxacinlevofloxacin

gatifloxacingatifloxacin

moxifloxacinmoxifloxacin

ee IV IV antipneumococcantipneumococcalal fluoroquinolonfluoroquinoloneses include include

levofloxacinlevofloxacin

gatifloxacingatifloxacin

moxifloxacinmoxifloxacin

No risk for No risk for P. P.

aeruginosaaeruginosa::

IV nonpseudomonal IV nonpseudomonal bb-lactam -lactam cc

+/- +/- bb-lactamase inhibitor -lactamase inhibitor dd

++

IV macrolideIV macrolide

OROR

IV antipneumococcal FQIV antipneumococcal FQ ee

With risk for With risk for P. P. aeruginosaaeruginosa::

IV antipseudomonal IV antipseudomonal bb--

lactamlactamff +/- +/- bb--

lactamase inhibitor lactamase inhibitor gg

+ + IV macrolide IV macrolide or or

IV antipneumococcal IV antipneumococcal FQ FQ

ee

+/-+/-aminoglycoside aminoglycoside oror

IV ciprofloxacinIV ciprofloxacin

Empiric Antimicrobial Therapy in Empiric Antimicrobial Therapy in CAPCAP

High Risk C A PHigh Risk C A P

Empiric Antimicrobial Therapy in Empiric Antimicrobial Therapy in CAPCAP

High Risk C A PHigh Risk C A P

AntipseudomoAntipseudomonalnal

AntipseudomoAntipseudomonalnal

ff IV IV bb-lactams-lactams includeinclude3rd gen cephalosporin3rd gen cephalosporin - ceftazidime - ceftazidime

4th gen cephalosporins4th gen cephalosporins - cefepime, - cefepime, cefpiromecefpirome

those w/ anaerobic activity:those w/ anaerobic activity: imipenem-cilastatin, imipenem-cilastatin, meropenemmeropenem

gg IV IV bb-lactams-lactams

w/ w/ bb-lactamase -lactamase inhibitorinhibitor

piperacillin-tazobactam, piperacillin-tazobactam, ticarcillin-clavulanic acid ticarcillin-clavulanic acid

Most patients w/ uncomplicated Most patients w/ uncomplicated bacterial pneumonia will respond bacterial pneumonia will respond to treatment within 24-72 hrsto treatment within 24-72 hrs

fever declines w/in 72 hrs; fever declines w/in 72 hrs; temperature normalizes within 5 temperature normalizes within 5 daysdays

respiratory signs, esp. tachypnea, respiratory signs, esp. tachypnea, return to normalreturn to normal

A A follow-up CXR NOT necessaryfollow-up CXR NOT necessary to confirm that to confirm that infiltrate has cleared for low-risk CAP patientsinfiltrate has cleared for low-risk CAP patients

How do we assess response to initial Rx ?How do we assess response to initial Rx ?

Switch Therapy to an oral agentSwitch Therapy to an oral agent if: if: Less cough & resolution of respiratory Less cough & resolution of respiratory

distressdistress Afebrile for > 24 hAfebrile for > 24 h Etiology is not a virulent/resistant Etiology is not a virulent/resistant

pathogenpathogen Stable co-morbid condition Stable co-morbid condition No life-threatening complicationNo life-threatening complication

This will allow This will allow early hospital dischargeearly hospital discharge ----> ----> cost savingscost savings

How do we assess response to initial Rx ?How do we assess response to initial Rx ?

Duration of antibiotic use based Duration of antibiotic use based on etiologyon etiology

Etiologic AgentEtiologic Agent Duration of therapy Duration of therapy (days)(days)

Most bacterial pneumonia Most bacterial pneumonia except except

GNB, GNB, S. aureus, P. S. aureus, P. aeruginosaaeruginosa

Enteric Gram (-) pathogens, Enteric Gram (-) pathogens, S. aureus, S. aureus,

P. aeruginosaP. aeruginosa

Mycoplasma & Mycoplasma & ChlamydophiliaChlamydophilia

Legionella sp. Legionella sp.

5-75-7

3 (azalides)3 (azalides)

10-1410-14

10-1410-14

14-2114-21

Follow-up CXRFollow-up CXR to determine: to determine: PneumothoraxPneumothorax CavitationCavitation Extension to previously uninvolved lobesExtension to previously uninvolved lobes Pulmonary edema; ARDSPulmonary edema; ARDS

Re-assess bacteriologic studiesRe-assess bacteriologic studies: to : to determine resistance to antibiotic being determine resistance to antibiotic being given or presence of other pathogens i.e., given or presence of other pathogens i.e., M. TB or fungi M. TB or fungi

** In elderly: In elderly: S. pneumoniaeS. pneumoniae & & L. L. pneumophilapneumophila may be causes of slowly may be causes of slowly resolving pneumoniaresolving pneumonia

0.5 ml IM0.5 ml IM

once a yearonce a year

Serious allergic reaction to a vaccine Serious allergic reaction to a vaccine componentcomponentmoderate or serious acute illnessmoderate or serious acute illness

C.I.C.I.

O.5 ml IM or SCO.5 ml IM or SCone-time one-time revaccination may revaccination may be given after 5 be given after 5 yearsyears

Adult doseAdult dose

InfluenzaInfluenza vaccinevaccine

PneumococcaPneumococcall vaccine vaccine

Guillain-Guillain-Barre Barre SyndromeSyndrome

PrecautionPrecautionss

How do we prevent How do we prevent pneumonia?pneumonia?