COMMUNITY ACQUIRED PNEUMONIA

Pneumonia

Definition : It is defined as the infection of lung parenchyma. Types : CAP (Community acquired pneumonia) HAP (Hospital acquired pneumonia) VAP (Ventilator associated pneumonia)

PNEUMONIA

CAP

HCAP

HAP

VAP

ETIOLOGY

Agent Factors Typical pathogens : Streptococcus pneumoniae Haemophilus influenza S. aureus GNB Klebsiella Pneumoniae Pseudomonas aeruginosa

Atypical pathogens : Chlamydiaophila pneumoniae Mycoplasma pneumoniae Legionella spp. Respiratory viruses Influenza Adeno RSV

Rare pathogens : Fungi Protozoa New viruses - Hantavirus Metapneumovirus Coronavirus (SARS) Changing trends : MDR strains of GNB and CA MRSA can cause necrotising pneumonia

HOST FACTORS

Breach of mechanical or immunological defences makes a host susceptible to infection

POSSIBLE ETIOLOGICAL AGENT ACCORDING TO SUSCEPTIBILITY

Alcoholism - Klebsiella pneumoniae, oral anaerobes,S Pneumoniae, M. Tb COPD and/or Smoking H. influenza, Moraxella catarrhalis,Pseudomonas, S. Pneumoniae Structural lung disease Pseudomonas aeruginosa,Burkholderia cepacia,S. aureus Decreased level of consciousness Oral anaerobes, gram neg bacilli

Exposure to birds Chlamydia psittaci H. capsulatum Stay in hotel or on cruise ship in previous 2 weeks Legionella

PATHOPHYSIOLOGY

Host defences trigger inflammatory response which lead to clinical syndrome of pneumonia Inflammatory mediators from macrophages and neutrophils create alveolar capillary leak equivalent to that seen in ARDS.

PATHOLOGY

Intact immunity or typical pathogen Localisation of infection and so lobar pneumonia pattern 4 Stages : Edema Red Hepatization-Erythrocytes Gray Hepatization-neutrophils Resolution-Macrophages Immunocompromised or atypical pathogensBronchopneumonia pattern

CLINICAL MANIFESTATIONS

CAP can vary from mild diseases to fatal in severity Symptoms : Cough, dyspnea, chestpain if parietal pleura involved Others : Fever, constitutional symptoms Signs

DIAGNOSIS

Clinical Radiological Etiological : Gram stain and culture of sputum Blood cultures Antigen tests PCR Serology

DIFFERENTIAL DIAGNOSIS
Acute exacerbation of COPD Heart Failure Pulmonary embolism Radiation Pneumonitis Acute Bronchitis

TREATMENT
Principles : Decide according to severity whether the patient is a candidate for outpatient or inhospital treatment Try to cover organism as per local epidemiological pattern Keep in mind the drug resistance patterns IV drugs when hospitalised Cover for pseudomonas and MRSA when suspected

Inhospital/Outpatient treatment decided as per PSI/CURB-65 criteria

PSI (Pneumonia Severity Index) variables : 20 in number CURB variables : C-Confusion U-Urea(>7 mmols) R-Respiratory rate (>30) B-Blood pressure (<90 sys or <60 diastolic)

Outpatient treatment PSI class 1&2 CURB score 0

Inhospital treatment PSI class 4&5 CURB score >2

ANTIBIOTIC GROUPS

Macrolides-Covers atypical org. but DRSP cases ineffective B-Lactams-No atypical coverage but DRSP cases effective Fluroquinolones-Less resistance and covers both Aminoglycosides-Add on drug for pseudomonas Drugs for MRSA

Pt. diagnosed as having pnemonia

Assess severity as per CURB

OUTPATIENT
(ORAL)

INHOSPITAL (I.V.)

SINGLE DRUG THERAPY , if no risk factors

NONICU

ICU

SINGLE / DUAL DRUGS

DUAL/TRIPLE DRUGS

Bacteremic Pneumococcal Pneumonia Dual therapy preferred

Definitive Treatment

What if organism isolated sensitive to Penicillins and we have started with B lactum+Macrolide or Fluroquinolones
What if no response and drug resistant to FQ+Macrolides+Penicillins (MDR)

DURATION OF THERAPY

Uncomplicated CAP : 5-day course suffices Bacteremic CAP/Virulent organism 10-14 days

Response to treatment in otherwise uncomplicated CAP:

Fever- Falls in 2 days Leucocytosis-decreases in 4 days Physical findings persist slightly longer Chest radiographic abnormalities may take 4-12 weeks to resolve

What if patient fails to improve?

Consider Noninfectious condition Resistance to drug Superinfection with new nosocomial pathogen

COMPLICATIONS
Seen usually when MDR pathogens present Respiratory Failure Shock and Multiorgan failure with DIC Metastatic infection Lung Abscess Complicated pleural effusion

PROGNOSIS

Depends on Age Presence of co-morbidities Site of treatment

PREVENTION

Immunocompromised/Susceptible Vaccination
Community outbreak Chemoprophylaxis+Vaccination