CommunityCommunity-acquired Pneumonia

Ri 2003/10/27

Definition


CommunityCommunity-acquired pneumonia (CAP) is defined as an acute infection of the lung parenchyma accompanied by symptoms of acute illness, which is not acquired in hospitals or other long-term care facilities. long-Clin. infect Dis. 2000;31:347-82 2000;31:347-

Epidemiology


One of the most common infectious diseases in the world. 12/1,000/year, about 600,000 hospitalization cases per year (in the U.S.). The 6th leading cause of death in the U.S. (7th in Taiwan). The most common cause of death due to infectious disease.
-N Engl J Med 1995; 333:1618-24 333:1618-

Epidemiology
Pathogens that cause CAP

-N Engl J Med 1995; 333:1618-24

Pathology


   

Primarily involve the interstitium or the alveoli. Lobar pneumonia bronchopneumonia Necrotizing pneumonia Lung abscess
-Harrisons Principles of Internal Medicine, 15th edition (2001) Harrison

Clinical Manifestations
  

Typical presentation Atypical presentation Syndromes of the two presentation sometimes might be overlapping
-Harrisons Principles of Internal Medicine, 15th edition (2001) Harrison

Clinical Manifestations


Typical presentation
     

Cough (>90%) Sudden onset of fever (80%) SOB (66%) Sputum production (66%) Pleuritic pain (50%) Signs of pulmonary consolidation (dullness, increased fremitus, egophony, bronchial breatathing sound, rales)
-N Engl J Med 2002; 347:2039-45 347:2039-

Clinical Manifestations


Atypical presentation
More gradual onset  Dry cough  Extrapulmonary symptoms


LegionellaLegionella-CNS, heart, liver, GI and GU  M.pneumoniae- upper RT, GI, skin M.pneumoniae

The point that extrapulmonary organ involvement separate atypical from typical pneumonia cannot be overemphasized!
-Eur J Clin Microbiol Infect Dis (2003) 22: 579-583 579-

Diagnosis
Does this patient have CAP?

Diagnosis


Prompt and accurate diagnosis of CAP is important, since it is the only acute respiratory tract infection in which delayed antibiotic treatment has been associated with increased risk of death.
-JAMA 1997;278:2080-4 1997;278:2080-

Diagnosis
   

History and physical examination Image study Laboratory-based approach LaboratoryInvasive procedures

History and Physical Examination

-Ann Intern Med. 2003;138:109-118

Image Study
 

CxR, hrCT hrCT CxR: the imperfect imperfect gold standard

   

Sensitivity/specificity Cost Availability Expertise

-Ann Intern Med. 2003;138:109-118 2003;138:109-

LaboratoryLaboratory-based approach
      

WBC count C-reactive protein Sputum culture and smear Blood culture Pleural effusion analysis Serology PCR
-Thorax 2002; 57:267-271 57:267-

Invasive Procedures


Bronchoscopy


Upper airway flora contamination Pathogen yield rate: 13~48% Pathogen yield rate: 12~30%
-Thorax 2002; 57:267-271 57:267-

Protected specimen brush (PSB)



Bronchoalveolar lavage (BAL)



Conclusion


Careful choice and combination of multiple diagnostic methods would yield optimal result.

Treatment

The Importance of Empirical Antibiotic Treatment



Despite the improvement in diagnostic methods, some cases of CAP (may up to 30%) cant can isolate a specific pathogen.
-Thorax 2002; 57:267-271 57:267-

The availability of diagnostic methods

-Chest 2001; 120:2021-2034

The Menace of Drug-Resistance Drug

About 34% of pneumococcal isolates are penicillinpenicillinresistant.

-Diagn Microbiol Infect Dis 1997; 29:249-257 29:249-

The mechanism of resistance: altered penicillin-binding penicillinprotein



Resistant to amoxicillin-clavulanate amoxicillin-Antimicrob Agent Chemother 1990;34:2075-2080 1990;34:2075-

Resistance to other antibiotic classes is higher among penicillin-resistant strains. penicillin-J Antimicrob Chemother 1996;38(suppl):71-84 1996;38(suppl):71-

Role of Fluoroquinolones
    

DNA gyrase inhibitors Potency Favorable pharmacokinetics Broad spectra of antimicrobial activities Excellent respiratory tissue penetration and activities against respiratory pathogens Drug resistance is uncommon
-Chest 2001; 120:2021-2034 120:2021-

Strategy of ManagementManagementthe PORT Score Assessment

-N Engl J Med 1997; 336:243-50

Empirical Treatment for Out-Patient Out

   

Macrolide (clarithromycin or azithromycin for H. influenzae) influenzae) Fluoroquinolones Doxycycline Amoxicillin-clavulanate Amoxicillin2nd generation cephalosporin
-Chest 2001; 120:2021-2034 120:2021-

Empirical treatment for In-patient In(General Ward)



 

3rd generation cephalosporin plus a macrolide or doxycycline Antipneumococcal fluoroquinolones Beta-lactam-betaBeta-lactam-beta-lactamase inhibitor plus a macrolide or doxycycline
-N Engl J Med 2002; 347:2039-45 347:2039-

Empirical treatment for In-patient In(ICU)



No risk of P. aeruginosa infection

3rd generation cephalosporin plus an antiantipneumococcal fluoroquinolones or a macrolide  Beta-lactam-beta-lactamase inhibitor plus antiBeta-lactam-betaantipneumococcal fluoroquinolones or macrolide


-N Engl J Med 2002; 347:2039-45 347:2039-

Empirical treatment for In-patient In(ICU)



With risk of P. aeruginosa infection

Antipseudomonal beta-lactam plus amino-glycoside betaaminoplus macrolide or antipneumococcal fluoroquinolones  Antipseudomonal beta-lactam plus ciprofloxacin beta

-N Engl J Med 2002; 347:2039-45 347:2039-

PathogenPathogen-specific Treatment

-Chest 2001; 120:2021-2034

PathogenPathogen-specific Treatment

-Chest 2001; 120:2021-2034

Poor Prognostic Factors

-N Engl J Med 1995; 333:1618-24

When Can In-Patient Discharge? In-

-N Engl J Med 2002; 347:2039-45

Thanks for Your Attention!