COMMUNITY AQUIRED

PNEUMONIA
 Definition
• Infection in the alveolar spaces
• Accumulation of inflammatory cells and
secretions
 PNEUMONIA.
CLASSIFICATION
• Community acquired pneumonia (outside
hospital)
• Nosocomial pneumonia (developed more
than 48 h after admission or more than 14
days after a hospitalisation)
– Special type: ventilatory-associated pneumonia

• Immunocompetents
• Immunosupressive conditions (HIV/nonHIV)
 Clinically suspicion of CAP
• Acute onset
• fever  chills
• Respiratory symptoms : cough 
sputum, dyspnoea  chest pain
• Modified general status
• tachycardia  hypotension
  clinically syndrom of pulmonary
consolidation
 “Typical” Pneumonia
• Acute onset
• Fever, chill, tºC = 38-40oC
• Pleuritic chest pain
• cough  purulent sputum/ “rusty” sputum
• Lung consolidation (dulness to percussion,
increased tactile and vocal fremitus, crackles)
 “Atypical” Pneumonia
• More indolent disease
• Nonproductive cough
• Headache, mialgia, arthralgia
• Faringitis, rhinitis
• Common: without lung consolidation
 Etiologic features
“Typical” Pneumonia “Atypical” Pneumonia
S. pneumoniae M. pneumoniae
• H. influenzae • C. pneumoniae
• Legionella
• Enterobacteriaceae • Respiratory viruses
(Klebsiella pneumoniae)
• S. aureus
 Value of the clinical signs in
the etiologic diagnosis of CAP

• Careful studies have shown the

impossibility to distinguish between
“typical” and “atypical” pneumonia on
clinical signs
• Important especially in young people
without comorbidities
 What is the probable etiology?
• Streptococcus p • Acute onset
• Haemophilus i • Pulmonary comorbidities
• Staph a • Influenza, abcess
• Legionella p • Risk factors
• Mycoplasma p • age< 25 years
• Chlamydia p
• Coxiella b • Birds contact
• BGN aerobi • Alcoholism, aspiration
 Chest X-ray
• The golden standard for the diagnosis
– The presence of a new opacity
– Mandatory in every high clinical suspicion
 “Typical”
– Alveolar opacity
• Segmental distribution/lobe
• Uniform (homogeneous) density
• Limitated by fisures
• Aeric bronchogram
 “Atypical”
• Interstitial opacities
– bilateral
– Not uniform involvement
– Without fissures delimitation
Z1 Z 10
 Tests

1. Chest x-ray

2. Bacteriological exam

3. Other tests
 Chest x-ray

• Recommended in any clinical

suspicion
• Important in:
– Diagnostic
– Presence of complications (cavitation, pleural
effusions)
 Bacteriological exam: sputum
• Before the antibiotic treatment
• Patient instructed:
– Rince out the mouth with water
– Provide a specimen resulting from a deep cough
• Specimen transported to the lab promtly
• Imposible to eliminate a degree of
oropharyngeal contamination
 Bacteriologic exam: sputum
• Valid sample:
– > 25 polymorfonuclear neutrophils
– < 10 squamous cells / low power field
(x100)
• Gram’s stain:
– Dominant pathogen
• Culture – corelation with clinical
presentation and Gram’s stain
 Bacteriologic exam
• Other specimen:
– Blood culture
– Pleural efussion
– Bronchial aspirates (bronchoscopy)
 Bacteriologic exam
• No information in some cases of
pneumonia:
– viruses
– Mycoplasma or Chlamidia
– Legionella
• Serological tests (IgM or IgG – paired
samples)
 Value of microbiological tests
• Limitated
• Negative results in many cases, despite
the invasive tests
• Positive only in 30-50% of cases
• Important especially in severe CAP or in
nonresolutive cases
• Not usually recommended in primary care
 Other tests
• Blood test
– leucocitosis: > 10.000
– neutropils
– Leukopenia in viral pneumonia
• CRP
 Other tests
- evaluation of severity -
• urea
• glucose
• Na
• pH
• PaO2 / SaO2
 Choise of treatment place

• Outside hospital
• Risk of mortality
• In hospital • Compliance
• Social situation
• In intensive care unit
 Risk factors for mortality

– Age > 65 years

– comorbidities
– Abnormalities at physical examination
– Abnormalities at lab tests
 CURB - 65 score
(British Thoracic Society)
(1 point):
- Confusion
-Urea > 42mg/dl
-Respiratory rate  30/min
-Blood pressure
(TAs < 90 mmHg, TAd  60 mmHg)
- Age  65 years

0 or 1 2 3

Outside hospital In hospital Consider in ICU

 FINE score
• age < 50 years • No abnormalities at
• No comorbities: physical examination:
– Neoplastic diseases – Altered mental status
– Heart failure – Heart rate  125/min
– Cerebrovascular – Resp rate  30/min
disease – Systolic BP < 90mmHg
– Chronic renal disease – tC <35C or >40C
– Chronic liver disease
 CLASS I
 Fine score
• age> 50 years • Abnormalities at lab
or tests:
• comorbidities – pH < 7,35
– urea > 65 mg/dl
or
– Na < 130 mEq/l
• Abnormalities at – glucose  250 mg/dl
physical examination – PaO2 < 60 mmHg (or
SaO2 < 90%)
 CLASS II-V – Pleural effusion
 Fine classification
Class Mort. Risk Treatment
I <0,5% Outside
hospital
II (70) <1% Mild
III (71-90) 1-3% Short
hospitalisation
IV (91-130) 8-12% Moderate At hospital
V (>130) 27-30% High ICU
CAP - Adult – Outside hospital
< 60 years, no > 60 years or
comorbidities comorbidities
• S. pneumoniae • S. pneumoniae
• M. pneumoniae • H. influenzae

• Enterobacteriaceae
• Viruses (K. pneumoniae)
• C. pneumoniae • S. aureus
• H. influenzae • L. pneumophila
Empirical treatment at home
• Adult < 65 years, no comorbidities:

– amoxicillin 1g x 3/zi

– Claritromycin 500mg x 2/zi

– Doxycyclin
 Empirical treatment at home
• smoker (H. influenzae)
– amoxicillin/beta lactamase inhibitor 1g x 3/zi
– Oral second cephalosporine (cefuroxim 500mg x
2/day)
– clarithromycin
• < 25 years or clinically presentation of “atypical”
CAP(M. pneumoniae, C. pneumoniae)
– Clarithromycin 500mg x2 /day
 Empirical treatment at home
• Adult > 65 years or comorbidities:
– Amoxicillin / beta lactamase inhibitor 1g x
3/day
– Oral second/third cephalosporine
(cefuroxim 500mg x 2/day)
– FQ with antipneumococcal action
(levofloxacin, moxifloxacin, sparfloxacin)
– No macrolide !!!
 Symptomatic treatment
• Dry, persistent cough:
dextromethorphan and codeine
• Hydratation: 2l/day
• No recommandations for:
– Expectorant
– mucolytics
– antihistamines
– bronchodilators
 Patient instruction

• Fever monitoring:
(6:00, 12:00, 18:00 and 24:00)
• Contact doctor when clinically
deterioration
 Evaluation of the initial
response to treatment
Clinically Pneumonia
evaluation
At 48-72h

IMPROUVEMENT RESOLUTIVE

PERSITENT NONRESOLUTIVE

DETERIORATION PROGRESSIVE
 Clinically signs of resolution
• Vital signs:
– tºC
– HR, RR, BP, PaO2/SaO2
• General status (appetite, mental status)

– Physical and radiological signs may persist

many days
 Decision at 48-72h
• resolutive pneumonia – continue the
treatment

• aggravation – promtly admission

• nonresolutive pneumonia –
reevaluation/change of treatment,
consider hospitalization
 Etiology of treatment failure –
INFECTIOUSE REASONS
• Unusual pathogens • Resistant pathogens
( immunocompromised): – viruses
– tuberculosis – M. pneumoniae, C.
– fungus pneumonia
– Nocardia, – Penicillin resistant
Actinomyces pneumococcus
(PRP)
– Pneumocystis carinii
– Multiresistent
bacteria
Etiology of treatment failure –
INFECTIOUSE REASONS

• Parapneumonic pleural effusion

• Purulent pleural effusion(empyema)
• cavitation (lung abcess)
Etiology of treatment failure –
NONINFECTIOUSE REASONS
• Neoplastic lung disease
– Postobstructive pneumonitis
• vasculitis, collagen vascular disease,
sarcoidosis
• BOOP
• Eosinophilic pneumonias, hypersensitivity
pneumonitis
• Drug-induced lung diseases
• Pulmonary thromboembolic disease
 Treatment
• “Typical” Pneumonia (S. pneumoniae
and H. influenzae): 7-10 days
• “Atypical”Pneumonia (M. pneumoniae,
C. pneumonie): 14 days
• S. aureus or BGN aerobi: 21 days
• Legionela: 21 days
 Radiological resolution
Fully resolution: Risk factors:
• age
• 50% at 2 weeks
• comorbidities
• 67% at 4 weeks • Multilobe involvement
• 75% at 6weeks • severity
• pathogen
• 80% at 8 weeks
 In practice
• Chest x-ray:
– 4 weeks: < 50 years, non-severe CAP
– 6-8 weeks: > 50 years or severe CAP or
multilobar CAP
• Partial / absent resolution: pulmonologist