INTRODUCTION

• Pneumonia is an infection of the pulmonary

parenchyma.
• Pneumonia historically was typically classified as
- community-acquired (CAP),
- hospital-acquired (HAP),
- ventilator-associated (VAP)
- health care– associated
pneumonia (HCAP)
ETIOLOGY
• etiologic agents in CAP includes bacteria, fungi,
viruses, and protozoa.
ETIOLOGY
CLINICAL MANIFESTATION
• febrile with tachycardia and/or chills and/or sweats.
• Cough may be either nonproductive or productive
of mucoid, purulent, or blood-tinged sputum.
• Gross hemoptysis is suggestive of CA-MRSA
pneumonia.
• Dyspnea
• Pleuritic chest pain
• 20% : GI symptom
CLINICAL MANIFESTATION
PHYSICAL EXAM
• Finding vary on degree of consolidation W/WO pleural effusion
• increased respiratory rate and use of accessory muscles of respiration
• Palpation may reveal increased or decreased
tactile fremitus
• percussion note can vary from dull to flat
• Crackles, bronchial breath sounds, and possibly a pleural friction rub
may be heard on auscultation.
INVESTIGATION
IMAGING
• CXR : Etiology and severity
• CT
INVESTIGATION

CLINICAL DIAGNOSIS ETIOLOGIC DIAGNOSIS

• CXR : Etiology and • Sputum G/S, C/S
severity • Blood culture
• CT • Urinary antigen test
• PCR
• Serology
• Biomarker
GRAM’S STAIN AND CULTURE OF SPUTUM

• Gram’s staining may also identify certain pathogens

• Adequate for culture, a sputum sample must have
>25 neutrophils and <10 squamous epithelial cells
per low-power field.
• yield of positive cultures from sputum samples is
≤50%
Question 1: In Adults with CAP, Should Gram Stain
and Culture of Lower Respiratory Secretions Be
Obtained at the Time of Diagnosis?
RECOMMENDATION
1. are classified as severe CAP, Esp. Intubation (Septic shock
with need for vasopressors and Respiratory failure
requiring mechanical ventilation )
2. are being empirically treated for MRSA or P. aeruginosa
3. were previously infected with MRSA or P. aeruginosa,
especially those with prior respiratory tract infection
4. were hospitalized and received parenteral antibiotics,
whether during the hospitalization event or not, in the
last 90 days
BLOOD CULTURES

• The yield from blood cultures, even when samples

are collected before antibiotic therapy, is
disappointingly low.
• Only 5–14% of cultures of blood from patients
hospitalized with CAP are positive, and the most
frequently isolated pathogen is S. pneumoniae.
Question 2: In Adults with CAP, Should Blood Cultures
Be Obtained atthe Time of Diagnosis?
RECOMMENDATION
1. are classified as severe CAP, Esp. Intubation (Septic shock
with need for vasopressors and Respiratory failure
requiring mechanical ventilation )
2. are being empirically treated for MRSA or P. aeruginosa
3. were previously infected with MRSA or P. aeruginosa,
especially those with prior respiratory tract infection
4. were hospitalized and received parenteral antibiotics,
whether during the hospitalization event or not, in the
last 90 days
URINARY ANTIGEN TESTS
• The sensitivity and specificity of the
- Legionella urine antigen test are as high as 70%
and 99%, respectively.
- pneumococcal urine antigen test is also quite
sensitive and specific (70% and >90%,respectively).

• Both tests can detect antigen even after the

initiation of appropriate antibiotic therapy
Question 3: In Adults with CAP, Should Legionella and
Pneumococcal Urinary Antigen Testing Be Performed
at the Time of Diagnosis?
RECOMMENDATION
1. in cases where indicated by epidemiological
factors, such as association with a Legionella
outbreak or recent travel
2. in adults with severe CAP
Question 4: In Adults with CAP, Should a Respiratory Sample
Be Tested for Influenza Virus at the Time
of Diagnosis?
RECOMMENDATION
• When influenza viruses are circulating in the
community,
• we recommend testing for influenza with a rapid
influenza molecular assay (i.e., influenza nucleic
acid amplification test), which is preferred over a
rapid influenza diagnostic test (i.e., antigen test)
BIOMARKERS
The two most commonly substances can serve as markers
of severe inflammation
- C-reactive protein (CRP) : identification of
worsening disease or treatment failure

- procalcitonin (PCT) : distinguishing bacterial from viral

infection, determining the need for antibacterial
therapy, or deciding when to discontinue treatment.
Question 5: In Adults with CAP, Should Serum
Procalcitonin plus Clinical Judgment versus Clinical
Judgment Alone Be Used to Withhold Initiation of
Antibiotic Treatment?
RECOMMENDATION
• Empiric antibiotic therapy should be initiated in adults with
clinically suspected and radiographically confirmed CAP
regardless of initial serum procalcitonin level

• suggested that procalcitonin levels of <0.1 mg/L indicate a

high likelihood of viral infection, whereas levels >0.25 mg/L
indicate a high likelihood of bacterial pneumonia
SITE OF CARE
• The two most frequently used are the Pneumonia Severity
Index (PSI), a prognostic model used to identify patients at
low risk of dying, and the CURB-65 criteria, a severity-of-
illness score.
PSI
CURB-65
Question 6: Should a Clinical Prediction Rule for
Prognosis plus Clinical Judgment versus Clinical
Judgment Alone Be Used to Determine Inpatient versus
Outpatient Treatment Location for Adults with CAP?
RECOMMENDATION
• recommend that clinicians use a validated clinical
prediction rule for prognosis, preferentially the
Pneumonia Severity Index (PSI) over the CURB-65.

• RCT demonstrated that use of the PSI safely

increases the proportion of patients who can
be treated in the outpatient setting.
Question 7: Should a Clinical Prediction Rule for
Prognosis plus Clinical Judgment versus Clinical
Judgment Alone Be Used to Determine Inpatient
General Medical versus Higher Levels of Inpatient
Treatment Intensity (ICU, StepDown, or Telemetry
Unit) for Adults with CAP?
RECOMMENDATION

ER , OPD IPD
- PSI (if > 90)
-CURB-65 (if ≥ 2)
Severity criteria
1. Septic shock with
ICU
need for
vasopressors
2.Respiratory failure
requiring
mechanical
ventilation