CAP management

● Treatment depends on whether the patient has a mild disease that can be
treated as an outpatient
or a more severe illness that must be treated with IV antibiotics as a
hospitalized inpatient.
● The pneumonia severity index (PSI) and the CURB-65 score are tools that can
help to determine whether to admit a patient.
 5 days duration
re-examined after 48–72 hours to evaluate
t
the efficacy of the prescribed antibiotic.

5–7 days
*more long duration if:
-patient not respondig to Tx
-Suspected or concern MRSA .
or P. aeruginosa infection
-Concurrent meningitis
- Unusual pathogens
Empiric therapy for pneumonia managed as an outpatient is with a macrolide, such as
azithromycin or clarithromycin.
because of the high frequency of Mycoplasma and Chlamydia pneumoniae as the cause
of less severe community-acquired pneumonia (CAP).
HAP
Hospital-acquired pneumonia (HAP): nosocomial pneumonia, with onset >
48 hours after admission.

❖ etiology :
1. Gram-negative bacilli such as (Pseudomonas, Klebsiella, E. coli, etc.)
2. gram-positive cocci such as MRSA.
Treatment for HAP
● Empiric therapy is with third generation cephalosporins with antipseudomonal
activity (such as ceftazidime)
● or carbapenems (such as imipenem)
● or with betalactam/beta-lactamase inhibitor combinations (such as
piperacillin/tazobactam)

● and coverage for MRSA with vancomycin or linezolid.

❖ Empiric antibiotic therapy should be narrowed as soon as feasible.

❖ Seven days of therapy are usually sufficient.
 ❖ Ventilator-associated pneumonia (VAP):

❖ Ventilator-associated pneumonia (VAP): a type of nosocomial pneumonia

that usually develops > 48 hours after endotracheal intubation.
❖ Patients usually have fever, purulent secretions, difficulty with ventilation
(increased respiratory rate, decreased tidal volume), and leukocytosis.

❖ diagnosis

The first step is to obtain a chest x-ray.

Patients with a normal chest x-ray are unlikely to have VAP and should be
evaluated for other causes.

if the chest x-ray is abnormal then lower respiratory tract sampling for
microscopic analysis (Gram stain) and culture is required.
Supportive therapy for pneumonia
● Sufficient rest (not absolute bed rest) and physical therapy
● Hydration with PO or IV fluids, supplemental oxygen as needed
● Incentive spirometer to maintain and improve lung function and To
prevent atelectasis
● Analgesics as needed
● Expectorants (thin bronchial secretions ) and mucolytics (liquefy mucus)
● Cough suppressant
Complications

● Parapneumonic pleuritis (inflammation of the pleura)

● Parapneumonic pleural effusion (common)
● Pleural empyema
● Lung abscess
● Acute respiratory distress syndrome
● Respiratory failure
● Sepsis
Prevention

● Pneumococcal vaccination ( An inactivated vaccine that confers

immunity against Streptococcus pneumoniae.)
Those who should receive the vaccine include:
- All patients age > 65.
- Those with any serious underlying lung, cardiac, liver, or renal disease.
- Immunocompromised patients, such as those on steroids, HIV-positive
persons,diabetics, and those with leukemia or lymphoma,

● Influenza vaccination
● Smoking cessation
Pneumococcal vaccination

● The vaccine is 60-70% effective.

● Re-dosing in 5 years is only necessary for those with severe
immunocompromise or in those who were originally vaccinated before
the age of 65.
● healthy persons vaccinated age > 65, a single dose of vaccine is
enough to confer lifelong immunity
Aspiration pneumonia

● Aspiration pneumonia: a type of pneumonia that occurs as a result

of oropharyngeal secretions and/or gastric contents aspiration

● Aspiration pneumonitis
○ Aspiration of gastric acid that initially causes tracheobronchitis,
with rapid progression to chemical pneumonitis
○ May cause ARDS in extreme cases
Risk factors for aspiration (predispose individuals to reduced epiglottic gag reflex and dysphagia)

● Altered consciousness: alcohol, sedation, general anesthesia, stroke

● Apoplexy and neurodegenerative conditions
● Gastroesophageal reflux disease, esophageal motility disorders
● Congenital defects (e.g., tracheoesophageal fistula)
● Use of a nasogastric feeding tub
Clinical features [36][37]
● Aspiration pneumonitis
○ Immediate symptoms: bronchospasms , dyspnea, wheezing and/or crackles, hypoxemia
○ Late symptoms: fever, shortness of breath, cough
● Aspiration pneumonia
○ Immediate symptoms: often none
○ Late symptoms: fever, shortness of breath, cough with foul-smelling sputum
Treatment

● Acute aspiration: airway management and respiratory support

● Aspiration pneumonitis: typically requires supportive care only
● Aspiration pneumonia: antibiotic therapy following standard pneumonia treatment regimens

Aspiration pneumonia requires antibiotic therapy while aspiration pneumonitis typically self-resolves within 24–48 hours
with supportive care alone. [
Complications

● Acute respiratory failure,

● acute respiratory distress syndrome (ARDS)
● Abscess