Lower Respiratory Tract

Infection -CAP
Therapy II – Lab
Definition - Pneumonia:
• Is an infection that inflames the air sacs
(pulmonary parenchyma) in one or both lungs.
• Can be classified according to site of acquisition:
(A) Community Acquired Pneumonia: acute
infection of the pulmonary parenchyma acquired
outside a health care setting or < 48 hours after
hospital admission. (individual @ risk: age >= 65
years, asplenia, CV, RS, Liver & kidney diseases,
smoking and alcohol consumption, D.M,
orodental/periodontal diseases)
• (B) Nosocomial Acquired Pneumonia: acute
infection of the pulmonary parenchyma
acquired in hospital settings and encompasses:
1. Hospital Acquired Pneumonia (HAP) refers
to pneumonia acquired ≥48 hours after
hospital admission.
2. Ventilator Acquired Pneumonia (VAP) refers
to pneumonia acquired ≥48 hours after
endotracheal intubation.
 Etiology:

Most common
cause are viral
infection &
streptococcus
pneumonia.
Clinical Presentation:
Constitutional &
respiratory
symptoms
Treatment:
• Goal of therapy:
1. Eradication of the offending organism
through selection of the appropriate
antibiotic(s).
2. Subsequent complete clinical cure.
3. Minimization of the unintended consequences
of therapy, including toxicities and selection
for secondary infections such a Clostridioides
difficile or antibiotic-resistant pathogens.
A. Determine level of care:
• Based on severity assessment tool (CURB –
65 or CRB-65): patients receive 1 point for
each criterion present: Confusion, Uremia
(BUN> 20 mg/dL [7.1 mmol/L]), Respiratory
rate ≥30 breaths/min, Blood pressure
(systolic<90 mm Hg, diastolic ≤60 mm Hg),
age ≥65 years.(= 2: hospitalization / >=3:
ICU)
B. Starting Empiric Antibiotic Therapy:

Antipneumococcal quinolones: moxifloxacin – levofloxacin, gemifloxacin

Out patient B-lactam: high dose amoxicillin (1g 3 times a day )– amoxicillinCA (2 g two
times a day)– ceftriaxone (IM) – cefpodoxime
In patient B-lactam: ceftriaxone (IV) – Cefotaxime – ampicillin, ertapenem.
Inpatient B-lactam (ICU): ampicillin/sulbactam – pipercillin/tazobactam.
Antipsuedomonal B-lactam: pipercillin-tazobactam – cefepime – meropenem – imipenem.
C. Monitoring:
• Initial resolution of symptoms should be seen
within 48 hours.
• Progression to complete resolution of
symptoms should be achieved with 5 – 7 days
(no more than 10 days).
Switching from IV to PO:

1. Hemodynamically stable.
2. Improving clinically.
3. Have normal gastrointestinal tract function.
4. Able to ingest oral medications
Duration of Treatment:
• The minimum duration of therapy for CAP is 5
days although CAP is commonly treated for 7
to 10 days.
• When discontinuing therapy, patients should
be afebrile for 48 to 72 hours and have no
more than one CAP-related sign of clinical
instability (ie, tachycardia, tachypnea,
hypotension, hypoxia, altered mental status).
 Use of Glucocorticoids
• Adjunctive glucocorticoids use in patients with CAP who have evidence
of an exaggerated or dysregulated host inflammatory response, defined
as septic shock that is refractory to fluid resuscitation and vasopressor
administration or respiratory failure with a fraction of inspired oxygen
requirement of >50 percent plus one or more of the following criteria:
metabolic acidosis with an arterial pH of <7.3, lactate >4 mmol/L, or a
C-reactive protein >150 mg/L.
• When using adjunctive glucocorticoids, we treat for five days. For
patients who are unable to take oral medications, we use
methylprednisolone 0.5 mg/kg IV every 12 hours. For patients who can
take oral medications, we use prednisone 50 mg orally daily. We do not
use adjunctive glucocorticoids in patients with influenza or other forms
of viral pneumonia or in patients at risk of aspergillosis.