Community-Acquired Pneumonia

Joanna M. Delaney, D.O. Georgetown University / Providence Hospital June 8, 2007

Objectives
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Describe the common pathogenesis and pathogens of pneumonia Discuss diagnosis and initial management of community acquired pneumonia (CAP) Understand features of the Pneumonia PORT Severity Index Discuss the IDSA/ATS guidelines and recommendations for final antibiotic choice Understand issues in basic management for pneumonia in children, nursing home patients, and immunocompromised patients.

Epidemiology

Unclear! Few population-based statistics on the condition alone  CDC combines PNA with influenza for morbidity & mortality data

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PNA & influenza = 7th leading causes of death in the US (2001) Age-adjusted death rate = 21.8 per 100,000 Mortality rate: 1-5% out-Pt, 12% In-Pt, 40% ICU Death rates increase with comorbidity and age Affects race and sex equally

6 million cases annually in the U. pneumo (6070% of CAP cases) .Community Acquired Pneumonia  Infection of the lung parenchyma in a person who is not hospitalized or living in a long-term care facility for ≥ 2 weeks  5.S.  Estimated total annual cost of health care = $8.4 billion  Most common pathogen = S.

which was not incubating at the time of admission  Ventilator-associated  pneumonia (VAP) Arises more than 48-72 hours after endotracheal intubation .“Nosocomial” Pneumonia  Hospital-acquired  pneumonia (HAP) Occurs 48 hours or more after admission.

received recent IV abx. chemotherapy. VAP. American Thoracic Society. resided in a nursing home or LTC facility.“Nosocomial” Pneumonia  Healthcare-associated pneumonia (HCAP)  Patients who were hospitalized in an acute care hospital for two or more days within 90 days of the infection. or attended a hospital or hemodialysis clinic  Guidelines for the Management of Adults with HAP. or wound care within the past 30 days of the current infection. 2005 . and HCAP.

aspiration and hematogenous spread are the 3 main mechanisms by which bacteria reaches the lungs  Primary inhalation: when organisms bypass normal respiratory defense mechanisms or when the Pt inhales aerobic GN organisms that colonize the upper respiratory tract or respiratory support equipment .Pathogenesis  Inhalation.

Pathogenesis  Aspiration: occurs when the Pt aspirates colonized upper respiratory tract secretions  Stomach: reservoir of GNR that can ascend. .  Hematogenous: originate from a distant source and reach the lungs via the blood stream. colonizing the respiratory tract.

Pathogens  CAP usually caused by a single organism  Even with extensive diagnostic testing. pneumo is causative pathogen 60-70% of the time . most investigators cannot identify a specific etiology for CAP in ≥ 50% of patients. S.  In those identified.

rusty sputum. malaise. fever. cough)  Lobar infiltrate on CXR  Suppressed host  25% bacteremic .g. shaking chills.Streptococcus pneumonia  Most common cause of CAP  Gram positive diplococci  “Typical” symptoms (e. pleuritic hest pain.

sore throat Legionella: higher mortality rate. rashes). extra-pulm Sx’s (anemia. headache. hyponatremia. non-productive cough. sore throat Chlamydia: year round. no focal infiltrate on CXR Mycoplasma: younger Pts. URI Sx.Atypical Pneumonia      #2 cause (especially in younger population) Commonly associated with milder Sx’s: subacute onset. diarrhea . water-borne outbreaks.

influenza. pneumo.Viral Pneumonia  More  common cause in children RSV. Staph aureus . especially during winter months  Post-influenza pneumonia (secondary bacterial infection)  S. parainfluenza  Influenza most important viral cause in adults.

foreign bodies (catheters. influenza Gram negative     Staphylococcus aureus  IVDU.sinus disease. COPD H. prosthetic joints) prior viral pneumonia .alcoholics Branhamella catarrhalis .Other bacteria   Anaerobes  Aspiration-prone Pt. dental disease Klebsiella . skin disease. putrid sputum. otitis.

Diagnosis and Management .

Guidelines  American Thoracic Society  Guidelines for the Management of Adults with CA (2001) Update of Practice Guidelines for the Management of CAP in Immunocompetent adults (2003) IDSA/ATS Consensus Guidelines on the Management of CAP in Adults (March 2007)  Infectious Diseases Society of America   ATS and IDSA joint effort  .

Guidelines  2001 ATS & 2003 IDSA Guideline Update  Expert panels  Evidence-based recommendations  Recommend patient stratification to identify likely pathogens and suggested empiric abx    Site of care Presence of cardiopulmonary disease Presence of “modifying factors” .

Clinical Diagnosis  Suggestive signs and symptoms  CXR or other imaging technique  Microbiologic testing .

hemoptysis Pleuritic chest pain Myalgia. rhonchi. bronchial breath sounds Dullness to percussion Atypical Sx’s in older patients . fatigue GI symptoms Dyspnea Rales. wheezing Egophony. malaise.Signs and Symptoms           Fever or hypothermia Cough with or without sputum.

multilobar disease) May not be possible in some outpatient settings CXR: classically thought of as the gold standard   .Clinical Diagnosis: CXR  Demonstrable  infiltrate by CXR or other imaging technique Establish Dx and presence of complications (pleural effusion.

anaerobes. flu. Legionella Viral. fungi Staph. Kleb Large effusion .Infiltrate Patterns Pattern Lobar Patchy Interstitial Cavitary Possible Diagnosis S. TB. GN Atypicals. S. pneumo. Kleb. aureus. viral. Legionella Anaerobes. PCP. H. Kleb.

Pox or ABG. two sets of blood Cx’s   If suspect drug-resistant pathogen or organism not covered by usual empiric abx. Severe CAP: Legionella urinary antigen. chemistry. obtain sputum Cx and Gram stain. consider bronchoscopy to identify pathogen .Clinical Diagnosis: Recommended testing  Outpatient: CXR. CBC. sputum Cx and Gram stain not required  Inpatient: CXR.

Clinical Diagnosis  Assess overall clinical picture  PORT Pneumonia Severity Index (PSI)   Aids in assessment of mortality risk and disposition Age. co-morbidities. physical exam lab/radiographic findings . gender. NH.

IDSA: Outpt Management in Previously Healthy Pt  Organisms: S. H. OR Advanced macrolide + amoxicillin. levo-. viral. pneumo. Mycoplasma. OR Advanced macrolide + amoxicillin-clavulanate  If abx within past 3 months:    . Chlamydia pneumo. gemi-). flu  Recommended abx:  Advanced generation macrolide (azithro or clarithro) or doxycycline Respiratory quinolone (moxi-.

H. aerobic GN rods. pneumo. S. viral. flu.IDSA: Outpt Management in Pt with comorbidities  Comorbidities: cardiopulmonary dz or immunocompromised state  Organisms: S. aureus  Recommended Abx:  Respiratory quinolone. OR advanced macrolide  Recent Abx:   Respiratory quinolone OR Advanced macrolide + beta-lactam .

OR Advanced macrolide plus a beta-lactam As above. Legionella  Recommended Parenteral Abx:   Respiratory fluoroquinolone. Regimen selected will depend on nature of recent antibiotic therapy.IDSA: Inpt ManagementMedical Ward  Organisms: all of the above plus polymicrobial infections (+/.anaerobes).  Recent Abx:  .

viral. ?Pseudomonas . GN. pneumo. OR  Two    of three minor criteria: SBP≤90mmHg. Multilobar disease PaO2/FIO2 ratio < 250  Organisms: S.IDSA: Inpt ManagementSevere/ICU  One   of two major criteria: Mechanical ventilation Septic shock. Mycoplasma. Legionella.

piperacillin/tazobactam). plus • IV antipseudomonal quinolone -OR-  Triple therapy: selected IV antipseudomonal betalactam plus IV aminoglycoside plus either IV macrolide. OR IV fluoroquinolone  Risk for Pseudomonas  Double therapy: selected IV antipseudomonal betalactam (cefepine. imipenem. meropenem.IDSA: Inpt Management: Severe/ICU  No risk for Pseudomonas  IV beta-lactam plus either • IV macrolide. OR IV antipseudomonal quinolone .

can can switch to oral therapy while still febrile.Switch to Oral Therapy  Four     criteria: Improvement in cough and dyspnea Afebrile on two occasions 8 h apart WBC decreasing Functioning GI tract with adequate oral intake  If overall clinical picture is otherwise favorable. .

Management of Poor Responders  Consider non-infectious illnesses  Consider less common pathogens  Consider serologic testing  Broaden antibiotic therapy  Consider bronchoscopy .

those at risk for influenza compolications. chronic illness and immunocompromised ≤ 64 yo . household contacts of high-risk persons and healthcare workers • Intranasal live. attenuated vaccine: 5-49yo without chronic underlying dz  Pneumococcal • Immunocompetent ≥ 65 yo.Prevention  Smoking  cessation  Vaccination per ACIP recommendations Influenza • Inactivated vaccine for people >50 yo.

URI Sx. tachypnea. poor feeding. retracting.Pneumonia in Children: Dx  Symptoms  Infants: non-specific manifestations • Fever. diarrhea. chest pain. wheezes. coarse breath sounds . nasal flaring. vomiting. tachycardia. Cyanosis usually very late. cough. grunting. irritability. cough. respiratory distress  Older children: more specific • Fever. crackles.  Signs/Physical exam    RR > 60 for all ages Hypoxia Rales.

trachomatis. GN enterics. pneumo. pneumo. viral . influenza. GN enterics. B. GBS.Pneumonia in Children: Pathogens  0-4 wks: GBS. S. S. pertussis  3 mos-4 yrs: Viral. Mycoplasma  > 5yrs: Mycoplasma (5-15yrs). Listeria. pneumo. M. Listeria  4-12 wks: C. H. C. catarrhalis. viral (RSV/parainfluenza). Grp A Strep.

aureus (skin wounds) and GN bacteria (aspiration) • Pneumonia in Older Residents of Long-term Care Facilities. .Pneumonia in the Elderly  Prevention important  Presentation can be subtle  Antibiotic choice in CAP is same as other adults  Healthcare associated pneumonia  Consider S. 70: 1495-1500. AFP 2004.

Pneumonia in Immunocompromised Pts  Smokers. insidious onset in AIDS. pneumo Mycoplasma P. alcoholics. immunocompromised. elderly  Common still common   S. acute in other immunocompromised Pts CXR: bilateral interstitial infiltrates Steroids for hypoxia TMP-SMZ still first line  Pneumocystis Carinii Pneumonia      . dyspnea. bedridden. jirovecii Fever. non-prod cough (triad 50%).

New Guideline .

low BP. age 65 yrs or greater) or PSI can be used to ID candidates for outpt management Acknowledges the low yield and infrequent positive impact on clinical care Outpt testing for etiologic Dx remain optional Inpt testing for etiologic Dx recommended for specific indications  Diagnostic Testing     Antimicrobial therapy: essentially unchanged . uremia. RR.IDSA/ATS 2007 Guideline  Hospital Admission Decision  CURB-65 criteria (confusion.

Summary  Use overall clinical presentation to guide therapy  The admission decision is an “art of medicine” decision  Use risk factors and guidelines to assist with clinical judgement .

Musher DM. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Dowell SF. Arch Ped Adol Med 1995. Wunderink RG. Whitney CG.37(11):1405-33. Am J Respir Crit Care Med 2001 Vol. 163:1730-1754. Campbell GD. Dean NC. Musher DM. Guidelines for the Management of Adults with Community-acquired Pneumonia. Bartlett JG. Clin Infect Dis 2007 Mar 1.44 Suppl 2:S27-72. . 149: 283-7. Anzueto A. Mandell LA. Bartlett JG. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Niederman MS. File TM Jr. Dowell SF. Mandell LA. Clin Infect Dis 2003 Dec 1. Whitney C. Torres A. File TM Jr.References American Thoracic Society.

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