Management of CAP in Adult in Routine Clinical Practic

7/29/2019 Management of CAP in Adult in Routine Clinical Practic

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Management of Community Acquired

Pneumonia at Routine Clinical Practice



Community Acquired Pneumonia: Introduction

•

Despite development leading cause of morbidity andmortality

• Important Issues:

– Correct diagnosis of pneumonia,

– Identification on exact causative pathogen and

– Appropriate empirical treatment

• Many pathogens have been associated but small range of

key pathogens are culprit

2JAPI Jan 2012;60:5.



Epidemiology

Annual

Incidence rate2 - 12 cases/1000

OPD

Mortality rate1 – 5%

Hospital

Mortality rate12%Awareness, Diagnosis &

Best First Line Treatment

will save lives !JAPI Jan 2012;60:6.



Risk Factors For Exposure And Causative

Organisms (conti….)

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Risk Factors For Exposure And Causative

Organisms

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Respiratory Defense Mechanism

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Pathophysiological Modes Of Spread

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Community Acquired Pneumonia Syndromes

Typical presentation in clinical history

and natural presentation

Clinical history and natural

presentation is different from typical.• M. Pneumoniae (mainly)

• Other Bacteria and Virus

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Pathogens Associated With Community-Acquired

Pneumonia

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Aetiological Classification Of Pneumonia

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Aetiological classification of pneumonia

Lobar pneumonia

Acute bacterial infection of part of a lobe or complete lobe

Common: Streptococcus pneumoniae, Staphylococcus aureus,

β Haemolytic streptococci

Less commonly: Haemophilus influenzae, Klebsiella pneumoniae

Bronchopneumo

nia

Acute bacterial infection of the terminal bronchioles characterized

by purulent exudates which extends into surrounding alveolithrough endobronchial route resulting into patchy consolidation

seen in extremes of age and in association with chronic debilitating

conditions

Commonly Streptococci, Staphylococcus aureus, β Haemolytic

streptococci, H. influenzae, K. pneumonia and Pseudomonas

Interstitial

pneumonia

Patchy inflammatory changes, caused by Viral or mycoplasma

infection, mostly confined to the interstitial tissue of the lung

without alveolar exudates.

Alveolar septal edema and mononuclear infiltrates

Mycoplasma pneumoniae, Respiratory syncytial virus, Influenza

virus, adenoviruses, cytomegaloviruses and uncommonly

Chlamydia and CoxiellaJAPI Jan 2012;60:8.



Clinical Manifestations Of Specific

Causes of Community AcquiredPneumonia



Streptococcus pneumoniae

• Most commonly isolated pathogen, identified in 20%-60% of adults cases

• Incidence peaks in the winter and spring

• Common in infants, elderly, alcoholic and immunocompromised patients

• Incidence in hospitalized patients: 25% with mortality rate of 20%

• Clinical Presentation: – Abrupt with acute febrile illness

– Preceded by mild coryza or other upper respiratory tract symptoms

– Continuous fever with 38.5-39.50C, for 5 and 10 day

– Pleuritic chest pain,

– Sputum: yellowish or greenish in colour, sometimes containing flecks of blood

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Streptococcus pneumoniae

• Physical findings:

– Sweating, flushed and ill looking, fever and sometimes delirum

– Tachycardia and Tachypnea, rapid and grunting respiration

– Impaired percussion note

– Elderly: Loss of mental clarity, somnolence or frank confusion

– Children: non-specific and misleading – Breath sounds: tubular bronchial breathing over the same area

associated with increased vocal fremitus and vocal resonance,aegophony and whispering pectoriloquy, localized crepts

– Chest X ray: Early: Normal, late: classic lobar pneumonia

• Clinical presentation non specific to particular pathogen andvary due to antibiotic use.

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Haemophilus influenzae

• Common in elderly individuals and in smokers with COPD

• Onset of symptoms: More insidious than S. pneumoniae,but the clinical pictures are indistinguishable

• Pneumonia is detected in the lower lobes more oftenthan in the upper lobes

• Chest x ray: bronchopneumonia or lobar pneumonia

• Pleural effusions: in 30% of patients and cavitation is rare

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Staphylococcus aureus

• Rarely seen with CAP

• Predisposing factor: influenza infection

• High risk patients: diabetes mellitus, immunocompromised state, patients receiving

dialysis, drug abusers, and those with influenza or measles

• Clinical manifestations: similar to other forms of bacterial pneumonia

• Often severe, associated with high fever and slow response to conventional therapy

• Rapid spread and aggressive destruction of lung tissue leading to:

– involve multiple lung segments

– Greater risk for lung abscesses, pnemothorax and empyema

•Chest x ray: patchy infiltrates or dense diffuse opacifications 16JAPI Jan 2012;60:11.



Pseudomonas aeruginosa

• High risk patients: COPD, congestive heart failure,

diabetes mellitus, kidney disease, alcoholism, malignant

otitis media, tracheostomy, or prolonged ventilation

• Results: microabscess, alveolar haemorrhage, andnecrotic areas

•Fulminating bacteraemic cases may results in septicshock with hypotension, oliguria and may develop ARDS

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Klebsiella pneumoniae

• High risk patients: alcoholic, diabetic, or hospitalized andreceiving mechanical ventilation

• More common in males

• Indistinguishable from other acute bacterial pneumoniashowever produce severe confluent pneumonia of lobardistribution

• Less widespread cavitation and abscess formation

• Sputum: viscid and may be blood-stained, like redcurrant jelly

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Moraxella catarrhalis

• High risk patients: alcoholism, COPD, diabetes mellitus or

immunocompromised status

• Segmental patchy bronchopneumonia in the lower lobes.

• Cavitation and pleural effusion are rare.

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Community-Acquired “Atypical” Pneumonia

• Different course from that of pneumococcal pneumonia

• Organisms: Legionella pneumophila, Mycoplasmapneumoniae, Chlamydia psittaci, Chlamydia pneumoniae,Coxiella burnetii, and Francisella tularensis

• Chest x ray: disproportionate to the pulmonary symptoms

•

Sputum analysis: numerous leukocytes and no organisms

• Significant overlap may occur in clinical manifestation of typical and atypical

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Legionella pneumophila

• High risk patients: Immunocompromised patients, smokers and elderly

people

• high fever, cough with small amount of cough, myalgias, and shortness of breath

• Other: GI symptoms, confusion, headache, abrupt onset of cough(hemoptysis in 30% of patients), chills, dyspnea, myalgia, arthralgia,diarrhoea, and relative bradycardia and change in mental status.

• Laboratory findings: similar to other acute pneumonia, hyponatremia (inone third patients)

• Chest x ray: lobar pneumonia, small pleural effusions, cavitary lesions inImmunocompromised patients

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Mycoplasma pneumoniae

• Patients under age 40 years, school-aged children

• Seasonal: summer and early fall

• Clinical Feature:

– Cough, fever, sore throat, pharyngitis, coryza, tracheobronchitis

and bullous myringitis (rare but unique feature)

–

Few cases: generalized lymphadenopathy, splenomegaly,pleural effusion, haemolytic anaemia, erythema multiforme,

hepatitis, thrombocytopenia, and Guillain-Barré syndrome

– Crepts, signs of local consolidation

22Bullous myringitis: painful haemorrhagic blisters on the ear-drum and external auditory canalJAPI Jan 2012;60:11.



Chlamydia pneumoniae

• Person-to-person spread occurs among school children,

family members, and military recruits

• Sporadically seen and presentation is similar to

mycoplasma, with sore throat, non-productive cough,hoarseness, headache, pharyngeal erythema and

wheezing

• Radiologic findings: similar to mycoplasma and may

include unilateral segmental patchy opacity.

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Investigation and Management



CURB 65 Sore

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CURB-65 Score: Algorithm based on five easily measurable above factors

JAPI Jan 2012;60:14.



Pneumonia Severity Index (PSI)

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PSI: Identify low-risk patients for

outpatient management.

JAPI Jan 2012;60:5.



Identification Of Bacteria

• Routine Investigations

– Gram Stain

–Sputum Culture

– Blood Culture

– Serology

– Nucleic Acid Detection

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• Specialized Investigations

– Fiberoptic Bronchoscopy

– Transthoracic NeedleAspiration –TTNA

– Transtracheal Needle

Aspiration

JAPI Jan 2012;60:14.



Diagnosis Of Pathogen Based On Specific Features

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Possible Organisms - Risk factors

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Radiology

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Chest X Ray of Lobar Pneumonia

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Lobar pneumonia showing dense

consolidation mostly confined to onelobe, cavitation is rare- air

bronchogram is seen in this right

upper lobe consolidation

JAPI Jan 2012;60:15.



Radiological Features of Staphylococcal Pnumonia

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Classical staphylococcal pneumonia with diffused infiltrates and

pneumatocele formation

JAPI Jan 2012;60:16.



Radiological Features of Klebsiella Pneumonia

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Klebsiella pneumonia - bulging fissures and cavitations due to intense exudation

JAPI Jan 2012;60:16.



Summary Of The Diagnostic Approaches

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Algorithm In Management Of CAP

35Lung India Jul- Sep 2012;S2:S28.



Summary

• CAP is important threat to patients particularly elderly with

co-morbid condition and children.

• Accurate and rapid diagnosis is necessary.

• Antimicrobial therapy should be properly selected based onindividual patient, antimicrobial agent and local resistancepattern.

• In the scenario, where rapid and accurate diagnostic methodsare not easily available, empiric treatment with broadspectrum of antibiotics with favorable tolerability must beutilized.

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Management of Community Acquired

Pneumonia in Adult Routine Clinical Practice

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Management of CAP in Adult in Routine Clinical Practic