OutlineOutline Diagnosis of CAPDiagnosis of CAP Site of care?Site of care? Tools for risk assessment?Tools for risk assessment? Diagnostic tests needed?Diagnostic tests needed? Management of severe CAP ?Management of severe CAP ?

Community-Acquired Pneumonia:Community-Acquired Pneumonia: A Clinical case scenario A Clinical case scenario

PresentationPresentation

A 66-year-old man accompanied by his wife, arrived at the Emergency Department complaining ofshortness of breath, fever, and cough.

His symptoms started 8 days ago with mild fever, cough, myalgia, headache & sore throat were he received antipyretic, antihistaminic and cough syrup after consulting his family doctor through a telephone call.

SymptomsSymptoms

SymptomsSymptoms After initial improvement, he had a

worsening of symptoms starting 3 days ago with productive cough, pleuritic chest pain, fever, chills and malaise.

Last night he developed dyspnea and high fever, so he decided to come to the Emergency Department today.

Medical HistoryMedical History X-smoker 2 years (30 pack years). COPD. Type 2 diabetes. Medications include

Inhaled salbutamol (100 μg)+ beclomethasone Inhaled salbutamol (100 μg)+ beclomethasone diproprionate (50 μg) 2 puffs x 3.diproprionate (50 μg) 2 puffs x 3.

Sustained released theophylline (200mg cap Sustained released theophylline (200mg cap 1x2).1x2).

Gliclcazide (80mg tab. 1x1).Gliclcazide (80mg tab. 1x1).

ExaminationExamination Confused. Temperature: 39.0°C. Blood pressure: 120/70. Pulse rate: 120 bpm. Respiratory rate: 30 per minute. Clinical signs of right upper zone consolidation and

bilateral scattered rhonchi. No cyanosis, pedal edema or jugular venous

distension is noted.

Chest X-rayChest X-ray

DiagnosisDiagnosisDose this patient have Dose this patient have Community-Acquired Community-Acquired Pneumonia (CAP)?Pneumonia (CAP)?

Definition of CAPDefinition of CAPInfection of the lung parenchyma in a person who is not hospitalized or not hospitalized or living in a long-term care facility for living in a long-term care facility for ≥ 2 weeks.≥ 2 weeks.

CAP: DiagnosisCAP: Diagnosis

“In addition to a constellation of suggestive suggestive

clinical featuresclinical features, a demonstrable infiltrate infiltrate

by chest radiograph or other imaging by chest radiograph or other imaging technique, with or without supporting with or without supporting

microbiological datamicrobiological data, is required for the diagnosis of pneumonia.”

Clinical features:Clinical features:Productive cough, dyspnea, fever, Productive cough, dyspnea, fever, clinical signs of consolidationclinical signs of consolidation

Radiological findings:Radiological findings:ConsolidationConsolidation

CAP – Risk Factors for PneumoniaCAP – Risk Factors for Pneumonia

Elderly Elderly SmokingSmoking COPDCOPD Extreme weather Extreme weather OvercrowdingOvercrowding AlcoholismAlcoholism DMDM

Renal insufficiencyRenal insufficiency CHFCHF Chronic liver Chronic liver

diseasedisease ImmunossuppresioImmunossuppresio

nn Loss of Loss of

consciousness consciousness Seizures Seizures

What is the value of CXR in CAP?What is the value of CXR in CAP? Establish DxEstablish Dx Evaluation of severity Evaluation of severity

e.g. multilobar or bilateral, pleural effusion.

Co-existing conditions Co-existing conditions e.g. bronchial obstruction, abscess.

PatternPattern

Infiltrate Patterns and PathogensInfiltrate Patterns and Pathogens

Initial investigations at ER:Initial investigations at ER: Hgb 13.4 gm/dl, Hct 40%. Hgb 13.4 gm/dl, Hct 40%. WBC 15,800/μl with 88% polymorphonuclear WBC 15,800/μl with 88% polymorphonuclear

cells, 8% bands.cells, 8% bands. Na+ 137 mEq/L, K+ 3.7 mEq/L. Na+ 137 mEq/L, K+ 3.7 mEq/L. BUN 32 mg/dl, creatinine1.8 mg/dl. BUN 32 mg/dl, creatinine1.8 mg/dl. RBG 260 mg/dl.RBG 260 mg/dl. Arterial blood gas (room air): Arterial blood gas (room air):

pH 7.38, PCOpH 7.38, PCO 2 2 53 mmHg, PO 53 mmHg, PO 2 2 58mmHg, O58mmHg, O 2 2 Sat.% 89%Sat.% 89%

CAP – Management based on PSI ScoreCAP – Management based on PSI Score

Would you hospitalize him? Would you hospitalize him?

Assess the ability to safely and reliably take oral Assess the ability to safely and reliably take oral medication & the availability of outpatient supportmedication & the availability of outpatient supportresourcesresources

CURB 65 scoreCURB 65 score

Thorax 2003,58:377Thorax 2003,58:377

(If study performed)(If study performed)

<60mmHg / SO<60mmHg / SO 2 2 <90% <90%

Pneumonia Pneumonia Severity Index Severity Index

(PSI) score(PSI) score

PSI= 146 Class V→ ICUPSI= 146 Class V→ ICU

Calculation of risk assessment (PSI score)Calculation of risk assessment (PSI score)

What testing would you do?What testing would you do?

Diagnostic testingDiagnostic testing““Recommendations for diagnostic testing remain controversial.”Recommendations for diagnostic testing remain controversial.”No convincing data that they improve outcomes.No convincing data that they improve outcomes.Outpatient setting: Outpatient setting: optional optional Inpatient setting: Inpatient setting:

Critically ill CAPCritically ill CAP Specific pathogens (suspected) Specific pathogens (suspected)

Diagnostic testing: Critically ill CAPDiagnostic testing: Critically ill CAP Sputum: Gram staining and culture. Blood cultures. Urinary antigen tests for Legionella &

Streptococcus pneumoniae. ± others FOB+BAL / Endotracheal tube aspirate Thoracentesis TNA

What testing would you do?What testing would you do?Pretreatment: Pretreatment: Sputum: Gram staining and culture. Sputum: Gram staining and culture. Expectorated sputum should be deep cough specimen obtained Expectorated sputum should be deep cough specimen obtained before antibiotic treatment and it should be rapidly transported and before antibiotic treatment and it should be rapidly transported and processed within a few hours of collection.*processed within a few hours of collection.*

Blood cultures (2 sets)Blood cultures (2 sets)2 sets of blood cultures should be drawn before initiation of 2 sets of blood cultures should be drawn before initiation of

antibiotic therapy during the first 24 hour.*antibiotic therapy during the first 24 hour.*

What treatment would you prescribe?What treatment would you prescribe?

TherapyTherapy

Fluid / dietFluid / diet Antipyretics (Paracetamol IV)Antipyretics (Paracetamol IV) Sugar blood chart & Insulin accordingly Sugar blood chart & Insulin accordingly Cough syrupCough syrup SR theophylline SR theophylline Inhalation ttt → salbutamol + ipratropium bromideInhalation ttt → salbutamol + ipratropium bromide OO22 therapy → NP 2 L/min therapy → NP 2 L/min Empiric Antibiotic tttEmpiric Antibiotic ttt

AntibioticAntibiotic

General & supportive General & supportive

What antibiotics are appropriate?What antibiotics are appropriate?

CAP: When to start empiric therapy?CAP: When to start empiric therapy? As soon as possible in ED CAP: delay-to-AB> 4h after arrivalCAP: delay-to-AB> 4h after arrival

Increased mortality Increased mortality Increased LOSIncreased LOS

Recommended empirical antibiotics Recommended empirical antibiotics for CAP: for CAP: Inpatient, ICU tttInpatient, ICU ttt

b-lactam plus either azithromycin or a b-lactam plus either azithromycin or a respiratory fluoroquinolonerespiratory fluoroquinolone (cefotaxime, ceftriaxone)

Levofloxacin 750mg/24h + Ceftriaxone 1gm /12h IVLevofloxacin 750mg/24h + Ceftriaxone 1gm /12h IV

2 hours after ICU admission2 hours after ICU admissionSputum (gram stain) Sputum (gram stain) →→Gram-positive diplococcusGram-positive diplococcus

Value of Gram stainValue of Gram stainFirst, it broadens initial empirical coverage for less common etiologies, First, it broadens initial empirical coverage for less common etiologies, such as infection with such as infection with S. aureus or gram-negative S. aureus or gram-negative organisms. *organisms. *

Second, it can validate the subsequent sputum culture result. A positive Second, it can validate the subsequent sputum culture result. A positive Gram stain was highly predictive of a subsequent positive culture.*Gram stain was highly predictive of a subsequent positive culture.*

Day 3Day 3Sputum culture & Sensitivity: Sputum culture & Sensitivity: Streptococcus pneumoniaeStreptococcus pneumoniaeSensitiveSensitive→ Cefotaxime, Ceftraixone and Levofloxacin.

Susceptibility testing should guide antibiotic choice when results are available.

Continue on the same antibioticsContinue on the same antibiotics

Day 3:Day 3: The patient's condition began to improve, but fever persisted. The patient's condition began to improve, but fever persisted.

Day 5: Day 5: The patient was a febrile for the first time.The patient was a febrile for the first time. Normal oral intake started. Normal oral intake started. Cough, dyspnea grade & chest wheezes improved.Cough, dyspnea grade & chest wheezes improved. Pulse 90 bpm, B/P 140/80.Pulse 90 bpm, B/P 140/80. WBC 6,800/μl with 3% bands.WBC 6,800/μl with 3% bands. BUN 18 mg/dl, creatinine1.4 mg/dl, 2 PPBS 170mg/dl. BUN 18 mg/dl, creatinine1.4 mg/dl, 2 PPBS 170mg/dl. OO 2 2 Sat.% on RA: 93%.Sat.% on RA: 93%.

Transferred to ward.Transferred to ward.

Switch from intravenous to oral Switch from intravenous to oral therapy?therapy?

Afebrile No abnormal GIT absorption Cough & respiratory distress improved WBC returning to normal

Levofloxacin 750 mg tab/24hrLevofloxacin 750 mg tab/24hr

Day 8:Day 8: Clinically stable Afebrile for 3days. CXR: partial resolution. Blood culture:

No growth up till now.

CAP: Duration of Therapy?CAP: Duration of Therapy?

“A minimum of 5 days… A minimum of 5 days…

Afebrile for 48-72 h … Afebrile for 48-72 h …

No more than 1 CAP-No more than 1 CAP-

associated sign of associated sign of

clinical instability’’clinical instability’’

Day 9:Day 9: Discharged and antibiotic stopped. Recommendations

ℜ/ pneumococcal polysaccharide vaccination ℜ/ During next influenza season, influenza

vaccination. ℜ/ ttt COPD & DM. FU CXR after 1 week.