By : Dr. ALI ALHAGAWY, R4

ObjectivesBy end of this lecture, you will:

Be able to identify the most common cause of CAP.

Be familiar with the evaluation and diagnostic approach to a patient with CAP.

Be able to identify when refer patient with CAP.

 Community-acquired pneumonia (CAP)

is defined as an acute infection of the pulmonary parenchyma in a patient who has acquired the infection in the community, as distinguished from hospital-acquired (nosocomial) pneumonia.

Community Acquired Pneumonia in children

Community acquired pneumonia is a significant cause of respiratory morbidity and mortality in children, especially in developing countries. Worldwide, CAP is the leading cause of death in children younger than five years. Factors that increase the incidence and severity of pneumonia in children include prematurity, malnutrition, low socioeconomic status, exposure to tobacco smoke, and child care attendance.

History

Physical Examinations

RADIOLOGIC EVALUATIONPlain radiograph

Exclusion of pneumonia in young children (3 to 36 months) with fever >39ºC and leukocytosis (≥20,000 [WBC]/microL)

When does a child or infant with CAP require hospitalization?

Which diagnostic laboratory and imaging tests should be used in a

child with suspected CAP in an outpatient setting?

Management increase water intake to at least eight 8- to 12-oz glasses per day.To control systemic symptoms of pneumonia, paracetamol is recommended. Patients should be advised to avoid cough suppressants.Patients should be advised that fatigue is common during the acute phase and that more rest than usual may be necessary.

Management

Recommendations The absence of tachypnea is the most useful clinical finding for

ruling out CAP in children. Grade C Chest radiography has not been shown to improve clinical outcomes

or change treatment of CAP in children. Grade B Empiric antibiotic choices in children with CAP should be based on

the patient’s age and severity of illness, and local resistance patterns of pathogens. Grade C

Oral amoxicillin and intravenous penicillin G are equally effective in the treatment of hospitalized children with non-severe CAP. However, amoxicillin is generally more cost-effective. Grade B

Macrolides are the empiric antibiotics of choice for children five to 16 years of age with CAP because of their activity against Mycoplasma pneumonia and Chlamydophila pneumonia. Grade C

Routine childhood immunization with the pneumococcal conjugate vaccine significantly reduces the incidence of invasive pneumococcal disease in children. Grade A

Community Acquired Pneumonia in Adult

Community Acquired Pneumonia in Adult is most significant cause of morbidity and mortality in adults. CAP is defined as an infection of the lung parenchyma that is not acquired in a hospital, long-term care facility, or other recent contact with the health care system.Pneumonia and influenza combined is the eighth leading cause of death in the United States and the most common cause of infection-related mortality.

Etiology

HistoryCommon symptoms include fever , chills, pleuritic chest pain, and a cough producing mucopurulent sputum.Absence of fever and sputum also significantly reduces the likelihood of pneumonia in outpatients.High fever (greater than 104° F [40° C]), male sex, multi-lobar involvement, and gastrointestinal and neurologic abnormalities have been associated with CAP caused by Legionella infection.The clinical presentation of CAP is often more subtle in older patients, and many of these patients do not exhibit classic symptoms.They often present with weakness and decline in functional and mental status.Patients should be asked about occupation, animals exposures, and sexual history to help identify a specific infectious agent.???????A recent travel history (within two weeks) may help identify Legionella pneumonia.

Physical ExaminationsTemperature in 80% of patients is high==> may normal in older adult patient.Respiratory rate more than 24 breath/min in 45-70% ==> most sensitive sign in older adult patient.Tachycardia.Chest examination reveals audible crackles in most patients and dullness to percussion and egophony.Pulse oximetry screening should be performed in all patients with suspected CAP.

Investigations Routine laboratory testing to establish an

etiology in outpatients with CAP is usually unnecessary.

white blood cell count greater than 10,400 per mm3 and a C-reactive protein level of 5.0 mg per dL (47.62 nmol per L) or greater are modestly helpful when positive, but it is important to note that normal values do not rule out pneumonia.

Blood and sputum culture in inpatient sitting.

Chest RadiographyChest radiography should be performed in:

Any patient with at least one of the following abnormal vital signs:Temperature > 100°F (37.8°C)Heart rate > 100 beats per minute Respiratory rate > 20 breaths per minute

Any patient with at least two of the following clinical findings:Decreased breath sounds Crackles (rales)Absence of asthma

When Refer ?According to CURB-65 Mortality Prediction Tool for Patients with Community-Acquired Pneumonia

A simplified version (CRB-65), which does not require testing for blood urea nitrogen, may be appropriate for decision-making in primary care practitioners' offices

In this version, admission to the hospital is recommended if one or more points are present.

ConfusionBlood Urea nitrogen level > 20 mg per dL (7.14 mmol per L) Respiratory rate ≥ 30 breaths per minuteBlood pressure (systolic < 90 mm Hg or diastolic ≤ 60 mm Hg) Age ≥ 65 years

Management

The importance of adherence to medication should be emphasised, even if the patient is feeling better.

Patients should be instructed to call their doctor if their symptoms do not improve within 72 hours.

Patients should be instructed to increase water intake to at least eight 8- to 12-oz glasses per day.

If a patient is a smoker, the importance of smoking cessation during this illness should be stressed. Patients should be told how smoking impairs natural mechanisms to eliminate pathogens and debris.

To control systemic symptoms of pneumonia, paracetamol is recommended. Patients should be advised to avoid cough suppressants. There is insufficient evidence to

support the use of either mucolytics or cough suppressants to reduce cough. Patients should be advised that fatigue is common during the acute phase and that more rest

than usual may be necessary. The patient can increase activity as tolerated after the acute phase.

Management Macrolides are the first-line treatment of choice in patients with no contraindications who have not had a recent course of antibiotics and have no risk of drug-resistant infections)Evidence B1)

azithromycin: 500 mg orally once daily on day one, followed by 250 mg once daily ???? ORdoxycycline: 100 mg orally twice daily

Comorbidities include chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; or immunosuppressing conditions or medication==>

levofloxacin: 750 mg orally once daily ORamoxicillin/clavulanate: 875 mg orally twice dailyoramoxicillin: 1000 mg orally three times daily

RecommendationsIn patients with clinically suspected CAP, chest radiography should be obtained to confirm the diagnosis. Grade C

Evaluation for specific pathogens that would alter standard empiric therapy should be performed when the presence of such pathogens is suspected on the basis of clinical and epidemiologic clues; this testing usually is not required in outpatients. Grade C

Mortality and severity prediction scores should be used to determine inpatient versus outpatient care for patients with CAP. Grade AAll patients with CAP who are admitted to the intensive care unit should be treated with dual therapy. Grade A

Prevention of CAP should focus on universal influenza vaccination and pneumococcal vaccination for patients at high risk of pneumococcal disease. Grade B

Thank You