comunity acquired pneumonia

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DR SHAHID PERVAIZ DR SHAHID PERVAIZ POST GRADUATE EGISTRAR POST GRADUATE EGISTRAR NISHTAR HOSPIATL MULTAN NISHTAR HOSPIATL MULTAN

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Page 1: Comunity Acquired Pneumonia

DR SHAHID PERVAIZDR SHAHID PERVAIZ

POST GRADUATE EGISTRARPOST GRADUATE EGISTRAR

NISHTAR HOSPIATL MULTANNISHTAR HOSPIATL MULTAN

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Community Acquired Pneumonia (CAP)Community Acquired Pneumonia (CAP)

DefinitionDefinition

… … an acute infection of the pulmonary parenchyma an acute infection of the pulmonary parenchyma

that is associated with some symptoms of acute that is associated with some symptoms of acute

infection, accompanied by the presence of an acute infection, accompanied by the presence of an acute

infiltrate on a chest radiograph, or auscultatory infiltrate on a chest radiograph, or auscultatory

findings consistent with pneumonia, in a patient not findings consistent with pneumonia, in a patient not

hospitalized or residing in a long term care facility hospitalized or residing in a long term care facility

for for >> 14 days before onset of symptoms. 14 days before onset of symptoms.

Bartlett. Clin Infect Dis 2000;31:347-82.

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Pneumonias – ClassificationPneumonias – Classification

Nosocomial Pneumonias

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CAP – PathogenesisCAP – Pathogenesis

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Community Acquired Pneumonia (CAP)Community Acquired Pneumonia (CAP)

EpidemiologyEpidemiology 4-5 million cases annually4-5 million cases annually ~500,000 hospitalizations – 20% require admission~500,000 hospitalizations – 20% require admission ~45,000 deaths~45,000 deaths Fewest cases in 18-24 yr groupFewest cases in 18-24 yr group Probably highest incidence in <5 and >65 yrsProbably highest incidence in <5 and >65 yrs Mortality disproportionately high in >65 yrs Mortality disproportionately high in >65 yrs Over all mortality is 2-30%; Hospitalized Pt Over all mortality is 2-30%; Hospitalized Pt mort mort <1% for those not requiring hospitalization<1% for those not requiring hospitalization

Bartlett. CID 1998;26:811-38.

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AgeAge Obesity; Exercise is protectiveObesity; Exercise is protective Smoking, PVD Smoking, PVD Asthma, COPDAsthma, COPD Immuno-suppression, HIVImmuno-suppression, HIV Institutionalization, Old age homes etcInstitutionalization, Old age homes etc DementiaDementia

CAP – Risk Factors for PneumoniaCAP – Risk Factors for Pneumonia

ID Clinics 1998;12:723. Am J Med 1994;96:313

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CAP – Age wise IncidenceCAP – Age wise Incidence

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CAP – Age wise MortalityCAP – Age wise Mortality

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CAP – The Two Types of PresentationsCAP – The Two Types of Presentations

ClassicalClassical

• Sudden onset of CAP• High fever, shaking chills• Pleuritic chest pain, SOB• Productive cough• Rusty sputum, blood tinge• Poor general condition• High mortality up to 20% in

patients with bacteremia• S.pneumoniae causative

• Gradual & insidious onset• Low grade fever• Dry cough, No blood tinge• Good GC – Walking CAP• Low mortality 1-2%; except

in cases of Legionellosis

• Mycoplasma, Chlamydiae, Legionella, Ricketessiae, Viruses are causative

AtypicalAtypical

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CAP – The Pathogens InvolvedCAP – The Pathogens Involved40-60% - No causative agent identified

2-5% - Two are more agents identified

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KEY POINTS TO REMEMBER WHEN KEY POINTS TO REMEMBER WHEN YOUR PATIENT HAS PNEUMONIAYOUR PATIENT HAS PNEUMONIA

CAPTypicalS. pneumoniaeH. influenzaeM. catarrhalis

AtypicalL. pneumophilaM. pneumoniaeC. pneumoniaeC. psittacosiC. burnetti

HAP (VAP)Gram –veP. aeroginosaAcinetobacter spp.Proteus spp.Klebsiella spp.E. cloacaeP. maltophilaLegionella spp.

Gram +veS. aureus (MRSA)S. pneumoniaeOther streptococciS. epidermidis

Polymicrobial

NHAPGram –veKlebsiella spp.P. aeroginosa

Gram +veS. aureus

Anaerobes

1. EPIDEMIOLOGY OF RESPIRATORY PATHOGENS

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CAP – Bacteriology in Hospitalized PtsCAP – Bacteriology in Hospitalized Pts

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Mortality of CAP – Based on Pathogen Mortality of CAP – Based on Pathogen

P. aeruginosa - P. aeruginosa - 61.0 %61.0 %

K. pneumoniae - K. pneumoniae - 35.7 %35.7 %

S. aureus - S. aureus - 31.8 %31.8 %

Legionella -Legionella - 14.7 %14.7 %

S. pneumoniae - S. pneumoniae - 12.0 %12.0 %

C. pneumoniae - C. pneumoniae - 9.8 % 9.8 %

H. influenza - H. influenza - 7.4 % 7.4 %

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Streptococcus pneumonia Streptococcus pneumonia (Pneumococcus)Pneumococcus)

Most common cause of CAPMost common cause of CAP About 2/3 of CAP are due to S.pneumoniaeAbout 2/3 of CAP are due to S.pneumoniae These are gram positive diplococciThese are gram positive diplococci Typical symptoms (e.g. malaise, shaking chills fever, Typical symptoms (e.g. malaise, shaking chills fever,

rusty sputum, pleuritic chest pain, cough)rusty sputum, pleuritic chest pain, cough) Lobar infiltrate on CXRLobar infiltrate on CXR May be Immuno suppressed hostMay be Immuno suppressed host 25% will have bacteremia – serious effects25% will have bacteremia – serious effects

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S. S. aereusaereus CAP is dangerous CAP is dangerous

This CAP is not common; Multi lobar InvolvementThis CAP is not common; Multi lobar Involvement Post Influenza complicationPost Influenza complication Compromised host, Co-morbidities, ElderlyCompromised host, Co-morbidities, Elderly MRSA – A Problem; MSSA also occursMRSA – A Problem; MSSA also occurs Empyema and Necrosis of lung with cavitationsEmpyema and Necrosis of lung with cavitations Multiple Pyemic abscesses, Septic ArthritisMultiple Pyemic abscesses, Septic Arthritis Hypoxemia, Hypoventilation, Hypotension commonHypoxemia, Hypoventilation, Hypotension common Vancomycin, Linezolide are the drugs for MRSAVancomycin, Linezolide are the drugs for MRSA

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CAP – Special Features – Pathogen wiseCAP – Special Features – Pathogen wise• Pneumococcal, Klebsiella, Legionella, H.influenzae CAP Pneumococcal, Klebsiella, Legionella, H.influenzae CAP

has associated pleural effusion has associated pleural effusion • S. aureus causes CAP in post-viral influenza; Serious CAPS. aureus causes CAP in post-viral influenza; Serious CAP• K.pneumoniae primarily in patients of chronic alcoholismK.pneumoniae primarily in patients of chronic alcoholism• P.Aeruginosa causes CAP in pts with CSLD or CF, P.Aeruginosa causes CAP in pts with CSLD or CF,

NosocomialNosocomial• Aspiration CAP only is caused by multiple pathogensAspiration CAP only is caused by multiple pathogens• Extra pulmonary manifestations only in Atypical CAPExtra pulmonary manifestations only in Atypical CAP

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CAP – Evaluation of a PatientCAP – Evaluation of a Patient

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PneumoniaPneumonia SymptomsSymptoms

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PNEUMONIA

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Cutaneous findings

Erythema multiforme M. pneumoniaeMaculopapular rash MeaslesErythema nodosum C. pneumoniaeEcthyma gangrenosum M. tuberculosis

P. aeruginosa

Oral findings

Peridontal disease anaerobic pathogens Foul smelling sputum

Clinical Approach to a Patient with CAPPhysical examination

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Differential Diagnosis of Common Radiographic Patterns in Patients with Pneumonia

Focal opacity Interstitial

S. pneumoniaeM. pneumoniaeL. pneumophilaC. pneumoniaeM. tuberculosisAspiration

Viral M. pneumoniaeP. cariniiC. psittaci

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Fluid and pus filled air space contains

bacteria

Inflammation of alveolar wall

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....

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VIRAL PNEUMONIASVIRAL PNEUMONIAS

• Frequently “interstitial”, NOT alveolarFrequently “interstitial”, NOT alveolar

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CAP – Management Guidelines CAP – Management Guidelines

Rational use of microbiology laboratoryRational use of microbiology laboratory Pathogen directed antimicrobial therapy Pathogen directed antimicrobial therapy

whenever possiblewhenever possible Prompt initiation of Antibiotic therapyPrompt initiation of Antibiotic therapy Decision to hospitalize based on Decision to hospitalize based on

prognostic criteria - PORT or CURB 65prognostic criteria - PORT or CURB 65

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PORT Scoring – PSIPORT Scoring – PSIPneumonia Patient Outcomes

Research Team (PORT)

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Classification of Severity - PORTClassification of Severity - PORT

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

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CURB 65 Rule – Management of CAPCURB 65 Rule – Management of CAP

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Algorithmic ApproachAlgorithmic Approach

Step 1Step 1Step 2Step 2

Step 3Step 3

Step 4Step 4

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Who Should be Hospitalized?Who Should be Hospitalized?

Class I and II Class I and II Usually do not require Usually do not require hospitalizationhospitalization

Class IIIClass III May require brief hospitalizationMay require brief hospitalization

Class IV and VClass IV and V Usually do require hospitalizationUsually do require hospitalization

Severity of CAP with poor prognosis Severity of CAP with poor prognosis

RR > 30; PaORR > 30; PaO22/FiO2 < 250, or PO/FiO2 < 250, or PO22 < 60 on room air < 60 on room air

Need for mechanical ventilation; Multi lobar involvementNeed for mechanical ventilation; Multi lobar involvement

Hypotension; Need for vasopressorsHypotension; Need for vasopressors

Oliguria; Altered mental statusOliguria; Altered mental status

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CAP – Laboratory TestsCAP – Laboratory Tests

• CXR – PA & lateral

• CBC with Differential

• BUN and Creatinine

• FBG, PPBG

• Liver enzymes

• Serum electrolytes

• Gram stain of sputum

• Culture of sputum

• Pre Rx. blood cultures

• Oxygen saturation

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CAP – Value of Chest RadiographCAP – Value of Chest Radiograph

• Usually needed to establish diagnosis

• It is a prognostic indicator

• To rule out other disorders

• May help in etiological diagnosis

J Chr Dis 1984;37:215-25

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Infiltrate Patterns and PathogensInfiltrate Patterns and Pathogens

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CAP – Gram’s Stain of SputumCAP – Gram’s Stain of Sputum

Good sputum samples is obtained only from 39%83% show only one predominant organism

Good sputum samples is obtained only from 39%83% show only one predominant organism

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Pathogens Retrieved from Blood CulturePathogens Retrieved from Blood Culture

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Traditional Treatment ParadigmTraditional Treatment Paradigm

Conservative start with ‘workhorse’ antibiotics

Reserve more potent drugs for non-responders

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New Treatment ParadigmNew Treatment Paradigm

Hit hard and early with appropriate antibiotic(s)

Short Rx. Duration; De-escalate where possible

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Objective 2Objective 2Objective 1Objective 1

Avoid Avoid emergence ofemergence ofmultidrug multidrug resistantresistantmicroorganismmicroorganismss

Immediate Immediate Rx.Rx.of patients of patients with serious with serious sepsissepsis

The Therapy ConundrumThe Therapy Conundrum

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Antibiotics of choice for CAPAntibiotics of choice for CAP

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INTERNATIONAL GUIDELINES FOR EMPIRICAL ANTIMICROBIAL THERAPY

OF COMMUNITY-ACQUIRED PNEUMONIA

Guidelines Outpatient General ward ICU

European RespiratorySociety (1998)

penicillin or aminopenicillins

Alternatives: macrolodes tetracyclines

cephalosporins quinolones

(2nd or 3rd generation cephalosporin or -lactam/-lactamase inhibitor or IV penicillin) macrolide or 2nd generation quinolones;

2nd or 3rd generation cephalosporin + 2nd generation quinolones rifampicin

Infectious Diseases Societyof America (2000)

doxycycline macrolide

new floroquinolone

-lactam with macrolide

OR

new fluoroquinolone

Extended spectrum cephalosporin or –lactam/-lactamase inhibitor + either IV fluoroquinolone or IV macrolide (if structural lung disease cover P. aeroginosa)

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HOW DO I EMPIRICALLY TREAT MY PATIENT WITH

COMMUNITY-ACQUIRED PNEUMONIA?

SETTING THERAPEUTIC OPTIONS

Ambulatory, not requiring hospitalization, age under 60 years

Oral macrolide (erythromycin or azithromycin)

Ambulatory, not requiring hospitalization, comorbidity or age over 60 years

Oral -lactam/-lactamase inhibitor + macrolideOROral antipneumococcal fluoroquinolone

Requiring hospitalization -lactam (sulperazone or ceftriaxone) + macrolide or antipneumococcal fluoroquinolone

Aspiration pneumonia requiring hospitalization

-lactam/-lactamase inhibitor alone(ampicillin/sulbactam, pipericillin/tazobactam))

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MY EMPIRICAL THERAPY OF SEVERE CAP IN COMPROMISED HOST

Compromised host Usual pathogen Empiric therapy

Chronic alcoholics Oral anaerobesand/orKlebsiella spp.

3rd or 4th generation cephalosporinORmeropenam

Postviral influenzae S. aureus CloxacillinORvancomycin

HIV S. pneumoniaeSalmonellaLegionella

new fluoroquinolone

Congenital/acquired asplenia or hyposplenia

S. pneumoniaeN. meningitidisH. influenzae

-lactam/-lactamase inhibitorORmeropenam

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New data – The Speed of Delay ! (Class 4,5)New data – The Speed of Delay ! (Class 4,5)

0

10

20

30

40

50

60

70

80

90

0.5 1 2 3 4 5 6

Delay in treatment (hours) from hypotension onset

Surv

ival

(%)

Each hour of delay carries 7.6% reduction in survival

Kumar, et al. Crit Care Med 2006;34:1589–1596

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CAP – Summary of Empiric TreatmentCAP – Summary of Empiric Treatment

Outpatient Rx – any one of the threeOutpatient Rx – any one of the three• Macrolide or Doxycycline or FluoroquinoloneMacrolide or Doxycycline or Fluoroquinolone

Patients in General Medical WardPatients in General Medical Ward• 3rd Generation Cephalosporin + Macrolide3rd Generation Cephalosporin + Macrolide• Betalactum / B-I + Macrolide or B / B-I + FQBetalactum / B-I + Macrolide or B / B-I + FQ• Fluroquinolone aloneFluroquinolone alone

Patients in ICUPatients in ICU• 3GC + Macrolide or 3GC + FQ3GC + Macrolide or 3GC + FQ• B/B-I + Macrolide or B/B-I + FQB/B-I + Macrolide or B/B-I + FQ

IDSA guidelines: Clin Infect Dis 2000;31:347-82

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CAP – Treatment SummaryCAP – Treatment Summary

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Duration of TherapyDuration of Therapy

• Minimum of 5 daysMinimum of 5 days• Afebrile for at least 48 to 72 hAfebrile for at least 48 to 72 h• No > 1 CAP-associated sign of clinical instabilityNo > 1 CAP-associated sign of clinical instability• Longer duration of therapy Longer duration of therapy

If initial therapy was not active against the identified If initial therapy was not active against the identified

pathogen or complicated by extra pulmonary infectionpathogen or complicated by extra pulmonary infection

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Strategies for Prevention of CAPStrategies for Prevention of CAP• Cessation smokingCessation smoking• Influenza Vaccine (Flu shot – Oct through Feb)Influenza Vaccine (Flu shot – Oct through Feb)

It offers 90% protection and reduces mortality by 80%It offers 90% protection and reduces mortality by 80%• Pneumococcal Vaccine (Pneumonia shot)Pneumococcal Vaccine (Pneumonia shot)

It protects against 23 types of PneumococciIt protects against 23 types of Pneumococci

70% of us have Pneumococci in our RT70% of us have Pneumococci in our RT

It is not 100% protective but reduces mortalityIt is not 100% protective but reduces mortality

Age 19-64 with co morbidity of high for pneumoniaAge 19-64 with co morbidity of high for pneumonia

Above 65 all must get it even without high riskAbove 65 all must get it even without high risk• Starting first dose of antibiotic with in 4 h & OStarting first dose of antibiotic with in 4 h & O22 status status

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Switch to Oral TherapySwitch to Oral Therapy

Four criteriaFour criteria Improvement in cough, dyspnea & clinical signsImprovement in cough, dyspnea & clinical signs Afebrile on two occasions 8 h apartAfebrile on two occasions 8 h apart WBC decreasing towards normalWBC decreasing towards normal Functioning GI tract with adequate oral intakeFunctioning GI tract with adequate oral intake

If overall clinical picture is otherwise favorable, If overall clinical picture is otherwise favorable, hemodynamically stable; can switch to oral hemodynamically stable; can switch to oral therapy while still febrile.therapy while still febrile.

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Management of Poor RespondersManagement of Poor Responders

Consider non-infectious illnessesConsider non-infectious illnesses Consider less common pathogensConsider less common pathogens Consider serologic testingConsider serologic testing Broaden antibiotic therapyBroaden antibiotic therapy Consider bronchoscopyConsider bronchoscopy

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CAP – ComplicationsCAP – Complications

Hypotension and septic shockHypotension and septic shock 3-5% Pleural effusion; Clear fluid + pus cells3-5% Pleural effusion; Clear fluid + pus cells 1% Empyema thoracis pus in the pleural space 1% Empyema thoracis pus in the pleural space Lung abscess – destruction of lung - CSLDLung abscess – destruction of lung - CSLD Single (aspiration) anaerobes, Single (aspiration) anaerobes, PseudomonasPseudomonas

Multiple (metastatic) Multiple (metastatic) Staphylococcus aureusStaphylococcus aureus

Septicemia – Brain abscess, Liver AbscessSepticemia – Brain abscess, Liver Abscess Multiple Pyemic AbscessesMultiple Pyemic Abscesses

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Viruses and PneumoniaViruses and Pneumonia

Pneumonia in the normal hostPneumonia in the normal host• Adults or ChildrenAdults or Children• Influenza A and B, RSV, Adenovirus Para InfluenzaInfluenza A and B, RSV, Adenovirus Para Influenza

Pneumonia in the immuno-compromisedPneumonia in the immuno-compromised• Measles, HSV, CMV, HHV-6, Influenza virusesMeasles, HSV, CMV, HHV-6, Influenza viruses• Can cause a primary viral pneumonia. Cause partial Can cause a primary viral pneumonia. Cause partial

paralysis of “mucociliary escalator” - increased risk of paralysis of “mucociliary escalator” - increased risk of secondary bacterial LRTI. secondary bacterial LRTI. S.aureus pneumonia S.aureus pneumonia is a is a known complication following influenza infection.known complication following influenza infection.

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Normal CXR & Pneumonic ConsolidationNormal CXR & Pneumonic Consolidation

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Lobar Pneumonia – S.pneumoniaeLobar Pneumonia – S.pneumoniae

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CXR – PA and Lateral ViewsCXR – PA and Lateral Views

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Lobar versus Segmental - Right SideLobar versus Segmental - Right Side

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Lobar PneumoniaLobar Pneumonia

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Special forms of ConsolidationSpecial forms of Consolidation

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Round Pneumonic ConsolidationRound Pneumonic Consolidation

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Special Forms of PneumoniaSpecial Forms of Pneumonia

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Special Forms of PneumoniaSpecial Forms of Pneumonia

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Complications of PneumoniaComplications of Pneumonia

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EmpyemaEmpyema

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Mycoplasma Pneumonia Mycoplasma Pneumonia

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Mycoplasma PneumoniaMycoplasma Pneumonia

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Chlamydia TrachomatisChlamydia Trachomatis

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Rare Types of PneumoniaRare Types of Pneumonia

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Vaccination in childrenVaccination in children

• Vaccination is important Vaccination is important in both children and in both children and adults. Vaccinations adults. Vaccinations against Haemophilus against Haemophilus influenza and influenza and Streptococcus Streptococcus pneumonia in the first pneumonia in the first year of life have greatly year of life have greatly reduced their role in CAP reduced their role in CAP in childrenin children

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Community Acquired Pneumonia and Vaccination Community Acquired Pneumonia and Vaccination for Pneumococcal infectionfor Pneumococcal infection

The pneumococcal vaccine (the The pneumococcal vaccine (the ‘pneumonia shot’) protects against 23 ‘pneumonia shot’) protects against 23 types of pneumococcal bacteria. types of pneumococcal bacteria.

Research proves the vaccine is not Research proves the vaccine is not 100% effective in preventing 100% effective in preventing pneumonia, but found that if you are pneumonia, but found that if you are vaccinated you are less likely to die vaccinated you are less likely to die from pneumonia.from pneumonia.

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Preventing InfluenzaePreventing Influenzae

• According to the U.S. According to the U.S. Centers for Disease Centers for Disease Control and Prevention Control and Prevention (CDC), anyone who (CDC), anyone who wants to reduce their risk wants to reduce their risk of getting the flu should of getting the flu should have a flu vaccine. have a flu vaccine.

• Older children and adults Older children and adults require only a single shot require only a single shot each year. However, each year. However, children under age 9 may children under age 9 may need two dosesneed two doses

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General Health MeasuresGeneral Health Measures

• Smoking cessation is Smoking cessation is important not only for important not only for treatment of any treatment of any underlying lung underlying lung disease, but also disease, but also because because cigarettecigarette  

• smoke interferes with smoke interferes with many of the body's many of the body's natural defences natural defences against CAP. against CAP.

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PreventionPrevention

• Influenza and pneumococcal vaccination Influenza and pneumococcal vaccination status should be ascertained and status should be ascertained and vaccines offered when appropriate. vaccines offered when appropriate.

• All patients with pneumonia who are All patients with pneumonia who are tobacco smokers should be encouraged tobacco smokers should be encouraged to join smoking cessation programs. to join smoking cessation programs.

• When a patient is prone to aspiration, When a patient is prone to aspiration, preventive measures should be taken, preventive measures should be taken, including attention to oral hygiene. including attention to oral hygiene.

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Thank you very Thank you very much for yourmuch for your kind attention kind attention ^__^^__^

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