2. References
Clinical Respiratory Medicine by Stephen G. Spiro
BTS Guideline for Management of Community Acquired Pneumonia in Adults
updated 2009
NICE Guideline for Diagnosis and Management of Community Acquired
Pneumonia in Adults ( Published in December 2014 )
Davidson’s Principles & Practice of Medicine
3. Objectives
To Briefly Review of Pneumonia
Management of Community Acquired Pneumonia in Adults
according to recently published NICE Guideline
4. Case Scenario
82 year old male , living in a Nursing Care, presented with Fever,
Breathlessness, purulent sputum with alter level of consciousness for the last 3
days. He has COPD and history of Smoking and Mild Dementia.
His Chest Xray shows new right lower lobe infiltrates
CBC shows Raised WBC count 18000/mm3
Initial Gram Staining report shows Prominent Stains of Gram +ve Organism
5. Case Scenario
What is your Diagnosis
Health Care Associated Pneumonia
What is most probable Causative Pathogen
Staphylococcus Aureus
What should be done next
Vancomycin 1 gram IV every 12 hours
Piperacillin and Tazobactam and intravenous levofloxacin incase of MRSA
6. Community Acquired Pneumonia
Acc. to BTS Guidelines CAP is defined as
Acute Lower Respiratory Tract Infection
Accompanied by New Infiltrates on Chest Radiograph
Or Ascultatory Findings Consistent with Pneumonia
in a patient Not Hospitalized or residing in a Long Term Care Facility
for More than 2 weeks
before onset of symptoms
7. What is An Acute Lower Respiratory Tract Infection
Acc. To NICE Guideline
An acute Illness (present for 21 days or less)
usually with Cough as main symptom
and with at least 1 other Lower respiratory tract symptoms such as
Fever
Sputum Production
Breathlessness
Wheeze
Chest Discomfort or Chest Pain
with No alternative explanation
Pneumonia, Acute Bronchitis and Exacerbation of COPD
8. Hospital Acquired Pneumonia
Pneumonia that develops in a Non-Incubating patient, 48 hours or
more after Hospital Admission
9. Ventilator Associated Pneumonia
Pneumonia that develops in a patient receiving Invasive Mechanical
Ventilation for at least 48 hours or more
10. Health Care Associated Pneumonia
Pneumonia that develops in a patient with recent contact with the
Health Care System, that include
Hospitalization for 2 days or more in the preceding 90 days
Residence in Nursing Care
Home Infusion Therapy including Antibiotics
Chronic Dialysis within 30 days
Home Wound Care
Family member with MDR Pathogen
11. Why it is important to differentiate CAP from
other Pneumonia
Timely Diagnosis and Treatment is the key in Successful
Management of Pneumonia
Early Pathogen detection and Choice of appropriate Antibiotic
will not only result in better outcome of Pneumonia, But also
reduces problems related to Antibiotic Resistant
12. Burden of Disease
Pneumonia remains common cause of Death
Globally Pneumonia ranked 6th
CAP is most common cause of Severe Sepsis
Despite introduction of Antibiotics, Imaging modalities and
Biomarker testing, mortalities related to CAP has not changed
significantly.
14. Risk Factors
Age
With the increase in Age , Immunity of body weakens
Every Year over 65, increases risk for Pneumonia
15. Risk Factors
Altered Immunity
Patients with Immunocompromised state such as
HIV
AIDS
Chemotherapy Treatment
Lymphopoliferative Diseases
Cancer
Diabetes
CLD
Heart Failure
are at increased risk for development of CAP
16. Risk Factors
Malnutrition
whatever the cause may be
Malnutrition leads to alterations in Immunity
Increasing the chance for Airway colonization and infection with Gram –ve Bacilli
17. Risk Factors
Environmental Factors
Overcrowding
Occupations associated with exposure to Dust, Fumes, various Chemicals,
Contaminated Water Supply and Cooling Towers of Air-Conditioning Units
Contact with Animals
18. Risk Factors
Airway Colonization
Results in Impairment of Innate Lung Defense
Common in Patients with Chronic Obstructive Pulmonary Disease
19. Risk Factors
Alcoholism
Leads to Impaired Level of Consciousness, Cough Reflex and Muco-cilliary Movement
Also impairs function of Lymphocytes, Monocytes and alveolar Macrophages
20. Risk Factors
Smoking
Smoking, itself is not a Risk Factor for Pneumonia
But it alters Muco-cilliary Transport
And increases adhesion of Pathogens to Orophyrangial epithelium
21. Pathogens
Virus , Bacteria and Fungi are pathogens of Pneumonia
Common Pathogens are
Streptococcus Pneumoniae
Staphylococcus Aureus
H. Influenza
Mycoplasma Pneumoniae
Ligeonalla Pneumophila
Pseudomonas
Clamydia
Ecoli
Klebsella Pneumoniae
MRSA
Anaerobes
22. Common Pathogens in CAP
Streptococcus Pneumoniae
Staphylococcus Aureus
H. Influenza
Mycoplasma Pneumoniae
Ligeonalla Pneumophila
Clamydia
Klebsella Pneumoniae
23. Common Pathogens in HAP
•E. Coli
•Pseudomonas
•Klebsella
Gram –ve are
Most Common
•Staphylococus Aureus
•MRSAGram +ve
Bacteriods
24. Common Pathogens in VAP
Pseudomonas aeruginosa
E.coli
Klebsiella pneumoniae
Acinetobacter
Staphylococcus Pneumoiae
25. Common Pathogens in HCAP
Staphylococcus aureus
Pseudomonas aeruginosa
Streptococcus pneumoniae
Haemophilus influenzae.
26. Streptococus Pneumoniae
Most Common
Pathogen of CAP
If left untreated , it
will eventually result
in Production of Rust
colored Sputum
Pneumonia caused
by Streptococus
Pneumoniae is a
Medical emergency
Because of
•Rapid multiplication
•High Risk for
Secondary
Complications
27. Staphylococus Pneumoniae
Most Severe form of CAP
Because of
Resistant to Multiple Antibiotics
Leads to formation of Bullae which may repute to Cause Pneumothorax,
Pneumo-Pyothorax and Septicemia
33. Clinical Presentation
On General Physical Examination
Hyperthermia
Tachycardia
Tachypnea
Use of Accessory Muscles
Central Cyanosis
Altered Mental Status
37. Typical
Caused by Typical Pathogens
Streptococus Pneumoniae
H. Influenze
Klebsella
Morexella Cataralis
Classical Syptoms are Dominant
Sudden in Onset
High Grade Fever
Intense Chills
Productive Cough
Pleuritic Chest Pain ( Occasionally)
CBC Shows Leukocytosis with Neutrophillic
Predominance
Atypical
Also Called Walking Pneumonia
Caused by Atypical Pathogens
Mycoplasma Pneumoniae
Clamydia Pneumophila
Ligionella
Systemic Menifestations are Dominant
Generalized Myalgea
Muscle Ache
Arthralgia
Diarhhea
Nausea
Vomiting
Abdominal Pain
Gradual in Onset
Low Grade Fever
Dry Cough
CBC Shows Absent Leukocytosis
Do not respond to common Antibiotics
Do not form Lobar Consolidations rather restricted to Small
Areas
38. Investigations
Baseline
Chest X ray
Complete Blood Count
Serum Electrolytes
Urea Creatinine
Liver Functioning Test
Specific
Arterial Blood Gases
Gram Staining
Sputum Culture
C – reactive Protein
Pneumococcal and Legionella
Urinary Antigen Test
39. C – reactive Protein
C-reactive protein is an acute phase reactant,
a protein made by the liver and released into the bloodstream
within a few hours
after tissue injury,
start of an infection,
or other cause of inflammation
40. Abbreviated Mental Test
Quick and Easy to Use Test to Assess Elderly patients for
Dementia
Confusion
Impaired Cognitive Functions
10 simple questions are asked from patient
1 Point is given for every Correct Answer and 0 Point for Incorrect Answers
41. Abbreviated Mental Test
Name
Time
Give the patient an address and ask for recall at end of test
Year
Name of the place
Identification of any two person ( Doctor, Nurse , Home Help etc)
Date of Birth
Any Historical Event
Name of President/ Prime Minister
Count backward from 20-1
Recall Adress
42. Differential Diagnosis of CAP
Acute bronchitis
Acute Exacerbation of COPD
Pulmonary T.B
Pulmonary Edema
Pulmonary Infarction
Pulmonary eosinophilia
Pulmonary fibrosis
Bronciolitis Oblitrans Organising Pneumonia
Bronchoalveolar Cell Carcinoma
Drug-induced pulmonary disease
Myocardial infarction
Congestive heart failure and pulmonary edema
44. Lower Respiratory Tract Infection
For people presenting with symptoms of Lower Respiratory Tract Infection
in Primary Care,
Consider C-reactive protein test
if after clinical assessment a diagnosis of Pneumonia has not been
made
and it is not clear whether Antibiotics should be prescribed
45. Lower Respiratory Tract Infection
Use the results of the C-reactive protein test to guide Antibiotic prescribing
in people without a clinical diagnosis of pneumonia as follows,
Do not routinely offer antibiotic therapy if the C-reactive protein
concentration is less than 20 mg/litre
Consider a Delayed Antibiotic Prescription (a prescription for use at a later
date if symptoms worsen) if the C-reactive protein concentration is
between 20 mg/litre and 100 mg/litre
Offer Antibiotic Therapy if the C-reactive protein concentration is greater
than 100 mg/litre
46. Community Acquired Pneumonia
When a clinical diagnosis of Community Acquired Pneumonia is made in
Primary Care
Severity is assessed
To determine whether patients are at Low, Intermediate or High risk of Death
using the CRB65 Score
47. CRB65 score
CRB65 Score is calculated by giving 1 Point for each of the following
prognostic features
Confusion (abbreviated Mental Test score 8 or less, or new
disorientation in person, place or time)
Raised Respiratory Rate (30 breaths per minute or more)
Low Blood Pressure (Diastolic 60 mmHg or less, or Systolic less than 90
mmHg)
Age 65 Years or more
48. Mortality Risk
Patients are stratified for Risk of Death as follows
0 Low risk (less than 1% mortality)
1 or 2 Intermediate risk (1-10% mortality risk)
3 or 4 High risk (more than 10% mortality risk)
49. Decision For Site Of Care
Use Clinical Judgment in conjunction with the CRB65 Score to inform
decisions about whether patients need Hospital assessment as
follows
Consider Home-Based Care for patients with a CRB65 score of 0
Consider Hospital Assessment for all other patients, particularly those
with a CRB65 Score of 2 or more
50. Community Acquired Pneumonia
When a clinical diagnosis of Community Acquired Pneumonia is made in
Hospital
Severity is assessed
To determine whether patients are at Low, Intermediate or High risk of
Death
using the CURB65 Score
51. CURB65 score
CURB65 Score is calculated by giving 1 Point for each of the
following prognostic features
Confusion (abbreviated Mental Test score 8 or less, or new
disorientation in person, place or time)
Raised Blood Urea Nitrogen (over 7 mmol/litre)
Raised Respiratory Rate (30 breaths per minute or more)
Low Blood Pressure (Diastolic 60 mmHg or less, or Systolic less than 90
mmHg)
Age 65 years or more
52. Mortality Risk
Patients are stratified for risk of death as follows
0 or 1 Low risk (less than 3% mortality risk)
2 Intermediate Risk (3-15% mortality risk)
3 to 5 High Risk (more than 15% mortality risk)
53. Management Of CAP
Use Clinical Judgment in conjunction with the CURB65 Score to Guide
Management of Community Acquired Pneumonia as follows
Consider Home-Based Care for patients with a CURB65 Score of 0 -1
Consider Hospital-Based Care for patients with a CURB65 Score of 2 or more
Consider Intensive Care assessment for patients with a CURB65 Score of 3 or more
54. Microbiological Test
Do not routinely offer Microbiological Tests to patients with Low-severity
Community Acquired Pneumonia
For patients with Moderate or High-Severity Community Acquired Pneumonia
take Blood and Sputum Cultures and
Consider Pneumococcal and Legionella Urinary Antigen Tests.
55. Timely Diagnosis And Treatment
Put in place processes to allow diagnosis (including X-rays) and
treatment of Community Acquired Pneumonia within 4 hours of
presentation to Hospital
Offer Antibiotic Therapy as soon as possible after diagnosis, and certainly
within 4 hours to all patients with Community Acquired Pneumonia who
are admitted to hospital
56. Antibiotic Therapy
Low-severity community-acquired pneumonia
Offer a 5-day course of a Single Antibiotic to patients with Low-Severity
Community Acquired Pneumonia
Consider Amoxicillin in preference to a Macrolide or a Tetracycline for patients
with Low-Severity Community Acquired Pneumonia
Consider a Macrolide or a Tetracycline for patients who are Allergic to Penicillin
Consider Extending the course of the Antibiotic for longer than 5 days as a
possible management strategy for patients with Low-Severity Community
Acquired Pneumonia whose symptoms do not improve as expected after 3
days
57. Antibiotic Therapy
Explain to patients with Low-Severity Community Acquired Pneumonia
treated in the community, and when appropriate their families or carer, that
they should seek further medical advice if their symptoms do not begin to improve
within 3 days of starting the antibiotic, or earlier if their symptoms are worsening.
Do not routinely offer patients with Low-Severity Community Acquired
Pneumonia
a Fluoroquinolone
Dual Antibiotic Therapy
58. Antibiotic Therapy
Moderate- and High-Severity Community Acquired Pneumonia
Consider a 7 to10 day course of Antibiotic Therapy for patients with Moderate
or High Severity Community Acquired Pneumonia
Consider Dual Antibiotic Therapy with Amoxicillin and a Macrolide for patients
with Moderate-Severity Community Acquired Pneumonia
Consider Dual Antibiotic Therapy with a Beta-Lactamase Stable Beta-Lactam
and a Macrolide for patients with High-Severity Community Acquired
Pneumonia
59. Site
Scoring
System
Severity Management
Antibiotic
Therapy
Antibiotic
Duration
Antibiotics
Primary
Care
CRB-65
Low ( 0 )
Home Based
Treatment
Single 5 Days
Amoxicillin(Preferred)
or
Macrolide
Or
Tetracycline
Moderate
(1-2)
Refer to Hospital
High (2-4)
Do not routinely offer Floroquinolone & Dual Antibiotic Therapy to patients with low-severity CAP
Consider Extending the course of the Antibiotic for longer than 5 days for patients with Low-Severity CAP whose
symptoms do not improve as expected after 3 days
Explain to patients with Low-Severity CAP, their families, that they should seek further Medical advice if their symptoms
do not begin to improve within 3 days of starting the antibiotic, or earlier if their symptoms are worsening
60. Site
Scoring
System
Severity Management
Antibiotic
Therapy
Antibiotic
Duration
Antibiotics
Hospital CURB-65
Low ( 0-1 )
Home Based
Treatment
Single 5 Days
Amoxicillin(Preferred)
or
Macrolide
Or
Tetracycline
Moderate
(2)
Hospital Based Care
Dual 7-10 Days
Amoxicillin
+
Macrolide
Intensive Care Unit
High (3-5) Dual
7-10 Days
Beta-Lactamase stable
beta-lactam
+
Marcrolide
Macrolides include Erythromycin, Clarithromycin, Azithromycin
Beta-Lactamase stable beta-lactam includes Co-Amoxiclave, Cefotaxime, Ceftroline, Fosamil, Ceftriaxone,
Piperacillin with Tazobactam
62. Glucocorticoid Treatment
Do not routinely offer a Glucocorticosteroid to patients with
Community Acquired Pneumonia unless they have other conditions
for which Glucocorticosteroid treatment is indicated
63. Monitoring in Hospital
Consider measuring a baseline C-reactive protein concentration in
patients with Community Acquired Pneumonia on admission to Hospital
Repeat the Test if clinical progress is uncertain after 48 to 72 hours
64. Safe Discharge from Hospital
Do not Routinely Discharge patients with Community Acquired Pneumonia
if in the past 24 hours they have had 2 or more of the following findings
Temperature higher than 37.5°C
Respiratory Rate 24 breaths per minute or more
Heart Rate over 100 beats per minute
Systolic Blood Pressure 90 mmHg or less
Oxygen Saturation under 90% on room air
Abnormal Mental Status
Inability to Eat without Assistance
65. Consider Delay Discharge
Consider Delaying Discharge for patients with Community Acquired
Pneumonia if their Temperature is higher than 37.5°C
66. Patient Counseling
Explain to patients with Community Acquired Pneumonia that after starting treatment their symptoms
should steadily improve, although the rate of improvement will vary with the severity of the pneumonia,
and most people can expect that by
1 week Fever should have resolved
4 weeks Chest Pain and Sputum production should have substantially reduced
6 weeks Cough and Breathlessness should have substantially reduced
3 months most symptoms should have resolved but Fatigue may still be present
6 months most people will feel back to Normal
67. Patient Counseling
Advise patients with Community Acquired Pneumonia to consult their Healthcare
Professional if they feel that their Condition is Deteriorating or not Improving as
expected
68. Hospital Acquired Pneumonia
Antibiotic Therapy
Offer Antibiotic Therapy as soon as possible after diagnosis, and certainly
within 4 hours, to patients with Hospital Acquired Pneumonia
Choose Antibiotic Therapy in accordance with Local Hospital Policy
(which should take into account knowledge of local microbial pathogens)
and clinical circumstances for patients with hospital-acquired pneumonia.
Consider a 5 to10 day course of Antibiotic Therapy for patients with
Hospital Acquired Pneumonia
69. Empirical Coverage for Uncommon Pathogens Causing CAP
Pseudomonas MRSA
Vancomycin
Linezolid
Piperacillin with Tazobactam Or
Cefepime Or Imepenem plus Either
Ciprofloxacin Or Levofloxacin
•Or
Aminoglycoside and Azithromycin
•Or
Beta-Lactam with Aztreonam
70. Common Causes of Non-Responding Pneumonia
Infective Etiology
Resistant Organism
•Staphylococcus Aureus
•Streptococcus Pneumoniae
Super Infection with Nosocomial
Organism
•Pseudomonas
Rare Organisms
•Fungi
•Mycobacteria
Extra Pulmonary Dissemination
• Endocarditis
• Meningitis
• Arthritis
Empyema or Abscess Formation
71. Common Causes of Non-Responding Pneumonia
Non-Infective Etiology
Pulmonary Embolism
MI
Heart Failure
Pulmonary Edema
Renal Failure
Vasculitis
Malignancy
Pulmonary Hemorrhage
Bronchiolitis Oblitrans with Organizing Pneumonia
Drug Induced Pulmonary Disease
72. Complications Of CAP
Lung Abscess
Para-pneumonic Effusion
Empyema
Broncho-pleural Fistula
Organizing Pneumonia
Bronchiectasis
73. Prevention
Vaccination against Streptococcus pneumonia and Influenza Virus
Vaccination status should be assessed at the time of admission
Vaccination should be performed either at Discharge or during Out Patient follow up
if needed
Risk Factor Modifications
Smoking and Alcohol abuse Cessation
