Ashraf Mokhtar Madkour, MD, Dr.med.

Chest Diseases Department

Ain Shams University Hospital

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


Community-Acquired Pneumonia:
A Clinical case scenario
Presentation
A 66-year-old man
accompanied by his wife,
arrived at the Emergency
Department complaining of
shortness 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.
Symptoms
Symptoms
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 History
X-smoker 2 years (30 pack years).
COPD.
Type 2 diabetes.
Medications include
Inhaled salbutamol (100 g)+ beclomethasone
diproprionate (50 g) 2 puffs x 3.
Sustained released theophylline (200mg cap 1x2).
Gliclcazide (80mg tab. 1x1).
Examination
Confused.
Temperature: 39.0C.
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-ray









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

Definition of CAP

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


IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia
in Adults. Clinical Infectious Diseases 2007; 44:S2772




CAP: Diagnosis

In addition to a constellation of suggestive
clinical features, a demonstrable infiltrate
by chest radiograph or other imaging
technique, with or without supporting
microbiological data, is required for the
diagnosis of pneumonia.

IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia
in Adults. Clinical Infectious Diseases 2007; 44:S2772


Clinical features:
Productive cough, dyspnea, fever,
clinical signs of consolidation
Radiological findings:
Consolidation

CAP Risk Factors for Pneumonia
Elderly
Smoking
COPD
Extreme weather
Overcrowding
Alcoholism
DM
Renal insufficiency
CHF
Chronic liver disease
Immunossuppresion
Loss of consciousness
Seizures
What is the value of CXR in CAP?
Establish Dx
Evaluation of severity
e.g. multilobar or bilateral, pleural effusion.
Co-existing conditions
e.g. bronchial obstruction, abscess.
Pattern
Infiltrate Patterns and Pathogens
CXR Pattern Possible Pathogens
Lobar
S.pneumoniae, Kleb, H. influ,
Gram Neg
Patchy Atypicals, Viral, Legionella
Interstitial Viral, PCP, Legionella
Cavitatory
Anaerobes, Kleb, TB, S.aureus,
Fungi
Large effusion Staph, Anaerobes, Klebsiella
Initial investigations at ER:
Hgb 13.4 gm/dl, Hct 40%.
WBC 15,800/l with 88% polymorphonuclear cells, 8%
bands.
Na+ 137 mEq/L, K+ 3.7 mEq/L.
BUN 32 mg/dl, creatinine1.8 mg/dl.
RBG 260 mg/dl.
Arterial blood gas (room air):
pH 7.38, PCO
2
53 mmHg, PO
2
58mmHg, O
2
Sat.% 89%
CAP Management based on PSI Score
PORT
Class
PSI Score Mortality % Treatment Strategy
Class I No RF 0.1 0.4 Out patient
Class II 70 0.6 0.7 Out patient
Class III 71 - 90 0.9 2.8
Brief
hospitalization
Class IV 91 - 130 8.5 9.3 Inpatient
Class V > 130 27 31.1 IP - ICU
Would you hospitalize him?



Assess the ability to safely and reliably take oral
medication & the availability of outpatient support
resources
CURB 65 score
CURB 65
Confusion
BUN 30
RR 30
BP SBP <90
/DBP <60
Age > 65
CURB 0 or 1 Home Rx
CURB 2 Short Hosp
CURB 3 Medical Ward
CURB 4 or 5 ICU care
Thorax 2003,58:377
(If study performed)
<60mmHg / SO
2
<90%
Pneumonia Severity
Index (PSI) score
Clinical
Parameter
Scoring
Age in years
Age in yrs
66
Co-morbid Illnesses
Neoplasia
0
Liver Disease
0
CHF
0
CVD
0
Renal Disease
0
Clinical Parameter Scoring
Clinical Findings
Altered Sensorium 20
Respiratory Rate > 30 20
SBP < 90 mm 0
Temp < 35
0
C or > 40
0
C 0
Pulse > 125 per min 0
Investigation Findings
Arterial pH < 7.35 0
BUN > 30 20
Serum Na < 130 0
Hematocrit < 30% 0
Blood Glucose > 250 10
Pa O
2
10
X Ray e/o Pleural Effusion 0
PSI= 146 Class V ICU
Calculation of risk assessment (PSI score)

The patient was hospitalized and admitted to ICU
What testing would you do?

Diagnostic testing
Recommendations for diagnostic testing remain
controversial.
No convincing data that they improve outcomes.
Outpatient setting: optional
Inpatient setting:
Critically ill CAP
Specific pathogens (suspected)






IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia
in Adults. Clinical Infectious Diseases 2007; 44:S2772


Diagnostic 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
IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia
in Adults. Clinical Infectious Diseases 2007; 44:S2772












What testing would you do?

Pretreatment:
Sputum: Gram staining and culture.
Expectorated sputum should be deep cough specimen obtained before
antibiotic treatment and it should be rapidly transported and processed
within a few hours of collection.*
Blood cultures (2 sets)
2 sets of blood cultures should be drawn before initiation of antibiotic
therapy during the first 24 hour.*
*IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia
in Adults. Clinical Infectious Diseases 2007; 44:S2772


What treatment would you
prescribe?
Therapy
Fluid / diet
Antipyretics (Paracetamol IV)
Sugar blood chart & Insulin accordingly
Cough syrup
SR theophylline
Inhalation ttt salbutamol + ipratropium bromide
O
2
therapy NP 2 L/min
Empiric Antibiotic ttt
Antibiotic
General & supportive
What antibiotics are appropriate?

CAP: When to start empiric therapy?

As soon as possible in ED
CAP: delay-to-AB> 4h after arrival
Increased mortality
Increased LOS


IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia
in Adults. Clinical Infectious Diseases 2007; 44:S2772


Site of
Care

RF Treatment 1 Treatment 2 Treatment 3
OP No RF AZ CLR ER / Doxy
OP RF FQ + M + Doxy
Med
Ward
RF FQ + AZ 3G + AZ Etrap + M
ICU
RF

3G + AZ 3G + FQ FQ+ AZT
Pseud
Extended +
Cipro / Levo
3G + AmGly
+ AZ
3G + AmGly
+ FQ

CA-
MRSA
+ Vanco/Linezo
Recommended empirical antibiotics
for CAP: Inpatient, ICU ttt
b-lactam plus either azithromycin or a respiratory
fluoroquinolone
(cefotaxime, ceftriaxone)


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

IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia
in Adults. Clinical Infectious Diseases 2007; 44:S2772



2 hours after ICU admission

Sputum (gram stain)
Gram-positive diplococcus


Value of Gram stain
First, it broadens initial empirical coverage for less common etiologies,
such as infection with S. aureus or gram-negative organisms. *
Second, it can validate the subsequent sputum culture result. A positive
Gram stain was highly predictive of a subsequent positive culture.*

*IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia
in Adults. Clinical Infectious Diseases 2007; 44:S2772



Day 3
Sputum culture & Sensitivity:
Streptococcus pneumoniae
Sensitive Cefotaxime, Ceftraixone and
Levofloxacin.
Susceptibility testing should guide antibiotic
choice when results are available.

Continue on the same antibiotics




Day 3:
The patient's condition began to improve, but fever
persisted.
Day 5:
The patient was a febrile for the first time.
Normal oral intake started.
Cough, dyspnea grade & chest wheezes improved.
Pulse 90 bpm, B/P 140/80.
WBC 6,800/l with 3% bands.
BUN 18 mg/dl, creatinine1.4 mg/dl, 2 PPBS 170mg/dl.
O
2
Sat.% on RA: 93%.
Transferred to ward.


Switch from intravenous to oral therapy?
Afebrile
No abnormal GIT absorption
Cough & respiratory distress improved
WBC returning to normal


Levofloxacin 750 mg tab/24hr
IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia
in Adults. Clinical Infectious Diseases 2007; 44:S2772


Day 8:
Clinically stable
Afebrile for 3days.
CXR: partial resolution.
Blood culture:
No growth up till now.


CAP: Duration of Therapy?

A minimum of 5 days
Afebrile for 48-72 h
No more than 1 CAP-
associated sign of
clinical instability

IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia
in Adults. Clinical Infectious Diseases 2007; 44:S2772


Day 9:
Discharged and antibiotic stopped.
Recommendations
/ pneumococcal polysaccharide vaccination
/ During next influenza season, influenza
vaccination.
/ ttt COPD & DM.
FU CXR after 1 week.