1. CAP Therapy Babak Sayad Associate Professor of Infectious Diseases
Department of Infectious Diseases
Kermanshah University of Medical Science
(KUMS)

2. Introduction
In 1901, Sir William Osler' noted in the fourth edition of his book, The Principles and Practice of Medicine, that "the most widespread and fatal of all acute diseases, pneumonia, is now Captain of the Men of Death“
Over a century later, the prominence of pneumonia a same clinical entity remains

3. Introduction
It remains among the top 10 most common causes of death among all age groups in the United States
It is the single most common cause of infection-related mortality

4. Management
The first decision confronting the clinician is whether the patient presenting with respiratory symptoms in fact has pneumonia.
The next decision is whether the patient is to be hospitalized or out patient treatment
The next problem is determining the most likely cause of pneumonia.
The final step in the management of CAP is Empirical Antibiotic Therapy

5. Management The patient in fact has pneumonia: Clinical evaluation
History
Physical Examination

6. Management The patient is to be hospitalized or out patient treatment:
PORT score (Patient Outcome ResearchTeam) or Pneumonia Severity Index (PSI)
CURB,CURB-65,CRB-65
C: Confusion
U: Urea> 7mmol/L
R: RR>30/min
B: BPs<90mm Hg or BPd<60mm Hg
65: Age>65Y

7. Management The most likely cause of pneumonia: Diagnostic Testing
Radiologic Examination
Sputum Examination
Blood Culture
Examination of Pleural Effusions
Serologic Studies
Urine Studies, Including Antigen Detection
Fiberoptic Bronchoscopy
Lung Biopsy

8. Management Empirical Antibiotic Therapy
For most patients, a specific diagnosis cannot be established with certainty before the onset of therapy
Recent controversies and questions have included when antibiotics should be started, how to determine the most appropriate antibiotics to use, and how long therapy should continue

9. Management Empirical Antibiotic Therapy
When antibiotics should be started?
In 2007, the Joint Commission suggested that antibiotics be started within 6 hours, even though no other data had been presented. The joint IDSA & ATS guidelines have suggested a more common sense approach that antibiotic treatment for pneumonia be started “as soon as possible” after the diagnosis is considered likely

10. Management Empirical Antibiotic Therapy
How to determine the most appropriate antibiotics to use?
Outpatient Therapy
Previously Healthy
Comorbidities
Inpatient Therapy
Medical Ward
Intensive Care Unit (ICU)
Health Care–Associated Pneumonia

11. Management Comorbidities COPD Diabetes Renal Failure
Congestive Heart Failure
Malignancy

12. Management Empirical Antibiotic Therapy Outpatient Therapy
Previously Healthy
No recent antibiotic therapy
Recent antibiotic therapy

13. Management Recent antibiotic therapy
That is, the patient was given a course of antibiotic(s) for treatment of any infection within the past 3 months, excluding the current episode of infection
Such treatment is a risk factor for drug-resistant Streptococcus pneumoniae and possibly for infection with gram-negative bacilli
Depending on the class of antibiotics recently given, one or another of the suggested options may be selected

14. Management Empirical Antibiotic Therapy Outpatient Therapy
Previously Healthy
No recent antibiotic therapy
Macrolide or doxycycline
Recent antibiotic therapy
A respiratory fluoroquinolone alone, an advanced macrolide plus oral β-lactam

15. Management Empirical Antibiotic Therapy Outpatient Therapy
Comorbidities
No recent antibiotic therapy
An advanced macrolide plus oral β-lactam or a respiratory fluoroquinolone
Recent antibiotic therapy
A respiratory fluoroquinolone alone or an advanced macrolide plus a β -lactam
Suspected aspiration with infection
Amoxicillin-clavulanate or clindamycin
Influenza with bacterial superinfection
Vancomycin,linezolid, or other coverage for MRSA or CA-MRSA

16. Management Empirical Antibiotic Regimens for Out- Patient CAP therapy:
Macrolide
Doxycycline
A respiratory fluoroquinolone alone
An advanced macrolide plus oral β-lactam
Amoxicillin-clavulanate
Clindamycin
Linezolid

17. Management Empirical Macrolide Azithromycin (500 mg once daily)
Clarithromycin ( mg twice daily)
Erythromycin ( mg four times a day)

18. Management
Empirical Doxycycline
Doxycycline (100 mg 2 times/day)

19. Management Empirical respiratory fluoroquinolone
Moxifloxacin (400 mg once daily)
Gemifloxacin (320 mg once daily)
Levofloxacin (750 mg once daily)

20. Management Empirical advanced macrolide plus oral β-lactam
Azithromycin (500 mg once daily)
Clarithromycin ( mg twice daily)
Oral β-lactam
High-dose amoxicillin (1 g three times a day)
High-dose amoxicillin-clavulanate (2 g twice daily)
Cefpodoxime (200 mg twice daily)
Cefuroxime (500 mg twice daily)

21. Management Empirical Amoxicillin-clavulanate
High-dose amoxicillin-clavulanate (2 g twice daily)

22. Management
Empirical Clindamycin
Clindamycin (300 mg PO q6h)

23. Management
Empirical Linezolid
Linezolid (600 mg twice daily)

24. Management Empirical Antibiotic Therapy Inpatient Therapy Medical Ward
No recent antibiotic therapy
A respiratory fluoroquinolone alone or an advanced macrolide plus an IV β -lactam
Recent antibiotic therapy
An advanced macrolide plus an IV β -lactam, or a respiratory fluoroquinolone alone (regimen selected will depend on nature of recent antibiotic therapy)

25. Management Empirical Antibiotic Therapy Inpatient Therapy
Intensive Care Unit (ICU)
Pseudomonas infection is not a concern
A β -lactam plus either an advanced macrolide or a respiratory fluoroquinolone
Pseudomonas infection is not a concern but patient has a β-lactam allergy
A respiratory fluoroquinolone, with or without clindamycin

26. Management Pseudomonas infection is a concern in:
Severe structural lung disease (e.g., bronchiectasis, cystic fibrosis)
Recent antibiotic therapy
Health care–associated exposures
Stay in hospital (especially in the ICU)

27. Management Empirical Antibiotic Therapy Inpatient Therapy
Intensive Care Unit (ICU) …
Pseudomonas infection is a concern
Either (1) an antipseudomonal β -lactam plus ciprolloxacin, or (2) an antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide
Pseudomonas infection is a concern but the patient has a β -lactam allergy
Aztreonam plus aminoglycoside plus a respiratory fluoroquinolone

28. Management Health care-associated pneumonia
Pneumonia developing in patients who have been hospitalized for 2 or more days within 90 days of developing infection
Patients attending hospital or hemodialysis clinics
Patients receiving intravenous antibiotic therapy, wound care, or chemotherapy at home within 30 days of developing infection
Residents of long-term care facilities or nursing homes

29. Management Empirical Antibiotic Therapy Inpatient Therapy
Health care-associated pneumonia
Either (1) an antipseudomonal β-lactam plus ciprofloxacin or levofloxacin or (2) an antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide plus vancomycin or linezolid (for MRSA coverage)

30. Empirical Antibiotic Regimens for In- Patient CAP therapy:
A respiratory fluoroquinolone alone
An advanced macrolide plus an IV β -lactam
A β-lactamg plus a respiratory fluoroquinolone
A respiratory fluoroquinolone with clindamycin
An antipseudomonal β-lactam plus ciprofloxacin
An antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide
Aztreonam plus aminoglycoside plus a respiratory fluoroquinolone
An antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide plus vancomycin or linezolid

31. Management Empirical Antibiotic Therapy
How long therapy should continue?
The classic 10 to 14days of care is unsupported by evidence
Recent data suggest that clinical stability occurs more quickly, and therefore antibiotic therapy may be safely discontinued earlier
Less than 7 days and as short as 3 days are just as effective as any longer durations of therapy for mild to moderate pneumonia.
Oral antibiotic therapy is safe after clinical stability has been reached

32. Management Empirical Antibiotic Therapy Adjunctive Therapy
Critical illness-related corticosteroid insufficiency (CIRCI) has been associated with community-acquired pneumonia
Statins also possess anti-inflammatory properties