2. 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 A Clinical case scenario

3. Presentation A 66-year-old man accompanied by his wife, arrived at the Emergency Department complaining of shortness of breath, fever, and cough.

4. 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

5. 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.

6. Medical History  X-smoker 2 years (30 pack years).  COPD.  Type 2 diabetes.  Medications include  Inhaled salbutamol (100 μg)+ beclomethasone diproprionate (50 μg) 2 puffs x 3.  Sustained released theophylline (200mg cap 1x2).  Gliclcazide (80mg tab. 1x1).

7. Examination  Confused.  Temperature: 39.0°C.  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.

8. Chest X-ray

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

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

11. CAP: Diagnosis suggestive “In addition to a constellation of suggestive clinical featuresinfiltrate clinical features, a demonstrable infiltrate by chest radiograph or other imaging with or without supporting technique, with or without supporting microbiological data microbiological data, is required for the diagnosis of pneumonia.” Clinical features: Productive cough, dyspnea, fever, clinical signs of consolidation Radiological findings: Consolidation

12. CAP – Risk Factors for Pneumonia  Elderly  Smoking  COPD  Extreme weather  Overcrowding  Alcoholism  DM  Renal insufficiency  CHF  Chronic liver disease  Immunossuppresio n  Loss of consciousness  Seizures

13. 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

14. Infiltrate Patterns and Pathogens

15. Initial investigations at ER:  Hgb 13.4 gm/dl, Hct 40%.  WBC 15,800/μl 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%

16. CAP – Management based on PSI Score

17. Would you hospitalize him?

18. Assess the ability to safely and reliably take oral medication & the availability of outpatient support resources

19. CURB 65 score Thorax 2003,58:377

20. (If study performed) (If study performed) <60mmHg / SO 2 <90% Pneumonia Severity Index (PSI) score

21. PSI= 146 Class V→ ICU Calculation of risk assessment (PSI score)

23. What testing would you do?

24. 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)

25. 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

26. 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.* 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.*

27. What treatment would you prescribe?

28. 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

29. What antibiotics are appropriate?

30. CAP: When to start empiric therapy?  As soon as possible in ED  CAP: delay-to-AB> 4h after arrival  Increased mortality  Increased LOS

31. 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

33. 2 hours after ICU admission 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.*

34. Day 3  Sputum culture & Sensitivity: Streptococcus pneumoniae  Sensitive  Sensitive → Cefotaxime, Ceftraixone and Levofloxacin.  Susceptibility testing should guide antibiotic choice when results are available.  Continue on the same antibiotics

35.  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/μl with 3% bands.  BUN 18 mg/dl, creatinine1.4 mg/dl, 2 PPBS 170mg/dl.  O 2 Sat.% on RA: 93%.  Transferred to ward.

36. Switch from intravenous to oral therapy?  Afebrile  No abnormal GIT absorption  Cough & respiratory distress improved  WBC returning to normal Levofloxacin 750 mg tab/24hr

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

38. CAP: Duration of Therapy? A minimum of 5 days…  “A minimum of 5 days… Afebrile for 48-72 h … Afebrile for 48-72 h … No more than 1 CAP- No more than 1 CAP- associated sign of clinical instability’’

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