1. Diagnosis, Empiric Management and Prevention of CAP

2. Pneumonia
Acute infection of the pulmonary parenchyma accompanied by symptoms of acute illness accompanied by abnormal chest findings.
Third leading cause of morbidity (2001) and mortality (1998) in Filipinos based on the Philippine Health Statistics (DOH).
CPG is a joint statement from PSMID, PCCP and PAFP.

3. 2004 CAP Guidelines in Immunocompetent Adults
CAP definition:
Lower respiratory tract infection
Acute onset of within 24 hrs to 2 wks
Patient with :
cough
Tachypnea (RR>20), tachycardia (HR>100), fever (T>37.8˚C)
At least one abnormal chest findings breath sounds, rhonchi, crackles, or wheeze

4. Chest x- ray is required for definitive Dx
CAP in Immunocompetent Adults Update
No particular sx & abnormal P.E. finding sufficiently sensitive or specific to confirm or exclude the Dx
Chest x- ray is required for definitive Dx
Clinical prediction rules may be utilized if CXR is not available

5. Diagnostic standard – Chest radiograph Assess severity
CAP in Immunocompetent Adults Update
Diagnostic standard – Chest radiograph
Assess severity
Presence of complications
pleural effusion
multilobar involvement
abscess
May suggest possible etiology
Differentiate pneumonia from other conditions
In addition to confirm the diagnosis of pneumonia, an initial chest radiographic examination is essential in assessing the severity of disease and presence of complication. Finding of bilateral or multilobar involvement, progression of infiltrates within 24 hours, pleural effusion, and lung abscess are suggestive of severe disease, poor prognosis and indicate the need for hospital admission. Chest radiography may also suggest possible etiology and help in differentiating pneumonia from other conditions that my mimic it (Grade A).

6. LOW Risk C A P ---> Outpatient Care
CAP in Immunocompetent Adults Update
Which patient will need hospital admission ?
Pts w/ stable VS:
RR < 30 breaths/min, PR < 125 beats/min
DBP > 60 mmHg & SBP > 90 mmHg
No / stable comorbid condition *
No evidence of extrapulmonary sepsis
No evidence of aspiration
CXR: localized infiltrates; no evidence of pleural effusion nor abscess; not progressive within 24 h
LOW Risk C A P ---> Outpatient Care

7. * Comorbid conditions include:
Diabetes mellitus (DM)
Neoplastic disease
Neurologic disease
Congestive heart failure (CHF)
Coronary artery disease (CAD)
Renal failure
COPD
Chronic liver disease
Chronic alcohol abuse

8. Patients which will need hospital admission ? Moderate CAP: In-patients
Pts w/ unstable VS:
RR > 30 breaths/min,
PR > 125 beats/min,
Temp > 40oC or <35oC
unstable comorbid condition *
extrapulmonary evidence of sepsis *
suspected aspiration
Chest X-ray: multilobar infiltrates; pleural effusion or abscess; progression of findings to >50% in 24 hrs

9. *Unstable comorbid conditions include:
uncontrolled diabetes mellitus (DM)
active malignancies
neurologic disease in evolution
congestive heart failure (CHF) Class II-IV
unstable coronary artery disease (CAD)
renal failure on dialysis
uncompensated COPD
decompensated liver disease

10. Patients which will need hospital admission ? High Risk CAP: ICU Care
Any criteria under moderate risk category
plus
Hemodynamic alterations and hypoperfusion
(i.e. altered mental state, DBP <60 mmHg or SBP <90 mmHg, urine output <30 ml/hr) or
Impending or frank respiratory failure
(i.e. Hypoxemia of PaO2 <60 mmHg or acute hypercapnea of PaCO2 >50 mmHg)

11. *Extrapulmonary evidence of sepsis:
Moderate Risk C A P:
Hepatic
Hematologic
Gastrointestinal
Endocrine
High Risk C A P:
CNS - altered mental state
CVS - DBP <60 mmHg or SBP <90 mmHg
Renal - urine output <30 ml/hr

12. CAP Algorithm: Management-Oriented Risk Stratification of
Community-Acquired Pneumonia
in Immunocompetent Adults
CAP
Any of the ff:
1. RR > 30/min
2. PR > 125/min
3. Temp > 40oC or <35oC
4. Extrapulmonary evidence of
sepsis
5. Suspected aspiration
6. Unstable comorbid conditions*
7. CXR: multilobar, pleural effusion
abscess, progression of
lesion to >50% of initial
within 24 hrs
YES
Any of the ff:
1. Shock or signs of hypoperfusion
- hypotension
- altered mental state
- urine output <30ml/hr
2. PaO2<60mmHg or
Acute hypercapnea
(PaCO2>50mmHg)
HIGH RISK CAP
YES
Intensive care
MODERATE RISK CAP NO
In-patient
LOW RISK CAP
Outpatient NO

13. Microbiologic studies are necessary in CAP?
Moderate Risk CAP
Blood CS
Sputum GS CS
Optional :
PA for M. pneumoniae
MIF for C. pneumoniae (for elderly & immunocompromised)
Urine Ag Test for L. pneumophila
DFA Test for L. pneumophila
High Risk CAP
Blood CS
Sputum GS CS
(ABG)
PA for M. pneumoniae
MIF for C. pneumoniae
Urine Ag Test for L. pneumophila
DFA Test for L. pneumophila

14. PRINCIPLES OF EMPIRICAL THERAPY
Treat early; give antibiotics within 4 h of admission
Cannot reliably differentiate etiology on basis of clinical findings
Treat most likely pathogens
S. pneumoniae; H. Influenzae
Atypicals
Others (local epidemiology)
*Recent antibiotics, recent hospitalization, etc.

15. Empiric Antimicrobial Therapy in CAP
Low risk: Amoxicillin, Co-trimoxazole, Macrolides (Azithromycin, Clarithromycin, Roxithromycin)
Co-amoxiclav, Sultamicillin
2nd Generation Cephaloporins: Cefuroxime, Cefaclor

16. Empiric Antimicrobial Therapy in CAP
Moderate Risk CAP: Macrolides, Antipneumococcal fluoroquinolones (PO or IV), β-lactams with β-lactamase inhibitor (IV)
2nd Generation Cephalosporins (IV)
3rd Generation Cephalosporins (Ceftriaxone, Cefotaxime, Ceftizoxime IV)
Carbapenems (Ertapenem IV)

17. Nonpseudomonal c IV b-lactams include
2nd gen cephalosporin cefuroxime sodium
3rd gen cephalosporins ceftriaxone, cefotaxime
those w/ anaerobic activity:
cefoxitin, ceftizoxime, ertapenem
d IV b-lactams w/ b-lactamase inhibitor include
ampicillin-sulbactam, amoxicillin-clavulanic acid

18. e IV antipneumococcal fluoroquinolones include
levofloxacin
gatifloxacin
moxifloxacin

19. Empiric Antimicrobial Therapy in CAP High Risk C A P
With risk for P. aeruginosa:
IV antipseudomonal b-lactamf +/- b-lactamase inhibitor g +
IV macrolide or
IV antipneumococcal FQ e
+/-
aminoglycoside or
IV ciprofloxacin
No risk for P. aeruginosa:
IV nonpseudomonal b-lactam c
+/- b-lactamase inhibitor d +
IV macrolide OR
IV antipneumococcal FQ e

20. Antipseudomonal f IV b-lactams include g IV b-lactams
3rd gen cephalosporin ceftazidime
4th gen cephalosporins cefepime, cefpirome
those w/ anaerobic activity:
imipenem-cilastatin, meropenem
g IV b-lactams
w/ b-lactamase inhibitor piperacillin-tazobactam, ticarcillin-clavulanic acid

21. fever declines w/in 72 hrs; temperature normalizes within 5 days
How do we assess response to initial Rx ?
Most patients w/ uncomplicated bacterial pneumonia will respond to treatment within hrs
fever declines w/in 72 hrs; temperature normalizes within 5 days
respiratory signs, esp. tachypnea, return to normal
A follow-up CXR NOT necessary to confirm that infiltrate has cleared for low-risk CAP patients

22. Switch Therapy to an oral agent if:
How do we assess response to initial Rx ?
Switch Therapy to an oral agent if:
Less cough & resolution of respiratory distress
Afebrile for > 24 h
Etiology is not a virulent/resistant pathogen
Stable co-morbid condition
No life-threatening complication
This will allow early hospital discharge ----> cost savings

23. Duration of antibiotic use based on etiology
Etiologic Agent
Duration of therapy (days)
Most bacterial pneumonia except
GNB, S. aureus, P. aeruginosa
Enteric Gram (-) pathogens, S. aureus,
P. aeruginosa
Mycoplasma & Chlamydophilia
Legionella sp.
5-7
3 (azalides)
10-14
14-21

24. Follow-up CXR to determine:
Pneumothorax
Cavitation
Extension to previously uninvolved lobes
Pulmonary edema; ARDS
Re-assess bacteriologic studies: to determine resistance to antibiotic being given or presence of other pathogens i.e., M. TB or fungi
* In elderly: S. pneumoniae & L. pneumophila may be causes of slowly resolving pneumonia

25. How do we prevent pneumonia?
Pneumococcal vaccine
Influenza vaccine
Adult dose
O.5 ml IM or SC
one-time revaccination may be given after 5 years
0.5 ml IM
once a year
C.I.
Serious allergic reaction to a vaccine component
moderate or serious acute illness
Precautions
Guillain-Barre Syndrome