COMMUNITY-ACQUIRED PNEUMONIA (CAP) - Anju Jain, MS, ATC, PA-C 08/03/19
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COMMUNITY-ACQUIRED
PNEUMONIA (CAP)
Anju Jain, MS, ATC, PA-C
08/03/19
Disclosures § I have no disclosures
OBJECTIVES § Identify Community-Acquired Pneumonia (CAP) , microbiology, clinical findings and diagnosis criteria § Differentiate between the clinical presentation of Bacterial CAP and Viral CAP § Identify risk stratifying diagnostic tools for mortality prediction for CAP § Identify classes of drugs and drug regimen therapy for CAP
COMMUNITY ACQUIRED PNEUMONIA
(CAP)
§ Community-acquired pneumonia (CAP)1: an
infection pulmonary parenchyma that is acute and
occurring in non-health care setting
§ Healthcare-associated pneumonia (HCAP)1:
pneumonia that occur in settings such as long-term care
facilities, dialysis centers or having been recently admitted
in the hospital
§ Hospital-acquired pneumonia (HAP)2: pneumonia
that occurs > 48 hours after an admission stay in the
hospital
COMMUNITY ACQUIRED PNEUMONIA
(CAP)
§ Even famous people are diagnosed with it….
MICROBIOLOGY
Typical Atypical/Viral
• Streptococcus Atypical
pneumoniae 3 • Mycoplasma pneumoniae
• MOST COMMON • Legionella pneumophila
• Chlamydophila pneumoniae
• Haemophilus influenzae
• Viral
• Moraxella catarrhalis • Influenza A and B
• Human rhinovirus
• Staphylococcus aureus • Respiratory syncytial virus
RISK FACTOR/PATHOGENS
RISK FACTOR PATHOGEN
Injection Drug Use1,4
-S. pneumoniae, anaerobes,
S. aureus
Alcoholism -M. tuberculosis, S.
pneumoniae, Anaerobic oral
flora
COPD/Smoking -H. influenzae, M. catarrhalis,
P. Aeruginosa
Aspiration -Anaerobic oral floraCLINICAL FINDINGS FOR CAP
§ SIGNS AND SYMPTOMS1-4
§ Pleuritic chest pain
§ Tachypnea
§ +/- cough with purulent sputum production
§ Elevated temperature> 100.40F /380C
§ Hypotensive
§ Decreased oxygen saturations
§ Altered mental status (severe)
§ Physical exam findings for consolidation (rales, fine
crackles, dullness to percussion, egophany, tactile
fremitus, etc.)DIAGNOSITC FINDINGS FOR CAP
§ LABORORATORY DATA1-4
§ Leukocytosis with a left shift
§ Leukopenia (in severe CAP)
§ Thrombocytopenia
§ ESR, CRP and +/- Procalcitonin
§ RAPID POINT OF CARE DATA5
§ Urine antigen tests for Legionella and/or
Pneumococcal
§ Rapid antigen detection test for Influenza (PCR)
§ Sputum Gram StainDIAGNOSITC FINDINGS FOR CAP § Rapid antigen detection test for Influenza (PCR)
DIAGNOSTIC FINDINGS FOR CAP
§ Sputum Gram Stain S. Pneumoniae
§Sputum Gram Stain M. CatarrhalisIMAGING FOR CAP CHEST RADIOGRAPH IS THE STANDARD1,7
IMAGING FOR CAP
§ Chest Radiographs for Typical Pathogens1,3
§ Typical Pneumococcal CAP demonstrates
a segmental infiltrate at the lobar regions
§ Chest X-ray for Atypical/Viral Pathogens1,3
§ Not very well defined, with patchy like appearance and
interstitial infiltrates that are generalized
§ Legionella pneumophila presents on radiograph with
diffuse infiltrates that do not appear in a typical lobar
patternIMAGING FOR CAP
IMAGING FOR CAP Pneumonia suggesting Viral Etiology
IMAGING FOR CAP Pneumonia suggesting Legionella
IMAGING FOR CAP Pneumonia suggesting Psuedomonas
CLINICAL PRESENTATION
Typical Bacterial CAP3 Viral CAP3
• Sepsis presentation • Exposure to sick contacts
• Lack of upper respiratory • Presences of upper
symptoms respiratory symptoms
• WBC> 15,000 with left • WBC will be within
shift average range or slightly
• Procalcitonin elevated elevated
• Lobar or dense • Procalcitonin within
consolidation on average range
radiograph • Infiltrates are patchy on
radiographOUTPATIENT OR ADMISSION? Pneumonia Severity Index (PSI)6 § https://www.mdcalc.com/psi-port-score- pneumonia-severity-index-cap -Risk Class I-V points added based on: § Age § Gender § Co-morbidities (renal or liver dysfunction, CHF, etc.) § Vital sings findings (tachycardia, tachypnea, fever, SPB
OUTPATIENT OR ADMISSION? CURB-65: Calculated Mortality Rate6 § http://www.mdcalc.com/curb-65-severity-score- community-acquired-pneumonia/ § Confusion § Uremia (BUN >19 mg/dL) § Respiratory rate: RR >30/min § Blood pressure: SBP or DBP hypotensive § Age > 65
OUTPATIENT OR ADMISSION? SMART-COP: Does not predict mortality6 -MD Calc for SMART-COP -Predicts the risk of admission and the need for intensive respiratory or vasopressor support (IRVS) in community- acquired pneumonia (CAP) Systolic blood pressure: SBP
OUTPATIENT OR ADMISSION? 6RiderAC, Frazee BW. Community-acquired pneumonia. Emerg Med Clin N Am. 2018;(36): 665–683.
COMPLICATIONS DUE TO CAP § Complications for Typical/Atypical Bacterial5 § Bacteremia § Sepsis § Empyema § Increase in Mortality rate § Infections in distant location (e.g., meningitis) § Complications for Viral5 § Increase in Mortality § Acute Respiratory Distress Syndrome § Residual functional abnormalities
DIFFERENTIAL DIAGNOSES § What else could it be other than CAP? § Acute exacerbation of Chronic Bronchitis § Sarcoidosis § Neoplasm of the Lung § Pulmonary Embolism
DRUG CLASS/TREATMENT REGIMEN
3
1Mandell LA, Wunderink RG, Anzueto A, et. al. Thoracic Society consensus guidelines on the management of community-
acquired pneumonia in adults. Clin Infect Dis. 2007;(44): S27-S72.DRUG CLASS/TREATMENT REGIMEN
§ Treatment for Bacterial Pathogen1,3,5
§ Start with treating empirically for S. Pneumo
§ Patient has not been on antibiotics in the last 90 days
§ Macrolides first line therapy (eg Azithromycin or
Clarithromycin)
§ Also Tetracycline due to low cost (Doxycycline) or allergies
§ Consider a probiotic or antifungal in conjunction
§ Treatment for Bacterial Pathogen with
comorbidities (Diabetes, immunosuppressed,
works in daycare, etc.)1,3,5
§ Fluoroquinolones: Levofloxacin, Moxifloxacin
§ Be mindful of use and risk of tendinopathyDRUG CLASS/TREATMENT REGIMEN
§ Treatment for Viral Pathogen1,3,5
§ Treatment for Influenza A or B
§ Osteltamivir (Tamiflu): 75mg twice daily by mouth x
5days (adjust dose for CrCl values)
§ Must start within 48 hours of onset of symptoms
§ For Influenza A can utilize Amantadine or
Rimantadine
§ These drugs may help speed recoveryPREVENTION OF CAP § For Immunocompetent/Immunocompromised Patients Greater Than 65 Years-old § PCV13 = 13-valent pneumococcal conjugate vaccine8 § PCV 13 be administered first and then….. § PPSV23 = 23-valent pneumococcal polysaccharide vaccine8 § PPPSV23 to be administered 12 months after the PCV13
References 1. Mandell LA, Wunderink RG, Anzueto A, et. al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community- acquired pneumonia in adults. Clin Infect Dis. 2007;(44): S27-S72. 2. Ramirez, JA. Overview of community-acquired pneumonia in adults. UpToDate Online. Waltham, MA; 2019. http://www.uptodateonline.com. Accessed July 1, 2019. 3. Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med. 2014;(371): 1619-1628.
References 4. Kaysin A, Viera A. Community-acquired pneumonia in adults: diagnosis and management. Am Fam Physician. 2016;(94): 698-706. 5. Chesnutt AN, Chesnutt MS, Prendergast NT, Prendergast TJ. Pulmonary Disorders: Pulmonary infections. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis & Treatment 2019 New York, NY: McGraw-Hill, 2019. 6. Rider, AC, Frazee, BW. Community-acquired pneumonia. Emerg Med Clin N Am. 2018;(36): 665–683.
References 7. Hill AT, Gold PM, El Solh AA et al. Adult outpatients with acute cough due to suspected pneumonia or influenza: CHEST guideline and expert panel report. Chest. 2019; 155(1):155-67. 8. Kobayashi M, Bennett NM, Gierke R, Almendares O, Moore MR, Whitney CG, et al. Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2015;64(34):944-7.
THANK YOU!!! anjujain@yahoo.com
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