community acquired pneumonia

1. Community Acquired Pneumonia Dr. Leena Mane PGY3 Resident Emory Family Medicine

3. Outline Epidemiology and etiology Diagnosis Admission decision The workup for C.A.P. Treatment- what to use, how to use,how long Recovery

4. Epidemiology 7 th most common cause of death in U.S. 5.6 million cases annually Annual Health care cost 8.4 billion Definition- pneumonia not acquired in a hospital or long term care facility

5. Etiology of C.A.P No etiology in ~ 50 % > 2 etiologies in 2-5% S. Pneumonia in : 2/3 of bacterial cases or 20 % of all cases H. Influenzae ( non typeable) Mycoplasma pneumonia Chlamydia p ~12% Influenza Legionella ~ 5%

6. Atypical Pneumonia Age (years)- less than 40 Onset- Gradual, coryzal prodrome Cough- Paroxysmal, hacking non productive Sputum- Minimal, mucoid Rigors- Absent Fever- Usually less than 39.5 °C

7. Atypical Pneumonia ctd Consolidation- Usually absent Leucocytosis - usually absent Chest x-ray- Initially interstitial, may progress to air space involvement

8. Atypical pneumonia

9. Acute Bacterial Pneumonia Age ( in yrs) : less than 5, over 40 Onset : Abrupt Cough : Productive Sputum : Rusty & Purulent Rigors : Frequently present Fevers : > 39.5° c Consolidation: present Leucocytosis : 15- 25,000 with neutrophilia Chest X-ray : alveolar with air bronchograms.

10. When To Suspect Which Bug…..

11. Causes & sign & symptoms S pneumonia – episodes of rigor, pleurisy, elderly , alcoholic H. Influenzae -- COPD M. catarhalis – COPD Anaerobic -- Putrid Sputum Influenza -- Winter epidemic Chlamydia P -- S.T, HA, hoarseness

12. Causes , Sign & symptoms PCP -- Immunocompromised patients Legionella – Severe illness, compromised host, Neg G.S.,organ transplant, outbreaks related with water source. Mycoplasma P – 2-4 wks of prodrome, dry cough

13. Diagnosis Cough/dyspnea /fever = CXR EBM – II ( moderate)

14. Admit or not 2 step decision rules

15. Step 1 Assign to risk class I OR Risk classes II- IV

16. Risk Class I < 50 years of age have none of five co- morbid conditions that increase mortality Neoplasm CHF Renal disease Cerebrovascular disease Liver disease

17. Step approach If not in class I Go on to Step 2 ( assign to one of classes II- V )

18. Step 2 Assess patient’s severity index and assign a score Demographics Co- morbidities P. E. findings Lab findings

19. Demographics Characteristics Points Age Male age( in years) Female age ( in years)- 10 Nursing home age ( in years) + 10 Residents

20. Co- morbidities Diseases Points Neoplasm + 30 Liver disease + 20 CHF + 10 CVD + 10 Renal disease + 10

21. Physical exam Finding Points AMS + 20 RR> 30 + 20 SBP<90mm + 20 T<35? or > 40? + 15 P> 125 + 10

22. Laboratory Findings Points Ph<7.35 + 30 Na< 130 + 20 Hct < 30% + 10 PO2< 60 + 10 Pleural effusion + 10

23. The" whole ‘ Shootin’ Match " Patient Assigned points Demographics Co- morbidities P. E. finding Lab finding

24. Stratification of Risk Score Risk Initial Treatment Risk class Based on Low Outpatient I Algorithm Outpatient II < 70 points Medium Observation III 71-90 points Inpatient IV 91- 130 point High Inpatient (ICU) V > 130

25. Other considerations Psychosocial contraindication to outpatient Rx Compliance problems Substance abuse Cognitive impairment Poor social support

26. Risk class mortality Risk class Mortality I 0. 1 % - outpatient II 0. 6 % - outpatient III 2.8 % - inpatient IV 8.2 % - inpatient V 29.2 % - inpatient

27. P. S. I. Pneumonia severity index can serve as general guideline for management , clinical judgment should always supersede the prognostic scores.

28. Sensitivity & Specificity of diagnostics tests Diagnostics Tests Sensitivity Specificity Chlamydia Rapid PCR( sputum) 30-90 >95 Serology( rise in Ab) 10 – 100 - Sputum Cx 10- 80 >95 Gm Neg rods Sputum GM stain 15- 100 11- 100

29. Sensitivity & specificity ctd Tests Sensitivity Specificity H. Inf, Moraxella Sputum Cx 20- 79 20- 79 Influenza Rapid DFA 22-75 90 Legionella DFA 22- 75 90 PCR 83- 100 >95 Serum acute titer 10- 27 >85 Urinary Ag 55- 90 > 95

30. Sensitivity & Specificity Ctd Tests Sensitivity Specificity Mycoplasma Antibody Titers 75-95 >90 Cold Agglutinins 50- 60 - PCR 30- 95 >95 Pneumococcal Pneumoniae Chest X-ray 40 - Sputum Cx 20- 79 20- 79 Sputum Gm stain 15- 100 11- 100

31. Blood Culture Positive blood cultures had no correlations with severity of disease and outcome Current ATS guidelines recommend that patient hospitalized for suspected CAP receive two sets of blood cultures. However are not necessary for outpatient diagnosis

32. Inpatient work up Inpatient Sputum Cx Level II ( moderate) Bld Cx Level I ( High) BMP Level II LFTs Level II PO2 Level II

33. Sputum Level II evidence Low power exam Acceptable specimen < 10 epithelial cells > 25 PMNs

34. Sputum samples Normal sputum Moraxella catarrahalis

35. Sputum Samples H. Influezae Klebsiella pneumoniae

36. Pseudomonas Strep Pneumoniae

37. Treatment Target etiology Watch for resistance pattern Be aware of co- morbidities

38. What to use Outpatient Macrolides Fluroquinolones Doxycycline

39. Management of CAP

40. What to use Inpatient- Fluroquinolones alone Extended spectrum cephalosporins + macrolides Level II evidence

41. What to Use ICU patients One of Cefotaxime, Ceftraixone, amp- sulbactum or pipercillin – tazobactum Plus One of macrolides or fluroquinolones

42. Bug & Treatment Pathogen Abx S. Pneumoniae Pen G, amoxicillin fluroquinolones H Influenzae bactrim, cefotaxime, rocephin/carbapenam S. Aureus nafcillin /vancomycin

43. Bug & Treatment Pathogen Abx Klebsiella carbapenams or 3rd gen cephalosporins Pseudomonas aminoglycoside plus antipse. Penicillins or Ceftazidime Chlamydia Doxy or quinolones Legionella Azithromycin or quinolones Anaerobes Clindamycin

44. Recovery Symtoms Time period Subjective Response 1-3 days Fever without bacteremia - 2.5 days with bacteremia – 6-7 days

45. Recovery Symptoms Time period CXR non elderly 30 days older patients 6-8 wks Legionella 12 wks Fatigue non elderly 30- 45 days elderly 90 days

46. Prevention Pneumococcal vaccine Influenza vaccine

47. Bibliography Diagnosis & treatment of CAP- aafp 2006 IDSA/ATS consensus guidelines on management of community acquired pneumonia in adults