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Community-Acquired Pneumonia

Community-Acquired Pneumonia. Objectives. Describe the common pathogenesis and pathogens of pneumonia Discuss diagnosis and initial management of community acquired pneumonia (CAP) Understand features of the Pneumonia PORT Severity Index

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Community-Acquired Pneumonia

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  1. Community-Acquired Pneumonia

  2. Objectives • Describe the common pathogenesis and pathogens of pneumonia • Discuss diagnosis and initial management of community acquired pneumonia (CAP) • Understand features of the Pneumonia PORT Severity Index • Discuss the IDSA/ATS guidelines and recommendations for final antibiotic choice • Understand issues in basic management for pneumonia in children, nursing home patients, and immunocompromised patients.

  3. Epidemiology • Unclear! Few population-based statistics on the condition alone • CDC combines PNA with influenza for morbidity & mortality data • PNA & influenza = 7th leading causes of death in the US (2001) • Age-adjusted death rate = 21.8 per 100,000 • Mortality rate: 1-5% out-Pt, 12% In-Pt, 40% ICU • Death rates increase with comorbidity and age • Affects race and sex equally

  4. Community Acquired Pneumonia • Infection of the lung parenchyma in a person who is not hospitalized or living in a long-term care facility for ≥ 2 weeks • 5.6 million cases annually in the U.S. • Estimated total annual cost of health care = $8.4 billion • Most common pathogen = S. pneumo (60-70% of CAP cases)

  5. “Nosocomial” Pneumonia • Hospital-acquired pneumonia (HAP) • Occurs 48 hours or more after admission, which was not incubating at the time of admission • Ventilator-associated pneumonia (VAP) • Arises more than 48-72 hours after endotracheal intubation

  6. “Nosocomial” Pneumonia • Healthcare-associated pneumonia (HCAP) • Patients who were hospitalized in an acute care hospital for two or more days within 90 days of the infection; resided in a nursing home or LTC facility; received recent IV abx, chemotherapy, or wound care within the past 30 days of the current infection; or attended a hospital or hemodialysis clinic • Guidelines for the Management of Adults with HAP, VAP, and HCAP. American Thoracic Society, 2005

  7. Pathogenesis • Inhalation, aspiration and hematogenous spread are the 3 main mechanisms by which bacteria reaches the lungs • Primary inhalation: when organisms bypass normal respiratory defense mechanisms or when the Pt inhales aerobic GN organisms that colonize the upper respiratory tract or respiratory support equipment

  8. Pathogenesis • Aspiration: occurs when the Pt aspirates colonized upper respiratory tract secretions • Stomach: reservoir of GNR that can ascend, colonizing the respiratory tract. • Hematogenous: originate from a distant source and reach the lungs via the blood stream.

  9. Pathogens • CAP usually caused by a single organism • Even with extensive diagnostic testing, most investigators cannot identify a specific etiology for CAP in ≥ 50% of patients. • In those identified, S. pneumo is causative pathogen 60-70% of the time

  10. Streptococcus pneumonia • Most common cause of CAP • Gram positive diplococci • “Typical” symptoms (e.g. malaise, shaking chills, fever, rusty sputum, pleuritic hest pain, cough) • Lobar infiltrate on CXR • Suppressed host • 25% bacteremic

  11. Pneumonia Atypical Pneumonia • #2 cause (especially in younger population) • Commonly associated with milder Sx’s: subacute onset, non-productive cough, no focal infiltrate on CXR • Mycoplasma: younger Pts, extra-pulm Sx’s (anemia, rashes), headache, sore throat • Chlamydia: year round, URI Sx, sore throat • Legionella: higher mortality rate, water-borne outbreaks, hyponatremia, diarrhea

  12. Viral Pneumonia • More common cause in children • RSV, influenza, parainfluenza • Influenza most important viral cause in adults, especially during winter months • Post-influenza pneumonia (secondary bacterial infection) • S. pneumo, Staph aureus

  13. Other bacteria • Anaerobes • Aspiration-prone Pt, putrid sputum, dental disease • Gram negative • Klebsiella - alcoholics • Branhamella catarrhalis - sinus disease, otitis, COPD • H. influenza • Staphylococcus aureus • IVDU, skin disease, foreign bodies (catheters, prosthetic joints) prior viral pneumonia

  14. Diagnosis and Management

  15. Guidelines • American Thoracic Society • Guidelines for the Management of Adults with CA (2001) • Infectious Diseases Society of America • Update of Practice Guidelines for the Management of CAP in Immunocompetent adults (2003) • ATS and IDSA joint effort • IDSA/ATS Consensus Guidelines on the Management of CAP in Adults (March 2007)

  16. Guidelines • 2001 ATS & 2003 IDSA Guideline Update • Expert panels • Evidence-based recommendations • Recommend patient stratification to identify likely pathogens and suggested empiric abx • Site of care • Presence of cardiopulmonary disease • Presence of “modifying factors”

  17. Clinical Diagnosis • Suggestive signs and symptoms • CXR or other imaging technique • Microbiologic testing

  18. Signs and Symptoms • Fever or hypothermia • Cough with or without sputum, hemoptysis • Pleuritic chest pain • Myalgia, malaise, fatigue • GI symptoms • Dyspnea • Rales, rhonchi, wheezing • Egophony, bronchial breath sounds • Dullness to percussion • Atypical Sx’s in older patients

  19. Clinical Diagnosis: CXR • Demonstrable infiltrate by CXR or other imaging technique • Establish Dx and presence of complications (pleural effusion, multilobar disease) • May not be possible in some outpatient settings • CXR: classically thought of as the gold standard

  20. Infiltrate Patterns

  21. Clinical Diagnosis: Recommended testing • Outpatient: CXR, sputum Cx and Gram stain not required • Inpatient: CXR, Pox or ABG, chemistry, CBC, two sets of blood Cx’s • If suspect drug-resistant pathogen or organism not covered by usual empiric abx, obtain sputum Cx and Gram stain. • Severe CAP: Legionella urinary antigen, consider bronchoscopy to identify pathogen

  22. Clinical Diagnosis • Assess overall clinical picture • PORT Pneumonia Severity Index (PSI) • Aids in assessment of mortality risk and disposition • Age, gender, NH, co-morbidities, physical exam lab/radiographic findings

  23. IDSA: Outpt Management in Previously Healthy Pt • Organisms: S. pneumo, Mycoplasma, viral, Chlamydia pneumo, H. flu • Recommended abx: • Advanced generation macrolide (azithro or clarithro) or doxycycline • If abx within past 3 months: • Respiratory quinolone (moxi-, levo-, gemi-), OR • Advanced macrolide + amoxicillin, OR • Advanced macrolide + amoxicillin-clavulanate

  24. IDSA: Outpt Management in Pt with comorbidities • Comorbidities: cardiopulmonary dz or immunocompromised state • Organisms: S. pneumo, viral, H. flu, aerobic GN rods, S. aureus • Recommended Abx: • Respiratory quinolone, OR advanced macrolide • Recent Abx: • Respiratory quinolone OR • Advanced macrolide + beta-lactam

  25. IDSA: Inpt Management-Medical Ward • Organisms: all of the above plus polymicrobial infections (+/- anaerobes), Legionella • Recommended Parenteral Abx: • Respiratory fluoroquinolone, OR • Advanced macrolide plus a beta-lactam • Recent Abx: • As above. Regimen selected will depend on nature of recent antibiotic therapy.

  26. IDSA: Inpt Management-Severe/ICU • One of two major criteria: • Mechanical ventilation • Septic shock, OR • Two of three minor criteria: • SBP≤90mmHg, • Multilobar disease • PaO2/FIO2 ratio < 250 • Organisms: S. pneumo, Legionella, GN, Mycoplasma, viral, ?Pseudomonas

  27. IDSA: Inpt Management: Severe/ICU • No risk for Pseudomonas • IV beta-lactam plus either • IV macrolide, OR IV fluoroquinolone • Risk for Pseudomonas • Double therapy: selected IV antipseudomonal beta-lactam (cefepine, imipenem, meropenem, piperacillin/tazobactam), plus • IV antipseudomonal quinolone -OR- • Triple therapy: selected IV antipseudomonal beta-lactam plus IV aminoglycoside plus either IV macrolide, OR IV antipseudomonal quinolone

  28. Switch to Oral Therapy • Four criteria: • Improvement in cough and dyspnea • Afebrile on two occasions 8 h apart • WBC decreasing • Functioning GI tract with adequate oral intake • If overall clinical picture is otherwise favorable, can can switch to oral therapy while still febrile.

  29. Management of Poor Responders • Consider non-infectious illnesses • Consider less common pathogens • Consider serologic testing • Broaden antibiotic therapy • Consider bronchoscopy

  30. Prevention • Smoking cessation • Vaccination per ACIP recommendations • Influenza • Inactivated vaccine for people >50 yo, those at risk for influenza compolications, household contacts of high-risk persons and healthcare workers • Intranasal live, attenuated vaccine: 5-49yo without chronic underlying dz • Pneumococcal • Immunocompetent ≥ 65 yo, chronic illness and immunocompromised ≤ 64 yo

  31. Pneumonia in Children: Dx • Symptoms • Infants: non-specific manifestations • Fever, poor feeding, irritability, vomiting, diarrhea, URI Sx, cough, respiratory distress • Older children: more specific • Fever, cough, chest pain, tachypnea, tachycardia, grunting, nasal flaring, retracting. Cyanosis usually very late. • Signs/Physical exam • RR > 60 for all ages • Hypoxia • Rales, wheezes, crackles, coarse breath sounds

  32. Pneumonia in Children: Pathogens • 0-4 wks: GBS, GN enterics, Listeria • 4-12 wks: C. trachomatis, GBS, GN enterics, Listeria, viral (RSV/parainfluenza), B. pertussis • 3 mos-4 yrs: Viral, S. pneumo, H. influenza, M. catarrhalis, Grp A Strep, Mycoplasma • > 5yrs: Mycoplasma (5-15yrs), C. pneumo, S. pneumo, viral

  33. Pneumonia in the Elderly • Prevention important • Presentation can be subtle • Antibiotic choice in CAP is same as other adults • Healthcare associated pneumonia • Consider S. aureus (skin wounds) and GN bacteria (aspiration) • Pneumonia in Older Residents of Long-term Care Facilities. AFP 2004; 70: 1495-1500.

  34. Pneumonia in Immunocompromised Pts • Smokers, alcoholics, bedridden, immuno-compromised, elderly • Common still common • S. pneumo • Mycoplasma • Pneumocystis Carinii Pneumonia • P. jirovecii • Fever, dyspnea, non-prod cough (triad 50%), insidious onset in AIDS, acute in other immunocompromised Pts • CXR: bilateral interstitial infiltrates • Steroids for hypoxia • TMP-SMZ still first line

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