Community Acquired Pneumonia

1. Community Acquired Pneumonia Peter Valenzuela, MD, MBA, FAAFP Assistant Dean for Clinical Affairs Assistant Professor/Dept. of Family Medicine

2. Objectives • Identify the pathogens common to CAP • Describe the signs and symptoms of CAP • Describe the diagnostic criteria for CAP • Discuss treatment options for CAP

3. Background • Total annual cost of health care for CAP in U.S. is $8.4 billion • 5.6 million cases of CAP in U.S. each year J Respir Dis 2002; 23:10-7 • Pneumonia and influenza combined are 7th leading cause of death in U.S. • 21.8 deaths per 100,000 Natl Vital Stat Rep 2003; 52:1-115

4. Definition • Community-Acquired Pneumonia (CAP)-lower respiratory tract infection in a non-hospitalized person associated with symptoms of acute infection with or without new infiltrate on chest radiograph

5. Types-Pathogens • Typical CAP (60-70%) • Streptococcus pneumoniae • Atypical CAP (30-40%) • Influenza virus • Mycoplasma • Chlamydia • Legionella

6. Signs & Symptoms • Clinical symptoms • Cough (productive or non-productive) • Fever (>100.4) • Chills/Rigors • Dyspnea • Fatigue/Myalgia • Gastrointestinal (Legionella)

7. Signs & Symptoms • Physical exam • Dullness to percussion of chest • Crackles or rales on auscultation • Bronchial breath sounds • Egophony (“E” to “A” changes)

8. Diagnosis- Labs • All patients with suspected CAP should have chest radiograph • Leukocyte count • Sputum Gram stain • Blood cultures x 2 • Serum/urine antigens

9. Radiograph findings • Lobar consolidation is common in typical pneumonia This image can be accessed at http://www.emedicine.com/med/images/187614_2228CONSOLID.JPG

10. Radiograph findings • Diffuse or patchy infiltrates are more common in atypical pneumonia This image can be accessed at http://www.mevis.de/~hhj/Lunge/ima/InfOrniThA54.JPG

11. Management • Inpatient cost for CAP is $7,500 • Outpatient cost for CAP is $150-$350 • Pneumonia Severity Index- assesses need for hospitalization This index can be accessed at http://www.medscape.com/content/2004/00/49/50/495094/art-jags495094.app.gif

12. Management Algorithm This algorithm can be accessed at http://www.aafp.org/afp/20060201/442_f1.gif

13. Treatment • Preferred outpatient management is single therapy with one of the following • Macrolide • Fluoroqunolone • Doxycycline • Preferred inpatient management • Beta-lactam + macrolide • Fluoroquinolone

14. Summary • Identify the pathogens common to CAP • Describe the signs and symptoms of CAP • Describe the diagnostic labs for CAP • Discuss treatment options for CAP

15. Questions?

16. References • Lutfiyya N, et al, Diagnosis and treatment of community-acquired pneumonia Am Fam Physician 2006;73:442-50 • Niederman MS. Community-acquired pneumonia: management controversies, part 1; practical recommendations from the latest guidelines. J Respir Dis 2002;23:10-7. • Arias E, Anderson RN, Kung HC, Murphy SL, Kochanek KD. Deaths: final data for 2001. Natl Vital Stat Rep 2003;52:1-115. • Fish D. Pneumonia. PSAP, Pharmacotherapy Self-Assessment Program. Kansas City, Mo.: American College of Clinical Pharmacy, 2002:202. • Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-50.