This document describes the case of a 70-year-old female patient admitted to the ICU with community acquired pneumonia. On examination, she displayed signs of confusion, fever, tachycardia, tachypnea, and hypoxemia. Diagnostic tests found consolidations in her left lung with a pleural effusion. She was given various antibiotic treatments but did not improve. A CT scan later found nonspecific interstitial pneumonia. The document also discusses definitions, causes, clinical features, severity indices, diagnostic testing, and treatment guidelines for community acquired pneumonia.

1. COMMUNITY ACQUIRED PNEUMONIA
DR. ABHAY MANGE

2.  70 year old female patient
 r/o Badegaon district Nagpur was admitted
in MICU, on 12/12/2013 with c/o
 Dry cough since 1 month
 Fever since 1 month
 Breathlessness since 15 days,
increased since 4days
 h/o arthralgia +
 No h/o bronchial Asthma, PTB/contact in past
 No h/o HTN/DM/IHD past,
 No h/o recent hospitalization

3. 0n examination
 Confused
 Febrile
 Pulse -140/min, ire. irregular
 RR-44/min
 SpO2 – 78 % in room air, 92 %
with O2( 5 L/min)
 BP- 120/80 mmHg
 Pallor +
 JVP- nr
 Edema feet absent
 No lymphadenopathy
 No s/o arthritis
 RS – AE decreased on lt side
crackles were present Lt.MA,
IAA,ISA .
 CVS- S I changing, no murmur
 PA- Soft, S/L np
 CNS – Confused ,no
menningeal signs
 CRB-65 =4

4. Investigations
 Hb – 9.9 gm%
 TLC-14000/cumm
 P-88% , L-10%,E-1%,M-1%
 BUL-95 mg%, SC-1.9mg%
 Na -147 meq/l, K-3.8 meq/l
 LFT- WNL,Except
S.Alb=2.8gm%
 ECG s/o Atrial fibrillation
 CXR S/O Consolidation Left
Lung with Synpneumonic
effusion

5. Provisional diagnosis
 Consolidation Left Lung
 Synpneumonic Effusion
 Atrial fibrillation

6. Severity indices
 CURB 65 = 4
 Confusion +
 Urea>19mgm/dl 95mg/dl
 Respiratory Rate >30/min 44/min
 Blood Pressure SP<90/ DP< 60 120/80
 Age>65 years +

7. Severity indices
CURB 30 DAYS
SCORE MORTALITY
0-1 1.5%
2 9.2%
3-5 22%
Sensitivity - 66%
Specificity - 73%

8. Severity indices
PSI SCORE =150 (CLASS-V)
CLINICAL PARAMETER SCORE
 AGE 70 YR , FEMALE 60
 ALTERED SENSORIUM 20
 RR >20 20
 BUN >30 20
 PULSE >125 10
 PLEURAL EFFUSION 10
 TOTAL 150

10. Severity indices

11. Severity indices

12. Severity indices
SMART-COP score =7
 Multilobar chest radiography involvement 1 point
 Low Albumin level 1 point
 High Respiratory rate(25/min) 1 point
 Tachycardia (>125) 1point
 Confusion 1 point
 Poor Oxygenation 2 points

13. Severity indices
SMART-COP
 Derived from the Australian CAP Study (ACAPS)
 Identifies patients who received invasive respiratory and vasopressor
support (IRVS).
Interpretation of SMART-COP score
 0 to 2 points—low risk of needing IRVS
 3 to 4 points—moderate risk (1 in 8) of needing IRVS
 5 to 6 points—high risk (1 in 3) of needing IRVS
 7 or more points—very high risk (2 in 3) of needing IRVS
 Severe CAP = a SMART-COP score of 5 or more points.

14. PARAMETER AGE <50 AGE >50 POINTS
SBP < 90 mmhg <90 mmhg 2
Multilobular CXR
involvement
+ + 1
Albumin <35gm/l <35gm/l 1
Resp.rate
>25 /min >25 /min
1
Tachycardia >125/min
>125/min
1
Confusion(acute) + + 1
Low Oxygen
PaO2 <70 or
SpO2<93 or
PaO2/FIO2 < 333
PaO2 <60 or
SpO2<90 or
PaO2/FIO2 < 250 2
PH < 7.35 <7.35 2

15. Treatment
 PUP, O2 5/L min IVF
 Inj. Piperacillin + tazobactum 4.5 gm bd
 Inj. Azithromycin 500 mg od
 Inj . Metrogyl 500 mg tds
 Inj . Diltiazem 12.5 mg stat
 Tab Diltiazem sr 60 mg od
 Nebulisation with duolin

16. Treatment and course on Day 3
ON EXAM TREATMENT
 No Clinical Improvement
 Febrile
 Pulse – 120/min
 RR – 40/min
 SpO2 – 95 % with O2
 BP 120/70
 Crackles persistent
Also on right Side (IC)
 Inj. Meropenam 1 gm tds
 Inj. Vancomycin I gm bd
 Inj. Levofloxacin 500 mg od
Blood Urea- 103mgm%
Serum Creat- 1.3mgm%

17. Treatment & Course on Day 6
ON EXAM TREATMENT
 Febrile
 Pulse -98/min,regular
 RR – 44/min
 SpO2 -91% with o2
 BP – 120/70
 Crackles persistent
 Present all over the right side
as well
 TLC 13800/cumm
 P79%, Platelets
1.10,000/cumm
 Tobramycin repsules 300mg
(5ml) bd
 Cap Tamiflu 75mg bd added

18. Day 9 – No Improvement in Cl Condt
 Inj. Colistin 2 MU bd,
 Inj . Linezolid 600 mg bd,
 Inj. Lasix 40 mg od,
•Sputum AFB- NEG
•H1N1 -ve
•Pleural fluid
•Exudative,
•TLC=380/cmm,N-28%,L-70%,
•ADA-Neg
CT Thorax planned

19. Day 15
 Clinically stable
 Inj antibiotics stopped
 Tab Cefixime 200 +
azithromycin 250 bd

20. CT -THORAX
B/L patchy inter-
lobular and intra-
lobular septal
thicknening with
associated ground
glass opacities
predomintly in sub
pleural location
Ground glass and
reticular opacities in
b/l upper lobes
FSO- Non specific
interstitial
pneumonia

21.  PULMONOLOGIST OPINION-
 Non specific Interstitial
Pneumonia
 ? Collagen Tissue Disorder
 RA factor – positive
 CRP- Negative
 ANA- Negative
 LE CELL –Negative
 E-NA - Negative

22. Final diagnosis
 Non specific Interstitial Pneumonia with
 MDR-Community acquired pneumonia

23. DISCUSSION

24. Definition
 IDSA define CAP as an acute infection of the pulmonary
parenchyma, accompanied by the presence of an acute infiltrate on a
chest radiograph (or altered auscultatory findings consistent with
pneumonia) in a patient not hospitalized or residing in a long-term
care facility for >14 days before onset of symptoms .

25. Microbial Causes of CAP, by Site of Care
 Outpatients Non-ICU ICU
 S. pneumoniae S. pneumoniae S.pneumoniae
 Mycoplasma pneumoniae M. pneumoniae Staphylococcus
aureus
 H. influenzae Chlamydia pneumoniae Legionella spp.
 C. pneumoniae H. influenzae Gram-negative
bacilli
 Respiratory virusesa Legionella spp. H. influenzae
Respiratory virusesa
 a=Influenza A and B, adenovirus, respiratory syncytial virus, and parainfluenza

26. Clinical Features
 Systemic complaints include
malaise, and high fever
 Pulmonary symptoms include any
combination of
 Dyspnea
 Chest discomfort
 Pleuritic pain
 Chest splinting
 Cough productive of purulent or
blood-tinged sputum
 Tachypnea
 Tachycardia
 In advanced cases you may see:
 Cyanosis
 Confusion
 Chest sounds include:
 Early on in disease a fine crepitant
rales over the involved portion of the
lung(s).
 Progression to lobar consolidation
results in:
 Dullness to percussion
 Vocal fremitus
 Whispered pectoriloquy
 Bronchial breathing
 Pleural effusions can occur with
the following symptoms:
 Pleural friction rub
 Dullness to percussion
 Decreased breathing sounds
 Egophony
 If necrosis of the lung occurs,
cavities in the lung develop resulting
in cavernous or amphoric breathing
directly over the cavitary lesion..

27. Site-of-Care Decisions (ATS)
Hospital admission decision.
 For patients with CURB-65 scores 2,
o more-intensive treatment—that is, hospitalization or, where
appropriate and available, intensive in-home health care services—is
usually warranted.
 Objective criteria or scores should always be supplemented with
o Physician determination of subjective factors, including the ability to
safely and Reliably take oral medication and the availability of
outpatient support resources

28. Site-of-Care Decisions – ATS Guidelines
ICU admission decision
 Direct admission to an ICU is
required for patients with septic
shock requiring vasopressors or
with acute respiratory failure
requiring intubation and
mechanical ventilation.
 Direct admission to an ICU or
high-level monitoring unit is
recommended for patients with 3
of the minor criteria for severe
CAP listed .
Minor criteria
 Respiratory rate > 30 breaths/min
 PaO2/FiO2 ratio <250
 Multilobar infiltrates
 Confusion/disorientation
 Uremia (BUN >20 mg/dL)
 Leukopenia (WBC count, <4000
cells/mm3)
 Thrombocytopenia (platelet count,
<100,000 cells/mm3)
 Hypothermia (core temperature, <36C)
 Hypotension
Major criteria
 Invasive mechanical ventilation
 Septic shock with the need for
vasopressors

29. Diagnostic Testing
Recommended diagnostic tests for etiology
Patients with CAP should be investigated for specific pathogens
 That would significantly alter standard (empirical) management
decisions,
 When presence of such pathogens is suspected on the basis of
clinical and epidemiologic clues

30. Diagnostic Testing
 Routine diagnostic tests to identify etiologic diagnosis are optional for outpatients with
CAP.
 Pretreatment blood samples for culture and an expectorated sputum sample for stain
and culture should be obtained from hospitalized patients with the clinical indications
listed below but are
 optional for patients without these conditions.
 Intensive care unit admission
 Failure of outpatient antibiotic therapy
 Cavitary infiltrates
 Leukopenia
 Active alcohol abuse
 Chronic severe liver diseas
 Severe obstructive/structural lung disease
 Asplenia (anatomic or functional)
 Recent travel (within past 2 weeks)
 Positive Legionella UAT
 Positive pneumococcal UAT result
 Pleural effusion

31. Diagnostic Testing
 Pretreatment Gram stain and culture of expectorated sputum should
be performed only if,
 a good-quality specimen can be obtained and
 quality performance measures for collection, transport, and
processing of samples can be met.
 Patients with severe CAP, should at least have blood samples drawn
for culture, urinary antigen tests for Legionella pneumophila and
Streptococcus pneumoniae performed, and expectorated sputum
samples collected for culture.
 For intubated patients, an endotracheal aspirate sample should be
obtained

32. Empirical antimicrobial therapy
Outpatient treatment
 Previously healthy and no
antibiotics in past 3 months
 A macrolide Clarithromycin
(500 mg PO bid) or
Azithromycin (500 mg PO once,
then 250 mg qd)
or
 Doxycycline (100 mg PO bid)
 Comorbidities or antibiotics
in past 3 months:
 select an alternative from a
different class A respiratory
fluoroquinolone
Moxifloxacin (400 mg PO qd),
Gemifloxacin (320 mg PO qd),
Levofloxacin (750 mg PO qd)]
or
 A -lactam [preferred: high-
dose amoxicillin (1 g tid) or
amoxicillin/clavulanate (2 g
bid); or
 ceftriaxone (1–2 g IV qd),
cefpodoxime (200 mg PO bid),
cefuroxime (500 mg PO bid)]
plus
 a macrolide

33. Empirical antimicrobial therapy
Inpatients, Non-ICU
 A respiratory fluoroquinolone
moxifloxacin (400 mg PO or IV qd),
gemifloxacin (320 mg PO qd),
levofloxacin (750 mg PO or IV qd)
or
 A -lactam [cefotaxime (1–2 g IV
q8h), ceftriaxone (1–2 g IV qd),
ampicillin (1–2 g IV q4–6h),
ertapenem (1 g IV qd in selected
patients)]
plus
 A macrolide [oral clarithromycin
or azithromycin (as listed above for
previously healthy patients) or IV
azithromycin (1 g once, then 500
mg qd)]
Inpatients, ICU
 A -lactam [cefotaxime (1–2 g IV
q8h), ceftriaxone (2 g IV qd),
ampicillin-sulbactam (2 g IV
q8h)]
plus
 Azithromycin or a
fluoroquinolone (as listed above
for inpatients, non-ICU

34. Empirical antimicrobial therapy
Special Concerns
If Pseudomonas is a consideration
 An antipneumococcal,
antipseudomonal –lactam
[piperacillin/tazobactam (4.5 g IV q6h),
cefepime (1–2 g IV q12h), imipenem
(500 mg IV q6h), meropenem (1 g IV
q8h)] plus either ciprofloxacin (400 mg
IV q12h) or levofloxacin (750 mg IV qd)
 The above –lactams plus an
aminoglycoside [amikacin (15 mg/kg qd)
or tobramycin (1.7 mg/kg qd) and
azithromycin]
 The above –lactams plus an
aminoglycoside plus an
antipneumococcal fluoroquinolone
If CA-MRSA is a consideration
 Add linezolid (600 mg IV q12h)
or
vancomycin (1 g IV q12h).

35. Empirical antimicrobial therapy
Duration of antibiotic therapy
 Patients with CAP should be treated for a minimum of 5 days ,
 should be afebrile for 48–72 h, and should have no more than 1
CAP-associated sign of clinical instability before discontinuation of
therapy
 A longer duration of therapy may be needed
 if initial therapy was not active against the identified pathogen or
 if it was complicated by extrapulmonary infection, such as meningitis
or endocarditis.

36. Multidrug-Resistant CAP
COMMON PATHOGENS
 Pseudomonas Aeruginosa
 Acinetobacter baumanii
 Staphylococcus aureus
 Klebsiella pneumoniae
 Streptococcus pneumoniae

37. Multidrug-Resistant CAP
Pseudomonas Aeruginosa
 Most worrisome characteristics of P. aeruginosa is its low antibiotic
susceptibility, which is attributable to a concerted action of multidrug
efflux pumps and the low permeability of the bacterial cellular
envelopes.
 Adjunctive antibiotic therapy with inhaled antibiotics has been
proposed in the management of MDR Pseudomonas; however, there
is no clear evidence for its use.
 The intrinsic susceptibility of P. aeruginosa is already limited to only
several antimicrobial classes, but
 Emergence of multidrug resistance compromises most of the
antipseudomonals except colistin and polymyxin B therapies.

38. Multidrug-Resistant CAP
Acinetobacter
 Acinetobacter baumanii is a Gram-negative coccobacillus that is
normally a commensal pathogen but can be a nosocomial pathogen.
 In 2004, the CDC reported an increasing number of Acinetobacter
baumannii infections in military ‘Operation Iraqi Freedom’ and in
Afghanistan during ‘Operation Enduring Freedom’.
 Most of these showed multidrug resistance , with a few isolates
resistant to all drugs tested
 Treatment options for MDR Acinetobacter include carbapenems,
polymyxins [polymyxin B and polymyxin E (colistin)], tigecycline, and
combination therapy with sulbactam or rifampicin, or combination of
carbapenem with colistin.

39. Multidrug-Resistant CAP
Acinetobacter
 Colistin is as safe and as efficacious as the standard antibiotics for
the treatment . Although the recommended dose of colistin is 2 MU
intravenously thrice a day, some studies suggest using higher doses
of colistin (9 MU/day) .
 Sulbactam is a relatively new agent for the treatment of MDR
Acinetobacter. The recommended dose for sulbactam is 40-80 mg/kg
(at least 6 g/day in divided doses).
 Rifampicin in combination with colistin has also been shown to be
beneficial in observational studies.
 Tigecycline is approved by the FDA for treatment of complicated
CAP

40. Multidrug-Resistant CAP
Staphylococcus aureus
 Community-acquired MRSA (CA-MRSA) has now emerged as an epidemic
that is responsible for rapidly progressive, fatal diseases, including
necrotizing pneumonia, severe sepsis.
 The first documented strain with complete (>16 μg/ml) resistance to
vancomycin, termed vancomycin-resistant Staphylococcus aureus(VRSA)
appeared in the United States in 2002.
 Linezolid-resistance in S. aureus was reported in 2001.
 Drugs approved for the treatment of MRSA pneumonia include vancomycin,
teicoplanin, and linezolid.
 Newer investigational drugs include lipoglycopeptides (telavancin,
dalbavancin), cephalosporins (ceftobiprole and ceftaroline), and
dihydrofolate reductase inhibitors (iclaprim)

41. Multidrug-Resistant CAP
Streptococcus pneumoniae
 Antibacterial resistance in Streptococcus pneumoniae is increasing
worldwide, affecting principally beta-lactams and macrolides
(prevalence ranging between 1% and 90% depending on the
geographical area).
 The major mechanism - mutations in genes encoding penicillin-
binding proteins.
 A large number of drugs with activity against these multi-drug
resistant strains (cephalosporins, carbapenems, glycopeptides,
ketolides, lincosamides, oxazolidinones, quinolones, deformylase
inhibitors).

42. Multidrug-Resistant CAP
Klebsiella pneumoniae
 Klebsiella pneumoniae is a facultative anaerobic, Gram-negative,
rod-shaped bacterium in the Enterobacteriaceae family.
 Klebsiella pneumoniae carbapenemase (KPC)-producing bacteria
are a group of emerging highly in a variety of clinical settings around
the world.
 Parenteral therapeutic options for infections with ESBLproducing and
carbapenem-resistant isolatesTigecycline, Colistin, Fosfomycin.

43. THANKS !