cap

1. COMMUNITY AQUIRED PNEUMONIA
Dr. Devawrat Buche, MD
FNB Fellow ( CCM )

2. • Definition
• Epidemiology
• Signs and symptoms
• Investigations
• Microbiology
• Risk stratification
• Treatment
• Prevention

3. DEFINITION
It is a syndrome in which acute infection of lung
develops in persons who have not been previously
hospitalized , with no regular exposure to health
care system.
Traditional definition ( NEJM, oct 2014 )
Newly developed lung infiltrate on chest imaging
along with fever, cough, sputum production,
shortness of breath with physical findings of
consolidation and leucocytosis.

4. • Joint ICS/ NCCP (I) Definition:
1. In the absence of CXR-
• Symptoms of acute LRTI for less than 1 week
• At least 1 systemic feature ( temp >37.7, chills
and rigors, severe malaise )
• New focal chest signs ( bronchial breath sounds/
crackles)
• No other explaination for the illness
2. In the presence of CXR –
• Above symptoms
• New radiologic shadowing
• With no other explaination ( edema / infarction)

5. EPIDEMIOLOGY
• World
• Social burden
• US stats : > 9 lakh cases/ year in > 65 yr age
• High rates of hospital admissions , prolonged inactivity
: health care burden
• INDIA
• NO large studies, data limited
• Attributable mortality to LRTI is around 20%
2008 stats :
• Mortality due to LRTI : 35.1/ lakh
• Mortlaity due to TB : 35.8 / lakh

6. ETIOLOGY

7. • Etiology in India (based on blood cultures ) :
S. Pneumoniae ( 35.3% )
s. Aureus ( 23.5%)
Kleb. Pneumoniae ( 20.5%)
H. Influenzae ( 8.8%)
• Legionella is often not considered in Indian
setting : 1 study found 27% patients
seropositive and 18 % urine ag positive
• No large studies to specifically address viruses
as the cause.

8. • Etiology in specific population groups :
1. Elderly
• S. pneumonia : 19- 58% of hospitalized pt.
• H. influenzae : 5- 14 %
2. Alcoholism
Increased CAP risk with dose response relationship
• S. pneumoniae: most common
• High incidence of bacteremia and increased severity
• Mortality rates similar to other groups.
3. COPD
• Increased incidence of pseudomonas and GNB
4. Diabetes mellitus
• Increased bacteremia, higher mortality rates.
• Pneumococcal pneumonia (m.c. )

9. • Risk factors for pseudomonas pneumonia :
1. Immunocompromiosed
2. Chronic respiratory disease
3. Enteral tube feeding
4. Cerebrovascular disease
5. Chronic neurological disorders
6. Structural respiratory disease : bronchiectasis

10. DIAGNOSTIC TESTING
• Physical examination
• Routine investigations
• Chest X ray
• Microbiological studies
• Immunological studies

11. Clinical diagnosis is based on:
• Presence of clinical features : cough, fever,
sputum production, pleuritic chest pain
• Physical examination: rales, bronchial breath
sounds, tachypnea, tachycardia, fever.
• Pulse oximetry : desaturation s/o severity
• Other : plasma glucose, CBC, LFT, KFT,
electrolytes

12. Chest radiography
• CXR useful in suggesting etiologic agents, prognoses,
alternative diagnosis and associated conditions
• A demonstrable infiltrate by chest radiograph or other
imaging technique is required for diagnosis of pneumonia (
level III evidence ) – should be done whenever possible.
• For hospitalized patients with suspected pneumonia having
negative CXR: continue empirical therapy and repeat CXR in
24-48 hrs.
• Salient findings :
1.Asymmetric lung opacification with air bronchogram
2. Presence of silhouette sign
3. Increased opacity with well defined interface

13. • HRCT salient findings :
1. Air space considation
2. Ground glass attenuation
3. Thickening of bronchovascular bundle
• Low sensitivity and specificity to discrimnate
bacterial from non bacterial etiology
• Recommendation :
1. Should not be routinely performed
2. Should be performed in those with nonresolving
pneumonias and for assessment of
complications.

14. Microbiological studies
1. Blood culture
• Low sensitivity , high specificity : for etiology
• Low yield : 5 – 33 %
Recommendations :
A. Should be obtained in all hospitalized
patients ( 2A )
B. Not required in routine outpatient
management ( 2A).

15. 2. Sputum Gram stain and culture
• Yield : 34 – 86 %
• Provides rapid results, narrows down etiology
SAMPLING
• 20 – 40 fields examined under low power
• If epithelial cells > 10/lpf : sample rejected
• If no. of pus cells is 10 times epi. Cells, with 3+ or4+ single
bacterial morphology : sample accepted
Recommendations :
1. Initial gram stain and culture obtained from all
hospitalized patients with CAP ( 2A)
2. Sputum for AFB obtained as per RNTCP guidelines ( 2A)
3. Sputum quality should be ensured for interpreting results
( 2A )

16. Other cultures
1.Thoracocentesis
• Pleural effusions >5 cm in lateral upright CXR
• Undergo thoracocentesis, GS and culture
• Yield is low
• But can impact management
2.BAL / tracheal aspirate.
• Not been studied prospectively in initial magt of
CAP
Best indications are :
• Immunocompromised patients with CAP
• Patients of CAP with failure of t/t

17. Immunological testing
1. Urinary pneumococcal Ag
• Rapid immunochromatographic membrane
tests
• Unfavourable cost : benefit ratio
• Only confirms etiology, no change in t/t
protocol.
Currently, not recommended routinely.

18. 2. Legionella urine Ag test
• High specificity ( 99 %), low sensitivity ( 74 %)
• Positive test is highly specific, changes duration of
antibiotic therapy
Currently recommended for patients with severe
CAP ( 1B)
3. Atypical pathogens
• Mycoplasma, chlamydia, viruses
• Serological assays used : variable results
• Currently not recommended for routine diagnosis
( 2A)

19. 4. Biomarkers
• Procalcitonin
• C reative protein
• Considered adjunct to clinical diagnosis.
• PCT can help to differentiate between bacterial
and viral etiology : aid in t/t protocols
Currrently not recommended for routine
investigations (2A)

20. Risk stratification
NEED:
• For triaging the site of treatment : OPD vs.
IPD, ward vs. ICU
• For ordering diagnostics
• For starting empirical treatment
• For prognostication
Aided by various scoring systems .

21. Scoring systems
• Well validated scoring systems :
1. CURB 65
2. Pneumonia severity index ( PSI )
3. SMART COP
4. ATS/ IDSA criteria
Other ( poorly validated ):
1. A DROP
2. REA- ICU index
3. CAP – PIRO
4. ESPANA scale

22. 1. CURB-65 SCORE
• Severity of illnes score
• Derived from pooled data from UK, NZ and Netherland
• Guide in triaging : for site of care
Score 0 – 1 : OPD
Score 2 : Wards
Score ≥ 3 : ICU
Modification is CRB 65: requires only clinical examination.

23. 2. Pneumonia Severity Index

24. • Prognostic prediction rule
• Defines severity of illness based on predicted
risk of mortality at 30 days.
• Includes 20 variables , stratified into 5 classes:
0-50 points : 0.1 % mortality
51 – 70 : 0.6 % mortality
71 -90 : 0.9 %
91 – 130 : 9.3 %
130 – 395 : 27 %

25. 3.IDSA/ATS CRITERIA

26. • Helps triaging site of care
• Criteria for ICU admission :
Any major criteria , or
At least 3 minor criteria
Definition of severe CAP : presence of both
major criteria ( need for ventilation and
vasopressors )

27. 4.SMART COP score
• Derived from Australian CAP study
• Point based severity score
• Score ≥ 3 : 92 % pt. require invasive ventilation and
vasopressors.

28. Treatment
1. Empirical
2. Definitive
The empirical t/t is guided by :
• Knowledge of most likely pathogen
• Local susceptibility patterns
• Pk/pd profile of antibiotics
• Compliance , safety and cost of drugs
• Any ongoing medical therapy / comorbidities..

29. Timing
• As soon as possible after CAP diagnosis is
established
• In severe CAP : asap, preferably within 1 hr.

30. A. OUTPATIENT
• Previously healthy & no antimicrobials within 3 months
1. Macrolide ( level I )
2. Doxycycline ( level III)
• comorbidities present / antibiotic use:
1. A respiratory FQ ( levofloxacin ) ( level I)
2. A β lactam + macrolide ( level I)
• For high infection rates( >25 %) or high resistance for S.
pneumoniae ( MIC ≥ 16 μg/ml)
- ceftriaxone/cefpodoxime/cefuroxime
- doxycycline

31. Joint ICS/NCCP (I) Recommendations :
• Stratification into patients with or without
comorbidities.
• Patients without comorbidity : monotherapy
with oral macrolides/ oral β lactam
• Patients with comorbidities : oral combinaton
therapy ( β lactam + macrolides )
• NO FQ

32. B. INPATIENT , NON ICU
• Respiratory FQ ( Level I evidence)
-moxifloxacin
-Gemifloxacin, or
- levofloxacin
• A β lactam + macrolide ( Level I evidence)
- cefotaxim/ ceftriaxone/ ampicillin
Joint ICS/NCCP (I) Recommendations:
• Resp. FQ can be used if TB is not a diagnostic
consideration.
• Patients should undergo testing for sputum AFB.
• Route of medication decided by the clinical condition

33. C. ICU PATIENTS
• A β lactam ( cefotaxim/ceftriaxone / ampicillin)
+
• Macrolide ( azithromycin ) / resp. FQ
FOR PENICILLIN ALLERGY
• A resp. FQ + Azetreonam
Joint ICS/NCCP (I) Recommendations:
• β lactam ( ceftriaxone/ amox-clav) + macrolide

34. D. HIGH RISK FOR PSEUDOMONAS
• Antipseudomal, antipneumococcal β lactam ( piperacillin
tazobactam/ cefepime/ imipenem/ meropenem )
OR
• β lactam ( as above ) + AG + MACROLIDE
OR
• β lactam ( as above ) + AG + antipneumococcal FQ
FOR PENICILLIN ALLERGY : substitute Azetreonam for β
lactam
Joint ICS/NCCP (I) Recommendations:
β lactam ( as above ) + AG + antipneumococcal FQ
• Resp. FQ can be used if TB is not a diagnostic consideration.
• Patients should undergo testing for sputum AFB

35. E. HIGH RISK FOR CA-MRSA
• Risk factors for S.aureus infection are :
1. ESRD
2. Injectable drug abuse
3. Prior influenza
4. Prior antibiotic t/t esp. with FQ.
EMPIRICAL TREATMENT :
β lactam + vancomycin / linezolid

36. F. ANAEROBIC COVER
• Indicated only in classic aspiration cases in
patients with :
• Loss of consciousness
• Alcohol/ drug overdose
• Post ictal
• Seizures in patient with gingival disease
• Loc/ seizures in patient with esophageal
motility disorder.

37. Pathogen directed treatment

38. • Switching from IV to Oral t/t :
• Hemodynamically stable
• Able to accept orally
• Normal functioning GI tract

39. • Duration of treatment
• minimum of 5 days
• Criteria before discontinuation is as below.
Patient should have these for 48 -72 hrs.

40. Reasons for lack of response

41. Outcomes ( NEJM Oct. 2014 )
• 30 day death rates in hospitalized : 10 -12 %
• Post hospital discharge : redamission within
30 days is 18 %
• Functional disability esp. in elderly
• Survivors after 30 days : mortality remains
elevated at 1 year, and in pneumococal pn. It
is elevated for 3 -5 years.

42. References
• IDSA/ ATS guidelines, 2007
• Joint ICS/NCCP (I) guidelines, Lung India, 2012
• BTS guidelines,2009
• NEJM Review article on CAP, Oct. 2014

43. THANK YOU !!