Community Acquired Pneumonia

1
Community Acquired Pneumonia

• Infectious Diseases Society of America
• And American Thoracic Society
• Guidelines on CAP in adults

2
Community acquired pneumonia

• Presence of an infiltrate on chest x ray as well
  as clinical signs and symptoms (such as fever,
  productive cough and chest pain)

3
Diagnostic testing

• Patients should be screened for hypoxia with
  pulse oximetry.
• Outpatients and hospitalized patients without
  cormobidities pretreatment sputum and blood
  cultures are optional.
• Patients with severe cap should have blood and
  sputum cultures and urinary antigen tests for
  Legionella pneumophila and streptococcus
  pneumoniae.
• Urinary antigen testing is also advised for
  patients who fail outpatient therapy.

4
Curb-65 criteria

• One point each for confusion, uremia, respiratory
  rate, low blood pressure, age 65 or older.
• And the Pneumonia Severity index can be used to
  determine treatment setting

5
Determine Treatment Setting

• Curb-65 of 2 indicates inpatient treatment or
  intensive home health care services. Depending on
  several factors such as family support.

6
ICU admission

• Patients requiring vasopressors or mechanical
  ventilation.
• Severe CAP having three of the following
  respiratory rate of 30, hypoxemia( PaO2/FiO) of
  250, multilobar infiltrates, confusion, uremia,
  leukopenia, thrombocytopenia or hypotension.

7
Outpatient treatment

• Healthy patients whove had no antibiotic within
  3 months. Macrolide ( clarithromycin or
  erythromycin) or doxycycline.
• Patients with cormobidities or use of an
  antibiotic within three months use a respiratory
  fluroquinolone (moxifloxin, gemifloxacin, or
  levofloxacin) or a B-lactam plus a macrolide.
  High dose amoxicillin (1 gm tid)

8
Outpatients continued

• Or amoxicillin-clavulanate(2 gm bid) alternatives
  include ceftriaxone,cefpodime and cefuroximine
  (500 bid) doxycycline is an alternative to the
  macrolide.
• Macrolide resistant areas S. pneumoniae infection
  rates greater than 25 use a flouroquinolone or a
  b-lactam or cephalosporin and doxycycline.

9
Inpatients

• Respiratory fluoroquinolone or the combination of
  B-lactam (cefotaxime, ceftriazone or ampicillin)
  and macrolide.
• In some patients ertapenem and macrolide can be
  used when there is anaerobic and drug resistant
  S. pneumoniae infection

10
Icu treatment

• B-lactam (cefotaxime,ceftriaxone, or
  ampicillin/sulbactam) in combination with
• Azithromycin or a respiratory fluroquinolone.
• Penicillin allergies use aztreonam with a
  fluoroquinolone

11
Icu continued

• Pseudomonas infection suspected use
  antipneumococcal, antipseudomonal B-lactam with
  either cipro or levofloxin. Alternative B-lactam
  and aminoglycoside and azithromycin or a
  fluoroquinolone.
• Community acquired methicillin resistant (MRSA)
  Add vancomycin or linezolid.

12
Influenza A

• Treat with Zanamivir or Oseltamivir within
• 48 hours of symptoms.
• If symptoms longer and are hospitalized they also
  can be given either medication.

13
Patients with influenza with exposure to live
poultry

• Test the patient for H5N1 infection, place on
  droplet precautions and treat with both
  antivirals and antibacterial.

14
Prevention

• Pneumococcal polysaccharide vaccine is
  recommended for patients aged 65 years old and
  for younger higher risk patients. If given prior
  to age 65 a second dose is recommended also.
• Inactivated Influenza vaccine is recommended for
  patients aged 50 or for younger persons at risk
  for complications of influenza, household
  contacts of high risk individuals and health care
  workers. Therefore, at least 2/3 of US population
  qualifies for it.

15
In Summary

• Decide on appropriate treatment setting.
• Diagnostic testing should be done when needed.
• Begin empiric antibiotic therapy
• Practice preventive measures through immunization
  of patients.