Community Acquired Pneumonia (2)

8/6/2019 Community Acquired Pneumonia (2)

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CommunityCommunity--acquiredacquired

PneumoniaPneumoniaRiRi

2003/10/272003/10/27


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DefinitionDefinition

CommunityCommunity--acquired pneumonia (CAP) isacquired pneumonia (CAP) is

defined as an acute infectionof the lungdefined as an acute infectionof the lung

parenchyma accompanied by symptoms of acuteparenchyma accompanied by symptoms of acuteillness, which is not acquired in hospitals orillness, which is not acquired in hospitals or

other longother long--term care facilities.term care facilities.

--Clin. infect Dis. 2000;31:347Clin. infect Dis. 2000;31:347--8282


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EpidemiologyEpidemiology

One of the most common infectious diseases in theOne of the most common infectious diseases in the

world.world.

12/1,000/year, about 600,000 hospitalization cases12/1,000/year, about 600,000 hospitalization casesper year (in the U.S.).per year (in the U.S.).

The 6th leadingcause of death in the U.S. (7th inThe 6th leadingcause of death in the U.S. (7th in

Taiwan).Taiwan).

The most common cause of death due to infectiousThe most common cause of death due to infectious

disease.disease.

--N Engl J Med 1995; 333:1618N Engl J Med 1995; 333:1618--2424


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EpidemiologyEpidemiology

Pathogens that cause CAP

-N Engl J Med 1995; 333:1618-24


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PathologyPathology

Primarily involve the interstitiumor thePrimarily involve the interstitiumor the

alveoli.alveoli.

Lobar pneumoniaLobar pneumonia

bronchopneumoniabronchopneumonia

NecrotizingpneumoniaNecrotizingpneumonia

LungabscessLungabscess

--HarrisonHarrisons Principles of Internal Medicine, 15th edition (2001)s Principles of Internal Medicine, 15th edition (2001)


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Clinical ManifestationsClinical Manifestations

Typical presentationTypical presentation

Atypical presentationAtypical presentation

Syndromes of the two presentation sometimesSyndromes of the two presentation sometimesmight be overlappingmight be overlapping

--HarrisonHarrisons Principles of Internal Medicine, 15th edition (2001)s Principles of Internal Medicine, 15th edition (2001)


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Typical presentationTypical presentation

Cough (>90%)Cough (>90%)

Suddenonset of fever (80%

)Suddenonset of fever (80%

) SOB (66%)SOB (66%)

Sputum production (66%)Sputum production (66%)

Pleuritic pain (50%)Pleuritic pain (50%)

Signs of pulmonary consolidation (dullness, increasedSigns of pulmonary consolidation (dullness, increasedfremitus, egophony, bronchial breatathingsound, rales)fremitus, egophony, bronchial breatathingsound, rales)



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Atypical presentationAtypical presentation

More gradual onsetMore gradual onset

Dry coughDry cough Extrapulmonary symptomsExtrapulmonary symptoms

LegionellaLegionella--CNS, heart, liver, GI and GUCNS, heart, liver, GI and GU

M.pneumoniaeM.pneumoniae-- upper RT, GI, skinupper RT, GI, skin

The point that extrapulmonaryorganThe point that extrapulmonaryorganinvolvement separate atypical from typicalinvolvement separate atypical from typicalpneumonia cannot be overemphasized!pneumonia cannot be overemphasized!

--Eur J Clin Microbiol Infect Dis (2003) 22: 579Eur J Clin Microbiol Infect Dis (2003) 22: 579--583583


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DiagnosisDiagnosis

Does this patient

have CAP?


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DiagnosisDiagnosis

Prompt and accurate diagnosis ofCAP isPrompt and accurate diagnosis ofCAP is

important, since it is the only acute respiratoryimportant, since it is the only acute respiratory

tract infection in which delayed antibiotictract infection in which delayed antibiotic

treatment has been associated with increasedtreatment has been associated with increased

riskof death.riskof death.

--JAMA 1997;278:2080JAMA 1997;278:2080--44


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DiagnosisDiagnosis

History and physical examinationHistory and physical examination

Image studyImage study

LaboratoryLaboratory--based approachbased approach Invasive proceduresInvasive procedures


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History and Physical ExaminationHistory and Physical Examination

-Ann Intern Med. 2003;138:109-118


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Image StudyImage Study

CxR, hrCTCxR, hrCT

CxR: theCxR: the imperfectimperfect

gold standardgold standard Sensitivity/specificitySensitivity/specificity

CostCost

AvailabilityAvailability

ExpertiseExpertise

--Ann Intern Med. 2003;138:109Ann Intern Med. 2003;138:109--118118


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LaboratoryLaboratory--based approachbased approach

WBC countWBC count

CC--reactive proteinreactive protein

Sputum culture and smearSputum culture and smear

Blood cultureBlood culture

Pleural effusion analysisPleural effusion analysis

SerologySerology

PCRPCR

--Thorax 2002; 57:267Thorax 2002; 57:267--271271


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Invasive ProceduresInvasive Procedures

BronchoscopyBronchoscopy

Upper airway flora contaminationUpper airway flora contamination

Protected specimen brush (PSB)Protected specimen brush (PSB)

Pathogen yield rate: 13~48%Pathogen yield rate: 13~48%

Bronchoalveolar lavage (BAL)Bronchoalveolar lavage (BAL)

Pathogen yield rate: 12~30%Pathogen yield rate: 12~30%

--Thorax 2002; 57:267Thorax 2002; 57:267--271271


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ConclusionConclusion

Careful choice and combinationofmultipleCareful choice and combinationofmultiple

diagnostic methods would yield optimal result.diagnostic methods would yield optimal result.


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TreatmentTreatment


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The Importance ofEmpiricalThe Importance ofEmpirical

Antibiotic TreatmentAntibiotic Treatment

Despite the improvement in diagnostic methods,Despite the improvement in diagnostic methods,

some cases ofCAP (mayup to30%) cansome cases ofCAP (mayup to30%) cantt

isolate a specific pathogen.isolate a specific pathogen.--Thorax 2002; 57:267Thorax 2002; 57:267--271271

The availabilityof diagnostic methodsThe availabilityof diagnostic methods

-Chest 2001; 120:2021-2034


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The Menace ofDrugThe Menace ofDrug--ResistanceResistance

About 34%of pneumococcal isolates are penicillinAbout 34%of pneumococcal isolates are penicillin--resistant.resistant.

--Diagn Microbiol Infect Dis 1997; 29:249Diagn Microbiol Infect Dis 1997; 29:249--257257

The mechanismof resistance: altered penicillinThe mechanismof resistance: altered penicillin--bindingbindingproteinprotein

Resistant to amoxicillinResistant to amoxicillin--clavulanateclavulanate--Antimicrob Agent Chemother 1990;34:2075Antimicrob Agent Chemother 1990;34:2075--20802080

Resistance toother antibiotic classes is higher amongResistance toother antibiotic classes is higher amongpenicillinpenicillin--resistant strains.resistant strains.

--J Antimicrob Chemother 1996;38(suppl):71J Antimicrob Chemother 1996;38(suppl):71--8484


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Role of FluoroquinolonesRole of Fluoroquinolones

DNAgyrase inhibitorsDNAgyrase inhibitors

PotencyPotency

Favorable pharmacokineticsFavorable pharmacokinetics

Broad spectra of antimicrobial activitiesBroad spectra of antimicrobial activities

Excellent respiratory tissue penetration and activitiesExcellent respiratory tissue penetration and activities

against respiratory pathogensagainst respiratory pathogens Drugresistance is uncommonDrugresistance is uncommon

--Chest 2001; 120:2021Chest 2001; 120:2021--20342034


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Strategy of ManagementStrategy of Management--

the PORT

Score Assessmentthe PORT

Score Assessment

-N Engl J Med 1997; 336:243-50


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Empirical Treatment for OutEmpirical Treatment for Out--PatientPatient

Macrolide (clarithromycinor azithromycinMacrolide (clarithromycinor azithromycin

forfor H. influenzaeH. influenzae))

FluoroquinolonesFluoroquinolones

DoxycyclineDoxycycline

AmoxicillinAmoxicillin--clavulanateclavulanate

2nd generation cephalosporin2nd generation cephalosporin

--Chest 2001; 120:2021Chest 2001; 120:2021--20342034


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Empirical treatment for InEmpirical treatment for In--patientpatient

(General Ward)(General Ward)

3rd generation cephalosporin plus a macrolide3rd generation cephalosporin plus a macrolide

or doxycyclineor doxycycline

Antipneumococcal fluoroquinolonesAntipneumococcal fluoroquinolones BetaBeta--lactamlactam--betabeta--lactamase inhibitor plus alactamase inhibitor plus a

macrolide or doxycyclinemacrolide or doxycycline



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(ICU)(ICU)

No riskofNo riskofP. aeruginosaP. aeruginosainfectioninfection

3rd generation cephalosporin plus an anti3rd generation cephalosporin plus an anti--

pneumococcal fluoroquinolones or a macrolidepneumococcal fluoroquinolones or a macrolide

BetaBeta--lactamlactam--betabeta--lactamase inhibitor pluslactamase inhibitor plus antianti--

pneumococcal fluoroquinolones orpneumococcal fluoroquinolones or macrolidemacrolide



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(ICU)(ICU)

With riskofWith riskofP. aeruginosaP. aeruginosainfectioninfection

AntipseudomonalAntipseudomonal betabeta--lactam plus aminolactam plus amino--glycosideglycoside

plus macrolide orplus macrolide or antipneumococcalantipneumococcal

fluoroquinolonesfluoroquinolones

AntipseudomonalAntipseudomonal betabeta--lactam plus ciprofloxacinlactam plus ciprofloxacin



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PathogenPathogen--specific Treatmentspecific Treatment

-Chest 2001; 120:2021-2034


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PathogenPathogen--specific Treatmentspecific Treatment

-Chest 2001; 120:2021-2034


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Poor Prognostic FactorsPoor Prognostic Factors

-N Engl J Med 1995; 333:1618-24


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When Can InWhen Can In--Patient Discharge?Patient Discharge?

-N Engl J Med 2002; 347:2039-45


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Community Acquired Pneumonia (2)