Community-Acquired Community-Acquired PneumoniaPneumonia

ObjectivesObjectives

Describe the common pathogenesis and Describe the common pathogenesis and pathogens of pneumoniapathogens of pneumonia

Discuss diagnosis and initial management of Discuss diagnosis and initial management of community acquired pneumonia (CAP)community acquired pneumonia (CAP)

Understand features of the Pneumonia PORT Understand features of the Pneumonia PORT Severity IndexSeverity Index

Discuss the IDSA/ATS guidelines and Discuss the IDSA/ATS guidelines and recommendations for final antibiotic choicerecommendations for final antibiotic choice

Understand issues in basic management for Understand issues in basic management for pneumonia in children, nursing home patients, pneumonia in children, nursing home patients, and immunocompromised patients.and immunocompromised patients.

EpidemiologyEpidemiology

Unclear! Few population-based statistics on the Unclear! Few population-based statistics on the condition alonecondition alone

CDC combines PNA with influenza for morbidity CDC combines PNA with influenza for morbidity & mortality data& mortality data PNA & influenza = 7th leading causes of death in the PNA & influenza = 7th leading causes of death in the

US (2001)US (2001) Age-adjusted death rate = 21.8 per 100,000Age-adjusted death rate = 21.8 per 100,000 Mortality rate: 1-5% out-Pt, 12% In-Pt, 40% ICUMortality rate: 1-5% out-Pt, 12% In-Pt, 40% ICU Death rates increase with comorbidity and ageDeath rates increase with comorbidity and age Affects race and sex equallyAffects race and sex equally

Community Acquired Community Acquired PneumoniaPneumonia

Infection of the lung parenchyma in a Infection of the lung parenchyma in a person who is person who is not hospitalized or living not hospitalized or living in a long-term care facility for ≥ 2 weeksin a long-term care facility for ≥ 2 weeks

5.6 million cases annually in the U.S.5.6 million cases annually in the U.S. Estimated total annual cost of health care Estimated total annual cost of health care

= $8.4 billion = $8.4 billion Most common pathogen = Most common pathogen = S. pneumo S. pneumo (60-(60-

70% of CAP cases)70% of CAP cases)

““Nosocomial” PneumoniaNosocomial” Pneumonia

Hospital-acquired pneumonia (HAP)Hospital-acquired pneumonia (HAP) Occurs 48 hours or more after admission, Occurs 48 hours or more after admission,

which was not incubating at the time of which was not incubating at the time of admissionadmission

Ventilator-associated pneumonia (VAP)Ventilator-associated pneumonia (VAP) Arises more than 48-72 hours after Arises more than 48-72 hours after

endotracheal intubationendotracheal intubation

““Nosocomial” PneumoniaNosocomial” Pneumonia

Healthcare-associated pneumonia (HCAP)Healthcare-associated pneumonia (HCAP) Patients who were hospitalized in an acute care Patients who were hospitalized in an acute care

hospital for two or more days within 90 days of the hospital for two or more days within 90 days of the infection; resided in a nursing home or LTC facility; infection; resided in a nursing home or LTC facility; received recent IV abx, chemotherapy, or wound care received recent IV abx, chemotherapy, or wound care within the past 30 days of the current infection; or within the past 30 days of the current infection; or attended a hospital or hemodialysis clinicattended a hospital or hemodialysis clinic

Guidelines for the Management of Adults with Guidelines for the Management of Adults with HAP, VAP, and HCAP. American Thoracic HAP, VAP, and HCAP. American Thoracic Society, 2005Society, 2005

PathogenesisPathogenesis

Inhalation, aspiration and hematogenous Inhalation, aspiration and hematogenous spread are the 3 main mechanisms by spread are the 3 main mechanisms by which bacteria reaches the lungswhich bacteria reaches the lungs

Primary inhalationPrimary inhalation: when organisms : when organisms bypass normal respiratory defense bypass normal respiratory defense mechanisms or when the Pt inhales mechanisms or when the Pt inhales aerobic GN organisms that colonize the aerobic GN organisms that colonize the upper respiratory tract or respiratory upper respiratory tract or respiratory support equipmentsupport equipment

PathogenesisPathogenesis

AspirationAspiration: occurs when the Pt aspirates : occurs when the Pt aspirates colonized upper respiratory tract colonized upper respiratory tract secretionssecretions Stomach: reservoir of GNR that can ascend, Stomach: reservoir of GNR that can ascend,

colonizing the respiratory tract.colonizing the respiratory tract. HematogenousHematogenous: originate from a distant : originate from a distant

source and reach the lungs via the blood source and reach the lungs via the blood stream. stream.

PathogensPathogens

CAP usually caused by a single organismCAP usually caused by a single organism Even with extensive diagnostic testing, Even with extensive diagnostic testing,

most investigators cannot identify a most investigators cannot identify a specific etiology for CAP in ≥ 50% of specific etiology for CAP in ≥ 50% of patients.patients.

In those identified, S. pneumo is causative In those identified, S. pneumo is causative pathogen 60-70% of the timepathogen 60-70% of the time

Streptococcus pneumoniaStreptococcus pneumonia

Most common cause of CAPMost common cause of CAP Gram positive diplococciGram positive diplococci ““Typical” symptoms (e.g. malaise, shaking Typical” symptoms (e.g. malaise, shaking

chills, fever, rusty sputum, pleuritic hest chills, fever, rusty sputum, pleuritic hest pain, cough)pain, cough)

Lobar infiltrate on CXRLobar infiltrate on CXR Suppressed hostSuppressed host 25% bacteremic25% bacteremic

Atypical PneumoniaAtypical Pneumonia

#2 cause (especially in younger population)#2 cause (especially in younger population) Commonly associated with milder Sx’s: Commonly associated with milder Sx’s:

subacute onset, non-productive cough, no focal subacute onset, non-productive cough, no focal infiltrate on CXRinfiltrate on CXR

Mycoplasma: younger Pts, extra-pulm Sx’s Mycoplasma: younger Pts, extra-pulm Sx’s (anemia, rashes), headache, sore throat(anemia, rashes), headache, sore throat

Chlamydia: year round, URI Sx, sore throatChlamydia: year round, URI Sx, sore throat Legionella: higher mortality rate, water-borne Legionella: higher mortality rate, water-borne

outbreaks, hyponatremia, diarrheaoutbreaks, hyponatremia, diarrhea

Viral PneumoniaViral Pneumonia

More common cause in childrenMore common cause in children RSV, influenza, parainfluenzaRSV, influenza, parainfluenza

Influenza most important viral cause in Influenza most important viral cause in adults, especially during winter monthsadults, especially during winter months

Post-influenza pneumonia (secondary Post-influenza pneumonia (secondary bacterial infection)bacterial infection) S. pneumo, Staph aureusS. pneumo, Staph aureus

Other bacteriaOther bacteria

AnaerobesAnaerobes Aspiration-prone Pt, putrid sputum, dental diseaseAspiration-prone Pt, putrid sputum, dental disease

Gram negativeGram negative Klebsiella - alcoholicsKlebsiella - alcoholics Branhamella catarrhalis - sinus disease, otitis, COPDBranhamella catarrhalis - sinus disease, otitis, COPD H. influenzaH. influenza

Staphylococcus aureusStaphylococcus aureus IVDU, skin disease, foreign bodies (catheters, IVDU, skin disease, foreign bodies (catheters,

prosthetic joints) prior viral pneumoniaprosthetic joints) prior viral pneumonia

Diagnosis and ManagementDiagnosis and Management

GuidelinesGuidelines

American Thoracic Society American Thoracic Society Guidelines for the Management of Adults with CA Guidelines for the Management of Adults with CA

(2001)(2001)

Infectious Diseases Society of AmericaInfectious Diseases Society of America Update of Practice Guidelines for the Management of Update of Practice Guidelines for the Management of

CAP in Immunocompetent adults (2003)CAP in Immunocompetent adults (2003)

ATS and IDSA joint effortATS and IDSA joint effort IDSA/ATS Consensus Guidelines on the IDSA/ATS Consensus Guidelines on the

Management of CAP in Adults (March 2007)Management of CAP in Adults (March 2007)

GuidelinesGuidelines 2001 ATS & 2003 IDSA Guideline Update2001 ATS & 2003 IDSA Guideline Update Expert panelsExpert panels Evidence-based recommendationsEvidence-based recommendations Recommend patient stratification to Recommend patient stratification to

identify likely pathogens and suggested identify likely pathogens and suggested empiric abxempiric abx Site of careSite of care Presence of cardiopulmonary diseasePresence of cardiopulmonary disease Presence of “modifying factors”Presence of “modifying factors”

Clinical DiagnosisClinical Diagnosis

Suggestive signs and symptomsSuggestive signs and symptoms CXR or other imaging techniqueCXR or other imaging technique Microbiologic testingMicrobiologic testing

Signs and SymptomsSigns and Symptoms

Fever or hypothermiaFever or hypothermia Cough with or without sputum, hemoptysisCough with or without sputum, hemoptysis Pleuritic chest painPleuritic chest pain Myalgia, malaise, fatigueMyalgia, malaise, fatigue GI symptomsGI symptoms DyspneaDyspnea Rales, rhonchi, wheezingRales, rhonchi, wheezing Egophony, bronchial breath soundsEgophony, bronchial breath sounds Dullness to percussionDullness to percussion Atypical Sx’s in older patientsAtypical Sx’s in older patients

Clinical Diagnosis: CXRClinical Diagnosis: CXR

Demonstrable infiltrate by CXR or other Demonstrable infiltrate by CXR or other imaging techniqueimaging technique Establish Dx and presence of complications Establish Dx and presence of complications

(pleural effusion, multilobar disease)(pleural effusion, multilobar disease) May not be possible in some outpatient May not be possible in some outpatient

settingssettings CXR: classically thought of as the gold CXR: classically thought of as the gold

standardstandard

Infiltrate PatternsInfiltrate Patterns

PatternPattern Possible DiagnosisPossible Diagnosis

LobarLobar S. pneumo, Kleb, H. flu, S. pneumo, Kleb, H. flu, GNGN

PatchyPatchy Atypicals, viral, Atypicals, viral, LegionellaLegionella

InterstitialInterstitial Viral, PCP, LegionellaViral, PCP, Legionella

CavitaryCavitary Anaerobes, Kleb, TB, S. Anaerobes, Kleb, TB, S. aureus, fungiaureus, fungi

Large effusionLarge effusion Staph, anaerobes, KlebStaph, anaerobes, Kleb

Clinical Diagnosis: Clinical Diagnosis: Recommended testingRecommended testing

Outpatient: CXR, sputum Cx and Gram Outpatient: CXR, sputum Cx and Gram stain not requiredstain not required

Inpatient: CXR, Pox or ABG, chemistry, Inpatient: CXR, Pox or ABG, chemistry, CBC, two sets of blood Cx’sCBC, two sets of blood Cx’s If suspect drug-resistant pathogen or If suspect drug-resistant pathogen or

organism not covered by usual empiric abx, organism not covered by usual empiric abx, obtain sputum Cx and Gram stain. obtain sputum Cx and Gram stain.

Severe CAP: Legionella urinary antigen, Severe CAP: Legionella urinary antigen, consider bronchoscopy to identify pathogenconsider bronchoscopy to identify pathogen

Clinical DiagnosisClinical Diagnosis

Assess overall clinical pictureAssess overall clinical picture PORT Pneumonia Severity Index (PSI)PORT Pneumonia Severity Index (PSI)

Aids in assessment of mortality risk and Aids in assessment of mortality risk and dispositiondisposition

Age, gender, NH, co-morbidities, physical Age, gender, NH, co-morbidities, physical exam lab/radiographic findingsexam lab/radiographic findings

IDSA: Outpt Management in IDSA: Outpt Management in Previously Healthy PtPreviously Healthy Pt

OrganismsOrganisms: S. pneumo, Mycoplasma, viral, : S. pneumo, Mycoplasma, viral, Chlamydia pneumo, H. fluChlamydia pneumo, H. flu

Recommended abxRecommended abx:: Advanced generation macrolide (azithro or clarithro) Advanced generation macrolide (azithro or clarithro)

or doxycyclineor doxycycline

If abx within past 3 monthsIf abx within past 3 months:: Respiratory quinolone (moxi-, levo-, gemi-), ORRespiratory quinolone (moxi-, levo-, gemi-), OR Advanced macrolide + amoxicillin, ORAdvanced macrolide + amoxicillin, OR Advanced macrolide + amoxicillin-clavulanateAdvanced macrolide + amoxicillin-clavulanate

IDSA: Outpt Management in IDSA: Outpt Management in Pt with comorbiditiesPt with comorbidities

ComorbiditiesComorbidities: cardiopulmonary dz or : cardiopulmonary dz or immunocompromised stateimmunocompromised state

OrganismsOrganisms: S. pneumo, viral, H. flu, aerobic GN : S. pneumo, viral, H. flu, aerobic GN rods, S. aureusrods, S. aureus

Recommended AbxRecommended Abx:: Respiratory quinolone, OR advanced macrolideRespiratory quinolone, OR advanced macrolide

Recent AbxRecent Abx:: Respiratory quinolone ORRespiratory quinolone OR Advanced macrolide + beta-lactamAdvanced macrolide + beta-lactam

IDSA: Inpt Management-IDSA: Inpt Management-Medical WardMedical Ward

OrganismsOrganisms: all of the above plus polymicrobial : all of the above plus polymicrobial infections (+/- anaerobes), Legionellainfections (+/- anaerobes), Legionella

Recommended Parenteral AbxRecommended Parenteral Abx: : Respiratory fluoroquinolone, ORRespiratory fluoroquinolone, OR Advanced macrolide plus a beta-lactamAdvanced macrolide plus a beta-lactam

Recent AbxRecent Abx:: As above. Regimen selected will depend on nature of As above. Regimen selected will depend on nature of

recent antibiotic therapy.recent antibiotic therapy.

IDSA: Inpt Management-IDSA: Inpt Management-Severe/ICUSevere/ICU

One of two major criteriaOne of two major criteria:: Mechanical ventilationMechanical ventilation Septic shock, ORSeptic shock, OR

Two of three minor criteriaTwo of three minor criteria:: SBP≤90mmHg, SBP≤90mmHg, Multilobar diseaseMultilobar disease PaO2/FIO2 ratio < 250PaO2/FIO2 ratio < 250

OrganismsOrganisms: S. pneumo, Legionella, GN, : S. pneumo, Legionella, GN, Mycoplasma, viral, ?PseudomonasMycoplasma, viral, ?Pseudomonas

IDSA: Inpt Management: IDSA: Inpt Management: Severe/ICUSevere/ICU

No risk for PseudomonasNo risk for Pseudomonas IV beta-lactam IV beta-lactam plus eitherplus either

• IV macrolide, IV macrolide, OR OR IV fluoroquinoloneIV fluoroquinolone

Risk for PseudomonasRisk for Pseudomonas Double therapyDouble therapy: selected IV antipseudomonal beta-lactam : selected IV antipseudomonal beta-lactam

(cefepine, imipenem, meropenem, (cefepine, imipenem, meropenem, piperacillin/tazobactam), piperacillin/tazobactam), plusplus

• IV antipseudomonal quinoloneIV antipseudomonal quinolone-OR--OR-

Triple therapyTriple therapy: selected IV antipseudomonal beta-lactam : selected IV antipseudomonal beta-lactam plusplusIV aminoglycoside IV aminoglycoside plus eitherplus either

IV macrolide, OR IV antipseudomonal quinoloneIV macrolide, OR IV antipseudomonal quinolone

Switch to Oral TherapySwitch to Oral Therapy

Four criteriaFour criteria:: Improvement in cough and dyspneaImprovement in cough and dyspnea Afebrile on two occasions 8 h apartAfebrile on two occasions 8 h apart WBC decreasingWBC decreasing Functioning GI tract with adequate oral intakeFunctioning GI tract with adequate oral intake

If overall clinical picture is otherwise If overall clinical picture is otherwise favorable, can can switch to oral therapy favorable, can can switch to oral therapy while still febrile.while still febrile.

Management of Poor Management of Poor RespondersResponders

Consider non-infectious illnessesConsider non-infectious illnesses Consider less common pathogensConsider less common pathogens Consider serologic testingConsider serologic testing Broaden antibiotic therapyBroaden antibiotic therapy Consider bronchoscopyConsider bronchoscopy

PreventionPrevention

Smoking cessationSmoking cessation Vaccination per ACIP recommendationsVaccination per ACIP recommendations

InfluenzaInfluenza• Inactivated vaccine for people >50 yo, those at risk Inactivated vaccine for people >50 yo, those at risk

for influenza compolications, household contacts of for influenza compolications, household contacts of high-risk persons and healthcare workershigh-risk persons and healthcare workers

• Intranasal live, attenuated vaccine: 5-49yo without Intranasal live, attenuated vaccine: 5-49yo without chronic underlying dzchronic underlying dz

PneumococcalPneumococcal• Immunocompetent ≥ 65 yo, chronic illness and Immunocompetent ≥ 65 yo, chronic illness and

immunocompromised ≤ 64 yoimmunocompromised ≤ 64 yo

Pneumonia in Children: DxPneumonia in Children: Dx

SymptomsSymptoms Infants: non-specific manifestationsInfants: non-specific manifestations

• Fever, poor feeding, irritability, vomiting, diarrhea, URI Sx, Fever, poor feeding, irritability, vomiting, diarrhea, URI Sx, cough, respiratory distresscough, respiratory distress

Older children: more specificOlder children: more specific• Fever, cough, chest pain, tachypnea, tachycardia, grunting, Fever, cough, chest pain, tachypnea, tachycardia, grunting,

nasal flaring, retracting. Cyanosis usually very late.nasal flaring, retracting. Cyanosis usually very late.

Signs/Physical examSigns/Physical exam RR > 60 for all agesRR > 60 for all ages HypoxiaHypoxia Rales, wheezes, crackles, coarse breath soundsRales, wheezes, crackles, coarse breath sounds

Pneumonia in Children: Pneumonia in Children: PathogensPathogens

0-4 wks0-4 wks: GBS, GN enterics, Listeria: GBS, GN enterics, Listeria 4-12 wks4-12 wks: C. trachomatis, GBS, GN : C. trachomatis, GBS, GN

enterics, Listeria, viral enterics, Listeria, viral (RSV/parainfluenza), B. pertussis(RSV/parainfluenza), B. pertussis

3 mos-4 yrs3 mos-4 yrs: Viral, S. pneumo, H. : Viral, S. pneumo, H. influenza, M. catarrhalis, Grp A Strep, influenza, M. catarrhalis, Grp A Strep, MycoplasmaMycoplasma

> 5yrs> 5yrs: Mycoplasma (5-15yrs), C. pneumo, : Mycoplasma (5-15yrs), C. pneumo, S. pneumo, viralS. pneumo, viral

Pneumonia in the ElderlyPneumonia in the Elderly

Prevention importantPrevention important Presentation can be subtlePresentation can be subtle Antibiotic choice in CAP is same as other adultsAntibiotic choice in CAP is same as other adults Healthcare associated pneumoniaHealthcare associated pneumonia

Consider S. aureus (skin wounds) and GN bacteria Consider S. aureus (skin wounds) and GN bacteria (aspiration)(aspiration)

• Pneumonia in Older Residents of Long-term Care Facilities. Pneumonia in Older Residents of Long-term Care Facilities. AFP 2004; 70: 1495-1500.AFP 2004; 70: 1495-1500.

Pneumonia in Pneumonia in Immunocompromised PtsImmunocompromised Pts

Smokers, alcoholics, bedridden, immuno-Smokers, alcoholics, bedridden, immuno-compromised, elderlycompromised, elderly

Common still commonCommon still common S. pneumoS. pneumo MycoplasmaMycoplasma

Pneumocystis Carinii PneumoniaPneumocystis Carinii Pneumonia P. jiroveciiP. jirovecii Fever, dyspnea, non-prod cough (triad 50%), insidious Fever, dyspnea, non-prod cough (triad 50%), insidious

onset in AIDS, acute in other immunocompromised Ptsonset in AIDS, acute in other immunocompromised Pts CXR: bilateral interstitial infiltratesCXR: bilateral interstitial infiltrates Steroids for hypoxiaSteroids for hypoxia TMP-SMZ still first lineTMP-SMZ still first line