Community-Acquired Pneumonia: A Clinical case scenario

1
Community-Acquired Pneumonia A Clinical case
scenario

• Ashraf Mokhtar Madkour, MD, Dr.med.
• Chest Diseases Department
• Ain Shams University Hospital

2
Community-Acquired Pneumonia A Clinical case
scenario

• Outline
• Diagnosis of CAP
• Site of care?
• Tools for risk assessment?
• Diagnostic tests needed?
• Management of severe CAP ?

3
Presentation

• A 66-year-old man accompanied by his wife,
  arrived at the Emergency Department complaining
  of
• shortness of breath, fever, and cough.

4
Symptoms

• His symptoms started 8 days ago with mild fever,
  cough, myalgia, headache sore throat were he
  received antipyretic, antihistaminic and cough
  syrup after consulting his family doctor through
  a telephone call.

5
Symptoms

• After initial improvement, he had a worsening of
  symptoms starting 3 days ago with productive
  cough, pleuritic chest pain, fever, chills and
  malaise.
• Last night he developed dyspnea and high fever,
  so he decided to come to the Emergency Department
  today.

6
Medical History

• X-smoker 2 years (30 pack years).
• COPD.
• Type 2 diabetes.
• Medications include
• Inhaled salbutamol (100 ?g) beclomethasone
  diproprionate (50 ?g) 2 puffs x 3.
• Sustained released theophylline (200mg cap 1x2).
• Gliclcazide (80mg tab. 1x1).

7
Examination

• Confused.
• Temperature 39.0C.
• Blood pressure 120/70.
• Pulse rate 120 bpm.
• Respiratory rate 30 per minute.
• Clinical signs of right upper zone consolidation
  and bilateral scattered rhonchi.
• No cyanosis, pedal edema or jugular venous
  distension is noted.

8
Chest X-ray
9
Diagnosis
Dose this patient have Community-Acquired
Pneumonia (CAP)?
10
Definition of CAP

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

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
11
CAP Diagnosis

• In addition to a constellation of suggestive
• clinical features, a demonstrable infiltrate
• by chest radiograph or other imaging
• technique, with or without supporting
• microbiological data, is required for the
• diagnosis of pneumonia.

Clinical features Productive cough, dyspnea,
fever, clinical signs of consolidation Radiologic
al findings Consolidation
IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
12
CAP Risk Factors for Pneumonia

• Elderly
• Smoking
• COPD
• Extreme weather
• Overcrowding
• Alcoholism
• DM

• Renal insufficiency
• CHF
• Chronic liver disease
• Immunossuppresion
• Loss of consciousness
• Seizures

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What is the value of CXR in CAP?

• Establish Dx
• Evaluation of severity
• e.g. multilobar or bilateral, pleural effusion.
• Co-existing conditions
• e.g. bronchial obstruction, abscess.
• Pattern

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Infiltrate Patterns and Pathogens
CXR Pattern Possible Pathogens
Lobar S.pneumoniae, Kleb, H. influ, Gram Neg
Patchy Atypicals, Viral, Legionella
Interstitial Viral, PCP, Legionella
Cavitatory Anaerobes, Kleb, TB, S.aureus, Fungi
Large effusion Staph, Anaerobes, Klebsiella
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Initial investigations at ER

• Hgb 13.4 gm/dl, Hct 40.
• WBC 15,800/µl with 88 polymorphonuclear cells,
  8 bands.
• Na 137 mEq/L, K 3.7 mEq/L.
• BUN 32 mg/dl, creatinine1.8 mg/dl.
• RBG 260 mg/dl.
• Arterial blood gas (room air)
• pH 7.38, PCO 2 53 mmHg, PO 2 58mmHg, O 2
  Sat. 89

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CAP Management based on PSI Score
PORT Class PSI Score Mortality Treatment Strategy
Class I No RF 0.1 0.4 Out patient
Class II ? 70 0.6 0.7 Out patient
Class III 71 - 90 0.9 2.8 Brief hospitalization
Class IV 91 - 130 8.5 9.3 Inpatient
Class V gt 130 27 31.1 IP - ICU
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Would you hospitalize him?
18
Assess the ability to safely and reliably take
oral medication the availability of outpatient
support resources
19
CURB 65 score
Thorax 2003,58377
20
(If study performed)
Pneumonia Severity Index (PSI) score
lt60mmHg / SO 2 lt90
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Calculation of risk assessment (PSI score)
Clinical Parameter Scoring
Clinical Findings
Altered Sensorium 20
Respiratory Rate gt 30 20
SBP lt 90 mm 0
Temp lt 350 C or gt 400 C 0
Pulse gt 125 per min 0
Investigation Findings
Arterial pH lt 7.35 0
BUN gt 30 20
Serum Na lt 130 0
Hematocrit lt 30 0
Blood Glucose gt 250 10
Pa O2 10
X Ray e/o Pleural Effusion 0
Clinical Parameter Scoring
Age in years
Age in yrs 66
Co-morbid Illnesses Co-morbid Illnesses
Neoplasia 0
Liver Disease 0
CHF 0
CVD 0
Renal Disease 0
PSI 146 Class V? ICU
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The patient was hospitalized and admitted to ICU
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What testing would you do?
25
Diagnostic testing

• Recommendations for diagnostic testing remain
  controversial.
• No convincing data that they improve outcomes.
• Outpatient setting optional
• Inpatient setting
• Critically ill CAP
• Specific pathogens (suspected)

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
26
Diagnostic testing Critically ill CAP

• Sputum Gram staining and culture.
• Blood cultures.
• Urinary antigen tests for Legionella
  Streptococcus pneumoniae.
• others
• FOBBAL / Endotracheal tube aspirate
• Thoracentesis
• TNA

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
27
What testing would you do?

• Pretreatment
• Sputum Gram staining and culture.
• Expectorated sputum should be deep cough
  specimen obtained before antibiotic treatment and
  it should be rapidly transported and processed
  within a few hours of collection.
• Blood cultures (2 sets)
• 2 sets of blood cultures should be drawn before
  initiation of antibiotic therapy during the
  first 24 hour.

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
28
What treatment would you prescribe?
29
Therapy
General supportive
Antibiotic

• Fluid / diet
• Antipyretics (Paracetamol IV)
• Sugar blood chart Insulin accordingly
• Cough syrup
• SR theophylline
• Inhalation ttt ? salbutamol ipratropium bromide
• O2 therapy ? NP 2 L/min
• Empiric Antibiotic ttt

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What antibiotics are appropriate?
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CAP When to start empiric therapy?
Site of Care RF Treatment 1 Treatment 2 Treatment 3
OP No RF AZ CLR ER / Doxy
OP RF FQ ? M ? Doxy
Med Ward RF FQ AZ ?3G AZ Etrap M
ICU RF ? 3G AZ ?3G FQ FQ AZT
Pseud Extended ? Cipro / Levo ? 3G AmGly AZ ? 3G AmGly FQ
CA-MRSA Vanco/Linezo Vanco/Linezo Vanco/Linezo

• As soon as possible in ED
• CAP delay-to-ABgt 4h after arrival
• Increased mortality
• Increased LOS

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
32
Recommended empirical antibiotics for CAP
Inpatient, ICU ttt

• b-lactam plus either azithromycin or a
  respiratory fluoroquinolone
• (cefotaxime, ceftriaxone)
• Levofloxacin 750mg/24h Ceftriaxone
  1gm /12h IV

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
33
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2 hours after ICU admission

• Sputum (gram stain)
• ?Gram-positive diplococcus
• Value of Gram stain
• First, it broadens initial empirical coverage for
  less common etiologies, such as infection with S.
  aureus or gram-negative organisms.
• Second, it can validate the subsequent sputum
  culture result. A positive Gram stain was highly
  predictive of a subsequent positive culture.

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
35
Day 3

• Sputum culture Sensitivity Streptococcus
  pneumoniae
• Sensitive? Cefotaxime, Ceftraixone and
  Levofloxacin.
• Susceptibility testing should guide antibiotic
  choice when results are available.
• Continue on the same antibiotics

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• Day 3
• The patient's condition began to improve, but
  fever persisted.
• Day 5
• The patient was a febrile for the first time.
• Normal oral intake started.
• Cough, dyspnea grade chest wheezes improved.
• Pulse 90 bpm, B/P 140/80.
• WBC 6,800/µl with 3 bands.
• BUN 18 mg/dl, creatinine1.4 mg/dl, 2 PPBS
  170mg/dl.
• O 2 Sat. on RA 93.
• Transferred to ward.

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Switch from intravenous to oral therapy?

• Afebrile
• No abnormal GIT absorption
• Cough respiratory distress improved
• WBC returning to normal
• Levofloxacin 750 mg tab/24hr

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
38

• Day 8
• Clinically stable
• Afebrile for 3days.
• CXR partial resolution.
• Blood culture
• No growth up till now.

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CAP Duration of Therapy?

• A minimum of 5 days
• Afebrile for 48-72 h
• No more than 1 CAP-
• associated sign of
• clinical instability

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
40

• Day 9
• Discharged and antibiotic stopped.
• Recommendations
• ?/ pneumococcal polysaccharide vaccination
• ?/ During next influenza season, influenza
  vaccination.
• ?/ ttt COPD DM.
• FU CXR after 1 week.

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