Community Acquired Pneumonia

1
Community Acquired Pneumonia
Prof. Adel Khattab , MD, FCCP

• Prof. Head Of Pulmonary Medicine Dept.
• Ain Shams University
• Advisor of the MOH for Chest Diseases Aviian Flu

2
Definition

• Community-acquired pneumonia (CAP) is a common
  respiratory disease with clinical outcomes
  ranging from mild illness with rapid and complete
  recovery to a fulminate clinical course with
  serious complications or death.

3
Impact of CAP

• 3-4 Million cases annually
• 10 Million physician visits
• 600,000 Hospitalizations
• 45,000 Deaths
• 64 Million days of restricted activity
• Most common cause of death from infection
• 6th Most common cause of death overall

4
ETIOLOGY OF CAP

• Conventional diagnostic testing for CAP is
  imperfect e.g role of sputum isolates in
  diagnosing aetiology of LRTI is controversial
  (colonization)
• No sufficiently rapid and accurate battery of
  diagnostic tests for CAP are available presently
• Etiology remains unknown in up to 50 of cases
• However, local knowledge of likely pathogen is
  imperative
• Carroll KC. J
  Clin Micro 2002403115-3120
• Bartlett et
  al. NEJM 19953331618-1624
  
• Niederman et
  al. Am J Respir Crit Care Med 20011631730-1754
• 
  

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Etiology of Community-Acquired Pneumonia
W S Lim,J T Macfarlane, et al. Thorax
200156296-301
6
Key Pathogens Associated with Community-Acquired
Pneumonia (CAP) Europe
(5,961 Adult Hospitalized CAP Patients in 26
Prospective Studies from 10 European Countries)
Atypicals 25
Proportion of Cases ()
Woodhead MA. Chest 1998113183S187S
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Aspiration Pneumonia

• The bacteriology of aspiration pneumonia
  arising in the community setting has been
  confusing, and the exact role of anaerobes is
  uncertain.
• Thus, the level of involvement of enteric
  Gram-negative pathogens in aspiration-related
  illnesses is quite high and must be considered
  when selecting therapy.

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RESISTANCE PROFILES OF RESPIRATORY TRACT
PATHOGENS
11
Penicillin Resistance with Streptococcus
pneumoniae in the United States
40
Resistant (MICs ³2)
35
Intermediate (MICs 0.12-1)
30
25
Percent
20
15
10
5
0
1979-87
1988-89
1990-91
1992-93
1994-95
1997-98
1999-00
2001-02
2002-03
5589 487 524 799 1527 1601 1531 1940 1828 35 15
17 19 30 34 33 45 44
1980s
1990s
2000s
Doern, AAC 2001451721 and unpublished data
12

• misuse of penicillin could lead to selection
  and propagation of mutant forms of bacteria
  resistant to the drug
• Alexander Flemming 1945

13
Middle East

• Egypt
• Strept. Pneumoniae
• Penicillin resistance 38
• Erythromycin resistance 55
• Clindamycin resistance 51
• Co-trimoxazole resistance 38
• Ceftrixone resistance 16
• Vancomycin resistance 0

El Kholy A , et al. Journal of antimicrobial
Chemotherapy (2003) 51. 625 -630
14
RESISTANCE PROFILES

• Multiple resistance in S.pneumoniae of particular
  concern
• More recently, clinical isolates of S.pneumoniae
  with high- level resistance to cefotaxime and
  ceftriaxone have been reported
• Emerging fluoroquinolone resistance although
  currently uncommon in most parts of the world

15
In Vitro Antibiotic Resistance
1987
1997
1986
1996
1996
Penicillin-resistant S pneumoniae
?-Lactamase-producing H influenzae
?-Lactamase-producing M catarrhalis
Thornsberry C, et al. Antimicrob Agents
Chemother. 1999432612-23.Jacobs MR, et al.
Antimicrob Agents Chemother. 1999431901-8.
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The Disease Process

• Definition Signs/symptoms of acute infection
  plus acute infiltrate or auscultatory findings
• Signs and symptoms chill and/or fever,
  pleuritic chest pain, productive cough,
  tachypnea, tachycardia, rales and/or
  consolidation
• Clinical sequelae bacteremia, metastatic foci of
  infection, death
• No association between signs/symptoms and
  bacterial etiology

Bartlett JG, et al. Clin Infect Dis.
200031347-82. Donowitz GR, Mandell GL.
Principles and Practice of Infectious Diseases
1995619-37. Fang GD, et al. Medicine
(Baltimore). 199069307-16.
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PNEUMONIA

• TYPICAL
• Sudden onset
• Productive,purulent or bloody sputum
• High fever
• Evident local signs
• Myalgia headache uncommon
• Focal alveolar or lobar infiltrates in CXR
• Leucocytosis is common

• ATYPICAL
• Gradual onset
• Nonproductive or only scant mucoid sputum
• Low-grade fever
• Minimal local signs
• Myalgia headache common
• Diffuse interstitial infiltrates in CXR
• Leucocytosis is uncommon

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Diagnostic Algorithm for CAP
Office History and physicalexamination Consider
chest X-ray Treat empirically
Emergency Room History and physicalexamination Ch
est X-rayCBC and diff oximetrychemistry ABG
Nursing Home History and physicalexamination Cons
ider chest X-ray Treat empirically
Ifnecessary
Ifnecessary
Ward
ICU
Blood culture Sputum Gram stain and
culture Serology Thoracentesis Legionella urinary
antigen testing
19
Serum Markers To Predict CAP Outcomes

• The two serum markers that have been most
• widely studied for this purpose are CRP and PCT.
  In
• general, both measures have been used to
  correlate
• with outcomes, but more data have recently been
• collected with PCT, and the most exciting finding
• has been that serial measures correlate not only
  with
• outcomes, but may also be useful for guiding the
• duration of therapy.

20

• Low levels in outpatients could indicate that
  it is safe to withhold antibiotic therapy.
• Serial measurements of PCT have also been used
  to define prognosis in patients with severe CAP.

21
Community-acquired pneumonia clinical
management
Diagnosis of community-acquired pneumonia
Assess severity of infection
Severe requires hospital treatment
Mild to moderate can be treated in the
community
Empirical antibiotic treatment
Follow-up patient for 2436 hours and change
treatment if necessary
not all cases of community-acquired pneumonia
are caused by bacteria
22
Pneumonia PORT Prediction Rule for MortalityRisk
Assessment
STEP 1
STEP 2
Class II(? 70 points)
Is the patient gt 50 years of age?
Assign points for Demographic variables Comorbid
conditions Physical observations Laboratory and
radiographic findings
Yes
No
Class III(71-90 points)
Does the patient have any of the following
coexisting conditions? Neoplastic disease
congestive heart failure cerebrovascular
disease renal disease liver disease
Yes
Class IV(91-130 points)
No
Yes
Class V(gt 130 points)
Does the patient have any of thefollowing
abnormalities? Altered mental status pulse ?
125/min respiratory rate ? 30/min systolic
blood pressure lt 90 mm Hg temperature lt 35ºC or
? 40ºC
Class I
No
Fine MJ, et al. N Engl J Med. 1997336243-50.
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Risk - Class Mortality Rates

• Risk Class Points Cohort
  Site of
• 
  Mortality Care
• I Absence of
  0.1 OUT
• Predictors
• II ? 70 0.6
  OUT
• III 71-90 2.8
  OUT or
• brief IN
• IV 91-130 8.2
  IN
• V gt130
  29.2 IN

24

• Any of
• Confusion
• Urea gt7 mmol/l
• Respiratory rate ³30/min
• Blood pressure (SBP lt90 mmHg or DBP 60 mmHg)
• Age ³65 years

CURB-65 score
2
3 or more
0 or 1
Group 2 Mortality intermediate (9.2) (n184
died 17)
Group 3 Mortality high (22) (n210 died 47)
Group 1 Mortality low (1.5) (n324 died 5)
Treatment options
Likely suitable for home treatment
Consider hospital supervised treatment Options
may include a) short stay inpatient b) hospital
supervised outpatient
Manage in hospital as severe pneumonia Assess for
ICU admission especially if CURB-65 score 4 or 5
Lim et al. Thorax, 2003
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IDSA / ATS Guidelines for CAP in Adults , 2007
28
IDSA / ATS Consensus Guidelines on
theManagement of CAP in Adults 2007
29
Advantages of Guidelines

• Synthesize large amounts of information
• Define the strength of existing data (evidence
  grading)
• Discuss and define relevant management issues,
  providing an orderly approach
• Help guide accurate initial empiric therapy
• Provide a standard against which care can be
  evaluated
• Focus on cost-effective management
• Identify defects in knowledge base to direct
  future research
• Tool to improve patient outcomes

29
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Concerns About Guidelines

• Management without thought
• Deviations may be basis for discipline
• If experts cannot all agree, how can we have
  accurate guidelines?
• What do we do if the existing knowledge base is
  of poor quality?
• How strong should new data be before changing and
  updating guidelines?

30
31
Inpatient Community-Acquired Pneumonia Guideline
Adherence Improves Mortality
Mortensen EM, et al. Am J Med. 2004117726-731.
32
Community-Acquired Pneumonia Guidelines
Implementation Why?

• Lower (30-day) mortality
• 5-year study of 28,700 patients (OR 0.69)
• Spanish hospital survival rate higher (OR 2.14)
• Hospitalization
• Pneumonia Severity Index fewer less-ill patients
  admitted (49 vs 31)
• American Thoracic Society (1993) hospital-rate
  decreased (13.6 vs 6.4)
• Cost
• Decreased by half (P0.01)
• Comprehensive protocol is greater than a single
  element

32
Mandell LA, et al. Clin Infect Dis. 200744(suppl
2)S27-S72.
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Implementation of Guideline Recommendations

• Locally adapted guidelines should be implemented
  to improve process of care variables and relevant
  clinical outcomes. (Strong recommendation level
  I evidence.)

35
Management of CAP Site-of-Care
Decisions Hospitalization ? ICU admission?
36
Assess the ability to safely and reliably take
oral medication the availability of outpatient
support resources
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Hospital admission decision

• Severity-of-illness scores, such as the CURB-65
  criteria (confusion, uremia, respiratory rate,
  low blood pressure, age 65 years or greater), or
  prognostic models, such as the Pneumonia Severity
  Index (PSI), can be used to identify patients
  with CAP who may be candidates for outpatient
  treatment. (Strong recommendation level I
  evidence.)

41
Hospital admission decision

• For patients with CURB-65 scores 2,
  more-intensive treatmentthat is, hospitalization
  or, where appropriate and available, intensive
  in-home health care servicesis usually
  warranted. (Moderate recommendation level III
  evidence.)

42
ICU admission decision.

• Direct admission to an ICU is required for
  patients with septic shock requiring vasopressors
  or with acute respiratory failure requiring
  intubation and mechanical ventilation.
• (Strong recommendation level II evidence.)
• Direct admission to an ICU or high-level
  monitoring unit is recommended for patients with
  3 of the minor criteria for severe CAP listed in
  next table .
• (Moderate recommendation level II evidence.)

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Diagnostic Testing

• 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.
• (Moderate recommendation level III evidence.)

46
Recommended diagnostic tests for etiology

• Routine diagnostic tests to identify an etiologic
  diagnosis are optional for outpatients with CAP.
• (Moderate recommendation level III
  evidence.)

47
Recommended diagnostic tests for etiology
(cont.)

• Pretreatment blood samples for culture and an
  expectorated sputum sample for stain and culture
  (in patients with a productive cough) should be
  obtained from hospitalized patients with the
  clinical indications listed in the next table but
  are optional for patients without these
  conditions.
• (Moderate recommendation level I evidence.)

48
Chest X-ray

• Can help to diagnose pneumonia
• Cant determine pathogen
• Helps to determine severity
• multilobar
• Cavities
• Pleural effusion.

49
Consolidation , Focal opacity

S pneumoniae

H influanzae

Atypical
50
Interstitial / Miliary

Viral

Mycoplasma

M TB
Fungi
51
Bil. hilar lymphadenopathy and nodular opacities




M TB

Atypical

Viral
52
Cavity Staph aureus, Klebsiella, Anaerobes, M TB
53
Sputum Gram Stain Culture

• Neither sensitive nor specific
• 30 of patients cant produce sputum
• With gradingonly 25-40 good quality
• At best 28 are good samples
• Cant detect atypicals
• Prior antibiotics affect results

54
Limitations of Sputum Culture

• Overdiagnosis
• - Contamination with upper respiratory tract
  flora
• - Chronic colonization of the lower respiratory
  tract with pathogens
• Underdiagnosis
• - Sampling errors
• - Atypical bacterial pathogens

55
Blood Cultures

• Outpatient lt 1
• Ward patients 6.6-17.6
• ICU patients 27
• Recommended for hospitalized patients
• It has a low sensitivity but high specificity

56
Serology

• Need paired assessments (acute convalescent)
• Results not available at time of initial
  treatment decision
• Not recommended for routine use

57
Laboratory diagnosis of C. pneumoniae infections
Feature Culture DFA PCR Serology ---------------
--------------------------------------------------
--------------------- Detection Infectious Antigen
DNA Antibodies organism Specimen Throat
Swab Throat Swab Throat Swab
Blood BAL BAL BAL Sputum Sputum ?
Blood ? Sensitivity 50 20-60 85-90
60-80 Specificity 100 70-95 95-100 90-100
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Diagnostic Tests for Legionella and CAP

• Test Specimen Sensitivity Specificity Time
  to diagnosis
• Culture Sputum lt 10-80 100 3-7
  days Blood 0-6 100 3-7 days
• Direct fluorescent Sputum 33-68 gt95 1
  hourantibody screen
• Antigen detection Urine 80-90 gt99 lt 1 hour
• Serology Serum 60-80 gt95 6-10 weeks
• PCR Urine/blood 75-82 90-100 2-4
  hours Respiratory 83-100 90-100 2-4 hours
  secretions

Waterer GW, et al. Am J Med. 200111041-8
Murdoch DR. CID 20033664-9
59
Invasive Procedures

• Fulminant course
• Unresponsiveness to standard antimicrobials
• Thoracentesis if effusion gt 10 mm on lateral
  decubitus

60
Invasive diagnostic techniques

• Bronchoscopy with a protected brush catheter
• Bronchoalveolar lavage with or without balloon
  protection
• Direct needle aspiration of the lung
• Thoracocentesis

61
Characteristics of Empyema

• Pleural fluid.
• PH lt 7.1
• WBC gt 10,000 cells / mm3
• Low glucose
• Culture or Gram stain demonstrating organisms

62
Recommended diagnostic tests for etiology

• Pretreatment Gram stain and culture of
  expectorated sputum should be performed only if a
  good-quality specimen can be obtained and quality
  performance measures for collection, transport,
  and processing of samples can be met. (Moderate
  recommendation level II evidence.)

63
Recommended diagnostic tests for etiology
(cont.)

• Patients with severe CAP, as defined above,
  should at least have blood samples drawn for
  culture, urinary antigen tests for Legionella
  pneumophila and Streptococcus pneumoniae
  performed, and expectorated sputum samples
  collected for culture.
• For intubated patients, an endotracheal aspirate
  sample should be obtained.
• (Moderate recommendation level II evidence.)

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Serum Markers To Predict CAP Outcomes

• The two serum markers that have been most
• widely studied for this purpose are CRP and PCT.
  In
• general, both measures have been used to
  correlate
• with outcomes, but more data have recently been
• collected with PCT, and the most exciting finding
• has been that serial measures correlate not only
  with
• outcomes, but may also be useful for guiding the
• duration of therapy.

66
Reasons to Perform Diagnostic Testing

• Confirm the presence of community-acquired
  pneumonia chest radiograph, serum markers
• Establish an etiologic diagnosis
• Proper therapy look for unusual or resistant
  pathogens
• Epidemiologic purposes eg, Legionella spp and
  environmental source, design of future empiric
  treatment
• Focused and tailored therapy proper duration,
  de-escalate, escalate
• Determine severity and prognosis bacteremia,
  procalcitonin, C-reactive protein
• Define duration of therapy procalcitonin

66
67
Reasons NOT to Perform Diagnostic Testing

• Expensive
• Time consuming
• May delay therapy
• Low yield of true positives role of prior
  antibiotics
• False positive may add to overuse of antibiotics
• False negatives may lead to undertreatment
• Mixed infection (atypicals) may not be detected,
  yet needs therapy
• No effect on outcome

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68
Recommended Testing When Community-Acquired
PneumoniaIs Suspected

• Diagnose with chest x-ray and clinical data1,2
• Look for specific pathogens that alter therapy
  based on historical and epidemiologic clues1
• Laboratory tests for hospitalized patients
  include arterial blood gas and basic blood
  chemistry (ie, red and white blood cell count,
  creatinine and urea nitrogen, aminotransferases,
  sodium, and potassium)2
• Blood cultures with severe illness1,2
• Sputum Gram-stain and culture prior to therapy IF
  good quality, rapid transport, and processing in
  lab1,2
• Legionella spp and pneumococcal urinary antigen
  for severe community-acquired pneumonia (CAP)1,2
• Endotracheal aspirate or sputum culture for
  severe CAP1,2

68
1. Mandell LA, et al. Clin Infect Dis.
200744(suppl 2)S27-S72. 2. Woodhead M, et al.
Eur Respir J. 2005261138-1180.
69
Community-Acquired Pneumonia Guidelines Urinary
Antigen Testing

• Role of urinary antigen testing1
• Pneumococcal
• Sensitivity 5080
• Specificity gt90
• Legionella spp
• Serogroup 1 (accounts for most)
• May not change therapy for most patients1
• Macrolide/atypical pathogen coverage included in
  empiric therapy recommendations1
• Serogroup 1 urinary antigen testing is
  recommended for patients with severe
  community-acquired pneumonia and in other
  patients where this infection is clinically or
  epidemiologically suspected1,2

69
1. Mandell LA, et al. Clin Infect Dis.
200744(suppl 2)S27-S72. 2. Woodhead M, et al.
Eur Respir J. 2005261138-1180.
70
Therapy
71
Therapy
General supportive
Antibiotic

• Fluid / diet
• Antipyretics
• Cough syrup
• O2 therapy
• TTT of complications Coexisting illness

72
CAP When to start empiric therapy?

• 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
73
Recommended empirical antibiotics for CAP
Outpatient

• 1 Previously healthy and no risk factors for
  drug-resistant S. pneumoniae (DRSP) infection
• Macrolides
• (Azithromycin, clarithromycin or erythromycin)
• (strong recommendation level I evidence)
• Doxycycline
• (weak recommendation level III evidence)

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
74
Recommended empirical antibiotics for CAP
Outpatient

• 2. Presence of comorbidities such as
• heart, lung, or renal disease, diabetes,
  alcoholism, malignancies, Asplenia,
  immunosuppressing conditions or drugs Antibiotic
  Use in last 90 days, or other risks of DRSP
  infection
• Respiratory fluoroquinolone
• (moxifloxacin, gemifloxacin, or levofloxacin
  750 mg)
• (strong recommendation level I evidence)
• B-lactam plus a macrolide
• (strong recommendation level I evidence)

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
75
Recommended empirical antibiotics for CAP
Outpatient

• Presence of comorbidities
• B-lactam plus a macrolide
• High-dose amoxicillin e.g. 1 g 3 times daily
  or Amoxicillin-clavulanate 2 g 2 times daily
• Alternatives Ceftriaxone, Cefpodoxime
  Cefuroxime, Doxycycline alternative to macrolide

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
76
Outpatient Treatment

• Previously healthy and no risk factors for
  drug-resistant S. pneumoniae (DRSP) infection
• A) Macrolide (azithromycin, clarithromycin, or
  erythromycin)
• (strong recommendation level I evidence)
• B) Doxycycline
• (weak recommendation level III evidence)

77
Outpatient Treatment (cont.)

• Presence of comorbidities, such as chronic heart,
  lung, liver, or renal disease diabetes mellitus
  alcoholism malignancies asplenia
  immunosuppressing conditions or use of
  immunosuppressing drugs use of antimicrobials
  within the previous 3 months (in which case an
  alternative from a different class should be
  selected) or other risks for DRSP infection

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Outpatient Treatment (cont.)

• A. A respiratory fluoroquinolone (levofloxacin ,
  moxifloxacin or gemifloxacin,)
• (strong recommendation level I evidence)
• B. A b-lactam plus a macrolide
• (strong recommendation level I evidence)
• (High-dose amoxicillin e.g., 1 g 3 times
  daily or amoxicillin-clavulanate 2 g 2 times
  daily is preferred alternatives include
  ceftriaxone, cefpodoxime, and cefuroxime 500 mg
  2 times daily doxycycline level II evidence
  is an alternative to the macrolide.)

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Outpatient Treatment (cont.)

• In regions with a high rate (gt25) of infection
  with high-level (MIC, 16 mg/mL)
  macrolide-resistant S. pneumoniae, consider the
  use of alternative agents listed above in
  recommendation 16 for any patient, including
  those without comorbidities.
• (Moderate recommendation level III evidence.)

80
Recommended empirical antibiotics for CAP
Inpatient, Non-ICU ttt

• a) Respiratory fluoroquinolone
• (strong recommendation level I evidence)
• b) b-lactam plus a macrolide
• Cefotaxime, Ceftriaxone, Ampicillin, or
  Ertapenem (strong recommendation level I
  evidence)
• Doxycycline as an alternative to the
  macrolide.
• (weak recommendation level III
  evidence)

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
81
Inpatient, non-ICU treatment

• A respiratory fluoroquinolone
• (strong recommendation level I evidence)
• A b-lactam plus a macrolide
• (strong recommendation level I evidence)
• (Preferred b-lactam agents include
  cefotaxime, ceftriaxone, and ampicillin
  ertapenem for selected patients with doxycycline
  level III evidence as an alternative to the
  macrolide.
• A respiratory fluoroquinolone should be used for
  penicillin-allergic patients.)

82
Inpatient, ICU treatment

• A b-lactam (cefotaxime, ceftriaxone, or
  ampicillin-sulbactam) plus either azithromycin
  (level II evidence) or a fluoroquinolone (level I
  evidence)
• (strong recommendation)
• (For penicillin-allergic patients, a respiratory
  fluoroquinolone and aztreonam are recommended.)

83
Inpatient, ICU treatment

• For Pseudomonas infection, use an
  antipneumococcal, antipseudomonal b-lactam
  (piperacillin-tazobactam, cefepime, imipenem, or
  meropenem) plus either ciprofloxacin or
  levofloxacin or the above b-lactam plus an
  aminoglycoside and azithromycin or the above
  b-lactam plus an aminoglycoside and an
  antipneumococcal fluoroquinolone (for
  penicillin-allergic patients, substitute
  aztreonam for the above b-lactam).
• (Moderate recommendation level III evidence.)

84
Inpatient, ICU treatment

• For community-acquired methicillin-resistant
  Staphylococcus aureus infection, add vancomycin
  or linezolid.
• (Moderate recommendation level III evidence.)

85
Recommended empirical antibiotics for CAP
Inpatient, ICU ttt

• A) b-lactam plus either azithromycin (level II
  evidence) or a respiratory fluoroquinolone
• (strong recommendation level I evidence)
• (cefotaxime, ceftriaxone, or
  ampicillin-sulbactam)

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
86
Recommended empirical antibiotics for CAP
Inpatient, ICU ttt

• If Pseudomonas is a consideration
• Antipseudomonal b-lactam (piperacillin-tazobactam
  , cefepime, imipenem, or meropenem) either
  ciprofloxacin or levofloxacin (750-mg dose)
• Or The above b-lactam aminoglycoside
  azithromycin
• Or The above b-lactam aminoglycoside an
  antipneumococcal fluoroquinolone

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
87
Recommended empirical antibiotics for CAP
Inpatient, ICU ttt

• Community Acquired MRSA (CA-MRSA)
• If CA-MRSA is a consideration
• add vancomycin or linezolid

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
88
Pathogen-directed therapy

• Once the etiology of CAP has been identified on
  the basis of reliable microbiological methods,
  antimicrobial therapy should be directed at that
  pathogen.
• (Moderate recommendation level III
  evidence.)

89
Switch from intravenous to oral therapy.

• Patients should be switched from intravenous to
  oral therapy when they are hemodynamically stable
  and improving clinically, are able to ingest
  medications, and have a normally functioning
  gastrointestinal tract.
• (Strong recommendation level II evidence.)

90
Switch from intravenous to oral therapy.

• Patients should be discharged as soon as they are
  clinically stable, have no other active medical
  problems, and have a safe environment for
  continued care.
• Inpatient observation while receiving oral
  therapy is not necessary.
• (Moderate recommendation level II evidence.)

91
Approaches to Switching from IV to oral therapy

• 1. Step down therapy
• Conversion from one antibiotic given IV to
  another given orally.
• 2. Transitional therapy
• Conversion from same antibiotic given IV to oral
  but not at the same dosage or strength.
• 3. Sequential therapy
• Conversion from same antibiotic IV to oral at the
  same dosage and strength.

92
CAP Duration of Therapy

• A minimum of 5 days Afebrile for 48-72 h (level
  I evidence),
• No more than1 CAP-
• associated sign of
• Clinical instability

IDSA /ATS Consensus Guidelines on the Management
of Community-Acquired Pneumonia in Adults.
Clinical Infectious Diseases 2007 44S2772
93
Duration of antibiotic therapy

• A longer duration of therapy may be needed if
  initial therapy was not active against the
  identified pathogen or if it was complicated by
  extra-pulmonary infection, such as meningitis or
  endocarditis.
• (Weak recommendation level III evidence.)

94
Considerations for patients worsening or failing
to improve by day three

• Predisposing condition requiring gt3 days for
  improvement
• (continue present Rx) e.g. elderly patient
• Incorrect diagnosis or complicating condition
• Common Pulmonary embolism or infarction,
  carcinoma, pulmonary edema, bronchiectasis, etc.
• Uncommon Pulmonary eosinophilia, alveolar
  hemorrhage, foreign body
• Unexpected pathogens eg, mycobacteria, MRSA etc.

95
Duration of antibiotic therapy

• Patients with CAP should be treated for a minimum
  of 5 days (level I evidence), should be afebrile
  for 4872 h, and should have no more than 1
  CAP-associated sign of clinical instability (next
  table) before discontinuation of therapy
• (Moderate recommendation , level II evidence)

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Management of Non-responding PneumoniaDefinitions
and classification

• The use of a systematic classification of
  possible causes of failure to respond, based on
  time of onset and type of failure , is
  recommended.
• (Moderate recommendation level II evidence.)

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Community-Acquired Pneumonia Guidelines, US
Nonresolving

• Failure to improve
• Early (lt72 hours) normal
• Delayed
• Resistant organism
• Effusion/empyema
• Superinfection
• Noninfectious
• Bronchitis obliterans-organized pneumonia
• Pleural effusion (PE)
• Congestive heart failure
• Drug fever

• Deteriorate/progression
• Early illness severity
• Organism resistance
• Metastatic infection
• PE, adult respiratory distress syndrome,
  vasculitis
• Delayed
• Superinfection
• Comorbid exacerbation
• Noninfectious complications
• PE, myocardial infarction, renal failure
• Management
• Transfer to higher care level
• More diagnostic testing
• Escalate/change treatment

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Mandell LA, et al. Clin Infect Dis. 200744(suppl
2)S27-S72.
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