CAP

2. Community Acquired Pneumonia(CAP)
Gamal Rabie Agmy, MD,FCCP
Professor of Chest Diseases, Assiut university

3. 3
Pneumonias – Classification
•Community Acquired CAP
•Health Care Associated HCAP
•Hospital Acquired HAP
•ICU Acquired ICUAP
•Ventilator Acquired VAP
Nosocomial Pneumonias

4. *HCAP: diagnosis made < 48h after
hospitalization with any of the following risk
factors:
(1)hospitalized in an acute care hospital for >
48h within 90d of the diagnosis;
(2) resided in a nursing home or long-term
care facility;
(3) received recent IV antibiotic therapy,
chemotherapy, or wound care within the 30d
preceding the current diagnosis; and
(4) attended a hospital or hemodialysis
clinic
HCAP

5. Infection of the lung parenchyma in a
person who is not hospitalized or living
in a long-term care facility for ≥ 2
weeks. This pneumonia develops in
the outpatient setting or within 48
hours of admission to a hospital.
Definition of CAP

6. Symptoms:

• Respiratory: Cough dry or productive,
mucopurulent sputum , sometimes
rusty, dyspnea, sometimes pleuritic
chest pain
• Non-respiratory: Fever, body aches,
altered mental state, vomiting or
diarrhea.
The clinical diagnosis of CAP

7. Signs:

Generally: Fever, sometimes
hypothermia, tachycardia, tachypnea.

Local: signs of consolidation
The clinical diagnosis of CAP

8. 8
CAP – The Two Types of Presentations
Classical
•Sudden onset of CAP
•High fever, shaking chills
•Pleuritic chest pain, SOB
•Productive cough
•Rusty sputum, blood tinge
•Poor general condition
•High mortality up to 20% in
patients with bacteremia
•S.pneumoniae causative

•Gradual & insidious onset
•Low grade fever
•Dry cough, No blood tinge
•Good GC – Walking CAP
•Low mortality 1-2%; except
in cases of Legionellosis
•Mycoplasma, Chlamydiae,
Legionella, Ricketessiae,
Viruses are causative
Atypical

9. Sputum Gram stain:
is a rapid and inexpensive test that can
help a lot:
• Differentiate Gm –ve from Gm +ve
bacteria.
• Excess pus cells without organism
suspect atypical infection.
The Bacteriological Diagnosis of CAP

10. Cultures to identify the causative
organism:
Sputum cultures are not recommended in
cases of CAP except in certain occasions:
• Patients admitted in hospital or ICU.
• Patients who do not respond to
empirical antibiotic therapy.
• Suspection of resistant strains of
S.pneumoniae.
The Bacteriological Diagnosis of CAP

11. Blood Culture:

Recommended for all patients with
moderate and high severity CAP,
preferably before antibiotic therapy is
commenced.

Examination of sputum for
Mycobacterium TB
The Bacteriological Diagnosis of CAP

12. 12
CAP – Pathogenesis
Inhalation
Aspiration
Hematogenous

14. 14

PORT Scoring – PSI

Clinical Parameter Scoring
Age in years Example
For Men (Age in yrs) 50
For Women (Age -10) (50-10)
NH Resident 10 points
Co-morbid Illnesses
Neoplasia 30 points
Liver Disease 20 points
CHF 10 points
CVD 10 points
Renal Disease (CKD) 10 points
Clinical Parameter Scoring
Clinical Findings
Altered Sensorium 20 points
Respiratory Rate > 30 20 points
SBP < 90 mm 20 points
Temp < 35
0
C or > 40
0
C 15 points
Pulse > 125 per min 10 points
Investigation Findings
Arterial pH < 7.35 30 points
BUN > 30 20 points
Serum Na < 130 20 points
Hematocrit < 30% 10 points
Blood Glucose > 250 10 points
Pa O
2 10 points
X Ray e/o Pleural Effusion 10 points
Pneumonia Patient Outcomes
Research Team (PORT)

15. 15
Classification of Severity - PORT
Predictors
Absent
Class
I
 70
Class
II
71 – 90
Class
III
91 - 130
Class
IV
> 130
Class
V

16. 16
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 > 130 27 – 31.1 IP - ICU

17. 17
CURB 65 Rule – Management of CAP
CURB 65
Confusion
BUN > 30
RR > 30
BP SBP <90
DBP <60
Age > 65
CURB 0 or 1 Home Rx
CURB 2 Short Hosp
CURB 3 Medical Ward
CURB 4 or 5 ICU care

19. 19
CAP – Criteria for ICU Admission
Major criteria
Invasive mechanical ventilation required
Septic shock with the need of vasopressors
Minor criteria (least 3)
Confusion/disorientation
Blood urea nitrogen ≥ 20 mg%
Respiratory rate ≥ 30 / min;
Core temperature < 36ºC
Severe hypotension;
 PaO2/FiO2 ratio ≤ 250
Multi-lobar infiltrates
WBC < 4000 cells;
Platelets <100,000

20. The Radiological Diagnosis
of CAP

21. 21
CAP – Value of Chest Radiograph
•Usually needed to establish diagnosis
•It is a prognostic indicator
•To rule out other disorders
•May help in etiological diagnosis
J Chr Dis 1984;37:215-25

22. 22
Infiltrate Patterns and Pathogens
CXR Pattern Possible Pathogens
Lobar S.pneumo, Kleb, H. influ, Gram Neg
Patchy Atypicals, Viral, Legionella
Interstitial Viral, PCP, Legionella
Cavitatory Anerobes, Kleb, TB, S.aureus, Fungi
Large effusion Staph, Anaerobes, Klebsiella

23. 23
Normal CXR & Pneumonic Consolidation

24. 24
Lobar Pneumonia – S.pneumoniae

25. 25
CXR – PA and Lateral Views

26. 26
Lobar versus Segmental - Right Side

27. 27
Lobar Pneumonia

28. 28
Special forms of Consolidation

29. 29
Round Pneumonic Consolidation

30. 30
Special Forms of Pneumonia

31. 31
Special Forms of Pneumonia

32. 32
Complications of Pneumonia

33. 33
Empyema

34. 34
Mycoplasma Pneumonia

35. 35
Mycoplasma Pneumonia

36. 36
Chlamydia Trachomatis

37. 37
Rare Types of Pneumonia

38. S Curve of Golden

When there is a mass
adjacent to a fissure, the
fissure takes the shape
of an "S". The proximal
convexity is due to a mass,
and the distal concavity is
due to atelectasis. Note the
shape of the transverse
fissure.
This example represents a
RUL mass with atelectasis

39. THE BAT VIEW
Chest wall
Pleural line

40. THE BAT VIEW
Chest wall
Pleural line

41. 41

45. Pneumonia
Posterior intercostal scan shows a hypoechoic
consolidated area that contains multiple
echogenic lines that represent an air
bronchogram.

46. Post-stenotic pneumonia
Posterior intercostal scan shows a hypoechoic
consolidated area that contains anechoic,
branched tubular structures in the bronchial tree
(fluid bronchogram).

47. Contrast-enhanced ultrasonography
of pneumonia
A: Baseline scan shows
a hypoechoic
consolidated area
B: Seven seconds after
iv bolus of contrast
agent, the lesion shows
marked and
homogeneous
enhancement
C: The lesion remains
substantially unmodified
after 90 s.

48. The Treatment of CAP

49. ANTIMICROBIAL DRUGS

50. MECHANISMS OF ACTION OF
ANTIBACTERIAL DRUGS
Mechanism of action
include:
Inhibition of cell
wall synthesis
Inhibition of protein
synthesis
Inhibition of nucleic
acid synthesis
Inhibition of
metabolic pathways
Interference with
cell membrane
integrity

51. EFFECTS OF
COMBINATIONS OF DRUGS
Sometimes the chemotherapeutic effects of
two drugs given simultaneously is greater than
the effect of either given alone.
 This is called synergism. For example,
penicillin and streptomycin in the treatment
of bacterial endocarditis. Damage to
bacterial cell walls by penicillin makes it
easier for streptomycin to enter.

52. EFFECTS OF
COMBINATIONS OF DRUGS
Other combinations of drugs can be
antagonistic.
For example, the simultaneous use of penicillin
and tetracycline is often less effective than
when wither drugs is used alone. By stopping
the growth of the bacteria, the
bacteriostatic drug tetracycline interferes
with the action of penicillin, which requires
bacterial growth.

53. EFFECTS OF
COMBINATIONS OF DRUGS
Combinations of antimicrobial drugs should
be used only for:
1.To prevent or minimize the emergence of
resistant strains.
2.To take advantage of the synergistic effect.
3.To lessen the toxicity of individual drugs.

54. Patterns of Microbial Killing
Concentration dependent
–Higher concentration greater killing
Aminoglycosides, Flouroquinolones, Ketolides,
metronidazole, Ampho B.
Time-dependent killing
–Minimal concentration-dependent killing (4x
MIC)
–More exposure more killing
Beta lactams, glycopeptides, clindamycin,
macrolides, tetracyclines, bactrim

55. The Ideal Drug*
1.Selective toxicity: against target pathogen but
not against host
 LD
50 (high) vs. MIC and/or MBC (low)
2.Bactericidal vs. bacteriostatic
3.Favorable pharmacokinetics: reach target site
in body with effective concentration
4.Spectrum of activity: broad vs. narrow
5.Lack of “side effects”
 Therapeutic index: effective to toxic dose ratio
6.Little resistance development

56. Resistance
Physiological Mechanisms
1. Lack of entry – tet, fosfomycin
2. Greater exit
 efflux pumps
 tet (R factors)
3. Enzymatic inactivation
 bla (penase) – hydrolysis
 CAT – chloramphenicol acetyl transferase
 Aminogylcosides transferases
REVIEW

57. Resistance
Physiological Mechanisms
4. Altered target
 RIF – altered RNA polymerase (mutants)
 NAL – altered DNA gyrase
 STR – altered ribosomal proteins
 ERY – methylation of 23S rRNA
5. Synthesis of resistant pathway
 TMP
r
plasmid has gene for DHF reductase;
insensitive to TMP
(cont’d)
REVIEW

58. Empirical Treatment is the
recommended strategy in
treatment of CAP and
shouldn’t be delayed.

59. 59
CAP – Special Features – Pathogen wise
Typical – S.pneumoniae, H.influenza, M.catarrhalis
Blood tinged sputum - Pneumococcal, Klebsiella, Legionella
H.influenzae
CAP has associated of pleural effusion:S.Pneumoniae –
commonest – penicillin resistance problem
S.aureus, K.pneumoniae, P.aeruginosa
S.aureus causes CAP in post-viral influenza; Serious CAP
K.pneumoniae primarily in patients of chronic alcoholism
P.Aeruginosa causes CAP in pts with CSLD or CF, Nosocom
Aspiration CAP only is caused by multiple pathogens
Extra pulmonary manifestations only in Atypical CAP

60. Outpatient treatment:
Oral Respiratory Fluroquinolones
OR Oral B-Lactam/ B-Lactamase + Oral
New Macrolide
OR IM 3rd Generation Cefalosporines +
New Macrolide
Recommendations for the Empirical Treatment:

61. In-patient treatment: Non-ICU:
Intravenous ( IV )Respiratory fluoro-
quinolone
OR IV B-Lactam/ B-Lactamase + IV New
Macrolide
OR IV 3rd Generation Cephalosporin + IV
New Macrolide
Recommendations for the Empirical Treatment:

62. In-patient treatment: ICU:
No Monotherapy.
IV Respiratory fluoroquinolone + 3rd or
4th generation cephalosporin
OR IV Imipenem + IV New Macrolide
Recommendations for the Empirical Treatment:

63. Special entities in ICU:
Aspiration:
As Before + i.v. Clindamycin OR Metronidazole
Risk of Pseudomonas Infection:
Antipseudomonal beta-lactam (3rd or 4th generation
cephalosporin OR Piperacillin-tazobactam OR
carbapenem) Plus (aminoglycoside OR
antipseudomonal fluoroquinolone)
For community -acquired methicillin-resistant
Staphylococcus aureus infection (MRSA):
Add Teicoplanin OR linezolid Alternative: Vancomycin
(considering its renal side effects)
Recommendations for the Empirical Treatment:

64. 64
Duration of Therapy
•Minimum of 5 days
•Afebrile for at least 48 to 72 h
•Longer duration of therapy
If initial therapy was not active against the identified
pathogen or complicated by extra pulmonary infection

65. 65
Strategies for Prevention of CAP
•Cessation smoking
•Influenza Vaccine It offers 90% protection and
reduces mortality by 80%
•Pneumococcal Vaccine (Pneumonia shot)
It protects against 23 types of Pneumococci
70% of us have Pneumococci in our RT
It is not 100% protective but reduces mortality
Age 19-64 with co morbidity of high for pneumonia
Above 65 all must get it even without high risk
•Starting first dose of antibiotic within 4 h & O
2 status

66. 66
Switch to Oral Therapy
Four criteria
Improvement in cough, dyspnea & clinical signs
Afebrile on two occasions 8 h apart
WBC decreasing towards normal
Functioning GI tract with adequate oral intake
If overall clinical picture is otherwise favorable,
hemodynamically stable; can switch to oral
therapy while still febrile.

67. 67
Management of Poor Responders
Consider non-infectious illnesses
Consider less common pathogens
Consider serologic testing
Broaden antibiotic therapy
Consider bronchoscopy

68. 68
CAP – Complications
Hypotension and septic shock
3-5% Pleural effusion; Clear fluid + pus cells
1% Empyema thoracis pus in the pleural space
Lung abscess – destruction of lung - CSLD
Single (aspiration) anaerobes, Pseudomonas
Multiple (metastatic) Staphylococcus aureus
Septicemia – Brain abscess, Liver Abscess
Multiple Pyemic Abscesses

69. 69
CAP – So How Best to Win the War?
Early antibiotic administration within 4-6 hours
Empiric antibiotic Rx. as per guidelines (IDSA / ATS)
PORT – PSI scoring and Classification of cases
Early hospitalization in Class IV and V
Change Abx. as per pathogen & sensitivity pattern
Decrease smoking cessation - advice / counseling
Arterial oxygenation assessment in the first 24 h
Blood culture collection in the first 24 h prior to Abx.
Pneumococcal & Influenza vaccination; Smoking
cessation

70. Broncho-Vaxom is an extract of
different bacterial species frequently
responsible of respiratory infections.

It stimulates the immune system in
order to increase the body’s natural
defences against a wide spectrum of
respiratory pathogens.
BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular sinusitis, rhinopharyngitis and middle ear infection, in adults and children.

71. Broncho-Vaxom prevents and/or
reduces the severity of acute attacks
of chronic bronchitis and recurrent
infections of the respiratory tract, in
particular sinusitis, rhinopharyngitis
and middle ear infection, in adults and
children.
BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular sinusitis, rhinopharyngitis and middle ear infection, in adults and children.

72. Immunostimulating agent
In animals, an increased resistance
towards experimental infections, a
stimulation of macrophages and B
lymphocytes as well as an increase in
immunoglobulins secreted by the
respiratory mucosal cells have been
reported.
BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular sinusitis, rhinopharyngitis and middle ear infection, in adults and children.

73. Immunostimulating agent

In humans, an increase in the rate of
circulating T lymphocytes, in salivary IgA,
in the non-specific response to polyclonal
mitogens and in the mixed lymphocyte
reaction have been observed.
BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular sinusitis, rhinopharyngitis and middle ear infection, in adults and children.

74. Safety
Extensive toxicity studies have not
revealed any toxic effect.
Effects on ability to drive and use
machines:
Broncho-Vaxom is presumed to be safe
and unlikely to produce an effect.

BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular sinusitis, rhinopharyngitis and middle ear infection, in adults and children.

75. Safety
Reproduction studies in animals have not
demonstrated any risk to the fetus, but
controlled studies in pregnant women are
not available. As regards breast-feeding,
no specific studies have been performed
and no data have been reported up to
now.
BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular sinusitis, rhinopharyngitis and middle ear infection, in adults and children.

76. Side effects

The overall incidence of adverse effects in clinical
trials lies between 3 and 4%. Gastrointestinal troubles
(nausea, abdominal pain, vomiting), dermatologic
reactions (rash, urticaria), and respiratory disorders
(coughing, dyspnea, asthma), as well as generalized
problems (fever, fatigue, allergic reactions) are the
most frequent complaints reported.


BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular sinusitis, rhinopharyngitis and middle ear infection, in adults and children.

77. Interaction

No drug interaction is known up to now..


BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular sinusitis, rhinopharyngitis and middle ear infection, in adults and children.