Community acquired pneumonia (cap)

diagnosis and treatment

1. COMMUNITY - ACQUIRED PNEUMONIA ANH LUONG.T.N MD

2. CONTENT DEFINITION EPIDEMIOLOGY DIAGNOSTIC APPROACH TO COMMUNITY- ACCUIRED PNEUMNIA (CAP) ASSESSING SEVERITY AND DERTERMINING THE APPROPRIATE SITE OF CARE TREATMENT OF CAP IN THE OUTPATIENT SETTING TREATMENT OF CAP WHO REQUIRE HOSPITALIZATION

3. 1. DEFINITION  Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma in a patient who has acquired the infection in the community, as distinguished from hospital-acquired (nosocomial) pneumonia (HAP).

4. 2. EPIDERMIOLOGY The incidence of CAP is approximately 5.16 to 6.11 cases per 1000 persons per year in US. The rate of CAP increases with increasing age. [1] M ore cases occurring during the winter months Men > women; black persons > Caucasians The etiology of CAP varies by geographic region; however, Streptococcus pneumoniae is the most commonly identified bacterial cause of CAP worldwide. Viruses are common causes of CAP as well [2], [3] All-cause mortality in patients with CAP is as high as 28 percent within one year.

5. US deaths due to pneumonia by patient age DOI: 10.3810/pgm.2010.03.2130

6. The overall mortality due to CAP doi.org/10.1016/j.rmed.2013.04.003

7. 3. DIAGNOSTIC APPROACH TO CAP The diagnosis of CAP generally requires 2 factors : T he demonstration of an infiltrate on chest radiograph Clinically compatible syndrome ( eg , fever, dyspnea, cough, and sputum production).

8. Clinical evaluation Marrie TJ. Community-acquired pneumonia. Clin Infect Dis 1994; 18:501. SYMTOM RATE OF APPERANCE Chest pain 30 % Chills 40 - 50 % Rigors 15% Febrile 80% A respiratory rate above 24 breaths/minute 45- 70 % Audible crackles most patients Decreased or bronchial breath sounds, dullness to percussion, tactile fremitus, and egophony 33%

9. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA 1997; 278:1440 N o clear constellation of symptoms and signs has been found to accurately predict whether or not the patient has pneumonia . As an example, the sensitivity of the combination of fever, cough, tachycardia, and crackles was less than 50 percent when chest radiograph was used as a reference standard.

10. Radiographic evaluation T he gold standard for diagnosing pneumonia I nclude lobar consolidation, interstitial infiltrates, and/or cavitation

11. Cases to argue (1) Clinical manifestations => normal X- ray => abnormal

12. Cases to argue (2) Clinical manifestations => abnormal X- ray => normal

13. Case 1: other causes for the radiographic abnormalities must be considered , such as malignancy, hemorrhage, pulmonary edema, pulmonary embolism, and inflammation secondary to noninfectious causes . Case 2: the radiograph may represent a false-negative result . In some cases, this can be clarified with a CT scan which has higher sensitivity and accuracy than chest radiographs for detecting CAP

14. High-resolution CT scan in pneumonia Viruses , Mycoplasma, and Chlamydia. In: Imaging of Pulmonary Infections, Müller NL, Franquet T, Lee KS ( Eds ), Lippincott Williams & Wilkins, Philadelphia 2007. Copyright © 2007 Lippincott Williams & Wilkins

15. Why is X- ray false-negative?

16. => Volume depletion may produce an initially negative radiograph, which "blossoms" into infiltrates following rehydration . => The ability of the absence of infiltrate at 24 hours after onset of symptom .

17. Some notices Lung ultrasound to diagnose pneumonia with the sensitivity of lung ultrasound was approximately 80 to 90 percent and the specificity approximately 70 to 90 percent. [4], [5]

18. Normal lung surface : bat sign, seashore sign DOI: 10.1186/2110-5820-4-1

19. Pleural effusion : the quad sign, sinusoid sign DOI: 10.1186/2110-5820-4-1

20. Lung consolidation DOI: 10.1186/2110-5820-4-1

21. Lung consolidation

22. Interstitial syndrome and the lung rockets DOI: 10.1186/2110-5820-4-1

23. Pneumothorax and the stratosphere sign DOI: 10.1186/2110-5820-4-1

24. Pneumothorax and the lung point DOI: 10.1186/2110-5820-4-1

25. Clinical indications for diagnostic testing for community-acquired pneumonia Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clin Infect Dis 2007; 44:S27.

26. Laboratory test Procalcitonin is not routinely used to aid in the diagnosis of CAP. It can help determine the appropriate duration of antibiotics. CRP has shown more limited utility, due in part to the paucity of studies. One study showed a CRP >40 mg/L had a sensitivity and specificity for bacterial pneumonia of 70 and 90 percent, respectively. Another study that included 364 patients with respiratory infection showed a sensitivity of 73 percent and specificity of 65 percent

27. 4. ASSESSING SEVERITY AND DERTERMINING THE APPROPRIATE SITE OF CARE

28. PSI

29. CURB-65 pneumonia severity score Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58:377. Lim WS, Baudouin SV, George RC, et al. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009; 64 Suppl 3:iii1. Qureshi KN, Hodkinson HM. Evaluation of a ten-question mental test in the institutionalized elderly . Age Ageing 1974; 3:152.

30. IDSA/ATS severity criteria- minor criteria for ICU admission Altered mental status Hypotension requiring fluid support Temperature <36°C (96.8°F) Respiratory rate ≥30 breaths/minute PaO 2 /FiO 2 ratio ≤250 Blood urea nitrogen ≥20 mg/ dL (blood urea 7 mmol /L) Leukocyte count <4000 cells/ microL Platelet count <100,000/mL Multilobar infiltrates => recommend ICU care for patients with at least three criteria.

31. 5. TREATMENT OF CAP IN THE OUTPATIENT SETTING the 2007 recommendations of the Infectious Diseases Society of America and the American Thoracic Society

32. Initial empirical treatment regimens for CAP the 2009 guideline recommendations of the British Thoracic Society

33. Treatment duration Most ambulatory patients with CAP should be treated for five days . Patients should be afebrile for ≥48 hours and clinically stable before therapy is discontinued

34. Usual duration of findings in treated community-acquired pneumonia Marrie TJ, Beecroft MD, Herman- Gnjidic Z. Resolution of symptoms in patients with community-acquired pneumonia treated on an ambulatory basis. J Infect 2004; 49:302. Metlay JP, Atlas SJ, Borowsky LH, Singer DE. Time course of symptom resolution in patients with community-acquired pneumonia. Respir Med 1998; 92:1137. Fine MJ, Stone RA, Singer DE, et al. Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study. Arch Intern Med 1999; 159:970.

35. Folow - up Clinical follow-up: within 24 to 48 hours after being diagnosed and a later visit is often indicated to assess for resolution of pneumonia . Follow-up chest radiograph: All CAP patients who are responding clinically is unnecessary Radiographs are performed 7 to 12 weeks following treatment to document resolution of the pneumonia and exclude underlying diseases, such as malignancy. F ollow-up chest radiograph is particularly important for males and smokers in > 50 years of age group

36. The nonresponding patient 6 to 15 percent require hospitalization

37. 6. TREATMENT OF CAP WHO REQUIRE HOSPITALIZATION

38. INITIAL EMPIRIC THERAPY the 2007 recommendations of the Infectious Diseases Society of America and the American Thoracic Society Treatment of community-acquired pneumonia in adults who require hospitalization

39. Risk factors for Pseudomonas or drug-resistant pathogens Gram-negative bacilli (including Pseudomonas)   : Previous antibiotic therapy Recent hospitalization Immunosuppression Pulmonary comorbidity ( eg , cystic fibrosis, bronchiectasis, or repeated exacerbations of chronic obstructive pulmonary disease that require frequent glucocorticoid and/or antibiotic use) Probable aspiration Multiple medical comorbidities ( eg , diabetes mellitus, alcoholism )

40. Methicillin-resistant Staphylococcus aureus: G ram-positive cocci in clusters seen on sputum Gram stain E nd-stage renal disease Contact sport participants Injection drug users Those living in crowded conditions Men who have sex with men, prisoners R ecent influenza-like illness A ntimicrobial therapy (particularly with a fluoroquinolone) in the prior three months Necrotizing or cavitary pneumonia, and presence of empyema

41. Streptococcus pneumoniae   : Age >65 years Beta-lactam , macrolide, or fluoroquinolone therapy within the past three to six months Alcoholism Medical comorbidities Immunosuppressive illness or therapy Exposure to a child in a daycare center

42. Timing of antimicrobial initiation  — We recommend that antimicrobials be administered as soon as possible after diagnosing CAP and before leaving the emergency department or clinic

43. Adjunctive glucocorticoids Controversial between reducing the inflammatory response to pneumonia and contributing to its morbidity and mortality. The decision of using steroid on a case-by-case basis.

44. Giving adjunctive glucocorticoids The patients are at high risk of mortality and are likely to benefit the most. Such patients who have evidence of an exaggerated or dysregulated host inflammatory response. It defined as sepsis or respiratory failure with an FiO 2 requirement of >50 percent plus one or more of the following features (metabolic acidosis with an arterial pH of <7.3, lactate >4 mmol /L, or a C-reactive protein >150 mg/L )

45. Reasons to avoid glucocorticoids: S evere adverse events such as recent gastrointestinal bleeding, poorly controlled diabetes, or severe immunocompromise . A void glucocorticoids in patients with CAP known to be caused by a viral pathogen such as influenza or a fungal pathogen such as Aspergillus . Generally find that the potential for harm outweighs the potential for benefit in patients who are at low risk for mortality.

46. U sing adjunctive glucocorticoids F ive days For patients who are unable to take oral medications , using methylprednisone 0.5 mg/kg IV every 12 hours . For patients who can take oral medications, we use prednisone 50 mg orally daily Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis; Siemieniuk RA, Meade MO, Alonso- Coello P, Briel M, Evaniew N, Prasad M, Alexander PE, Fei Y, Vandvik PO, Loeb M, Guyatt GH ; Ann Intern Med. 2015;163(7): 519 Adjunctive Systemic Corticosteroids for Hospitalized Community-Acquired Pneumonia: Systematic Review and Meta-Analysis 2015 Update; Horita N, Otsuka T, Haranaga S, Namkoong H, Miki M, Miyashita N, Higa F, Takahashi H, Yoshida M, Kohno S, Kaneko T ; Sci Rep. 2015;5:14061.

47. Influenza therapy Antiviral treatment is recommended as soon as possible for all persons with suspected or confirmed influenza requiring hospitalization or who have progressive, severe, or complicated influenza infection, regardless of previous health or vaccination status Antiviral agents for the treatment and chemoprophylaxis of influenza --- recommendations of the Advisory Committee on Immunization Practices (ACIP); Fiore AE, Fry A, Shay D, Gubareva L, Bresee JS, Uyeki TM, Centers for Disease Control and Prevention (CDC) ; MMWR Recomm Rep. 2011;60(1):1.

48. Clinical response to therapy With appropriate antibiotic therapy, some improvement in the patient's clinical course is usually seen within 48 to 72 hours . Patients who do not demonstrate some clinical improvement within 72 hours are considered nonresponders

49. Patients who respond to therapy Narrowing therapy Switching to oral therapy

50. Duration of hospitalization Hospital discharge when: clinically stable from the pneumonia Can take oral medication no other active medical problems Has a safe environment for continued care Patients do not need to be kept overnight for observation following the switch.

51. Duration of therapy Graphic 89823 Version 1.0, U ptodate

52. Clinical follow-up after discharge   U sually within one week. A later visit is often indicated to assess for resolution of pneumonia.

53. Risk factors for rehospitalization initial treatment failure one or more instability factors ( eg , vital signs or oxygenation) on discharge risk factors for non-pneumonia-related readmissions were age ≥65 and decompensated comorbidities (most commonly cardiac or pulmonary).

54. Prevention Vaccination Screening for influenza vaccination status is warranted during influenza season ( eg , from October through March in the northern hemisphere) in all patients . Screening for pneumococcal vaccination status is warranted in patients age 65 or older or with other indications for vaccination Vaccination can be performed during outpatient treatment

55. Smoking cessation Smoking cessation should be a goal for patients with CAP who smoke

56. Reference [1] Marrie TJ, Huang JQ. Epidemiology of community-acquired pneumonia in Edmonton, Alberta: an emergency department-based study. Can Respir J 2005; 12:139. [2] Gadsby NJ, Russell CD, McHugh MP, et al. Comprehensive Molecular Testing for Respiratory Pathogens in Community-Acquired Pneumonia. Clin Infect Dis 2016; 62:817. [3] Jain S, Self WH, Wunderink RG, et al. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N Engl J Med 2015; 373:415 . [4] Long L, Zhao HT, Zhang ZY, et al. Lung ultrasound for the diagnosis of pneumonia in adults: A meta-analysis. Medicine (Baltimore) 2017; 96:e5713. [5] Llamas- Álvarez AM, Tenza -Lozano EM, Latour -Pérez J. Accuracy of Lung Ultrasonography in the Diagnosis of Pneumonia in Adults: Systematic Review and Meta-Analysis. Chest 2017; 151:374.

57. [6] Treatment of community-acquired pneumonia in adults who require hospitalization, Thomas M File, Jr, MD [7] Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care, Donald M Yealy , MD, FACEP, Michael J Fine, MD, MSc   [8] Diagnostic approach to community-acquired pneumonia in adults, John G Bartlett, MD [9] Epidemiology, pathogenesis, and microbiology of community-acquired pneumonia in adults, Thomas J Marrie , MD, Thomas M File, Jr, MD [10] Treatment of community-acquired pneumonia in adults in the outpatient setting, Thomas M File, Jr, MD