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Community aquired pneumonia : Dr. Devawrat Buche MD (FNB )
- 1. COMMUNITY AQUIRED PNEUMONIA Dr. Devawrat Buche, MD FNB Fellow ( CCM )
- 2. • Definition •Epidemiology • Signs and symptoms • Investigations • Microbiology • Risk stratification • Treatment • Prevention
- 3. DEFINITION It isa syndrome in which acute infection of lung develops in persons who have not been previously hospitalized , with no regular exposure to health care system. Traditional definition ( NEJM, oct 2014 ) Newly developed lung infiltrate on chest imaging along with fever, cough, sputum production, shortness of breath with physical findings of consolidation and leucocytosis.
- 4. • Joint ICS/NCCP (I) Definition: 1. In the absence of CXR- • Symptoms of acute LRTI for less than 1 week • At least 1 systemic feature ( temp >37.7, chills and rigors, severe malaise ) • New focal chest signs ( bronchial breath sounds/ crackles) • No other explaination for the illness 2. In the presence of CXR – • Above symptoms • New radiologic shadowing • With no other explaination ( edema / infarction)
- 5. EPIDEMIOLOGY • World • Social burden • US stats : > 9 lakh cases/ year in > 65 yr age • High rates of hospital admissions , prolonged inactivity : health care burden • INDIA • NO large studies, data limited • Attributable mortality to LRTI is around 20% 2008 stats : • Mortality due to LRTI : 35.1/ lakh • Mortlaity due to TB : 35.8 / lakh
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- 7. • Etiology inIndia (based on blood cultures ) : S. Pneumoniae ( 35.3% ) s. Aureus ( 23.5%) Kleb. Pneumoniae ( 20.5%) H. Influenzae ( 8.8%) • Legionella is often not considered in Indian setting : 1 study found 27% patients seropositive and 18 % urine ag positive • No large studies to specifically address viruses as the cause.
- 8. • Etiology inspecific population groups : 1. Elderly • S. pneumonia : 19- 58% of hospitalized pt. • H. influenzae : 5- 14 % 2. Alcoholism Increased CAP risk with dose response relationship • S. pneumoniae: most common • High incidence of bacteremia and increased severity • Mortality rates similar to other groups. 3. COPD • Increased incidence of pseudomonas and GNB 4. Diabetes mellitus • Increased bacteremia, higher mortality rates. • Pneumococcal pneumonia (m.c. )
- 9. • Risk factorsfor pseudomonas pneumonia : 1. Immunocompromiosed 2. Chronic respiratory disease 3. Enteral tube feeding 4. Cerebrovascular disease 5. Chronic neurological disorders 6. Structural respiratory disease : bronchiectasis
- 10. DIAGNOSTIC TESTING •Physical examination • Routine investigations • Chest X ray • Microbiological studies • Immunological studies
- 11. Clinical diagnosis isbased on: • Presence of clinical features : cough, fever, sputum production, pleuritic chest pain • Physical examination: rales, bronchial breath sounds, tachypnea, tachycardia, fever. • Pulse oximetry : desaturation s/o severity • Other : plasma glucose, CBC, LFT, KFT, electrolytes
- 12. Chest radiography •CXR useful in suggesting etiologic agents, prognoses, alternative diagnosis and associated conditions • A demonstrable infiltrate by chest radiograph or other imaging technique is required for diagnosis of pneumonia ( level III evidence ) – should be done whenever possible. • For hospitalized patients with suspected pneumonia having negative CXR: continue empirical therapy and repeat CXR in 24-48 hrs. • Salient findings : 1.Asymmetric lung opacification with air bronchogram 2. Presence of silhouette sign 3. Increased opacity with well defined interface
- 13. • HRCT salientfindings : 1. Air space considation 2. Ground glass attenuation 3. Thickening of bronchovascular bundle • Low sensitivity and specificity to discrimnate bacterial from non bacterial etiology • Recommendation : 1. Should not be routinely performed 2. Should be performed in those with nonresolving pneumonias and for assessment of complications.
- 14. Microbiological studies 1.Blood culture • Low sensitivity , high specificity : for etiology • Low yield : 5 – 33 % Recommendations : A. Should be obtained in all hospitalized patients ( 2A ) B. Not required in routine outpatient management ( 2A).
- 15. 2. Sputum Gramstain and culture • Yield : 34 – 86 % • Provides rapid results, narrows down etiology SAMPLING • 20 – 40 fields examined under low power • If epithelial cells > 10/lpf : sample rejected • If no. of pus cells is 10 times epi. Cells, with 3+ or4+ single bacterial morphology : sample accepted Recommendations : 1. Initial gram stain and culture obtained from all hospitalized patients with CAP ( 2A) 2. Sputum for AFB obtained as per RNTCP guidelines ( 2A) 3. Sputum quality should be ensured for interpreting results ( 2A )
- 16. Other cultures 1.Thoracocentesis • Pleural effusions >5 cm in lateral upright CXR • Undergo thoracocentesis, GS and culture • Yield is low • But can impact management 2.BAL / tracheal aspirate. • Not been studied prospectively in initial magt of CAP Best indications are : • Immunocompromised patients with CAP • Patients of CAP with failure of t/t
- 17. Immunological testing 1.Urinary pneumococcal Ag • Rapid immunochromatographic membrane tests • Unfavourable cost : benefit ratio • Only confirms etiology, no change in t/t protocol. Currently, not recommended routinely.
- 18. 2. Legionella urineAg test • High specificity ( 99 %), low sensitivity ( 74 %) • Positive test is highly specific, changes duration of antibiotic therapy Currently recommended for patients with severe CAP ( 1B) 3. Atypical pathogens • Mycoplasma, chlamydia, viruses • Serological assays used : variable results • Currently not recommended for routine diagnosis ( 2A)
- 19. 4. Biomarkers •Procalcitonin • C reative protein • Considered adjunct to clinical diagnosis. • PCT can help to differentiate between bacterial and viral etiology : aid in t/t protocols Currrently not recommended for routine investigations (2A)
- 20. Risk stratification NEED: • For triaging the site of treatment : OPD vs. IPD, ward vs. ICU • For ordering diagnostics • For starting empirical treatment • For prognostication Aided by various scoring systems .
- 21. Scoring systems •Well validated scoring systems : 1. CURB 65 2. Pneumonia severity index ( PSI ) 3. SMART COP 4. ATS/ IDSA criteria Other ( poorly validated ): 1. A DROP 2. REA- ICU index 3. CAP – PIRO 4. ESPANA scale
- 22. 1. CURB-65 SCORE • Severity of illnes score • Derived from pooled data from UK, NZ and Netherland • Guide in triaging : for site of care Score 0 – 1 : OPD Score 2 : Wards Score ≥ 3 : ICU Modification is CRB 65: requires only clinical examination.
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- 24. • Prognostic predictionrule • Defines severity of illness based on predicted risk of mortality at 30 days. • Includes 20 variables , stratified into 5 classes: 0-50 points : 0.1 % mortality 51 – 70 : 0.6 % mortality 71 -90 : 0.9 % 91 – 130 : 9.3 % 130 – 395 : 27 %
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- 26. • Helps triagingsite of care • Criteria for ICU admission : Any major criteria , or At least 3 minor criteria Definition of severe CAP : presence of both major criteria ( need for ventilation and vasopressors )
- 27. 4.SMART COP score • Derived from Australian CAP study • Point based severity score • Score ≥ 3 : 92 % pt. require invasive ventilation and vasopressors.
- 28. Treatment 1. Empirical 2. Definitive The empirical t/t is guided by : • Knowledge of most likely pathogen • Local susceptibility patterns • Pk/pd profile of antibiotics • Compliance , safety and cost of drugs • Any ongoing medical therapy / comorbidities..
- 29. Timing • Assoon as possible after CAP diagnosis is established • In severe CAP : asap, preferably within 1 hr.
- 30. A. OUTPATIENT •Previously healthy & no antimicrobials within 3 months 1. Macrolide ( level I ) 2. Doxycycline ( level III) • comorbidities present / antibiotic use: 1. A respiratory FQ ( levofloxacin ) ( level I) 2. A β lactam + macrolide ( level I) • For high infection rates( >25 %) or high resistance for S. pneumoniae ( MIC ≥ 16 μg/ml) - ceftriaxone/cefpodoxime/cefuroxime - doxycycline
- 31. Joint ICS/NCCP (I)Recommendations : • Stratification into patients with or without comorbidities. • Patients without comorbidity : monotherapy with oral macrolides/ oral β lactam • Patients with comorbidities : oral combinaton therapy ( β lactam + macrolides ) • NO FQ
- 32. B. INPATIENT ,NON ICU • Respiratory FQ ( Level I evidence) -moxifloxacin -Gemifloxacin, or - levofloxacin • A β lactam + macrolide ( Level I evidence) - cefotaxim/ ceftriaxone/ ampicillin Joint ICS/NCCP (I) Recommendations: • Resp. FQ can be used if TB is not a diagnostic consideration. • Patients should undergo testing for sputum AFB. • Route of medication decided by the clinical condition
- 33. C. ICU PATIENTS • A β lactam ( cefotaxim/ceftriaxone / ampicillin) + • Macrolide ( azithromycin ) / resp. FQ FOR PENICILLIN ALLERGY • A resp. FQ + Azetreonam Joint ICS/NCCP (I) Recommendations: • β lactam ( ceftriaxone/ amox-clav) + macrolide
- 34. D. HIGH RISKFOR PSEUDOMONAS • Antipseudomal, antipneumococcal β lactam ( piperacillin tazobactam/ cefepime/ imipenem/ meropenem ) OR • β lactam ( as above ) + AG + MACROLIDE OR • β lactam ( as above ) + AG + antipneumococcal FQ FOR PENICILLIN ALLERGY : substitute Azetreonam for β lactam Joint ICS/NCCP (I) Recommendations: β lactam ( as above ) + AG + antipneumococcal FQ • Resp. FQ can be used if TB is not a diagnostic consideration. • Patients should undergo testing for sputum AFB
- 35. E. HIGH RISKFOR CA-MRSA • Risk factors for S.aureus infection are : 1. ESRD 2. Injectable drug abuse 3. Prior influenza 4. Prior antibiotic t/t esp. with FQ. EMPIRICAL TREATMENT : β lactam + vancomycin / linezolid
- 36. F. ANAEROBIC COVER • Indicated only in classic aspiration cases in patients with : • Loss of consciousness • Alcohol/ drug overdose • Post ictal • Seizures in patient with gingival disease • Loc/ seizures in patient with esophageal motility disorder.
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- 38. • Switching fromIV to Oral t/t : • Hemodynamically stable • Able to accept orally • Normal functioning GI tract
- 39. • Duration oftreatment • minimum of 5 days • Criteria before discontinuation is as below. Patient should have these for 48 -72 hrs.
- 40. Reasons for lackof response
- 41. Outcomes ( NEJMOct. 2014 ) • 30 day death rates in hospitalized : 10 -12 % • Post hospital discharge : redamission within 30 days is 18 % • Functional disability esp. in elderly • Survivors after 30 days : mortality remains elevated at 1 year, and in pneumococal pn. It is elevated for 3 -5 years.
- 42. References • IDSA/ATS guidelines, 2007 • Joint ICS/NCCP (I) guidelines, Lung India, 2012 • BTS guidelines,2009 • NEJM Review article on CAP, Oct. 2014
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