Community acquired pneumonia

Community acquired pneumonia

What is your likely Dx?
□ ผู้ป่วยชาย 60 เป็น เบาหวานมาตรวจดัวย อ้าการ ”เขทอเสมหะเฆียว เหนื่อยมา 3 วัน
□ ตรวจร่างกายพบ crepitation @ RUL
ประวัติเพิ่มพบว่ามี”!,ฟ้ตรมา 1+ เดือน เพลียและผอมฝิง
ประวัติเพิ่มพบว่า3บบุหรี่ 2 «ชอง/วัน มา
30 U

Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults
Clinical Infectious Diseases 2007;44:527-72
British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009
Ttorax 2009;64(Suppl เท):iiil-iii55

For the purposes of these guidelines, CAP in the community
has been defined as:
► Symptoms of an acute lower respiratory tract illness (cough
and at least one other lower respiratory tract symptom).
► New focal chest signs on examination.
► At least one systemic feature (either a symptom complex of
sweating fevers, shivers, aches and pains and/or tempera-
ture of 38JC or more).
► No other explanation for the illness, which is treated as CAP
with antibiotics.
For the purposes of these guidelines, CAP in hospital has
defined as:
►- Symptoms and signs consistent with an acute lower respiratory tract infection associated with new radiographic shadowing for which there is no other explanation (eg, not pulmonary oedema or infarction).
► The illness IS the primary reason for hospital admission and is managed as pneumonia.

Diagnosis of CAP
1. New pulmonary infiltration
2. Acute onset ( < 2 wk )
3. Symptoms and Signs of LRI (3/5)
□ Fever
□ dyspnea
□ Cough,/productive sputum
□ Pleuritic chest pain
□ Consolidation or crackles on P.E.
R/O critGricia
Recently d/c from hospital (< 3 wk) Immunocompromised host

What is your management?
□ ผู้ป่วยชาย 60 เป็น เบาหวานมฺาตรวจด้วย อ้าการ ”เขทอเสมหะเฆียว เหนื่อยมา 3 วัน
□ ตรวจร่างคายพบ
□ T 39 c, RR 24, BP 110/70, P 90
□ Alert ,well co-operate, mild respiratory distress
□ crepitation @ RUL
Confirm Dx, OPD vs IPD, which antibiotic etc??

British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009
When should a chest radiograph be performed in hospital?
2. All pa t ien ts a d m it t ed t o h OS pit al wit h รฆร/^cf CAP should have a chest radiograph performed as soon as possible to confirm or refute the diagnosis. [D] The objective of any service
Thorax 2009;64(Suppl Ill};iii1-iii55

Table 2. Elements important for local community-acquired pneumonia guidelines.
All patients
Initiation of antibiotic therapy at site of diagnosis for hospitalized
Antibiotic selection Empirical Specific Admission decision support Assessment of oxygenation Intensive care unit admission support Smoking cessation
Influenza and pneumococcal vaccine administration Follow-up evaluation Inpatients only Diagnostic studies
Types of studies Prophylaxis against thromboembolic disease Early mobilization
Thoracentesis for patients with significant parapneumonic effusions
Discharge decision support
Patient education



CRB65 severity score:
1 point for each feature present:
■ Confusion
– Respiratory rate > 30/m in
* Blood pressure (SBP < 90 or
DBF < 60rrimHg)
■ Age ^ 65 years J
Treat according to clinical judgement and CRBS5 severity score


Low severity
Moderate severity
High severity
Likely suitable Consider
for home hospital referral
Antibiotics as per
Urgent hospital admission
Empirical antibiotics if life- threatening (see section 0,5)
Consider social circumstances and home support when deciding on whetherto refer to hospital or manage in the community

Box 2 Abbreviated Mental Test
The Abbreviated Mental Test (each question scores 1 mark, total 10 marks)
► Age
► Date of birth
► Time (to nearest hour)
► Year
► Hospital name
► Recognition of two persons (eg, doctor, nurse)
► Recall address (eg, 42 West Street)
► Date of First World War
► Name of monarchs
► Count backwards 20 —> ใ
A score of 8 or less has been used to define mental confusion in the CURB65 severity score.


NQ consolidation
Does the patient meet
criteria for CAP?

BUN>7 mmol/l

Treat according to clinical judgement arid CURB65 severity score
Consider other diagnoses


Low severity Moderate severity High seventy
(risk of death <3%) (risk of death 9%) (risk of death 15-40%)

Low severity (risk of death <3%)
Moderate severity High severity (risk of death 9%) (risk of death 15-40%)
Other reasons for admission (unstable co-morbidity, social)
as per table
Supportive care
Microbiological investigations as per table 4
Antibiotics given as per table 5
Antibiotics as per table 5
Supportive care
Microbiological investigations as per table 4
Antibiotics given as per table 5
Urgent senior review
Decision re transfer to critical care unit (especially if CURB65 = 4 or 5)

ICU admission
Table 4. Criteria for severe community-acquired pneumonia.
Minor criteria
Respiratory rateb ^30 breath s/m in
PaCVFiO; ratiob ^2DiO
Multilobar infiltrates
Conf us ion/d isor ientation
Uremia (BUN level, ^20 ทา g/dU
Leukopenia0 (WBC count, <4000 cell s/m ms)
Thrombocytopenia (platelet count, <100,000 cells/mm3)
Hypothern’lia (core temperature, <3S°C!’
Hypotension requiring aggressive fluid resuscitation
Major criteria
Invasive mechanical ventilation
Septic shock with the need for vasopressors
1 major or
3 minor

other diagnostic test
Wj0 1
_ ” 1 »
* * w 1 a| >, , s
พ^ ร*, c

* «

_ ฟ้^ 1

What general investigations should be done in the community?
General investigations are not necessary for the majority of patients with CAP who are managed in the community. [C] Pulse oxi¬meters allow for Simple assessment of oxyge¬nation. General practitioners, particularly those working in out-of-hours and emergency assessment centres, should consider then use.

What general investigations should be done in a patient admitted to hospital?
All patients should have the following tests performed on admission:
– Oxygenation saturations and, where neces¬sary, arterial blood gases in accordance with the BTS guideline for emergency oxygen use in adult patients. [B+]
– Chest radiograph to allow accurate diagnosis.
– Urea and electrolytes to inform seventy assessment. [B+]
– C-reactive protein to aid diagnosis and as a baseline measure. [B+]
– Full blood count. [B—]
– Liver function tests. [D]

What microbiological investigations should be performed in hospital?
Blood cultures are recommended for all patients with moderate and high severity CAP, preferably before anti¬biotic therapy IS commenced. [D]
Sputum samples should be sent for culture and sensitivity tests from patients with CAP of moderate severity who are able to expectorate purulent samples and have not received prior antibiotic therapy. Specimens should be transported rapidly to the laboratory. [A—]

Diagnostic Testing
Routine diagnostic tests to identify an etiologic diagnosis are optional for outpatients with CAP
Ta 1)๒ 5. Clinical indications for more extensive diagnostic testing.
Blood Sputum Legioneifa Pneumococcal
Indication culture culture UAT UAT Other
Intensive care unit admission X X X X xa
Failure of outpatient antibiotic therapy X X X
Cavitary infiltrates X X xb
Leukopenia X X
Active alcohol abuse X X X X
Chronic severe liver disease X X
Severe obstructive/structural lung disease X
Asplenia (anatomic or functional) X X
Recent travel (within past 2 weeks) X xc
Positive Legionella UAT result xd NA
Positive pneumococcal UAT result X X NA
Pleural effusion X X X X X*

General management strategy tor patients treated in hospital
Ail patients should receive appropriate oxygen therapy with monitoring of oxygen saturations and inspired oxygen concentration with the aim to maintain arterial oxygen tension (Pac>2) at ^8 kPa and oxygen saturation (Spo2) 94-98%. High concentrations of oxygen can safely be given in patients who are not at risk of hypercapnic respiratory failure. [D]
Patients should be assessed for volume depletion and may require intravenous fluids. [C]

Monitoring in hospital
Temperature, respiratory rate. pulse, blood pressure, mental status, oxygen saturation and inspired oxygen concentration should be monitored and recorded initially at least twice daily and more frequently in those with severe pneumonia or requiring regular oxygen therapy. [C]
= E r? rr* ะ’ CT ะ ะ1
C-reactive protein should be remeasured and a chest radiograph repeated in patients who are not progressing satisfactorily after 3 days of treatment. [B+]

When should the chest radiograph be repeated during recovery?
The chest radiograph need not be repeated prior to hospital discharge in those who have made a satisfactory clinical recovery from

Table 6. Most common etiologies of community-acquired pneumonia.
Patient type Etiology
Outpatient Streptococcus pneumoniae Mycoplasma pneumoniae Haemophilus influenzae Chlamydophifa pneumoniae Respiratory viruses3
เกpatient (non-ICU) 5. pneumoniae M pneumoniae
c. pneumoniae H. influenzae Legionella species Aspiration Respiratory viruses^
Inpatient (ICU) ร. pneumoniae Staphylococcus aureus Legionella species Gram-negative bacilli ห. influenzae
Antibiotic cType c Time oduration

Community-Acquired Pneumonia in Southeast Asia
The Microbial Differences Between Ambulatory and Hospitalized Patients CHEST 2003; I23il5l2-I5l9
£ 30-
QutpaHent definite I I Outpatient presumptive
เพ่ฟ้ft Inpatient definite L J Inpatient presumptive

[ Iln I
ร pnAtunontae M. vnuumoniac £ pJS^imophOa
FIGURE ไ. Etiology in 98 outpatients and 147 hospitalised patients with CAP. GNB-Gram-nepjitive bacilli 1

Table 7. Recommend๗ empirical antibiotics for community ac(|uiretl pneumonia.
Outpatient treatment
1. Previously healthy and no use of antimicrobials within the
previous 3 months
A macrolide (strong recommendation; level I evidence) Doxycyline (weak recommendation; level III evidence)
2. Presence of comorbidities such as ohronio heart, lung, liver
or renal disease; diabetes mellitus; alcoholism; malignan¬cies; asplenia; immunosuppressing conditions or use of im mu nosup pressing drugs: or use of antimicrobials within the previous 3 months (เท which case an alternative from a different class should be selected)
A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) (strong recommendation: level I evidence)
A.6-lactam plus a macrolide (strong recommendation; level I evidence)
3. เท regions with a high rate t>25%) of infection with high-level
(MIC 5=10 Jig/m L) macrolide-resistant Streptococcus pneu¬moniae, consider use of alternative agents listed above in (2) for patients without comorbidities (moderate recommen¬dation; level III evidence)

Inpatients, non-ICU treatment
A respiratory fluoroquinolone (strong recommendation: level I evidence)
A jU-lactaทา plus a macrolide (strong recommendation; level I evidence)
Inpatients, ICU treatment
A .5-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbacta ทา) plus either azithromycin (level II evidence) or a respiratory fluoroquinolone (level I evidence) (strong recommendation) (for penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are recommended)

Special concerns If Pseu&monas is a consideration
An anti pneumococcal, antipseudomonal .3-lactam (piperaoillin- tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750 mg)
The above .5-1 actam plus an aminoglycoside and azithromycin or
The above .5-lactam plus an aminoglycoside and an anti pneu-mococcal fluoroquinolone (for penicillin^allergic patients,
substitute aztreonaกา for above £-1 actaกา)
(moderate recommendation; level III evidence)
If CA-MRSA is a consideration, add vancomycin or linezolid (moderate recommendation; level III evidence)

Pathogen-Directed Therapy
Once die etiology of CAP has been identified oเใ the basis of reliable microbiological methods, antimicrobial therapy should be directed at that pathogen. (Moderate
recommendation; level III evidence.)

ทเทe to First Antibiotic Dose
For patients admitted through the ED, the first antibiotic dose should be administered while still in the ED. (Mod-erate recommendation; level III evidence.}

When should the intravenous route be changed to oral?
Patients treated initially with parenteral antibiotics should be transferred to an oral regimen as soon as clinical improve-ment occurs and the temperature has been normal for 24 h, providing there IS no contraindication to the oral route. Pointers to clinical improvement are given in box 4. [B+]
Switch from Intravenous to Oral Therapy
Patients should be switched from intravenous to oral therapy when they are hemodynamically stable and im-proving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract. (Strong recommendation; level II evidence.)

Bax 4 Features indicating response to initial empirical parenteral therapv permitting consideration of oral antibiotic substitution
► Resolution of fever for >24 h
► Pulse rate <100 beats/min
► Resolution of tachypnoea
► Clinically hydrated and taking oral fluids
► Resolution of hypotension
► Absence of hypoxia
► Improving white cell count
► Non-bacteraemic infection
► No microbiological evidence of legionella, staphylococcal or Gram-negative enteric bacilli infection
► No concerns over gastrointestinal absorption

Duration of Antibiotic Therapy
Patients with CAP should be treated for it minimum of 5 days (level I evidence), should be afebrile for 4๙-72 เใ1 and should have no more than 1 CAP-assodated si^n of din if al instability (table 10) before discontinuation of therapy (level II evidence). (Moderate recom¬mendation.)
A longer duration of therapy may be needed if in it id therapy was not active against the identified pathogen or if it was complicated by extra pul mo nary infection, such as meningitis or endocarditis. (Weak recommen¬dation; level III evidence.)

How long should antibiotics be given for?
For patients managed in the community and for most patients admitted to hospital with low or moderate severity and uncomplicated pneumonia,. 7 days of appro- pnate antibiotics is recommended. [Cl
For those with high severity microbiologically-undefined pneumonia. 7-10 days of treatment is proposed. This may need to be extended to 14 or 21 days according to clinical judgement; for example., where Staphylococcus aureus or Gram-negative enteric bacilli pneumonia IS suspected or confirmed. [Cl

Patients should be reviewed within 24 h of planned discharge home, and those suitable for discharge should not have more than one of the following characteristics present (unless they represent the usual baseline status for that patient): temperature >37.8’C. heart rate >100/min. respiratory rate >24/min, systolic blood pressure <90 mm Hg, oxygen saturation <90%, inability to maintain oral intake and abnormal mental status. [B+]
Follow-up arrangements
Clinical review should be arranged for all patients at around 6 weeks, either with their general practitioner or in a hospital clinic. [D]

Patients should be discharged as soon as they are clin¬ically 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.)
Table 10. Criteria for clinical stability.
Temperature 37.8?c Heart rate =5100 beats/m in Respiratory rate ร*’;24 breaths/min Systolic blood pressure ^!50 mm Hg
Arterial oxygen saturation ร1 S0% or pCu *-^0 mm Hg on room air Ability to maintain oral intake^
Normal mental status3

Table 11. Patterns and etiologies of types of failure to respond
Failure to improve Early (<72 h of treatment) Normal response
Delayed Resistant microorganism Uncovered pathogen Inappropriate by sensitivity Parap ne umoni c effusio n/em pyem a Nosooo m ia I ร น pe ri nfectio ท Nosocomial pneumonia Extrapul monarv Nonin feet ions Complication of pneumonia (e.g., BOOP) Misdiagnosis: PE, CHE vasculitis Drug fever

Deterioration or progression Early (<72 h of treatment)
Severity of illness at presentation R esistant ทา ic roo rga ท is เท Uncovered pathogen Inappropriate by sensitivity Metastatic infection E mpy e ma/pa ra pn e LI mo ท ic Endocarditis 1. meningitis, arthritis Inaccurate diagnosis PE, aspiration, ARDS Vasculitis (e.g.1. SLE)
Delayed Nosoco เท ia I ร LI pe ri nfectio ท Nosocomial pneumonia Extrapul monary Exacerbation of comorbid illness Intercurrent noninfectious disease PE
Myocardial infarct ion Renal failure

Take home messages
□ Site of care: adding CURB-65 & ICU admission criteria
□ Diagnostic work up more define the group of pts who need H/C & sputum
□ Non complicated :macrolice/doxycydine
□ Others: respiratory fluroquinolone/BL- Bl+macrolide
□ Inititial dose of ABC should give ASAP
□ Minimum duration of treatment is 5 day


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