Community Acquired Community Acquired PneumoniaPneumonia

Peter Valenzuela, MD, MBA, FAAFPPeter Valenzuela, MD, MBA, FAAFP

Assistant Dean for Clinical AffairsAssistant Dean for Clinical Affairs

Assistant Professor/Dept. of Family MedicineAssistant Professor/Dept. of Family Medicine

ObjectivesObjectives

Identify the pathogens common to CAPIdentify the pathogens common to CAP

Describe the signs and symptoms of CAPDescribe the signs and symptoms of CAP

Describe the diagnostic criteria for CAPDescribe the diagnostic criteria for CAP

Discuss treatment options for CAPDiscuss treatment options for CAP

BackgroundBackground

Total annual cost of health care for CAP in Total annual cost of health care for CAP in U.S. is $8.4 billionU.S. is $8.4 billion

5.6 million cases of CAP in U.S. each year5.6 million cases of CAP in U.S. each year J Respir Dis 2002; 23:10-7J Respir Dis 2002; 23:10-7

Pneumonia and influenza combined are 7Pneumonia and influenza combined are 7thth leading cause of death in U.S.leading cause of death in U.S.– 21.8 deaths per 100,000 21.8 deaths per 100,000 Natl Vital Stat Rep 2003; 52:1-115Natl Vital Stat Rep 2003; 52:1-115

DefinitionDefinition

Community-Acquired Pneumonia (CAP)Community-Acquired Pneumonia (CAP)--lower respiratory tract infection in a non-lower respiratory tract infection in a non-hospitalized person associated with hospitalized person associated with symptoms of acute infection symptoms of acute infection with or with or withoutwithout new infiltrate on chest radiograph new infiltrate on chest radiograph

Types-PathogensTypes-Pathogens

Typical CAP (60-70%)Typical CAP (60-70%)– Streptococcus pneumoniaeStreptococcus pneumoniae

Atypical CAP (30-40%)Atypical CAP (30-40%)– Influenza virusInfluenza virus– MycoplasmaMycoplasma– ChlamydiaChlamydia– LegionellaLegionella

Signs & SymptomsSigns & Symptoms

Clinical symptoms Clinical symptoms – Cough (productive or non-productive)Cough (productive or non-productive)– Fever (>100.4)Fever (>100.4)– Chills/RigorsChills/Rigors– DyspneaDyspnea– Fatigue/MyalgiaFatigue/Myalgia– Gastrointestinal (Legionella)Gastrointestinal (Legionella)

Signs & SymptomsSigns & Symptoms

Physical examPhysical exam– Dullness to percussion of chestDullness to percussion of chest– Crackles or rales on auscultationCrackles or rales on auscultation– Bronchial breath soundsBronchial breath sounds– Egophony (“E” to “A” changes)Egophony (“E” to “A” changes)

Diagnosis- LabsDiagnosis- Labs

All patients with suspected CAP should All patients with suspected CAP should have chest radiographhave chest radiograph

Leukocyte countLeukocyte count

Sputum Gram stainSputum Gram stain

Blood cultures x 2Blood cultures x 2

Serum/urine antigensSerum/urine antigens

Radiograph findingsRadiograph findings

Lobar consolidation is Lobar consolidation is common in typical common in typical pneumoniapneumonia

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Radiograph findingsRadiograph findings

Diffuse or patchy Diffuse or patchy infiltrates are more infiltrates are more common in atypical common in atypical pneumoniapneumonia

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ManagementManagement

Inpatient cost for CAP Inpatient cost for CAP is $7,500is $7,500

Outpatient cost for Outpatient cost for CAP is $150-$350CAP is $150-$350

Pneumonia Severity Pneumonia Severity Index- assesses need Index- assesses need for hospitalization for hospitalization

This index can be This index can be accessed at accessed at http://www.medscape.http://www.medscape.com/content/2004/00/com/content/2004/00/49/50/495094/art-jags49/50/495094/art-jags495094.app.gif495094.app.gif

Management AlgorithmManagement Algorithm

This algorithm can be accessed at This algorithm can be accessed at http://www.aafp.org/afp/20060201/442_f1.http://www.aafp.org/afp/20060201/442_f1.gifgif

TreatmentTreatment

Preferred outpatient management is single Preferred outpatient management is single therapy with one of the followingtherapy with one of the following– MacrolideMacrolide– FluoroqunoloneFluoroqunolone– DoxycyclineDoxycycline

Preferred inpatient managementPreferred inpatient management– Beta-lactam + macrolideBeta-lactam + macrolide– Fluoroquinolone Fluoroquinolone

SummarySummary

Identify the pathogens common to CAPIdentify the pathogens common to CAP

Describe the signs and symptoms of CAPDescribe the signs and symptoms of CAP

Describe the diagnostic labs for CAPDescribe the diagnostic labs for CAP

Discuss treatment options for CAPDiscuss treatment options for CAP

Questions?Questions?

ReferencesReferences

Lutfiyya N, et al, Diagnosis and treatment of community-acquired pneumonia Am Fam Physician 2006;73:442-50

Niederman MS. Community-acquired pneumonia: management controversies, part 1; practical recommendations from the latest guidelines. J Respir Dis 2002;23:10-7.

Arias E, Anderson RN, Kung HC, Murphy SL, Kochanek KD. Deaths: final data for 2001. Natl Vital Stat Rep 2003;52:1-115.

Fish D. Pneumonia. PSAP, Pharmacotherapy Self-Assessment Program. Kansas City, Mo.: American College of Clinical Pharmacy, 2002:202.

Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-50.