Community Acquired Pneumonia

CAP - BugsPATIENT TYPE ETIOLOGY

Outpatient Streptococcus pneumoniaeMycoplasma pneumoniaeHaemophilus influenzaeChlamydophila pneumoniaeRespiratory viruses*

Non-ICU Inpatient S. pneumoniaeM. pneumoniaeC. pneumoniaeH. influenzaeLegionella speciesAspirationRespiratory viruses*

ICU Inpatient S. pneumoniaeStaphylococcus aureusLegionella speciesGram-negative bacilliH. influenzae

*Influenza A and B, adenovirus, respiratory syncytial virus, and parainfluenza.

CAP- epidemiologic considerationsCONDITION ORGANISMS

Alcoholism Strep pneumo, oral anerobes, Klebsiella, Acinetobacter, Mycobaterium tuberculosis

COPD/smoking H flu, Pseudomonas, Legionella, Strep pneumo, Moraxella, Chlamydophila pneumoniae

Aspiration Gram negative enterics, oral anaerobes

Lung abscess MRSA, oral anaerobes, M. tuberculosis, atypcial mycobacterium, fungal

Exposure to bat/bird droppings Histoplasma capsulatum

Exposure to birds Chlamydophila psittaci

Exposure to rabbits Francisella tularensis

Exposure to farm animals Coxiella burnetti (Q fever)

Injection drug use S. aureus, anaerobes, M. tuberculosis, S. pneumoniae

Cough >2weeks with whoop Bordetella pertussis

Structural lung disease (bronchiectasis)

Pseudomonas, Burkholderia , S. aureus

CAP – Clinical Features

Productive coughFeverPleuritic chest painDyspneaGI symptomsMental status changes

CAP - Physical Exam Findings

FebrileRR >24 breaths/minuteTachycardiaRales+egophany

CAP - Diagnosis

Chest Xray with infiltrate Leukocytosis Blood cultures Sputum – gram stain and culture Urine antigens Influenza testing Viral culture ABG

**If hospitalized within last 90 days or if lives at ECF, received outpatient dialysis then patient would be considered as hospital or healthcare associated pneumonia

CAP - Admit or Not?

Severity Scores CURB-65 PSI = Pneumonia Severity Index

Helps to determine severity of illness Helps to determine if patient should

be admitted and whether needs admitted to ICU

CAP - CURB 65

Confusion Urea (BUN >20mg/dL)Respiratory Rate > 30

breaths/minuteBlood Pressure (systolic <90mmHg

or diastolic <60mmHg)Age >65 years

* 1 point for each

CAP – CURB65SCORE RISK 30 DAY

MORTALITYMANAGEMENT

0 Low 0.6% Outpatient

1 Low 2.7% Outpatient

2 Moderate 6.8% Inpatient vs Outpatient

3 Severe 14% Inpatient

4 Highest 27.8% Inpatient/ICU

5 Highest 27.8% Inpatient/ICU

CAP - PSI

POINTS

Age in Years + 1 point per year

Gender -10 pts for women

ECF Resident + 10 points

Cancer + 30 points

Liver Disease + 20 points

CHF + 10 points

CVA + 10 points

CKD + 10 points

Altered Mental Status

+ 20 points

Respiratory Rate + 20 points

POINTS

SBP + 20 points

Temp not 95-104 F

+ 15 points

HR >125bmp + 10 points

pH <7.35 + 30 points

PaO2 <60mmHg

+ 10 points

Na < 130mEq/L + 20 points

BUN >64 mg/dL

+ 20 points

Glucose >250 + 10 points

Hct <30% + 10 points

Pleural Effusion + 10 points

CAP - PSI

CLASS POINTS MORTALITY RISK MANAGEMENT

Class 1 0 0.1% Low Outpatient

Class 2 <70 0.6% Low Outpatient

Class 3 71-90 2.8% Low Observation

Class 4 91-130 8.2% Moderate Inpatient

Class 5 >130 29.2% High Inpatient/ICU

CAP – Inpatient Treatment

PATIENT POPULATION

Antibiotic Option 1 Antibiotic Option 2

Non-ICU Patient (without pseudomonal

risk)

B-lactam(ceftriaxone, unasyn, or

ertapenem)+

Macrolide(azithromycin)

Moxifloxacin

ICU Patient (without pseudomonal

risk)

B-lactam (ceftriaxone or unasyn)

(use aztreonam if B-lactam allergy)

+Azithromycin or

Moxifloxacin

Non-ICU or ICU Patient

with Pseudomonal

risk*

Anti-pseudomonal B-lactam(zosyn, cefepime, imipenem)

+Aminoglycoside

(tobramycin or amikacin)+

Azithromycin or Moxifloacin)

Anti-pseudomonal B-lactam

(zosyn, cefepime, imipenem)

+Ciprofloxacin

*If B-lactam allergy use aztreonam, moxifloxacin, and amioglycoside

CAP – Inpatient TreatmentSuspected MRSA- add vancomycin or

linezolidSuspected aspiration- ertapenem or

moxifloxacin *Pseudomonal risk factors =

Bronchiectasis documented on admission Structural lung disease and h/o pneumonias

or chronic steroid use

CAP – Inpatient Treatment Switch to Oral Therapy

When clinically improving, hemodynamically stable, able to take oral meds

Duration of Hospitalization Several studies support that it is not necessary to observe

pt overnight after change to PO antibiotics Consider discharge after no signs of clinical instability which

is defined as: Temp >100, RR>24, SBP <90, HR>100, O2 sat <90, altered mental status, inability to take PO

Duration of Treatment Minimum of 5 days (most treat 7-14 days) Before consideration of discontinuing abx need to have:▪ Afebrile for 48-72 hours▪ No supplemental O2▪ No signs of clinical instability

CAP – Follow Up Recs

When should you get a follow up CXR? No clear evidence Most recommend f/u CXR for patients

>40 years and h/o smoking to document resolution of disease and no underlying malignancy

Obtain CXR 7-12 weeks after completion of treatment

CAP Quality Measures

Blood cultures prior to first antibiotic dose

Oxygen assessment Initial antibiotics within 6 hours of

presentationAppropriate antibiotic selectionPneumococcal vaccine for pts >65 Influenza vaccine for pts >50 during

Oct-MarchSmoking cessation counseling