1. MANAGEMENT OF
COMMUNITY-ACQUIRED
PNEUMONIA
Prepared by
DR.NAHID SHERBIN
INTERNAL MEDICINE

2. THE CLINICAL PROPLEM
A 65-Y old man with hypertension and
degenerative joint disease presents to
emergency department with a3-days
history of a productive cough and fever.
 0E Temp38.8’C ,BP144/92mmHg
,RR22/min ,HR90/min ,O2 sat 92percent.
Chest auscultation reveals crackles and
egophony in the right lower lung field.

3.  WBC 14,000per cubic millimeter ,all
biochemical results are normal.
 CXR show an infiltrate in the right lower
lobe.
 How should this patient be treated?

4. STATISTICS
4 million cases of CAP in USA each year.
 Around 1 million hospitalization.
 Inpatient management of pneumonia is
more than 20 times as expensive as
outpatient care.
 The length of hospitalization is the key
determinant of inpatient costs.
 30-50 percent of hospitalized patients
have low-risk cases.

5. DIAGNOSIS AND TREATMENT
 Usual presentation
Cough >90percent
Dyspnea 66percent
Sputum production 66percent
Pleuritic chest pain 50percent
Non respiratory symptoms

6.  All definitions of pneumonia require the
finding of a pulmonary infiltrate on chest
radiograph.
 The initial antibiotics regimen should be
chosen empirically to cover both typical
and atypical pathogen.
 Atypical organisms in 20%-40% of CAP.

7. Recommendation for initial
empirical treatment of pneumonia
Hospital setting Antibiotic therapy Common organism
General word 3rd gen.ceph+macrolide+or
doxycycline
Typical:
Strept.pneumonia
Antipneumoccocal fluroquinolone Haemophilius
B-lactam-b-lactamase Atypical: Mycoplasma
inhibitor+macrolide+or doxycycline Legionella,chlamydia
ICU (no risk of 3rd gen.cepha+antipneumoccocal Same+staph.aurus,drug
fluroquinolone or macrolide resistant strep.&G-rods
pseudomonas.
B-lactam-b-lactamase
aeroginosa) inhibitor+fluroqunilone or macrolide
ICU (risk of Antipseudomonous B-lactam Same+pseudomonus.ae
+aminoglycoside+fluroquinolone or oginosa &other resistant
pseudomonas. G-ve rods
macrolide
Aeroginosa) Antipseudomonal B-lactam+Cipro

8.  Two large observational studies found that
antibiotic regimens that cover both typical
and atypical organisms are associated
with a lower risk of death than regimens
that cover just typical bacteria.
#Gleason
#Houk PM
 Duration 10-14 Days

10. Risk stratification& decision to hospitalize
 30-50% of patient who are hospitalized
have low risk class.
 The decision to admission based on :
stability of the clinical condition ,risk of
death ,complication ,presence or
absence of active medical problems.

11.  The most widely disease-specific
prediction rules used is
–The Pneumonia Severity Index-
5 risk classes,mortality rate from 1%-27%
 The higher the score ----the higher risk of
death---adm to ICU---readm---longer stay.
 So, What are the steps and criteria of
PSI?

12. Step I PATIENT WITH COMMUNITY
ACQUIRED PNEUMONIA
IS THE PATIENT>50Y? yes
no
DOSE THE PATIENT HAVE
A HISTORY OF ANY OF THE
FOLLOWING COEXISTING
CONDITIONS? yes
-NEOPLASTIC DISEASE
-LIVER DISEASE
-CHF-CVA-CRF
no
DOSE THE PATIENT HAVE y ASSIGN PATIENT TO
n ANY OF FOLLOWING e RISK CLASS II,III,IV&V
ASSIGN PATIENT o ABNORMALITIES? s ACCOURDING TO TOTAL
TO RISK CLASS I -ALTERED MENTAL STATUS SCORE USING THE
-RR>30/min –P>125/min PREDICTION RULE.
-SYSTOLIC BP<90mmHg
-TEMP<35’C OR >40’C

13. Step II character No. of points
assigned
Demorphic factors Age :men Age in years
women Age -10y
Nursing home care +10
Coexisting condition:
Neoplastic dis +30
Liver dis +20
CHF +10
CVA +10
CRF +10
Finding on Alteredmental status +20
RR>30/min +20
physical exam Sys BP<90mmHg +20
T<35’C or >40’C +15
Pulse>125 b/min +10

14. Cont.
character No. of points
Lab & Arterial pH<7.35 +30
BUN>30mg/dl +20
radiographic
=(11mmol/l)
finding Na<130mmol/l +10
Glu>250mg/dl +10
=(14mmol/l)
Haematocrit<30% +10
Partial pressure of
arterial
oxygen<60mmHg +10
Or O2 sat<90%
Pleural effusion
+10

15. Stratification of risk score
Risk Risk class Score Mortality
Low I Based on 0.01%
algorithm
Low II <70 0.6%
Low III 71-90 0.9%
Moderate IV 91-130 9.3%
High V >130 27%

17. Algorithm for Determining
Whether a Patient with
Community-Acquired
Pneumonia
Should be Admitted or Treated
as Outpatient

18. Diagnosis of pneumonia is confirmed
in immunocompetent adult with CAP
Absolute contra indication to out pt treatment
• Hypoxemia (O2 sat<90%)
yes
•Haemodynamic instability.
•Active coexisting condition requiring hospital.
•Inability to tolerate oral medication.
no
Use PSI to determine the risk.
yes
Risk class I,II,III Risk class IV,V
Other mitigating factors
Frail physical condition yes
No response to oral therapy Inpatient
Unstable living condition treatment
no
Out patient treatment Intermediate options

19. Cont.
 All patients with suppurative or metastatic
diseases( Empyema, Lung abscess ,
Endocarditis ,Meningitis or Osteomyelitis)
or infections due to high risk
pathogens( e.g staph.aurus ,G-ve rods or
anaerobes) should be admitted.
 Several studies have established safety
and effectiveness of PSI.

20. A controlled trial of a critical
pathway for treatment of CAP
 This is a strongest evidence ,it is a
randomized controlled trial involving 19
hospitals.
 The hospitals that were randomly
assigned to study admitted fewer low risk
patients than did the control hospitals
(31%vs.49%).

21. Results of the study
1. There were no significant difference
between groups in the hospitalization
rates among moderate –high risk
patients whom the protocol recommend
admission .
2. The intervention reduced the overall
number of hospital bed-days per patient
without any increase in deaths,
complications,use of ICU or readmission.

22. Results of the study
3. Applying this protocol 60
 decrease initial
50
hospitalization rates
of death among low 40
risk without any
change in the rates 30 no PSI
of death, symptom 20
PSI
resolution,
functional recovery 10
and patient
stratification. 0
%

23. Results of the study
4. The most common reasons for admission
of low risk patients include: presence of
coexisting conditions ,patient preference
and inadequate home support.
5. Selected elderly patient can be treated as
outpatient in good results.
*This study mentioned in JAMA 2002

24. Criteria for stability &discharge
1.Pt. vital signs are stable for 24h period
T<37.8’C , RR<24 , HR<100b/min
Sys BP>90mmHg ,O2 sat>90% in room air
2.Take oral antibiotic
3.Maintain adequate hydration and nutrition
4.Normal mental status
5.Has no other active clinical or
psychosocial problems requiring
hospitalization.

25.  The median time to clinical stability is ~
low risk 3 days
moderate 4 days
high 6 days
 Several studies confirm safety of this type
of discharge criteria.
 Data from controlled trials and prospective
studies indicate that early conversion from
IV to oral therapy doesn’t adversely affect
outcomes & no need to observe patients
for 24h after a switch to oral therapy.

26. The American thoracic society
recommend following criteria for
switching to oral antimicrobial
agents
1. Improvement in cough & dyspnea.
2. T<37.8’C two times 8h apart.
3. Decrease in WBC.
4. Functioning GIT with adequate oral
intake.

27.  Patientneed to be told that they will
probably feel sick for awhile (few weeks)
 One week after
*80% of CAP patients have
cough and
fatigue.
*50% have dyspnea and sputum

28. Guidelines of Infectious Diseases
Society of America (IDSA)
 CLASS I & II  DON’T REQUIRE
HOSPITALIZATION
 CLASS III  BREIF HOSPITAL STAY
 CLASS IV & V SHOULD BE
HOSPITALIZED

29. A 65-Y old man with hypertension and
degenerative joint disease presents to
emergency department with a3-days
history of a productive cough and fever.
 0E Temp38.8’C ,BP144/92mmHg
,RR22/min ,HR90/min ,O2 sat 92percent.
Chest auscultation reveals crackles and
egophony in the right lower lung field.
 WBC 14,000per cubic millimeter ,all
biochemical results are normal.

30. Finally,
 Answer
OF the case in 1st slide
 PSI =65
 Class II
 Outpatient
 Treatment : advanced Macrolide or
Fluroquinolone.

31. MAIN SOURSES
 THE NEW ENGLAND JOURNAL OF
MEDICINE 2004
 IDSA GUIDELINES
 www.nejm.org
 http://ursa.kcom.edu/CAPcalc/default.htm