Pneumonia: Recent Evidence
Based Updates
Introduction
• Pneumonia is a common clinical problem world-wide.
• Pneumonia is the sixth leading cause of death in the United States,
and an estimated 4 million cases occur annually.(ATS, 2001)
• The annual incidence in the community is 5-11 per 1000 adult
population.(BTS,2004)
• Mortality with CAP managed in the community is less than 1%, at
hospital is 5.7% to 14% and in intensive care unit (ICU) is more
than 50%.(BTS,2004)
Definitions
• Defining Pneumonia is not straightforward.
• Acute respiratory illness that produces a new
radiological shadow can be the working definition of
pneumonia (Davidsons’ Medicine, 2007)
• Community acquired pneumonia is that happens in the
community (at least 2 days prior to hospital
admission).
Guidelines for the management of Adult with CAP, ATS, 2001
Atypical Pneumonia
• The term “Atypical pneumonia” is abandoned by
almost all the organizations.
• Its the pneumonia that is cause by some atypical
organism with atypical presentation.
Guidelines for the management of CAP, BTS, 2004
Pathogens
• S. pneumoniae is the most frequently identified
pathogen but its resistance pattern is variable.
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Organisms Causing CAP in Outpatients
• Unknown- 40–50%
• Pneumococcus- 9–20%
• M. pneumoniae- 13–37%
• Chlamydia pneumoniae- 17%
• Legionella-0.7 to 13%
• viral
Guidelines for the management of Adult with CAP, ATS, 2001
Organisms Causing CAP in Non-ICU Hospitalized
patients
• S. pneumoniae- the most commonly identified pathogen (20–
60%)
• H. influenzae-3–10%
• Staphylococcus aureus
• Enteric gram-negatives
• Legionella
• M. pneumoniae
• C. pneumoniae and
• Viruses
Guidelines for the management of Adult with CAP, ATS, 2001
Organisms causing CAP in Hospitalized patients
requiring ICU admission
• The most common organisms in patients falling into this
category are pneumococcus, Legionella, and H. influenzae,
with some series reporting S. aureus as a common pathogen.
• Gram-negative aerobic organisms have been identified with an
increased frequency in intensive care unit.
• Enterobacteriaceae have been found in up to 22% of patients
and up to an additional 10–15% of ICU patients in some series
have infection with P. aeruginosa.
Guidelines for the management of Adult with CAP, ATS, 2001
THE RISK FACTORS FOR INFECTION WITH SPECIFIC
PATHOGENS
Penicillin-resistant and drug-resistant pneumococci
Age>65 yr
-Lactam therapy within the past 3 month
Alcoholism
Immune-suppressive illness (including therapy with corticosteroids)
Multiple medical comorbidities
Exposure to a child in a day care center
Enteric gram-negatives
Residence in a nursing home
Underlying cardiopulmonary disease
Multiple medical comorbidities
Recent antibiotic therapy
Pseudomonas aeruginosa
Structural lung disease (bronchiectasis)
Corticosteroid therapy (>10 mg of prednisone per day)
Broad-spectrum antibiotic therapy for >7 d in the past month
Malnutrition
Guidelines for the management of Adult with CAP, ATS, 2001
Chest Radiograph
• If possible, all patients with CAP
should have a chest radiograph to
establish-
the diagnosis and
the presence of complications
(pleural effusion, multi-lobar
disease)
Guidelines for the management of Adult with CAP, ATS, 2001
Microbiological Examination
• Sputum microbiology should be done in suspected
cases.
• Sputum culture should be done in non-responders or
sever cases
• Blood culture is recommended for all patients
admitted with CAP, preferably before antibiotic
treatment is commenced
Guidelines for the management of CAP, BTS, 2006
Serology
• Pneumococcal urine antigen tests should be performed for
patients with severe CAP.
• Legionella urine antigen tests should be performed for patients
with severe CAP, patients with specific risk, in outbreaks.
• Chlamydia antigen detection technique should be available for
invasive respiratory sample from severe CAP or where there is
strong suspicion of psittacosis.
Guidelines for the management of CAP, BTS, 2006
Severity Assessment
• The most widely studied scoring systems are the
Pneumonia Severity Index (PSI) and the CURB-65 (a
modification of the British Thoracic Society rule).
• Each has advantages and limitations, with the more-
complex PSI developed to identify low-mortality risk
patients, and the CURB-65, which is simpler, being
developed to easily identify more severely ill individuals.
Guidelines for the management of CAP, ATS, 2001
CURB-65 score
• C- Confusion
• U-Uremia (B.Urea> 7mmol/L)
• R- Respiratory rate 30/min or more
• BP- SBP<90 or DBP 60 mm of Hg or less
• Age>65yrs.
CURB-65 score
• Patients who have a CURB-65 score of 0 are at low
risk of death and do not normally require
hospitalization for clinical reasons.
• Patients who have a CURB-65 score of 1 or 2 are at
increased risk of death and hospital referral and
assessment should be considered, particularly with
Score 2.
• Patients who have a CRB-65 score of 3 or more are at
high risk of death and require urgent hospital
admission.
Guidelines for the management of CAP, BTS, 2006
Pneumonia Severity Index (PSI)
• The rule uses demographics (whether someone is older, and is
male or female), the coexistence of co-morbid illness, findings
on physical examination and vital signs, and essential
laboratory findings.
• A Risk Class I pneumonia patient can be sent home on oral
antibiotics. A Risk Class II-III pneumonia patient may be sent
home with IV antibiotics or treated and monitored for 24 hours
in hospital. Patients with Risk Class IV-V pneumonia patient
should be hospitalized for treatment.
Guidelines for the management of Adult with CAP, ATS, 2001
Management of Pneumonia
• Effective management of patients with CAP requires
selection of the proper site of care and appropriate
empiric antimicrobial.
• Given the elevated rates of resistance among S.
pneumoniae, local resistance patterns must be
considered when choosing empiric therapy.
Guidelines for the management of CAP, ATS, 2001
Empirical Antibiotics
• Outpatients and non-sever cases: Oral
fluoroquinolones or macrolides are the drug of choice.
• Outpatients with Cardiopulmonary disease and/or
modifying factor: Oral beta-lactums plus macrolides or
doxacycline.
Guidelines for the management of CAP, ATS, 2001
Empirical Antibiotics
• Inpatients, not in ICU patients without any
cardiopulmonary Disease and/or Modifying factor:
Intravenous Azythromycine or Monotherapy with
antipseudomonal fleuroquinolones.
• Inpatients, not in ICU patients with cardiopulmonary
Disease and/or Modifying Factors (Including Being
from a Nursing Home): intravenous beta-lactam
(cefotaxime, ceftriaxone, ampicillin/sulbactam, high-
dose ampicillin) plus Intravenous or oral macrolide or
doxycycline or Intravenous antipneumococcal
fluoroquinolone alone.
Guidelines for the management of CAP, ATS, 2001
Pneumonia at ICU
• The infection has been acquired at-
Community,
Hospital,
Long-term care facilities,
ICU requiring mechanical ventilation for different reasons.
• Organisms vary according to site of infection and co-morbidity.
Emmi et al. Guidelines for management of pneumonia in ICU.2007
Treatment : Pneumonia at ICU
• A combination therapy with beta-lactams (ceftriaxone,
cefotaxime, ampicillin/sulbactam, piperacillin/tazobactam) and a
new generation macrolide or respiratory fluoroquinolone is
recommanded for the treatment of pneumonia in ICU.
• Whenever a Pseudomonas etiology is suspected guidelines
suggest the use of an anti-pseudomonas beta-lactam (such as
piperacillin/tazobactam, carbapenems, cefepime) associated with
an anti-pseudomonas fluoroquinolone (high doses ciprofloxacin).
• An anti-pseudomonas beta-lactam plus an aminoglycoside or
aminoglicosyde plus fluoroquinolone can be an alternative.
Emmi et al. Guidelines for management of pneumonia in ICU.2007
Pneumonia at ICU
• Late onset VAP and HAP in patients with risk factors for
multi-resistant should be treated with a combination therapy.
• In case of defined or suspected P. aeruginosa, Klebsiella
pneumoniae, Acinetobacter sp. etiology, it is required the use
of an anti-pseudomonas cephalosporin or an anti-pseudomonas
carbapenem or b-lactam + beta-lactamase inhibitor associated
with an anti-pseudomonas fluoroquinolone or an
aminoglicoside.
Emmi et al. Guidelines for management of pneumonia in ICU.2007
HOSPITAL-ACQUIRED PNEUMONIA(HAP)
HEALTHCARE-ASSOCIATED PNEUMONIA(HCAP), AND
VENTILATOR-ASSOCIATED PNEUMONIA(VAP)
• HAP is defined as pneumonia that occurs 48 hours or more
after admission, which was not incubating at the time of
admission.
• HCAP includes any patient who was hospitalized in an acute
care hospital for two or more days within 90 days of the
infection; resided in a nursing home or long-term care facility;
received recent intravenous antibiotic therapy, chemotherapy,
or wound care within the past 30 days of the current infection;
or attended a hospital or hemodialysis clinic.
• VAP refers to pneumonia that arises more than 48–72 hours
after endotracheal intubation.
Guidelines for the management of HAP,HCAP,VAP. ATS,2005
Pathogens of HAP,HCAP,VAP
• Pathogens: may be polymicrobial, and
rarely due to viral or fungal pathogens.
• Common pathogens:
P. aeruginosa,
Escherichia coli,
Klebsiella pneumoniae, and
Acinetobacter species,
Staphylococcus aureus, particularly methicillin-
resistant S. aureus (MRSA).
• S. aureus is more common in patients with diabetes mellitus,
head trauma, and those hospitalized in ICUs.
Guidelines for the management of HAP,HCAP,VAP. ATS,2005
INITIAL EMPIRIC THERAPY
Antipseudomonal cephalosporin (cefepime, ceftazidime)
or -Lactam/ -lactamase inhibitor (piperacillin–
tazobactam)
plus
Antipseudomonal fluoroquinolone
(ciprofloxacin or levofloxacin) or Aminoglycoside
(amikacin, gentamicin, or tobramycin)
plus
Linezolid or vancomycin
Guidelines for the management of HAP,HCAP,VAP. ATS,2005
Non-responders to initial therapy
• If the patient has no host factor for a slow response, if there is no
response after 7 d of therapy, or if there is clinical deterioration
after 24 h of therapy, he is considered as non-responder.
• Common etiologies are-
Inadequate antimicrobial selection
Unusual pathogens
Complication of pneumonia
Noninfectious illness
Guidelines for the management of CAP, ATS, 2001
Recommendations for evaluating non-
responding patients
• Bronchoscopy:
For collection of lower respiratory sample for cultures and
should be sent to evaluate for drug-resistant and unusual
pathogens, including tuberculosis.
• Computed Tomography
• Lung Scanning, spiral CT scanning, Pulmonary angiography;
for patients with risk factor for pulmonary embolism
• Open Lung Biopsy: If this extensive diagnostic evaluation has
not been useful and if the patient is seriously ill
Guidelines for the management of CAP, ATS, 2001
Prevention
• Pneumococcal Vaccine
• Influenza Vaccine
• Chemoprophylaxis
Guidelines for the management of CAP, ATS, 2001
Conclusion
• Pneumonia is a common clinical problem.
• Initial approach involves determination of presence of relevant
factors that influence likely etiological pathogens-
Severity of illness
Presence of cardiopulmonary disease
Presence of risk factors for drug resistance and
Gram negative organism
Selection of site of care
• Initial antimicrobial therapy
• Evaluate the response
• If response is not adequate, evaluate the causes.
• Take measure to prevent pneumonia is susceptible individuals.
Guidelines for the management of CAP, ATS, 2001
