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© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
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© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
in the clinic
CommunityAcquired
Pneumonia
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
Who is at increased risk for CAP?
 Persons with:
 Comorbid illness (respiratory disease; cardiovascular
disease; diabetes mellitus; chronic liver disease)
 Immune suppression
 Chronic kidney disease
 History of splenectomy
 Elderly
 Cigarette smokers
 Alcoholism
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
Who should receive pneumococcal
vaccination and when?
 All individuals aged 65 years and older
 Other high-risk persons regardless of age
 Those living in special environments (long-term care)
 Chronic heart disease (CHF, cardiomyopathy but not HT)
 Chronic lung disease (COPD but not asthma)
 Diabetes mellitus; Chronic liver disease
 Cerebrospinal fluid leaks; Cochlear implants
 Functional or anatomical asplenia (sickle cell disease)
 Immune-suppression
 Cigarette smoking; Alcoholism
 Alaskan natives or American Indians
 Anyone hospitalized for a medical illness
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
 When to give vaccination
 In those without high-risk conditions: age 65
 Risk factors: when risk first identified, irrespective of age
 How to give vaccination
 Timing varies by age and presence of high-risk conditions
 Generally:
 PCV-13 first (more immunogenic)
 PPS-23 (for additional strain coverage) 6-12 mo later
 In immune-compromised patients <65 years: PPS-23 only 8
weeks after PCV-13
 In those who received 1 or 2 doses of PPS-23 before age
65, repeat dose at ≥65 years if ≥5 years have passed since
prior dose
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
What is the role of influenza vaccination in
preventing CAP and its complications?
 Immunize yearly
 All patients at increased risk for influenza complications
 Anyone likely to transmit the infection to high-risk patients
 Recombinant influenza vaccine: Use in adults age ≤49
 Option: Live attenuated vaccine (intranasal) in healthy,
nonpregnant adults age ≤49
 Don’t give to health care workers in contact with severely
immune-compromised patients
 Don’t give to those with immunosuppression and chronic
medical conditions
 High-dose influenza vaccine: available for those >65
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
CLINICAL BOTTOM LINE: Prevention...
 Offer pneumococcal vaccination to those at risk for CAP
 Immune-competent: PCV-13, then PPS-23 after 6-12 mo
 Immune-suppressed: PCV-13, then PPS-23 after only 8 wk
 If received PPS-23 previously: 1 dose PCV-13 ≥1 year after
 In those ≥65 who received previous doses before age 65:
repeat PPS-23 vaccination after 5 years
 In immune-suppressed at at any age: repeat PPS-23
vaccination after 5 years
 Offer influenza vaccine yearly to at-risk persons
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
Which symptoms should lead clinicians to
consider CAP?
 Pneumonia with respiratory and systemic symptoms
 Cough, purulent sputum, pleuritic chest pain
 Dyspnea, chills, fever, night sweats, weight loss
 Hemoptysis suggests necrotizing infection
 Most patients present with acute illness 1–2d in duration
 Older patients and those with chronic illness may
develop nonrespiratory symptoms only
 Confusion, weakness, lethargy
 Falling, poor oral intake, decompensation of chronic illness
 Symptoms may be present for longer periods in elderly
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
Which organisms cause CAP?
 Streptococcus pneumoniae (pneumococcus)
 Haemophilus influenzae
 Mycoplasma pneumoniae
 Chlamydophila pneumoniae
 Legionella
 Influenza virus
 Parainfluenza virus
 Respiratory syncytial virus
 Adenovirus
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
Modifying Factors That Increase the Risk
for Infection With Specific Pathogens
 Penicillin-resistant and drug-resistant pneumococci
 Age >65; beta-lactam therapy in past 3 months;
alcoholism; immune-suppressive illness; multiple medical
comorbid conditions; exposure to child in day care center
 Enteric gram-negative bacteria
 Residence in a nursing home; underlying cardiopulmonary
disease; multiple medical comorbid conditions; recent
antibiotic therapy
 Pseudomonas aeruginosa
 Structural lung disease (bronchiectasis); corticosteroid
therapy; broad-spectrum antibiotic therapy for >7 d in the
past month; malnutrition
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
What is the role of history and physical
examination in the diagnosis of CAP?
 Suggests the presence of pneumonia
 Suggestive: fever or hypothermia, tachypnea, crackles,
bronchial breath sounds on auscultation, pleural effusion
 Identifies risk factors for HCAP
 Predicts the cause
 Identifies those who might have less common cause
 Helps define severity
 Associated with poor outcome:
 Respiratory rate >30 breaths/min
 Diastolic BP <60 mm Hg; systolic BP <90 mm Hg
 Heart rate >125 beats/min
 Temperature <35°C or >40°C
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
When should clinicians use chest radiography?
 When patients have clinical features suggesting CAP
 To define the presence of parenchymal lung infection
 To identify certain pneumonia complications
 When diagnosis is questionable
 Pleural effusion, lung abscess, necrotizing pneumonia, or
multilobar illness suspected
 Assume pneumonia in absence of radiographic infiltrate if
patient has convincing history and focal physical findings
 To aid management if severe illness is present
 Confirm with decubitus film, thoracic ultrasound, or CT
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
What is the role of other laboratory tests?
 Outpatients: to assess oxygenation only (pulse oximetry)
 Inpatients: to define severity and identify cause
 Pulse oximetry
 Arterial blood gases (if CO2 retention suspected)
 Sputum (Gram stain and culture before therapy started)
 Rapid diagnostic testing of respiratory secretions with
molecular methods
 Culture endotracheal aspirate in intubated and
mechanically ventilated patients
 Serum levels of C-reactive protein or procalcitonin
 Severe pneumonia: collect 2 sets of blood cultures and test
urine for Legionella and pneumococcal antigens
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
What other disorders should clinicians
consider in those suspected of having CAP?
 Virus or an unusual
bacterial pathogens
 Bronchoalveolar cell
carcinoma
 Bronchiolitis obliterans with
organizing pneumonia
 Lymphoma
 Pulmonary vasculitis
 Congestive heart failure
 Pulmonary embolus
 Hypersensitivity
pneumonitis
 Antibiotic-induced colitis
 Interstitial diseases
 Empyema, meningitis,
endocarditis
 Lung cancer
 Lymphangitic carcinoma
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
When should clinicians consider specialty
consultation for diagnosis, and which
types of specialists should they consult?
 Infectious disease
 To identify infectious complications of pneumonia and
unusual infections
 Pulmonary specialist
 To identify inflammatory lung disease and pulmonary
embolus
 To perform bronchoscopy and transbronchial biopsy
 Surgeon
 To perform thoracoscopic or open lung biopsy
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
CLINICAL BOTTOM LINE: Diagnosis...
 History helps define risk factors for specific pathogens
 Physical findings help define disease severity
 Confirm diagnosis with chest radiograph
 Laboratory testing has limited value
 Diagnosing specific pathogens early is less useful because
most initial therapy is empirical
 If patient does not respond to initial therapy, consult
specialists and consider bronchoscopy and lung biopsy
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
How should clinicians determine if a patient
requires outpatient, inpatient, or ICU care?
 Pneumonia Severity Index or British Thoracic Society rule
 Guidelines support ICU care if patient:
 Needs assisted ventilation
 Has septic shock requiring vasopressors
 Has ≥3 of following
 Respiratory rate ≥30 breaths/min
 PaO2/ FiO2 ratio ≤250
 Multilobar infiltrates, confusion or disorientation
 Blood urea nitrogen ≥7.1 mmol/L (20 mg/dL)
 Leukocyte count <4 × 109 cells/L
 Platelet count <100 × 109 cells/L
 Temperature <36°C
 Hypotension requiring aggressive fluid resuscitation
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
What is the role of nondrug therapies?
 Outpatients
 Oral hydration
 Hospitalized patients
 IV hydration and oxygen for hypoxemia
 Chest physiotherapy if >30 mL/d sputum and clearance of
secretions is impaired
 Severely ill ICU patient
 Noninvasive ventilatory support
 Mechanical ventilation for respiratory failure
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
Which antibiotics should be prescribed for
outpatients?
 If patient has no cardiopulmonary disease and no
factors that increase infection risk with DRSP or enteric
gram-negative bacteria
 Macrolide or doxycycline
 If patient has cardiopulmonary disease or factors that
increase infection risk with DRSP or enteric gramnegative bacteria
 Antipneumococcal quinolone or combination beta-lactam +
macrolide or doxycycline
 If patient received antibiotic in past 3 months, avoid
using antibiotic of same class
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
Drug Treatment for CAP
 Antibiotics for community-acquired MRSA
—linezolid, clindamycin, vancomycin
 Antipseudomonal beta-lactams
—piperacillin/tazobactam, cefepime, imipenem, meropenem
 Cephalosporins
—cefuroxime, cefpodoxime, ceftriaxone, cefotaxime
 Glycylcycline
—tigecycline
 Macrolides
—azithromycin, clarithromycin
 Penicillins
—amoxicillin/clavulanate, ampicillin, ampicillin/sulbactam
 Quinolones
—ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin
 Tetracyclines
—doxycycline
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
How should clinicians follow patients
during outpatient treatment?
 Patients should monitor response to therapy
 Measure temp orally every 8h
 Drink at least 1 to 2 quarts of liquid daily
 Report chest pain, severe or increasing shortness of
breath, or lethargy
 Complete course of antibiotics on schedule
 If response satisfactory: return exam in 10-14 days
 Give pneumococcal and influenza vaccinations if needed
 Repeat chest radiograph ≥1 month after starting therapy
to screen for nonresolution of infiltrates
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
How soon after admission should
antibiotics be started?
 As soon as possible after diagnosis and before leaving
the emergency department
 For hospitalized patients who are not in ICU
 IV azithromycin if no cardiopulmonary disease and no
factors that increase risk for DRSP or gram-neg bacteria
 IV or oral quinolone or combination beta-lactam +
macrolide or doxycycline if have cardiopulmonary disease
or factors that increase risk for DRSP or gram-neg bacteria
 Individualize antibiotic choice by risk factors for MDR
pathogens if patients have HCAP
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
Which antibiotics should be given to patients
admitted to the ICU?
 Do not use empirical monotherapy
 Assess for risk factors for P. aeruginosa
 No risk factors: IV ceftriaxone or cefotaxime plus
azithromycin or quinolone
 Risk factors: IV antipseudomonal beta-lactam plus IV
quinolone effective against P. aeruginosa
 Risk factors (alternative): IV antipseudomonal beta-lactam
combined with aminoglycoside plus IV macrolide or IV
antipneumococcal quinolone
 If community-acquired MRSA suspected, add linezolid
alone or vancomycin combined with clindamycin
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
What are the other components of ICU care
for CAP?
 Hydration
 Supplemental oxygen
 Chest physiotherapy
 Ventilatory support for respiratory failure
 Systemic corticosteroids
 Especially if relative adrenal insufficiency suspected or if
patient with pneumococcal pneumonia has associated
meningitis
 Vasopressors
 Serum lactate measurement
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
When can clinicians switch hospitalized
patients from IV to oral antibiotics?
 When cough, sputum production, and dyspnea improve
 When afebrile on 2 occasions 8 hours apart
 When able to receive oral medications
 Select oral regimen that covers all organisms isolated in
blood or sputum cultures and reflects IV therapy
 Patients who responded to beta-lactam–macrolide
combination can be continued on macrolide monotherapy
unless cultures justify dual therapy
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
When should a consultation be requested
for hospital patients, and who should be
consulted?
 Infectious disease or pulmonary: Questions about initial
antibiotic therapy selection or poor response to initial therapy
 Pulmonary or critical care: Decisions about vasopressors use,
appropriate site of care, need for ventilatory support
 Pulmonary physician: If pleural effusion documented and
decision needed about thoracentesis
 Pulmonary or thoracic surgical: Placement of chest tube if
complicated parapneumonic effusion or empyema found on
thoracentesis
 Thoracic surgeon: Surgical decortication for advanced and
loculated pleural effusion and empyema
 Cardiologist: Cardiac ischemia complications or CHF
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
When can inpatients be discharged from
the hospital?
 Once a switch to oral therapy made
 Once coexisting medical conditions are under control
 No proven benefit for continued hospital observation
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
What are the indications for follow-up
chest radiography?
 If patient has good clinical response to therapy
 Repeat chest radiograph at least 4 to 6 weeks after initial
therapy
 Radiographic resolution lags behind clinical resolution by
6 to 8 weeks, but early improvement is usually substantial
 If patient deteriorates despite therapy and doesn’t reach
clinical stability
 Conduct aggressive evaluation
 Order early follow-up chest radiograph
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
How can patients prevent recurrent CAP?
 Update pneumococcal and influenza vaccinations
 Avoid smoking cigarettes
 Receive optimal therapy for comorbid illnesses
 Obtain care for medical conditions that predispose to
recurrent infection
 Pursue evaluation for aspiration risk factors
 If pneumonia recurs in same location, consider possible
bronchiectasis, aspirated foreign body, or
endobronchial obstruction
 If patient has recurrent pneumonia or pneumonia with
an unusual pathogen, consider immune deficiency
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.
CLINICAL BOTTOM LINE: Treatment...
 Determine site of care (outpatient, hospital, or ICU)
 Select antibiotic therapy
 Deliver supportive care (oxygen, hydration)
 Determine need for ventilatory support
 Consult specialist in severe disease and for complications
 Transition to oral antibiotics after treatment response
 Delay chest radiography 4-6 weeks if responsive to therapy
 Monitor for comorbid illness and update vaccinations
 Encourage smoking cessation
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 163 (5): ITC5-1.