069_CAP Clinical Scenario

Ashraf Mokhtar Madkour, MD, Dr.med.Ashraf Mokhtar Madkour, MD, Dr.med. Chest Diseases Department Chest Diseases Department

Ain Shams University HospitalAin Shams University Hospital

OutlineOutlineDiagnosis of CAPDiagnosis of CAPSite of care?Site of care?Tools for risk assessment?Tools for risk assessment?Diagnostic tests needed?Diagnostic tests needed?Management of severe CAP ?Management of severe CAP ?

Community-Acquired Pneumonia:Community-Acquired Pneumonia: A Clinical case scenario A Clinical case scenario

PresentationPresentationA 66-year-old man accompanied by his wife, arrived at the Emergency Department complaining ofshortness of breath, fever, and cough.

His symptoms started 8 days ago with mild fever, cough, myalgia, headache & sore throat were he received antipyretic, antihistaminic and cough syrup after consulting his family doctor through a telephone call.

SymptomsSymptoms

SymptomsSymptomsAfter initial improvement, he had a worsening

of symptoms starting 3 days ago with productive cough, pleuritic chest pain, fever, chills and malaise.

Last night he developed dyspnea and high fever, so he decided to come to the Emergency Department today.

Medical HistoryMedical HistoryX-smoker 2 years (30 pack years).COPD.Type 2 diabetes.Medications include

Inhaled salbutamol (100 Inhaled salbutamol (100 g)+ beclomethasone g)+ beclomethasone diproprionate (50 diproprionate (50 g) 2 puffs x 3.g) 2 puffs x 3.

Sustained released theophylline (200mg cap 1x2).Sustained released theophylline (200mg cap 1x2).Gliclcazide (80mg tab. 1x1).Gliclcazide (80mg tab. 1x1).

ExaminationExaminationConfused. Temperature: 39.0°C. Blood pressure: 120/70. Pulse rate: 120 bpm.Respiratory rate: 30 per minute. Clinical signs of right upper zone consolidation and

bilateral scattered rhonchi.No cyanosis, pedal edema or jugular venous

distension is noted.

Chest X-rayChest X-ray

DiagnosisDiagnosisDose this patient have Dose this patient have Community-Acquired Community-Acquired Pneumonia (CAP)?Pneumonia (CAP)?

Definition of CAPDefinition of CAPInfection of the lung parenchyma in a person

who is not hospitalized or living in a long-not hospitalized or living in a long-term care facility for ≥ 2 weeks.term care facility for ≥ 2 weeks.

IDSA /ATS Consensus Guidelines on the Management of Community-Acquired IDSA /ATS Consensus Guidelines on the Management of Community-Acquired PneumoniaPneumoniain Adults. Clinical Infectious Diseases in Adults. Clinical Infectious Diseases 20072007; 44:S27–72; 44:S27–72

CAP: DiagnosisCAP: Diagnosis“In addition to a constellation of suggestive suggestive clinical featuresclinical features, a demonstrable infiltrate infiltrate by chest radiograph or other imaging by chest radiograph or other imaging technique, with or without supporting with or without supporting microbiological datamicrobiological data, is required for the diagnosis of pneumonia.”

IDSA /ATS Consensus Guidelines on the Management of Community-Acquired IDSA /ATS Consensus Guidelines on the Management of Community-Acquired PneumoniaPneumoniain Adults. Clinical Infectious Diseases in Adults. Clinical Infectious Diseases 20072007; 44:S27–72; 44:S27–72

Clinical features:Clinical features:Productive cough, dyspnea, Productive cough, dyspnea, fever, clinical signs of fever, clinical signs of consolidationconsolidationRadiological findings:Radiological findings:ConsolidationConsolidation

CAP – Risk Factors for PneumoniaCAP – Risk Factors for Pneumonia

Elderly Elderly SmokingSmokingCOPDCOPDExtreme weather Extreme weather OvercrowdingOvercrowdingAlcoholismAlcoholismDMDM

Renal insufficiencyRenal insufficiencyCHFCHFChronic liver diseaseChronic liver diseaseImmunossuppresionImmunossuppresionLoss of Loss of

consciousness consciousness Seizures Seizures

What is the value of CXR in CAP?What is the value of CXR in CAP?Establish DxEstablish DxEvaluation of severity Evaluation of severity

e.g. multilobar or bilateral, pleural effusion.Co-existing conditions Co-existing conditions e.g. bronchial obstruction, abscess. PatternPattern

Infiltrate Patterns and PathogensInfiltrate Patterns and Pathogens

Initial investigations at ER:Initial investigations at ER:Hgb 13.4 gm/dl, Hct 40%. Hgb 13.4 gm/dl, Hct 40%. WBC 15,800/μl with 88% polymorphonuclear cells, 8% WBC 15,800/μl with 88% polymorphonuclear cells, 8%

bands.bands.Na+ 137 mEq/L, K+ 3.7 mEq/L. Na+ 137 mEq/L, K+ 3.7 mEq/L. BUN 32 mg/dl, creatinine1.8 mg/dl. BUN 32 mg/dl, creatinine1.8 mg/dl. RBG 260 mg/dl.RBG 260 mg/dl.Arterial blood gas (room air): Arterial blood gas (room air):

pH 7.38, PCOpH 7.38, PCO 2 2 53 mmHg, PO 53 mmHg, PO 2 2 58mmHg, O58mmHg, O 2 2 Sat.% 89%Sat.% 89%

CAP – Management based on PSI ScoreCAP – Management based on PSI Score

Would you hospitalize him? Would you hospitalize him?

Assess the ability to safely and reliably take oral Assess the ability to safely and reliably take oral medication & the availability of outpatient supportmedication & the availability of outpatient supportresourcesresources

CURB 65 scoreCURB 65 score

Thorax 2003,58:377Thorax 2003,58:377

(If study performed)(If study performed)

<60mmHg / SO<60mmHg / SO 2 2 <90% <90%Pneumonia Severity Pneumonia Severity

Index (PSI) scoreIndex (PSI) score

PSI= 146 Class V→ ICUPSI= 146 Class V→ ICU

Calculation of risk assessment (PSI score)Calculation of risk assessment (PSI score)

The patient was hospitalized and admitted to ICUThe patient was hospitalized and admitted to ICU

What testing would you do?What testing would you do?

Diagnostic testingDiagnostic testing““Recommendations for diagnostic testing remain Recommendations for diagnostic testing remain

controversial.”controversial.”No convincing data that they improve outcomes.No convincing data that they improve outcomes.Outpatient setting: Outpatient setting: optional optional Inpatient setting: Inpatient setting:

Critically ill CAPCritically ill CAPSpecific pathogens (suspected) Specific pathogens (suspected)

IDSA /ATS Consensus Guidelines on the Management of Community-Acquired PneumoniaIDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumoniain Adults. Clinical Infectious Diseases in Adults. Clinical Infectious Diseases 20072007; 44:S27–72; 44:S27–72

Diagnostic testing: Diagnostic testing: Critically ill CAPCritically ill CAPSputum: Gram staining and culture. Blood cultures.Urinary antigen tests for Legionella &

Streptococcus pneumoniae.± others

FOB+BAL / Endotracheal tube aspirateThoracentesisTNA


What testing would you do?What testing would you do?Pretreatment: Pretreatment: Sputum: Gram staining and culture. Sputum: Gram staining and culture. Expectorated sputum should be deep cough specimen obtained before Expectorated sputum should be deep cough specimen obtained before

antibiotic treatment and it should be rapidly transported and processed antibiotic treatment and it should be rapidly transported and processed within a few hours of collection.*within a few hours of collection.*

Blood cultures (2 sets)Blood cultures (2 sets)2 sets of blood cultures should be drawn before initiation of antibiotic 2 sets of blood cultures should be drawn before initiation of antibiotic therapy during the first 24 hour.*therapy during the first 24 hour.*

*IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia*IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumoniain Adults. Clinical Infectious Diseases in Adults. Clinical Infectious Diseases 20072007; 44:S27–72; 44:S27–72

What treatment would you What treatment would you prescribe?prescribe?

TherapyTherapyFluid / dietFluid / dietAntipyretics (Paracetamol IV)Antipyretics (Paracetamol IV)Sugar blood chart & Insulin accordingly Sugar blood chart & Insulin accordingly Cough syrupCough syrupSR theophylline SR theophylline Inhalation ttt → salbutamol + ipratropium bromideInhalation ttt → salbutamol + ipratropium bromideOO22 therapy → NP 2 L/min therapy → NP 2 L/minEmpiric Antibiotic tttEmpiric Antibiotic ttt

AntibioticAntibiotic

General & supportiveGeneral & supportive

What antibiotics are appropriate?What antibiotics are appropriate?

CAP: When to start empiric therapy?CAP: When to start empiric therapy?As soon as possible in EDCAP: delay-to-AB> 4h after arrivalCAP: delay-to-AB> 4h after arrival

Increased mortality Increased mortality Increased LOSIncreased LOS


Recommended empirical antibiotics Recommended empirical antibiotics for CAP: for CAP: Inpatient, ICU tttInpatient, ICU ttt

b-lactam plus either azithromycin or a respiratory b-lactam plus either azithromycin or a respiratory fluoroquinolonefluoroquinolone

(cefotaxime, ceftriaxone)

Levofloxacin 750mg/24h + Ceftriaxone Levofloxacin 750mg/24h + Ceftriaxone 1gm /12h IV1gm /12h IV


2 hours after ICU admission2 hours after ICU admissionSputum (gram stain) Sputum (gram stain) →→Gram-positive diplococcusGram-positive diplococcus

Value of Gram stainValue of Gram stain First, it broadens initial empirical coverage for less common etiologies, First, it broadens initial empirical coverage for less common etiologies,

such as infection with such as infection with S. aureus or gram-negative S. aureus or gram-negative organisms. *organisms. * Second, it can validate the subsequent sputum culture result. A positive Second, it can validate the subsequent sputum culture result. A positive

Gram stain was highly predictive of a subsequent positive culture.*Gram stain was highly predictive of a subsequent positive culture.*

*IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumonia*IDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumoniain Adults. Clinical Infectious Diseases in Adults. Clinical Infectious Diseases 20072007; 44:S27–72; 44:S27–72

Day 3Day 3Sputum culture & Sensitivity: Sputum culture & Sensitivity:

Streptococcus pneumoniaeStreptococcus pneumoniaeSensitiveSensitive→ Cefotaxime, Ceftraixone and

Levofloxacin. Susceptibility testing should guide antibiotic

choice when results are available.

Continue on the same antibioticsContinue on the same antibiotics

Day 3:Day 3: The patient's condition began to improve, but fever persisted. The patient's condition began to improve, but fever persisted.

Day 5: Day 5: The patient was a febrile for the first time.The patient was a febrile for the first time.Normal oral intake started. Normal oral intake started. Cough, dyspnea grade & chest wheezes improved.Cough, dyspnea grade & chest wheezes improved.Pulse 90 bpm, B/P 140/80.Pulse 90 bpm, B/P 140/80.WBC 6,800/μl with 3% bands.WBC 6,800/μl with 3% bands.BUN 18 mg/dl, creatinine1.4 mg/dl, 2 PPBS 170mg/dl. BUN 18 mg/dl, creatinine1.4 mg/dl, 2 PPBS 170mg/dl. OO 2 2 Sat.% on RA: 93%.Sat.% on RA: 93%.Transferred to ward.Transferred to ward.

Switch from intravenous to oral therapy?Switch from intravenous to oral therapy?

Afebrile No abnormal GIT absorption Cough & respiratory distress

improved WBC returning to normal

Levofloxacin 750 mg tab/24hrLevofloxacin 750 mg tab/24hrIDSA /ATS Consensus Guidelines on the Management of Community-Acquired PneumoniaIDSA /ATS Consensus Guidelines on the Management of Community-Acquired Pneumoniain Adults. Clinical Infectious Diseases in Adults. Clinical Infectious Diseases 20072007; 44:S27–72; 44:S27–72

Day 8:Day 8: Clinically stableAfebrile for 3days. CXR: partial resolution. Blood culture:

No growth up till now.

CAP: Duration of Therapy?CAP: Duration of Therapy?“A minimum of 5 days… A minimum of 5 days… Afebrile for 48-72 h … Afebrile for 48-72 h … No more than 1 CAP-No more than 1 CAP-associated sign of associated sign of clinical instability’’clinical instability’’


Day 9:Day 9:Discharged and antibiotic stopped.Recommendations

/ pneumococcal polysaccharide vaccination / During next influenza season, influenza

vaccination. / ttt COPD & DM.FU CXR after 1 week.

069_CAP Clinical Scenario

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