CAP by Dr Sarma

8/4/2019 CAP by Dr Sarma

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Dr. R V S N Sarma., MD., MSc., (Canada)

Consultant Physician & Chest Specialist

visit us at: www.drsarma.in



The New Treatment Paradigm –

Selecting Appropriate Empiric Antibiotics



3

Pneumonias – Classification

• Community Acquired

CAP

• Health Care Associated

HCAP

• Hospital Acquired

HAP

• ICU Acquired

ICUAP

• Ventilator Acquired

VAP

Nosocomial Pneumonias



4

Community Acquired Pneumonia (CAP)

Definition

… an acute infection of the pulmonary parenchyma

that is associated with some symptoms of acute

infection, accompanied by the presence of an acute

infiltrate on a chest radiograph, or auscultatory

findings consistent with pneumonia, in a patient not

hospitalized or residing in a long term care facility

for > 14 days before onset of symptoms.

Bartlett. Clin Infect Dis 2000;31:347-82.



5

Guidelines for CAP

American Thoracic Society (ATS)

Guidelines - Management of Adults with CAP (2001)

Infectious Diseases Society of America (IDSA)

Update of Practice Guidelines Management of CAP

in Immuno-competent adults (2003)

ATS and IDSA joint effort (we will follow this)

IDSA/ATS Consensus Guidelines on the

Management of CAP in Adults (March 2007)



6

Evidence-based practice Best outcome for patients

Best use of resource

Restricts idiosyncratic behaviour

Legal protection

Identify research needs

A tool for education

Gain public confidence

Why Guidelines?



CAP – The Two Types of Presentations

Classical

• Sudden onset of CAP

• High fever, shaking chills

• Pleuritic chest pain, SOB

• Productive cough

• Rusty sputum, blood tinge

• Poor general condition• High mortality up to 20% in

patients with bacteremia

• S.pneumoniae causative

• Gradual & insidious onset

• Low grade fever

• Dry cough, No blood tinge

• Good GC – Walking CAP

• Low mortality 1-2%; except

in cases of Legionellosis• Mycoplasma, Chlamydiae,

Legionella, Ricketessiae,

Viruses are causative

Atypical



CAP – Pathogenesis

Inhalation

Aspiration

Hematogenous



Age

Obesity; Exercise is protective

Smoking, PVD Asthma, COPD

Immuno-suppression, HIV

Institutionalization, Old age homes etc Dementia

CAP – Risk Factors for Pneumonia

ID Clinics 1998;12:723. Am J Med 1994;96:313



Community Acquired Pneumonia (CAP)

Epidemiology

4-5 million cases annually

~500,000 hospitalizations – 20% require admission

~45,000 deaths

Fewest cases in 18-24 yr group

Probably highest incidence in <5 and >65 yrs

Mortality disproportionately high in >65 yrs

Over all mortality is 2-30%; Hospitalized Pt mort

<1% for those not requiring hospitalization

Bartlett. CID 1998;26:811-38.



CAP – The Pathogens Involved

56%

10%

6%

6%

5%

4%

4%

9%

S.pneumoniae

H.influenza

Chlamydia

Legionella spp

S.aureus

MycoplasmaGram Neg bacilli

Viruses

40-60% - No causative agent identified

2-5% - Two are more agents identified



Streptococcus pneumonia(Pneumococcus)

Most common cause of CAP

About 2/3 of CAP are due to S.pneumoniae

These are gram positive diplococci

Typical symptoms (e.g. malaise, shaking chillsfever, rusty sputum, pleuritic chest pain, cough)

Lobar infiltrate on CXR

May be Immuno suppressed host

25% will have bacteremia – serious effects



CAP – Special Features – Pathogen wise

Typical – S.pneumoniae, H.influenza, M.catarrhalis – Lungs

Blood tinged sputum - Pneumococcal, Klebsiella, Legionella

H.influenzae CAP has associated of pleural effusion

S.Pneumoniae – commonest – penicillin resistance problemS.aureus, K.pneumoniae, P.aeruginosa – not in typical host

S.aureus causes CAP in post-viral influenza; Serious CAP

K.pneumoniae primarily in patients of chronic alcoholismP.Aeruginosa causes CAP in pts with CSLD or CF, Nosocom

Aspiration CAP only is caused by multiple pathogens

Extra pulmonary manifestations only in Atypical CAP



14

S. aereus CAP – Dangerous

This CAP is not common; Multi lobar Involvement

Post Influenza complication, Class IV or V

Compromised host, Co-morbidities, Elderly

CA MRSA – A Problem; CA MSSA also occurs

Empyema and Necrosis of lung with cavitations

Multiple Pyemic abscesses, Septic Arthritis Hypoxemia, Hypoventilation, Hypotension common

Vancomycin, Linezolid are the drugs for MRSA



15

CAP – Age wise Incidence

0

200

400

600

800

1000

1200

1400

<5 5 to 17 18-24 25-44 45-64 >65

# of cases



16

CAP – Age wise Mortality

0

10

20

30

40

50

60

70

80

<4 5 to 14 15-24 25-44 45-64 >65

0 0 02

5.7

74.9

# of deaths



17

Older, Unemployed, Unmarried

Recurrent common cold

Asthma, COPD; Steroid or bronchodilator use Chronic diseases, Diabetes, CHF, Neoplasia

Amount of smoking

Alcohol is NOT related to increased risk for hospitalization

CAP – Risk Factors for Hospitalization




18

Age > 65

Bacteremia (for S. pneumoniae)

S. aureus, MRSA , Pseudomonas

Extent of radiographic changes

Degree of immuno-suppression

Amount of alcohol consumption

CAP – Risk Factors for Mortality




19

CAP – Bacteriology in Hospitalized Pts



20

CAP – Evaluation of a Patient

Hx. PE, CXR

No Infiltrate

Alternate Dx.

Infiltrate or Clinical

evidence of CAP

Evaluate needfor Admission

PORT &CURB 65

OutPatient

MedicalWard

ICU Adm.



21

CAP – Management Guidelines

Rational use of microbiology laboratory

Pathogen directed antimicrobial therapy

whenever possible Prompt initiation of Antibiotic therapy

Decision to hospitalize based on

prognostic criteria - PORT or CURB 65



22

PORT Scoring – PSI

Clinical Parameter Scoring

Age in years Example

For Men (Age in yrs) 50

For Women (Age -10) (50-10)

NH Resident 10 points

Co-morbid Illnesses

Neoplasia 30 points

Liver Disease 20 points

CHF 10 points

CVD 10 points

Renal Disease (CKD) 10 points

Clinical Parameter Scoring

Clinical Findings

Altered Sensorium 20 points

Respiratory Rate > 30 20 points

SBP < 90 mm 20 points

Temp < 350 C or > 400 C 15 points

Pulse > 125 per min 10 points

Investigation Findings

Arterial pH < 7.35 30 points

BUN > 30 20 points

Serum Na < 130 20 points

Hematocrit < 30% 10 points

Blood Glucose > 250 10 points

Pa O2 10 points

X Ray e/o Pleural Effusion 10 points

Pneumonia Patient Outcomes

Research Team (PORT)



23

Classification of Severity - PORT

Predictors Absent

ClassI

70

ClassII

71 – 90

ClassIII

91 - 130

Class

IV> 130

Class

V



24

CAP – Management based on PSI Score

PORT Class PSI Score Mortality % Treatment Strategy

Class I No RF 0.1 – 0.4 Out patient

Class II 70 0.6 –

0.7 Out patient

Class III 71 - 90 0.9 – 2.8 Brief hospitalization

Class IV 91 - 130 8.5 –

9.3 Inpatient

Class V > 130 27 – 31.1 IP - ICU



25

CURB 65 Rule – Management of CAP

CURB 65

Confusion

BUN > 30

RR > 30

BP SBP <90

DBP <60Age > 65

CURB 0 or 1 Home Rx

CURB 2 Short Hosp

CURB 3 Medical Ward

CURB 4 or 5 ICU care



26

Algorithmic Approach

CAP Patient

< 50 YearsNo

Co-morbidity

No CURB

Class I

Only OP

CURB +

OP / IP/ICU

Class II-V

Co-morbidity

Present

50 Years

PORT

Step 1Step 2 Step 3

Step 4



27

Who Should be Hospitalized?

Class I and II Usually do not require hospitalization

Class III May require brief hospitalization

Class IV and V Usually do require hospitalization

Severity of CAP with poor prognosis

RR > 30; PaO2/FiO2 < 250, or PO2 < 60 on room air

Need for mechanical ventilation; Multi lobar involvement

Hypotension; Need for vasopressors

Oliguria; Altered mental status



28

CAP – Criteria for ICU Admission

Major criteria

Invasive mechanical ventilation required

Septic shock with the need of vasopressors

Minor criteria (least 3)

Confusion/disorientation

Blood urea nitrogen ≥ 20 mg%

Respiratory rate ≥ 30 / min; Core temperature < 36ºC

Severe hypotension; PaO2/FiO2 ratio ≤ 250

Multi-lobar infiltrates

WBC < 4000 cells; Platelets <100,000



29

CAP – Laboratory Tests

• CXR – PA & lateral

• CBC with Differential

• BUN and Creatinine

• FBG, PPBG

• Liver enzymes

• Serum electrolytes

• Gram stain of sputum

• Culture of sputum

• Pre Rx. blood cultures

• Oxygen saturation



30

CAP – Value of Chest Radiograph

• Usually needed to establish diagnosis

• It is a prognostic indicator • To rule out other disorders

• May help in etiological diagnosis

J Chr Dis 1984;37:215-25



31

Infiltrate Patterns and Pathogens

CXR Pattern Possible Pathogens

Lobar S.pneumo, Kleb, H. influ, Gram Neg

Patchy Atypicals, Viral, Legionella

Interstitial Viral, PCP, Legionella

Cavitatory Anerobes, Kleb, TB, S.aureus, Fungi

Large effusion Staph, Anaerobes, Klebsiella



32

CAP – Gram’s Stain of Sputum

Efficiency of test S. pneumoniae H. influenza

Sensitivity 57 % 82 %

Specificity 97 % 99 %

Positive Predictive Value 95 % 93 %

Negative Predictive Value 71 % 96 %

Good sputum samples is obtained only from 39%

83% show only one predominant organism



33

Pathogens Retrieved from Blood Culture

68%

16%

11%5%

S.pneumoniae

Enterobacteria

Staph.aureus

Others



34

Mortality of CAP – Based on Pathogen

P. aeruginosa - 61.0 %

K. pneumoniae - 35.7 %

S. aureus - 31.8 % Legionella - 14.7 %

S. pneumoniae - 12.0 %

C. pneumoniae - 9.8 %

H. influenza - 7.4 %



35

Traditional Treatment Paradigm

Conservative start with ‘workhorse’ antibiotics

Reserve more potent drugs for non-responders



36

New Treatment Paradigm

Hit hard and early with appropriate antibiotic(s)

Short Rx. Duration; De-escalate where possible



37

Objective 2Objective 1

Avoid emergence

of

multidrug resistant

microorganisms

Immediate Rx.

of patients with

serious sepsis

The Therapy Conundrum



38

Inappropriate therapy (%)

0

30

50

10

CAP

20

40

HAP HAP on CAP

17

34

45

Kollef, et al. Chest 1999;115:462 –474

The Effect of the Traditional Approach



39

New data – Don’t Wait for Results !

Switching after

susceptibility results

p<0.001

Adequate treatment

within „a few hours‟

Mortality (%) n=75

Tumbarello, et al. Antimicrob Agents Chemother 2007;51:1987 –1994



40

Risk assessment approach

Early Antibiotic selection

Change treatment driven by localsurveillance

Hit hard and hit early

As short a duration as possible De-escalate when and where possible

CAP Treatment Consensus



41

OPAT – OP Parenteral Antimicrobial Therapy



42

Antibiotics of choice for CAP

Macrolide -M

• Azithromycin

• Clarithromycin

• Erythromycin

• Telithromycin

• Doxycycline

Fluroquinolone-FQ

• Levofloxacin• Moxifloxacin

• Gatifloxacin

• Trovafloxacin

Betalactum -

B

• Ceftriaoxone

• Cefotaxime

• B Inhibitor -

BI• Sulbactam

• Tazobactam

• Piperacillin



43

Antibiotic Dosage, Route, Frequency and Duration

Doxyclycline 100-200 mg PO/IV BID for 7 to 10 days

Azithromycin 500 mg OD IV –3 days + 500 mg OD PO for 7-10 daysClarithromycin 250 – 500 mg BID PO for 7 – 14 days

Telithromycin 800 mg PO OD for 7 – 10 days

Levofloxacin 750 mg PO/IV OD for 5 days

Gatifloxacin 400 mg PO or IV OD for 5 to 7 days

Moxifloxacin 400 mg PO or IV OD for 5 to 7 days

Gemifloxacin 320 mg PO OD for 5 – 7 days

Amoxyclav 2 g of Amoxi +125 mg of Clauv PO BID for 7 to 10 days

Ceftriaxone 2 g IV BID for 3 to 5 days + PO 3G CS

Ertapenum 1 g OD IV or IM for 7 to 14 days



44

Empiric Treatment – Outpatient

Healthy and no risk factors for DR S.pneumoniae1. Macrolide or Doxycycline

Presence of co-morbidities, use of antimicrobials

within the previous 3 months, and regions with a

high rate (>25%) of infection with Macrolide

resistant S. pneumoniae

1. Respiratory FQ – Levoflox, Gemiflox or Moxiflox

2. Beta-lactam (High dose Amoxicillin, Amoxicillin-Clavulanate is preferred; Ceftriaxone, Cefpodoxime,

Cefuroxime) plus a Macrolide or Doxycycline



45

Empiric Treatment – Inpatient – Non ICU

1. A Respiratory Fluoroquinolone (FQ) Levo or

2. A Beta-lactam plus a Macrolide (or Doxycycline)

(Here Beta-lactam agents are 3 Generation

Cefotaxime, Ceftriaxone, Amoxiclav)

3. If Penicillin-allergic Respiratory FQ or

Ertapenem is another option



46

Empiric Treatment: Inpatient in ICU

1. A Beta-lactam (Cefotaxime, Ceftriaxone,

or Ampicillin-Sulbactam) plus

either Azithromycin or Fluoroquinolone

2. For penicillin-allergic patients, a respiratory

Fluoroquinolone and Aztreonam



47

Empiric Rx. – Suspected Pseudomonas

1. Piperacillin-Tazobactam, Cefepime, Carbapenums

(Imipenem, or Meropenem) plus either Cipro or Levo

2. Above Beta-lactam + Aminoglycoside + Azithromycin

3. Above Beta-lactam + Aminoglycoside + an

antipseudomonal and antipneumococcal FQ

4. If Penicillin allergic - Aztreonam for the Beta-lactam



48

Empiric Rx. – CA MRSA

For Community Acquired Methicillin-Resistant

Staphylococcus aureus (CA-MRSA)

Vancomycin or Linezolid

Neither is an optimal drug for MSSA For Methicillin Sensitive S. aureus (MSSA)

B-lactam and sometimes a respiratory

Fluoroquinolone, (until susceptibility results). Specific therapy with a penicillinase-resistant

semisynthetic penicillin or Cephalosporin



49

Duration of Therapy

• Minimum of 5 days

• Afebrile for at least 48 to 72 h

• No > 1 CAP-associated sign of clinical instability

• Longer duration of therapy

If initial therapy was not active against the identified

pathogen or complicated by extra pulmonary infection



50

New data – The Speed of Delay ! (Class 4,5)

0

10

20

30

40

50

60

70

80

90

0.5 1 2 3 4 5 6

Delay in treatment (hours) from hypotension onset

S u r v i v a l ( % )

Each hour of delay carries

7.6% reduction in survival

Kumar, et al. Crit Care Med 2006;34:1589 –1596



51

CAP – Summary of Empiric Treatment

Outpatient Rx – any one of the three

• Macrolide or Doxycycline or Fluoroquinolone

Patients in General Medical Ward

• 3rd Generation Cephalosporin + Macrolide• Betalactum / B-I + Macrolide or B / B-I + FQ

• Fluroquinolone alone

Patients in ICU• 3GC + Macrolide or 3GC + FQ

• B/B-I + Macrolide or B/B-I + FQ

IDSA guidelines: Clin Infect Dis 2000;31:347-82



52

CAP – Treatment Summary

CAP Class Site of Care Treatment 1 Treatment 2 Treatment 3

Class I OP AZ CLR ER / Doxy

Class II OP FQ B + M B + Doxy

Class III OP + IP FQ IV I V - B + AZ Aztreo + FQ

Class IV Med Ward FQ + AZ B 3G + AZ Etrap + M

Class V ICU B 3G + AZ B 3G + FQCarbepenum

Sulbac ,Tazob



53

Strategies for Prevention of CAP

• Cessation smoking

• Influenza Vaccine (Flu shot – Oct through Feb)

It offers 90% protection and reduces mortality by 80%

• Pneumococcal Vaccine (Pneumonia shot)

It protects against 23 types of Pneumococci

70% of us have Pneumococci in our RT

It is not 100% protective but reduces mortality

Age 19-64 with co morbidity of high for pneumonia

Above 65 all must get it even without high risk

• Starting first dose of antibiotic with in 4 h & O2 status



54

Switch to Oral Therapy

Four criteria Improvement in cough, dyspnea & clinical signs

Afebrile on two occasions 8 h apart

WBC decreasing towards normal

Functioning GI tract with adequate oral intake

If overall clinical picture is otherwise favorable,

hemodynamically stable; can switch to oral

therapy while still febrile.



55

Management of Poor Responders

Consider non-infectious illnesses

Consider less common pathogens

Consider serologic testing Broaden antibiotic therapy

Consider bronchoscopy



56

CAP – Complications

Hypotension and septic shock

3-5% Pleural effusion; Clear fluid + pus cells

1% Empyema thoracis pus in the pleural space

Lung abscess – destruction of lung - CSLD

Single (aspiration) anaerobes, Pseudomonas

Multiple (metastatic) Staphylococcus aureus

Septicemia – Brain abscess, Liver Abscess

Multiple Pyemic Abscesses



57

Pneumocystis carinii (PCP)

Important cause of pneumonia in the severely

immuno-compromised, i.e. not a “primary atypical

pneumonia”.

Classically PCP pneumonia presents with slight fever,

dyspnea and non-productive cough

Diagnosis – usually histological (silver staining).

Treatment – Co-trimoxazole or Pentamidine.



58

Viruses and Pneumonia

Pneumonia in the normal host

• Adults or Children

• Influenza A and B, RSV, Adenovirus Para Influenza

Pneumonia in the immuno-compromised• Measles, HSV, CMV, HHV-6, Influenza viruses

• Can cause a primary viral pneumonia. Cause partial

paralysis of “mucociliary escalator” - increased risk of

secondary bacterial LRTI. S.aureus pneumonia is a

known complication following influenza infection.



59

CAP – So How Best to Win the War?

Early antibiotic administration within 4-6 hours Empiric antibiotic Rx. as per guidelines (IDSA / ATS)

PORT – PSI scoring and Classification of cases

Early hospitalization in Class IV and V

Change Abx. as per pathogen & sensitivity pattern

Decrease smoking cessation - advice / counseling

Arterial oxygenation assessment in the first 24 h Blood culture collection in the first 24 h prior to Abx.

Pneumococcal & Influenza vaccination; Smoking X



60

Normal CXR & Pneumonic Consolidation



61

Lobar Pneumonia – S.pneumoniae



62

CXR – PA and Lateral Views



63

Lobar versus Segmental - Right Side

b P i



64

Lobar Pneumonia

S i l f f C lid ti



65

Special forms of Consolidation

R d P i C lid ti



66

Round Pneumonic Consolidation

S i l F f P i



67

Special Forms of Pneumonia

S i l F f P i



68

Special Forms of Pneumonia

C li ti f P i



69

Complications of Pneumonia

E



70

Empyema

M l P i



71

Mycoplasma Pneumonia

M l P i



72

Mycoplasma Pneumonia

Chl di T h ti



73

Chlamydia Trachomatis

Rare T pes of Pne monia



74

Rare Types of Pneumonia

शोम शतेनैव न कडऱेन



शोम ् श ुतनव न क ु डऱन दानेन पािणर ् नत ु किकेन वभात कायः किा पिराा परोपकारेि न चदनेन

shrothram shruthae naiva na kundalaena

dhaanaena paanir na thu kankanaena

vibhaathi kaayah karunaa paraanaam

paropakaaraena na chandanaena

BHARTHRU HARI

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CAP by Dr Sarma

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