Community Acquired Pneumonia
Definitions
• Community acquired pneumonia (CAP)
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Infection of the lung parenchyma in a person who is not hospitalized or living in a long-term care
facility for ≥ 2 weeks
• Hospital-acquired pneumonia (HAP)
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Occurs 48 hours or more after admission, which was not incubating at the time of admission
• Healthcare-associated pneumonia (HCAP) is defined as
pneumonia that occurs in a non-hospitalized patient with
extensive healthcare contact, as defined by one or more of
the following:
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Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days.
Residence in a nursing home or other long-term care facility
Hospitalization in an acute care hospital for two or more days within the prior 90 days
Attendance at a hemodialysis clinic within the prior 30 days
• Ventilator-associated pneumonia (VAP)
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Arises more than 48-72 hours after endotracheal intubation
Initial Evaluation of Suspected
Pneumonia
• Common clinical features
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Cough
Fever/Chills
Pleuritic chest pain
Dyspnea
Sputum production
Some may have GI symptoms including nausea, vomiting and
diarrhea
• Physical Exam
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Fever
Respiratory Rate >24
Tachycardia
Chest examination may reveal audible rales
Initial Evaluation of Suspected
Pneumonia
• A chest radiograph should be obtained in patients with
suspected pneumonia when possible; a demonstrable
infiltrate by chest radiograph or other imaging technique is
required for the diagnosis of pneumonia, according to the
2007 consensus guidelines from the Infectious Diseases
Society of America and the American Thoracic Society
(IDSA/ATS)
• The radiographic appearance of Pneumonia may include
lobar consolidation, interstitial infiltrates, and/or cavitation.
Initial Evaluation of Suspected
Pneumonia
• The 2007 IDSA/ATS consensus guidelines
recommend for diagnostic testing:
– For outpatients with CAP routine diagnostic tests
are optional.
– Hospitalized patients should have CBC w/ diff,
blood cultures and sputum Gram stain and culture
– Patients with severe CAP requiring ICU admission
should have blood cultures, urinary antigen tests,
and sputum culture (either expectorated or
endotracheal aspirate)
Hospital Admission
• There are a Severity-of-illness scores that can help guide
whether to admit or not but should not be used over
clinical judgment of the patient and situation
• CURB-65 criteria (>2, more-intensive treatment)
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Confusion
Urea 7 mmol/L (20 mg/dL)
Increased respiratory rate >30
low blood pressure (SBP <90 or DBP <60)
• Pneumonia Severity Index (PSI)
– uses demographics, the coexistence of co-morbid
illnesses findings on physical examination, vital signs
and essential laboratory findings
ICU Admission
• Minor criteria (need 3)
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Respiratory rate >30 breaths/min
PaO2/FiO2 ratio <250
Multilobar infiltrates
Confusion
BUN level, >20 mg/dL
Leukopeniac (WBC count, <4000
cells/mm3
– Thrombocytopenia (platelet count,
< 100,000 cells/mm3
– Hypothermia (core temperature,
<36 degrees C
– Hypotension requiring aggressive
fluid resuscitation
• Major criteria
– Invasive mechanical ventilation
– Septic shock with the need for
vasopressors
CAP Pathogens
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic
Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect
Dis 2007; 44 Suppl 2:S27.
CAP Treatment Outpatient
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
CAP Inpatient
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
Prevention
• All persons >50 years of age, others at risk for influenza complications,
household contacts of high-risk persons, and health care workers
should receive inactivated influenza vaccine
• Health care workers in inpatient and outpatient settings and long-term
care facilities should receive annual influenza immunization.
• Pneumococcal polysaccharide vaccine is recommended for persons
>65 years of age and for those with selected high-risk concurrent
diseases
• Smoking cessation should be a goal for persons hospitalized with CAP
who smoke.
• Respiratory hygiene measures, including the use of hand hygiene and
masks or tissues for patients with cough, should be used in outpatient
settings and EDs as a means to reduce the spread of respiratory
infections.
References
• Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases
Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired
pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
• American Thoracic Society, Infectious Diseases Society of
America. Guidelines for the management of adults with hospitalacquired, ventilator-associated, and healthcare-associated
pneumonia. Am J Respir Crit Care Med 2005; 171:388.
• Schuetz P, Christ-Crain M, Thomann R, et al. Effect of
procalcitonin-based guidelines vs standard guidelines on
antibiotic use in lower respiratory tract infections: the ProHOSP
randomized controlled trial. JAMA 2009; 302:1059.