iseases and is an important cause of mortality and morbidity worldwide.

Essential update: Survival benefits of azithromycin outweigh MI risk in

elderly patients with pneumonia
Although recent research suggests that azithromycin may be associated with increased
cardiovascular events, Mortensen and colleagues found that in elderly patients hospitalized
with community-acquired pneumonia, early survival benefits with azithromycin greatly
exceeded the risk of nonfatal MI. Their retrospective cohort study included 73,690 veterans
most of them men and all of them 65 years of age or olderwho received guidelinerecommended combination antibiotic therapy.[1, 2]
In the study, 90-day mortality was significantly lower in patients whose treatment included
azithromycin than in those whose treatment did not include azithromycin (17.4% vs 22.3%).
within the first 90 days of hospitalization, treatment with azithromycin averted seven deaths
for every nonfatal MI. Patients treated with azithromycin had a small but significant
increased risk of MI compared with those who received other treatments (5.1% vs 4.4%), but
did not have a significantly increased risk of experiencing any cardiac event, cardiac
arrhythmias, or heart failure.[1, 2]

Presentation and pathogens in typical CAP

Typical bacterial CAP pathogens include Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis; these 3 pathogens account for approximately 85% of
CAP cases. Patients with bacterial CAP typically present with fever, usually with a
productive cough and often with pleuritic chest pain. Other pulmonary findings on physical
examination are as follows:

Purulent sputum is characteristic

Rales are heard over the involved lobe or segment
Increased tactile fremitus, bronchial breathing, and E-to-A change may be present if
consolidation has occurred
Decreased tactile fremitus and dullness on chest percussion may result from pleural
effusion (usually due to H influenzae infection) or empyema

Particular patient settings and the specific CAP pathogens that are most often associated with
them include the following:

Most common overall: S pneumoniae

Exacerbation of chronic bronchitis leading to CAP that requires hospitalization: M
catarrhalis
Influenza[3] : Staphylococcus aureus

Atypical CAPs
The clinical presentation of atypical CAP is often subacute. In addition, patients with CAP
due to atypical CAP pathogens present with a variety of pulmonary and extrapulmonary
findings (eg, CAP plus diarrhea). Atypical CAP includes the following:

Psittacosis
Q fever
Tularemia
Mycoplasma pneumonia
Legionnaires disease
Chlamydophila (Chlamydia) pneumonia

Extrapulmonary signs and symptoms seen in some forms of atypical CAP may include the
following:

Mental confusion
Prominent headache
Myalgias
Ear pain
Abdominal pain
Diarrhea
Rash (Horder spots in psittacosis; erythema multiforme in Mycoplasma pneumonia)
Nonexudative pharyngitis
Hemoptysis
Splenomegaly
Relative bradycardia

Pleural effusion in a patient with CAP and extrapulmonary manifestations should suggest
Legionella infection. Pleural effusion with appropriate epidemiologic history findings, such
as contact with a rabbit or deer, may suggest tularemia.

Workup
Laboratory studies for CAP are as follows:

Chest radiography
Sputum Gram stain and/or culture (do not send the sputum of patients with COPD for
Gram stain or culture, because these specimens invariably demonstrate a mixed or
normal flora)
Blood cultures

Other laboratory tests

If atypical CAP is suspected, because of extrapulmonary findings, the workup may include
the following:

Serum transaminase levels

Serum phosphorus levels
Urinalysis
Ferritin levels
Creatine phosphokinase (CPK) levels
C-reactive protein (CRP) levels
Procalcitonin levels
Cold agglutinin titers

Otherwise unexplained early, transient, and slight increases in serum transaminases in a

patient with CAP suggest the presence of psittacosis, Q fever, or Legionella pneumonia.[4]
Otherwise unexplained hypophosphatemia or microscopic hematuria in a patient with CAP
suggests Legionnaires disease.[5]
Chest radiography
Obtain chest radiographs in all patients with suspected CAP to exclude conditions that mimic
CAP and to confirm the presence of an infiltrate compatible with the presentation of CAP.[6, 7]
Patients presenting very early with CAP may have negative findings on chest radiography. In
these patients, repeat chest radiography within 24 hours. Serial chest radiography can be used
to observe the progression of CAP.

Hospital admission
Although patients with mild CAP may be treated in an ambulatory setting, patients with CAP
who are moderately to severely ill should be hospitalized.[8] Patients with severe CAP who
require invasive ventilation require admission to an intensive care unit (ICU).[9, 10, 11, 12, 13, 14]

Antibiotic Therapy
CAP may be treated with monotherapy or combination therapy. Effective monotherapy
antibiotics include the following[15, 16, 17, 18] :

Doxycycline
Respiratory quinolones

Combination therapy usually consists of ceftriaxone plus doxycycline or azithromycin.

Immunocompromised hosts who present with CAP are treated in the same manner as
otherwise healthy hosts but may require a longer duration of therapy.
Inpatient therapy for CAP is usually with IV antibiotics, followed by an oral course of
therapy for a total of 14 days.[19, 20, 21, 22] Patients who are severely ill or who are unable to
tolerate or absorb oral medications require a longer duration of IV therapy before switching
to an oral antibiotic.[23]
Mild to moderately ill patients with CAP may be treated entirely via the oral route, either on
an inpatient or outpatient basis.

Image library

Gram stain showing Streptococcus pneumoniae.