COMMUNITY-ACQUIRED

PNEUMONIA
BELLO, MICKAELA BIANCA A.
GUMIRAN, NOMER

General Objective:
To discuss Community-Acquired Pneumonia
Specific objectives:
To present a case of Community-Acquired
Pneumonia
To discuss its epidemiology
To determine its pathogenesis
To identify the different classification of
Community Acquired Pneumonia
To be able to manage and prevent pneumonia
according to the Clinical Practice Guidelines

General Data

DM
40 years old
Female
Married
Factory worker
Filipino
Catholic
June 3, 1976
Quezon City
#144 Alley 1- Howmart road Baesa, Quezon City
December 14, 2016

Chief complaint: cough

History of Present Illness:
-1 week Prior to Consultation:
Cough (productive, greenish sputum,
amounting to half teaspoon)
Loss of appetite
Insomnia

(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)

Chest pain
Hemoptysis
Easy fatigability
Weight loss
Fever
Night sweats
Dyspnea
Anorexia
Back pain

 Self medicated with Carbocisteine

500mg- temporary relief
No consult done
Persistence of symptoms prompted
patient to seek consult

Past Medical History

Complete immunization
(+) measles
(+) mumps
No history of previous hospitalization
(-) surgeries
(-) accidents
(-) trauma
(-) blood transfusion
No known allergy to food and drugs
No history of disease such as hypertension,
diabetes, asthma, goiter, PTB, arthritis, hepatitis
No history of pneumonia

Family History
Father- alive, hypertensive
Mother- alive, essentially well
No other heredofamilial disease such
as DM, asthma, goiter, malignancies
No communicable disease such as
PTB, hepatitis

Personal and Social history

3rd child
High school graduate
Factory worker
Married with 3 children
Living in a bungalow with 2 windows, total of 4 occupants
(+) TB exposure
Source of water: Maynilad
Waste disposal: collected 2x week
Pour flush latrine
Prefers eating vegetable and fish
Sleeps 5 hours a day
Nonsmoker
Non-alcoholic drinker
Denies illicit drug use

Ob-Gyne history
Menarche- 12 years old
Gravida- 3
Interval- Regular
Parity- 3
Duration- 3 days
Term-3
Amount- 3 pads per day
Preterm-0
Symptoms-none
Abortion-0
PMP: 10/19/16
Living-3
LMP:11/15/16

Review of systems
General: (-)chills (-) fatigue
Skin: (-) color change (-) sores (-) rash (-) itching (-)
scaling (-) bleeding
Head: (-) Headache (-) trauma
Eyes: (-) redness (-) dryness (-) diplopia (-) blurring
of vision
Ears: (-) pain (-) tinnitus
Nose: (-) colds (-)discharge (-) pain (-) sneezing
Mouth: (-) bleeding gums (-) ulcers (-) hoarseness
Cardiovascular: (-) chest pain (-) dyspnea (-)PND (-)
orthopnea (-) palpitations
Gastrointestinal: (-) dysphagia (-) hematemesis (-)
diarrhea

 Genitourinary: (-) dysuria (-) hematuria (-)

frequency (-) urgency
Musculoskeletal: (-) pain (-) weakness (-)
tenderness (-) cramps (-) trauma
Endocrine: (-) polyuria (-) polydipsia (-)
polyphagia
Hematologic: (-) pallor (-) easy bruising
Nervous: (-) syncope (-) seizure (-) tremor
Psychiatric: (-) hallucination (-)depression

Physical examination
General:Patient is conscious, coherent, ambulatory,
not in cardiorespiratory distress
Vital signs: BP:120/80mmHg CR: 98bpm RR:21cpm
T:37.0C
Anthropometric: Ht: 156cm Wt: 48kg
BMI: 19.72kg/m2 (Normal)
IBW: 50.4kg
Skin is brown, no lesions, no masses, warm to touch
HEENT:Anicteric slcera, pink palpebral conjunctiva, no
nasoaural discharge, no tonsillopharyngeal
congestion, no cervical lymphadenopathy

Chest and Lungs: symmetrical chest expansion,

no retraction, no lagging, clear breath sounds
Heart: Adynamic precordium, normal rate,
regular rhythm, no murmur
Abdomen: flabby, normoactive bowel sounds,
soft, non-tender
Extremities: Grossly normal extremities, no
edema, full equal pulses

Salient features

D.M. 40 years old, female

Chief complaint: cough
Productive cough x 1 week
Factory worker
History of TB exposure
Nonsmoker
No known history of disease such as hypertension, diabetes
mellitus, PTB,
No history of previous pneumonia
RR= 21bpm
PR= 98 bpm
BP=120/80mmHg
Ht: 156cm Wt: 48kg BMI: 19.72kg/m2 (Normal) IBW: 50.4kg
Symmetrical chest expansion, no lagging , no retraction,
clear breath sounds

Differential diagnosis
PTB

Cough
Anorexia
Insomnia
(+) TB exposure
Chest pain
Fever
Night sweats
Hemoptysis
Weight loss
Weakness

Bronchitis

Low-risk CAP

Cough
Sputum
production
Fever
Nausea
Vomiting
Sore throat
Headache

Cough
No comorbidities
such as
hypertension,
diabetes mellitus
Stable vital signs
RR= 21bpm
PR= 98 bpm
BP=120/80mmHg

Assessment
Community Acquired PneumoniaLow risk r/o Pulmonary tuberculosis

Plan
For Chest x-ray PA view
Start Clarithromycin 500mg, 1 tab BID x
7 days with meals
Erdosteine 500mg, 1 tab BID x 5 days
Vitamin B complex, 1 tab ODHS
Increase oral fluid intake
Follow up on December 20, 2016 with
results or to come back anytime if with
problem

 CURRENT CLASSIFICATION
1. Community acquired pneumonia (CAP)
2. Health Care-Associated Pneumonia
(HCAP)
a) Hospital-Acquired Pneumonia (HAP)
b) Ventilator-Associated pneumonia (VAP)

 RISK FACTORS FOR CAP

Alcoholism
Asthma
Immunosuppression
Institutionalization
Age > 70 years
Dementia
Seizure disorders
Tobacco smoking
Chronic obstructive pulmonary disease
(COPD

CLINICAL MANIFESTATIONS
vary from indolent to fulminant; mild to fatal
Fever
Tachycardia
Chills and/or sweats
Productive or non-productive cough
Dyspnea (occasionally)
Pleuritic chest pain (if pleura is involved)
Fatigue, headache, myalgias
Physical findings:
- Increased RR
- Use of accessory muscles of respiration
- Increased tactile fremitus, dull percussion
note for consolidation
- Decreased tactile fremitus, flat percussion
note for effusion
- Crackles, bronchial breath sounds on
auscultation

NON-INFECTIOUS CAUSES OF FEVER & PULMO

INFILTRATES
THAT MAY MIMIC CAP
Pulmonary edema
Pulmonary infarction
Acute respiratory distress syndrome (ARDS)
Pulmonary hemorrhage
Lung cancer/metastatic cancer
Atelectasis
Radiation pneumonitis
Drug reactions involving the lung
Extrinsic allergic alveolitis
Pulmonary vasculitis
Pulmonary eosinophilia
Bronchiolitis obliterans and organizing pneumonia

 CRITERIA FOR CAP

Cough
Tachycardia CR > 100
Tachypnea RR > 20
Fever T >37.8C
At least one abnormal chest findings
o diminished breath sounds
o rhonchi, crackles or wheeze
New x-ray infiltrate with no clear
alternative such as
lung cancer or pulmonary edema

CAP CLASSIFICATION
1. LOW RISK CAP
- Stable vital signs
RR < 30/min
PR < 125/min
SBP > 90, DBP > 60 mmHg
Temp. < 40 C
- No or stable co-morbid conditions
DM, neoplastic disease, neurologic disease, CHF
Class I, CAD, immunosuppressive therapy
Renal insufficiency
COPD, chronic liver disease, or chronic alcohol
abuse

MODERATE RISK CAP

- Vital Signs: any one of the following
RR > 30/min
PR > 125/min
Temp. > 40 C
- X-ray findings of:
Multi-lobar involvement
Progression of lesion to 50% within 24 hours
Abscess
Pleural effusion
- with suspected aspiration
- extra-pulmonary findings of sepsis: hepatic,
hematologic, gastrointestinal, endocrine
- Unstable comorbid condition: uncontrolled DM,
active malignacies, neurologic disease in evolution,
CHF Class II-IV, unstable CAD, renal failure on
dialysis, uncompensated COPD, decompensated liver
disease

 HIGH RISK CAP

- All criteria under moderate risk plus
- Impending or frank respiratory failure
Hypoxemia with PaO2 < 60 mmHg
Acute hypercapnia with PaCO2 > 50 mmHg
- Hemodynamic alterations and
hypoperfusion:
SBP < 90mmHg, DBP < 60mmHg
Urine output < 30cc/hour
Altered mental state

LABORATORY PROCEDURES
TO BE DONE

1. Chest Radiograph (confirm the dx)

2. Gram Stain
May help identify pathogens by their
appearance
Main purpose is to ensure suitability of sputum
for culture (> 25 neutrophils and <10 squamous
epithelial cells per LPF)
3. Sputum Culture
Sensitivity and specificity is highly variable (< 50%)
Greatest benefit is to alert the physician of
unsuspected and/or resistant pathogens
4. Blood Culture
gold standard
Only 5-14% of cultures of blood are positive
No longer considered necessary for all
hospitalized CAP patients
Should be done in certain high-risk patients (i.e.
severe CAP; chronic liver disease

 5. Antigen tests
Two commercially available tests detect
pneumococcal and Legionella antigens in
urine
Sensitivity and specificity are high for both
tests
Can detect antigen even after the initiation of
appropriate antibiotic therapy
Limited availability
6. Serology

EMPERIC ANTIMICROBIAL THERAPHY

FOR CAP WITH USUAL
RECOMMENDATION DOSAGES IN 50-60
KG.ADULTS FOR NORMAL LIVER AND
LOW RISK CAP
RENAL FUNCITON
Previously healthy and no antibiotics in past 3
months
Macrolide (Clarithromycin 500mg BID or
Azithromycin 500mg OD) or
Doxycycline 100mg BID
Comorbidities or antibiotics in past 3 months:
select an
alternative from a different class
Fluoroquinolone (Moxifloxacin 400mg OD,
Gemifloxacin 320mg OD, Levofloxacin 750mg OD) or
Beta-lactam (Amoxicillin 1gm TID,
Amoxicillin/Clavulanate 2gm BID, Cefpodoxime
200mg BID, Cefuroxime 500mg BID) plus Macrolide

 MODERATE RISK CAP

Fluoroquinolone (Moxifloxacin 400mg PO
or IV OD,
Gemifloxacin 320mg PO OD, Levofloxacin
750mg PO
or IV OD)
Beta-lactam (Cefotaxime 1-2gm IV q8h,
Ceftriaxone
1-2gm IV OD, Ampicillin 1-2gm IV q4-q6)
plus
macrolide

 HIGH RISK CAP (no risk for

Pseudomonas)
Beta-lactam (Cefotaxime 1-2gm IV
q8h, Ceftriaxone
2gm IV OD, Ampicillin-Sulbactam
2gm IV q8) plus
Azithromycin or a fluoroquinolone

 FAILURE TO IMPROVE W/N 48-72 HRS

OF THERAPY
Cancer, embolus, hemorrhage
Resistant pathogen
Wrong drug
Right drug, wrong dose
Unusual pathogens - Mycobacterial,
anaerobic, viral,
fungal
Nosocomial superinfections

COMPLICATIONS

- Respiratory failure
- Shock; Multiorgan failure
- Bleeding diathesis
- Exacerbation of comorbid illnesses
- Metastatic infections
- Brain abscess; Endocarditis
- Lung abscess - usually occurs in the setting of
aspiration, should be drained
- Pleural effusion - should be tapped for
diagnostic
and therapeutic purposes

 RATE OF RESOLUTION
Fever 2-4days
Cough 4-9days
Crackles 3-6days
leukocytosis 3-4days
CXR abnormalities 4-12wks
Patient is considered to have responded if:
- Fever declines within 72 hrs
- Temperature normalizes within 5 days
- Respiratory signs (tachypnea) return to
normal

IMMUNIZATION

1. PNEUMOCOCCAL VACCINE
60 yrs old and above
Chronic illness: cardiovascular disease, lung
disease,
DM, alcohol abuse, chronic liver disease, asplenia
Immune system disorder: HIV, malignancy
2. INFLUENZA VACCINE
50 yrs old and above
Chronic illness
Immune system disorder
Residents of nursing homes
Health care workers
Persons in contact with high risk patients

HEALTH CARE-ASSOCIATED PNEUMONIA (HCAP)

*a newly recognized form of pneumonia, included in the 2005
American Thoracic Society (ATS)/Infectious Diseases Society
of America (IDSA) guidelines for nosocomial pneumonia
- Hospitalization for 2 or more days within 90 days of
the present infection
- Resident of a nursing home or long-term care facility
- Received recent IV antibiotic therapy, chemotherapy
or wound care in the past 30 days of the current
infection
- Attended a hospital or hemodialysis clinic
a. Ventilator Associated Pneumonia (VAP)
- Pneumonia that arises more than 48-72 hours after
endotracheal intubation
b. Hospital Acquired Pneumonia (HAP)
- pneumonia that occurs 48 hours or more after
admission, which was not incubating at the time of
admission