Community Acquired

Pneumonias
update

Dr.T.V.Rao MD
Pneumonia - Definition
 Pneumonia is an
abnormal inflammat
ory condition of
the lung. It is often
characterized as
including
inflammation of
the parenchyma of
the lung (that is,
the alveoli) and abn
or-mal alveolar
filling with fluid
(consolidation and exudation)
 Community Acquired
Pneumonia
 Definition:
Acute infection of the pulmonary
parenchyma that is associated with at
least 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. Clinical Infect Diseases 2000;31:347-82.
 Community-Acquired
Pneumonia ( CAP )
 Community-acquired
pneumonia refers to
pneumonia acquired
outside of hospitals or
extended-care
facilities.
 Community-acquired
pneumonia (CAP) is
one of the most
common infectious
diseases diagnosed by
clinicians.
 Why Community Acquired
Pneumonia is a Important disease
CAP causes major changes
in the Functional
physiology of the
Respiratory tract
 Who Develops Community
Acquired Pneumonia
 Community-acquired
pneumonia develops in
people with limited or no
contact with medical
institutions or settings.
 CAP occurs throughout
the world and is a
leading cause of illness
and death
Community Acquired
Pneumonia
 Risk Factors for pneumonia
– age
– alcoholism
– smoking
– asthma
– Immuno suppression
– institutionalization
– COPD
– dementia
 Community acquired pneumonia
Emerging Health Problem
 Causes of CAP -
 Bacteria, viruses, fungi, and parasites.
CAP can
be diagnosed by symptoms and physical
examination alone, though x-rays,
examination of the sputum, and other
tests are often used. Individuals with CAP
sometimes require hospitalization
and treatment in a hospital.
Several Microbes can cause
CAP
 The most commonly
identified pathogens are
Streptococcus
pneumoniae,
Haemophilus
influenzae, and
atypical organisms
(i.e., Chlamydia
pneumoniae,
Mycoplasma
pneumoniae,
Legionella sp).
 Typical x Atypical
etiological agents
 Typical pneumonia usually is caused
by bacteria such as Streptococcus
pneumoniae.
Atypical pneumonia usually is caused
by the influenza virus, mycoplasma,
Chlamydia, Legionella, adenovirus, or
other unidentified microorganism.
The patient's age is
the main differentiating factor between
typical and atypical pneumonia; young
adults are more prone to atypical
causes, and very young and older persons
are more predisposed to typical causes.
 X ray chest gives the
leading clues in Diagnosis
 Pathophysiology
 CAP is usually acquired via inhalation or
aspiration of pulmonary pathogenic
organisms into a lung segment or lobe.
Less commonly, CAP results from
secondary bacteraemia from a distant
source, such as Escherichia coli urinary
tract infection and/or bacteraemia. CAP
due to aspiration of Oropharyngeal
contents is the only form of CAP
involving multiple pathogens.
 Etiological agents in Community-
Acquired Pneumonia in Children
From Birth to 3 weeks
 Group B
streptococci,
Listeria
Monocytogenes,
gram-negative
bacilli,
cytomegalovirus
From 3 weeks to 3 months
 Streptococcus
pneumoniae, viruses
(RSV, Parainfluenza
viruses,
metapneumovirus),
Bordetella pertussis,
Staphylococcus
aureus, Chlamydia
trachomatis (trans
natal exposure)
 From 4 months to 4 years
 S. pneumoniae,
viruses
(RSV, Parainfluenza
viruses, influenza
viruses, adenovirus,
rhinovirus,
metapneumovirus),
 Mycoplasma
pneumoniae (in older
children), group A
streptococci
5 years to 15 years
 S. pneumoniae,
 M. pneumoniae,
and
Chlamydia
pneumoniae
 COMMUNITY-
ACQUIRED
PNEUMONIA IN
ADULTS
 Outpatients—with no
modifying factors present
 Streptococcus
pneumoniae,
 Mycoplasma pneumoniae,
 Chlamydia pneumoniae,
 Haemophilus influenzae,
respiratory viruses,
miscellaneous
 (Legionella sp,
Mycobacterium
tuberculosis, endemic
fungi
Outpatients—modifying
factors present
 S. pneumoniae, including
drug resistant forms; M.
pneumoniae;
 C. pneumoniae; mixed
infection (bacteria +
atypical pathogen or
virus); H. influenzae;
enteric gram-negative
organisms; respiratory
viruses; miscellaneous
(Moraxella catarrhal is,
Legionella sp,
anaerobes [aspiration],
M. tuberculosis,
endemic fungi)
 CAP in Inpatients not
admitted in ICU
 S. pneumoniae, H.
influenzae;
C.Pneumonia; C.
pneumoniae; mixed
infection (bacteria +
atypical pathogen or
virus); respiratory
viruses; Legionella sp,
miscellaneous (M.
tuberculosis, endemic
fungi, Pneumocystis
jiroveci)
CAP in ICU patients—with
no
Pseudomonas risk factor
 S. pneumoniae,
including drug resistant
forms, Legionella sp,
 H. influenzae, enteric
gram-negative
organisms, S. aureus,
C.Pneumonia,
respiratory viruses,
miscellaneous (C.
pneumoniae, M.
tuberculosis, endemic
fungi
Non-bacterial pathogens
causing CAP
 Non
bacterial pathogens
in the differential
include many
viruses (influenza,
adenovirus,
rhinovirus, etc.)
and fungi
(Aspergillusspp., Ca
ndida spp., Coccidi
oides immitis, etc.)
Value of chest x-ray in
Diagnosis of CAP
•A chest x-ray is
recommended to make
the diagnosis of
pneumonia An
imperfect gold standard
•No studies specifically
demonstrate improved
patient outcomes through
use of chest x-ray in
adults
Radiological diagnosis can be
supported by Microbiological
studies
Microbiological
Diagnosis
 Common Laboratory
Tests
 Common laboratory tests
for pneumonia have
included leukocyte count,
sputum Gram stain, two
sets of blood cultures,
and urine antigens.
However, the validity of
these tests has recently
been questioned after low
positive culture rates
were found (e.g., culture
isolates of S. pneumoniae
were present in only 40 to
50 percent of cases).
Microbiological diagnosis is
confirmatory
  Is not possible to distinguish the causative
organisms of pneumonia other than by
microbiology as no pathogen leads to a
clinical, laboratory or radiological pattern
sufficiently characteristic to be the basis of a
confident diagnosis, but clinical symptoms
and epidemiological features  may provide
clues to the aetiology as some differences in
presentation do occur. 
 Bacteriological
Investigations on sputum
 Expectorated
sputum collected
( poorly collected)
without proper
instructions may
not yield optimal
results
Sputum gram staining and
culture
• A good quality sputum
sample with a
predominant pus cells
with proportionately less
epithelial cells and
bacterial pathogens can
be observed in
approximately 15%of the
cases studied
Blood for Bacterial
culture
 Blood cultures should
always be taken from
patients with pneumonia.
 Blood culture collection
before initial hospital
antibiotics
• Pre-treatment blood
cultures - positive
results in 5-14% of
patients hospitalized
with CAP
 Newer methods – Diagnosis of
Community associated
Pneumonias
 Antigen detestation in
sputum urine by
Fluorescent
methods
Immunoelectrophoresis
Latex agglutination
tests
ELISA
Diagnosis in cases of Atypical
Pneumonias
 By serological
methods using
acute and
convalescent sera
 Raise of significant
titer or rising titer
of antibodies give
clues to diagnosis.
Emerging methods in
Diagnosis
 Newer
amplified DNA
detection
methods likely
to improve the
diagnosis of
several cases
of pneumonias
 Advances in Diagnosis of
CAP
 Polymerase chain reaction assay
for Mycoplasma pneumoniae from throat swab or
sputum culture and urinary or serologic antigen
tests for Legionella  have made inroads into
accurately diagnosing CAP caused by atypical
organisms
 Urinary antigen detection of the C polysaccharide
common to Streptococcus pneumoniae now
rapidly identifies the presence of this organism.
To obtain higher yield specimens, transthoracic
needle aspiration and bronchoscopic protected
specimen brush techniques are being used
among sicker patients.
 Other markers suggestive
of CAP
 C - reactive protein
trends have been
correlated to clinical
progress in CAP, and
administration of its
activated form
(drotrecogin alpha)
appears to reduce
mortality in severe
sepsis.
 Changing terminology in
Pneumonias
 The distinction between typical and
atypical pneumonia, although previously
widely used, is not useful today.   It is,
however, helpful to distinguish between
typical and atypical pathogens in
pneumonia. Although these can only be
determined by microbiology, not by
clinical signs and symptoms, atypical
pathogens are less common in patients
aged 75 years and over.
 CDC guidelines on
Laboratory testing
 The current recommendations issued by
the CDC panel focused on laboratory
testing and surveillance. The panel
acknowledged that its suggestion to
move the penicillin break points upward
will require changes in the way
laboratories report and clinicians
interpret susceptibility results;
susceptibility break points will differ
according to the clinical syndrome being
treated.
 Pencillin still continues to
be preferred antibiotic
 With a bloodstream or
lung infection, you can
get a much higher
concentration of
antibiotic to the site of
the infection. Because
of that, you can use a
standard agent, such
as penicillin, even
when there is some
resistance,“
Dr. Whitney.
All isolates of Pneumococcus should be
tested for Minimum inhibitory
concentration for antibiotic sensitivity
 Laboratories should
report MIC’s for
penicillin and
extended-spectrum
cephalosporins for
all pneumococcal
isolates from
appropriately
collected
[specimens]," the
report states.
All isolates of Pneumococcus should be
tested with multiple antibiotics for
sensitivity pattern
 The panel recommended that all local
laboratories should include the following
antimicrobials in surveillance for ant
pneumococcal activity: penicillin, Cefotaxime
(or Ceftriaxone), erythromycin, Doxycycline
(or tetracycline), Clindamycin, and
Flouroquinolones. Reference laboratories
should also survey amoxicillin, Cefuroxime,
cefpodoxime (or cefprozil), Clindamycin,
vancomycin, trimethoprim-Sulphmethoxazole,
and meropenem.
 Antimicrobial therapy –
Empirical approach
 Antimicrobial therapy is the mainstay of
management for community-acquired
pneumonia (CAP). Accordingly, the choices
of treatment are influenced by the likely
aetiologies, local resistance patterns of the
pathogens, as well as patient factors. As the
leading cause of acute CAP, the
susceptibility patterns of Streptococcus
pneumoniae have greatly influenced
antimicrobial agents and dosage
recommended for empirical treatment of this
condition.
 MRSA – a concern in treating
Community acquired
Pneumonias
The worldwide
emergence of
community-acquired
Methicillin-
resistant Staphylococcus
aureus has also led to
discussion of this
pathogen in recent
revisions of the
international CAP
guidelines. 
 CDC new regimes of
treatment
 pneumococcal resistance pose a challenge
for physicians who treat patients with
community-acquired pneumonia (CAP).
When should Streptococcus pneumoniae be
considered susceptible to penicillin and other
antimicrobial agents? How is resistance
defined in patients with CAP? Should
pneumococcal resistance to ß-lactamase
influence CAP therapy? What are the best
empiric antimicrobial regimens for the
treatment of outpatients and hospitalized
patients with CAP?
 Panel recommendations on
Pencillin Usage with MIC
determinations
 Panel recommended adjusting the
penicillin susceptibility categories for
pneumonia-causing pneumococcal
isolates so that all isolates with MIC no
greater than 1 µg/mL would be defined as
susceptible, isolates with MIC of 2 µg/mL
would be considered intermediate, and
isolates with MIC of no less than 4 µg /mL
would be classified as resistant.
 Epidemiology
 Theepidemiology of CAP is unclear
because few population-based statistics
on the condition alone are available. The
Centers for Disease Control and
Prevention (CDC) combines pneumonia
with influenza when collecting data on
morbidity and mortality, although they do
not combine them when collecting
hospital discharge data
 Vaccination in children
 Vaccination is important
in both children and
adults. Vaccinations
against Haemophilus
influenzae and
Streptococcus
pneumoniae in the first
year of life have greatly
reduced their role in
CAP in children
 Community Acquired Pneumonia
and Vaccination for Pneumococcal
infection
 The pneumococcal vaccine
(the ‘pneumonia shot’)
protects against 23 types of
pneumococcal bacteria.

 Research proves the vaccine is

not 100% effective in
preventing pneumonia, but
found that if you are
vaccinated you are less likely
to die from pneumonia.
 Preventing Influenzae
 According to the U.S.
Centers for Disease
Control and Prevention
(CDC), anyone who
wants to reduce their
risk of getting the flu
should have a flu
vaccine.
 Older children and
adults require only a
single shot each year.
However, children under
age 9 may need two
doses
General Health Measures
 Smoking cessation is
important not only for
treatment of any
underlying lung
disease, but also
because cigarette 
smoke interferes with
many of the body's
natural defences
against CAP.
Future goals on reducing child
deaths – 2015 by Hand
washing
 Handwashing with soap is
among the most effective and
inexpensive ways to prevent
diarrheal diseases and
pneumonia, which together are
responsible for the majority of
child deaths. a significant
contribution to meeting
the Millennium Development
Goal of reducing deaths among
children under the age of five by
two-thirds by 2015.
Created for Dr.T.V.Rao MD’s
‘e’ learning Programme
Email
doctortvrao@gmail.com