CAP IN A CAPSULE

MODERATOR: Dr.SELVAMUTHUKUMARAN

Introduction
William Osler once described pneumonia as the old mans friend as death was often quick and painless CAP is the second most common cause of death from infectious diseases in India the leading cause of childhood mortality Studies reveal that the causative organism of CAP is identified in only 29% of cases.

Risk factors
Case fatality with invasive pneumococcal pneumonias in India was reported to be about 30% according to the IBIS study for a 10-year period. CAP incidence is the highest in winter more in males with ratio of 1.4 : 1 increased with age (1564 years)

 Streptococcus pneumonia is more frequently isolated from alcoholic patients than others There was no relationship between mortality and alcohol, but the severity was more in these patients. tobacco smoking is a risk for CAP HIV-positive patients had a higher prevalence of Mycoplasma pneumonia in a study from CMC Vellore

etiology
Fang et al. conducted a prospective, multicenter study in 359 cases to evaluate the new and emerging causes of CAP S. pneumoniae (15.3%), H. infuenzae (10.9%), Legionella spp. (6.7%) and C. pneumoniae (6.1%). Mortality was the highest for S. aureus (50%) and the lowest for C. pneumoniae (4.5%). The study concluded that empiric antibiotic prescriptions must be infuenced by the realization that C. pneumoniae and Legionella spp. are common etiologies for CAP

 The emerging etiologies for CAP were also examined in a 12-month prospective study, which evaluated the microbiological yield with a new diagnostic polymerase chain reaction (PCR) platform along with conventional methods It was possible to establish microbial etiology in about 67% (n=124) of patients . A microbiological agent was identifed in 89%

 S. pneumoniae [70 patients (38%)] and respiratory virus [53 patients (29%)] were the most frequently detected pathogens. Forty-three (35%) patients out of 124, were detected with two or more pathogens. The most common causative pathogen in Europe, the United States, the United Kingdom, Iraq, Delhi, and Mumbai is S. pneumoniae whereas in Singapore, it is K. pneumoniae

Indian Data
In the Indian scenario, studies on bacteriological etiology are a few and far between, and are mostly confned to limited geographical areas S. pneumoniae predominates as etiological agent of CAP in Shimla and Delhi whereas, P. aeruginosa in Ludhiana

 bansal et al. conducted a study to identify the clinical and bacteriological profle in Shimla S. pneumoniae, S. aureus, K. pneumoniae, M. pneumoniae, E. coli and other Gram-negative bacteria were the most frequently isolated pathogens

 A study by Shah5 et al. showed that factors that can predict mortality in a patient of CAP at the time of admission are Patients above 65 years of age History of chronic obstructive pulmonary disorder Smoking Hypotension and altered sensorium Respiratory failure Staphylococcal pneumonia

Tests to Determine Etiology of CAP

Blood cultures, sputum Gram-stain and culture are the most common tests used In addition to this, serological tests are also performed. an adequate sputum sample is defned as >25 polymorphs and <10 squamous epithelial cells/LPF blood cultures are rarely positive, but if positive, then it is indicative of severe disease

Serologic Tests
The Immunoglobulin M (IgM) antibodies against mycoplasma rise 1 week after infection and remain positive for 6 months to 1 year after infection. This accounts for poor sensitivity and specifcity The IgM antibodies to Chlamydia take 3 weeks to become detectable accounting for poor sensitivity. Antigen detection tests for viruses in respiratory secretions have reasonably good sensitivity and specifcity, but are not currently available Antibody tests for viruses have poor sensitivity/ specifcity

Limitations of Common Investigations

Gram-Stain and Culture: Microbe identifcation is possible in 50% of patients only and depends on quality of sputum sample. Blood cultures give poor results Serology requires rising titres; it is expensive and not easily available Viral cultures are not useful; viral antigens are better

General and Radiological Investigations

The most useful signs and symptoms for the diagnosis of CAP include: Fever Dyspnea Tachypnea Positive signs on respiratory examination Studies show that traditional chest physical examination alone is not sufficiently accurate to confirm or exclude the diagnosis of pneumonia

 Especially in elderly the symptoms are less severe and at times are replaced with nonspecifc symptoms, such as functional failure, falls or confusion. They also have a lesser tendency to have fever compared to younger patients.

Symptoms specific to organism

Streptococcus pneumoniae: Increasing age, comorbidity, acute onset, high fever and pleuritic chest pain. Bacteremic pneumonia: Female sex, excess alcohol, diabetes mellitus, chronic obstructive pulmonary disease. Legionella pneumophila: Younger patients, smokers, absence of comorbidity, diarrhea, neurological symptoms, more severe infection and evidence of multisystem involvement (e.g. abnormal liver function tests, elevated serum creatine kinase).

 Mycoplasma pneumoniae: Younger patients, prior antibiotics, less multisystem involvement. Chlamydophila pneumoniae: Longer duration of symptoms before hospital admission, headache. Coxiella burnetii: Males, dry cough, high fever.

 Absence of vital sign abnormalities substantially reduced the probability of the infection. The gold standard for the diagnosis of pneumonia is chest radiography. Sensitivity and specifcity of chest radiograph are not well-known and also limited data is available on costs of false-positive and falsenegative results.

 Wipf et al.2 conducted a study to determine the accuracy of various physical examination maneuvers in diagnosing pneumonia and to compare the inter-observer reliability of maneuvers among three examiners. Male patients with symptoms of lower respiratory tract infection (cough and change in sputum) were enrolled in this prospective study (n=52).

 A standard form was used to record the examination fndings by lung site and whether the examiner diagnosed pneumonia. Radiologists read the chest radiography flms. the three examiners clinical diagnosis of pneumonia had a sensitivity of 4769% and specifcity of 5875%

Vital Sign Abnormalities

Nolt et al. conducted a study which examined the strength of the association among vital sign abnormalities, advanced age and the diagnosis of CAP in the evaluation of adults with acute cough illness It was found that vital sign abnormality (including fever, hypoxemia, tachycardia or tachypnea) and age greater than 50 years were the only signifcant predictors of CAP strong association was found between hypoxemia and CAP

 Mayaud et al. carried out an evaluation study on data related to age and clinical and radiological fndings. The data showed that absolute lack of vital signs has a good negative predictive value in CAP. The presence of unilateral crackles has a good positive predictive value

Role of Chest Radiograph

Lieberman et al. conducted a prospective, clinical study with the aim to determine the reliability of physicians judgements in respiratory tract infections (RTIs) patients by clinical assessment alone compared with chest radiography. Ambulatory patients with febrile RTI were enrolled (n=250).

 compared to the results of chest radiography, physicians judgements of pneumonia had a sensitivity of 74%, a specifcity of 84%, a negative predictive value of 97% and a positive predictive value of only 27%. Physicians had good ability to negate radiography-confrmed pneumonia by clinical assessment in febrile adult RTI patients. However, they had poor ability to successfully predict the condition

 OBrien et al.9 carried out a study to develop a prediction rule for the use of chest radiographs in evaluating CAP based on presenting signs and symptoms. The study included 350 adult patients with acute respiratory symptoms and positive chest radiographic results The study included an equal number of agematched controls with acute respiratory symptoms but negative radiographic results

 It was found that vital sign and physical examination fndings are useful screening parameters for CAP, demonstrating a sensitivity of 95%, and a specifcity of 56% in the presence of vital sign or physical examination abnormalities. The study fndings were suggestive of nonrequirement of chest radiographs in the absence of vital signs abnormalities or physical fndings

 In a study conducted in three hopitals in the Netherland, it was found Pneumonia cannot be treated based on clinical fndings alone. Manifestation of pneumonia on chest X-ray varies considerably depending upon the degree of infammation and stage of the disease process. Radiographic fndings may lag behind clinical fndings and are poor indicators of etiological diagnosis. Pneumonia was frequently overdiagnosed clinically by general practitioners.

Chest X-ray is Considered as Gold Standard for Diagnosis of Pneumonia: The Netherland Study Findings

British Thoracic Society Guidelines

British Thoracic Society guidelines do not recommend chest radiography in patients with suspected CAP unless the diagnosis is not clear and chest radiograph would help in differential diagnosis and management of acute illness. Chest X-ray is considered when there is no satisfactory treatment progress at the time of review or the patient is at risk of underlying lung pathology The guidelines also recommend routine chest radiograph 6 weeks after discharge.

American thoracic society

The IDSA/ATS consensus guidelines recommend the use of chest radiograph or other technique with or without microbiological data for the diagnosis of pneumonia. Identification of causative microorganism through microbiological studies may support the diagnosis of pneumonia.

Importance of Severity Assessment Important

Community-acquired pneumonia (CAP) represents a signifcant therapeutic challenge to physicians, as they have to decide whether the patient is to be treated in a clinic or a hospital setting. Therefore, it is vital to assess the severity of the disease Several scoring systems are available to help clinicians assess the severity of the illness

 there are three scoring systems available for assessing the severity of CAP. These systems aim to assess the mortality risk associated with the illness and thus accurately determine the severity. The three scoring systems are2 Pneumonia Severity Index (PSI) CURB 65 CRB 65

Pneumonia Severity Index

It is a mortality prediction tool that was first introduced by Fine et al. in 1997. It classifies CAP patients into five categories of an increased risk for short-term mortality based on 20 variables routinely available at presentation.

 The PSI score is assigned after answering the following three questions:3 Is the patient >50 years of age? Does the patient have any coexisting abnormalities Does the patient have altered mental status, pulse rate 125 beats/min; respiratory rate 30 breaths/min; systolic blood pressure <90 mmHg or temperature <35C or 40C?

 While the PSI is a relatively reliable tool for mortality assessment in CAP, there remain some limitations that prevent its widespread use. One of the major limitations is that the tool relies heavily on the age of the patient, which may result in underestimation of the severity of the illness, especially in younger patients.

CURB 65
CURB 65 is a modification of the British Thoracic Society (BTS) rule in assessing pneumonia mortality risk. It uses five variables to arrive at overall death risk in CAP Lim et al. also examined the efficacy of this scoring system after excluding BUN. CRB 65 that effectively categorizes patients according to the need for home care, hospital assessment or urgent (ICU) hospital admission

 Bauer et al found that CURB and CRB 65 had an equivalent predictive power for 14-day mortality. Thus, CURB, CURB 65 and CRB 65 allow for similar predictions of death from CAP as compared to the PSI. Among these severity assessment scales, the CRB 65 is the only tool that can be applied to outpatients as wel

PSI vs. CURB 65

PSI is indicated for identifying low-risk patients CURB 65 is ideal for identifying high mortality risk patients with severe illness. In the Indian context, Shah et al. found that both PSI and CURB 65 had equal sensitivity in predicting the risk of death from CAP. The PSI was more sensitive in predicting ICU admission than CURB 65, although the latter had better overall specificity.

Recommendations
Use CURB 65/CRB65 over PSI in India for judging site of care and severity both PSI and the CURB 65 have several limitations These scoring systems are designed primarily to predict mortality. They are not very effective for predicting ICU admission and are of limited use in the critical care environment.

Importance of Identifying Patients in Need of ICU Admission

Identifying appropriate patients to optimize the use of limited ICU resources. An increase in mortality is observed in patients who are transferred to the ICU for delayed respiratory failure or delayed onset of septic shock. Microbial etiologies for ICU patients are different from that of CAP in general

Predictive Models for Severe CAP

There are three scoring systems available for identifying severe CAP that necessitates ICU admission. ATS/IDSA Criteria SMART-COP Rule SCAP Rule

ATS/IDSA Criteria

Limitations
Variables like ventilation and vasopressors, as specifed in the ATS criteria, might not be available at admission in the emergency department (ED). This might lead to errors in deciding the siteof-care; for example, patients might be admitted to the ward instead of the ICU. This might lead to an increase in the risk of mortality.

SMART COP score

 SMART COP is the result of an extensive study on CAP called the Australian CAP Study (ACAPS). The tool was designed to overcome the limited ability of PSI and CURB 65 to predict which patients will require intensive respiratory or vasopressor support (IRVS).

The interpretation of SMART-COP score

0-2 points: Low risk of needing intensive respiratory or vasopressor support (IRVS) 3-4 points: Moderate risk (1 in 8) of needing IRVS 5-6 points: High risk (1 in 3) of needing IRVS 7 or more points: Very high risk (2 in 3) of needing IRVS

SCAP rule

 advantage of this model is its ability to identify seriously ill patients with CAP who are at risk for an adverse outcome. The variables are easy to interpret and access in causality The sensitivity of SCAP to identify severe CAP is 92% it is more sensitive but not specific when compared to PSI or CURB 65 In the study, SCAP was found to be effective in predicting adverse outcomes such as ICU admission, mechanical ventilation, development of severe sepsis and therapeutic failure.

 Keeping in view the limitations of the ATS and the SMART-COP scoring systems, SCAP may be more suited in the Indian scenario. More practical in predicting ICU admission Cost-effective Accessible Useful in taking quick decision for ICU admission.

Role of Biomarkers
Three prognostic markers, C-reactive protein (CRP), procalcitonin (PCT) and cortisol, have been investigated to assess CAP severity and predict outcome Biomarkers can help differentiate patients with pneumonia from heart failure and chronic obstructive pulmonary disease (COPD) exacerbation, with the latter not requiring antibiotics. can be used to assess the treatment response.

Procalcitonin
Significantly higher PCT levels have been observed in patients with a higher PSI score or with complications or death than those with an uncomplicated clinical course. In the CAPNETZ study, Krger et al. Nonsurvivors had significantly higher median PCT levels than survivors (1.2 vs. 0.3 mmol/L; p=0.0001) Even in patients with high CRB 65, low PCT was able to accurately predict patients who are at very low risk of death. Procalcitonin has a high negative predictive potential (98.9% with PCT level of <0.6 mmol/L). Therefore patients with low PCT might be safely treated as outpatients.

advantages
Identifying need for aggressive management Identifying patients to be treated on outpatient basis When PCT is used as a prognostic marker, patients can be counseled appropriately for adverse events.

limitations
Cost Availability Reporting time Serial assessment

 C-reactive protein is an acute-phase protein synthesized in the liver. Chalmers et al. carried out a prospective study and found that admission CRP <100 mg/L has a high negative predictive value. The CRP levels <100 mg/L indicated reduced risk, whereas failure of CRP to fall by 50% or more at day 4 was associated with increased risks for 30-day mortality, need for mechanical ventilation, and/ or inotropic support, and complicated pneumonia. Thus, CRP can be an independent marker of severity in CAP.

PCT vs. CRP

Simon et al. compared the predictive value of PCT and CRP in assessing the severity of CAP and found that PCT (88%) was more sensitive than CRP (75%) in the distinction of bacterial and noninfective causes of infammation. Also, PCT (81%) was more specifc than CRP (67%) in differentiating bacterial from noninfective causes of infammation. SCAP criteria with the use of biomarkers is one potential solution. Procalcitonin seems to offer the greatest potential among all biomarkers

Management of Community-Acquired Pneumonia

Indian Setting
An important concern in India is tuberculosis. Tuberculosis accounts for 7% cases of CAP. Newer fuoroquinolones have excellent activity against Mycobacterium tuberculosis. There is a delay in the initiation of appropriate antituberculosis treatment (21 days vs. 5 days), thus increasing the risk of spread of tuberculosis in the community.

 The widespread and indiscriminate use of these broadspectrum quinolones (often in subtherapeutic doses) can enhance the quinolone resistance of organisms, including mycobacteria. Based on this, with the use of newer fuoroquinolones, there may be: Potential masking of active tuberculosis Probability of an emerging epidemic of extensively drugresistant tuberculosis Therefore, in areas of tuberculosis endemicity, restricted use of newer fuoroquinolones may be considered. Macrolides may have an extended role in these endemic areas.

Recommendation
Amoxicillin remains the preferred agent to initiate empiric antibiotic therapy in clinic/ outpatient settings. Macrolides such as clarithromycin and azithromycin are recommended in those patients who are hypersensitive to penicillins. Given the endemic nature of tuberculosis in India, macrolides such as clarithromycin and azithromycin may be preferred to quinolones/ doxycycline as the initial empiric therapy.

 Most of the bacteria causing communityacquired pneumonia are found to be resistant to doxycycline. Hence, doxycycline is not recommended. In the presence of comorbidities, a respiratory fuoroquinolone or a -lactam plus a macrolide or amoxicillinclavulanate is preferred.

Coverage of Atypical Pathogen

Restrepo et al. compared clinical outcomes of patients with CAP treated with and without atypical coverage. In the study, the long-term (90 days) and short-term (30 days) mortality was assessed with the use of macrolides in patients with severe sepsis due to pneumonia. The use of macrolide was associated with reduced mortality at 30 as well as at 90 days. The study concluded that empiric therapy with a regimen that covers atypical pathogens might be considered for all hospitalized patients with CAP.

Monotherapy vs. Dual Therapy

Waterer et al. confirmed that monotherapy may not be optimal for CAP patients hospitalized. On the basis of culture results, empirical therapy in this study was classified as single effective therapy (SET), dual effective therapy (DET) or more than DET (MET). Multivariate analysis confirmed that SET was an independent predictor of worse outcome. Among patients who were given coverage for atypical pathogen, 9.9% died as compared to 22.6% without atypical coverage (p=0.02). Subjects who did not receive coverage for atypical organisms had a significantly higher predicted mortality than those who received it (27.3% vs. 21.8%, respectively; p=0.047);

 It was observed that subjects receiving SET were 6.4 times more likely to die of their illness after adjusting for the severity of pneumonia. The same premise was also evaluated in a review by Weiss and Tillotson. This review also suggested that for hospitalized patients, dual therapy combining a -lactam and an advanced macrolide represents a good choice

potental benefts of combinaton therapy include

Better atypical microorganisms coverage The combination regimen that acts at two different sites in the bacteria (cell wall for -lactams and the inhibition of protein synthesis for macrolides), Demonstrated effective antiinfammatory properties of macrolides via reduced production of interleukin-8 and tumor necrosis factor-. Beta-lactams and fuoroquinolones that might be responsible for perpetrating the inflammation process because they are known to kill a large number of bacteria in a short amount of time, thus releasing numerous intracellular components.

Agents Used in Combination Therapy

Anderson et al. compared the effects of subinhibitory concentrations of antibiotics on pneumolysin production by a macrolide-susceptible strain and two macrolide-resistant strains [erm(B) or mef(A)] of S. pneumoniae This study indicated that only macrolides and macrolide-like antibiotics were found to inhibit the production of pneumolysin by all three strains of the pneumococcus, with clarithromycin, erythromycin, telithromycin and clindamycin exhibiting comparable activities, whereas azithromycin was generally somewhat less active..

 Furthermore, in comparison with the other classes of antibiotics tested, macrolides at sub-MICs effectively antagonize the production of pneumolysin by both macrolidesusceptible and macrolide-resistant strains of the pneumococcus compatible with a role for these agents as adjuncts to p-lactams in the treatment of severe pneumococcal disease

Recommendations
Combination therapy is the way forward in patients hospitalized with moderate severity CAP. Amoxicillin plus macrolides like clarithromycin orally is the preferred regimen in these cases. In patients hypersensitive to penicillins oral doxycycline, levofoxacin or moxifoxacin is recommended. If oral administration is not possible IV amoxicillin or benzylpenicillin plus macrolide like clarithromycin IV is recommended. For hospitalized patients, the necessary change in antibiotics can be done only after the sputum culture test, till then empiric therapy is continued.

Empirical Antibiotic Choice for Adults Admitted in ICU with CAP

Macrolides may contribute to better outcomes in patients with severe sepsis due to CAP, as they have A synergistic antibacterial mechanism Atypical pathogen coverage An immunomodulatory effect If the specific pathogen has been isolated, then the choice is relatively straightforward.

 IDSA/ATS recommends a respiratory fuoroquinolone or a combination of b-lactam plus a macrolide for non-ICU inpatients (strong recommendation, Level 1 evidence for both regimens). IDSA/ATS recommends a b-lactam plus either azithromycin (Level II) or a respiratory fuoroquinolone (Level I) for ICU-admitted inpatients. BTS recommends an I.V. combination of a broadspectrum b-lactamase-stable antibiotic such as coamoxiclav plus a macrolide like clarithromycin. In patients allergic to penicillin, cephalosporins can be used in combination with clarithromycin.

Recommendations
Dual or combination therapy should be considered for severe CAP. Macrolides were found to be compatible as adjuncts to broad-spectrum -lactamase stable antibiotic in severe CAP. An intravenous combination of a broad-spectrum b-lactamase stable antibiotic such as coamoxiclav together with a macrolide such as clarithromycin may be preferred over fouroquinolones or their combinations in India considering the tuberculosis endemicity.

Timing of antibiotic
an important performance indicator in community-acquired pneumonia (CAP). The European guidelines recommend initiation of antibiotics within the first two hours of hospitalization, whereas the current Infectious Disease Society of America/ American Thoracic Society consensus guidelines advise the initiation of the first antibiotic dose in the emergency department.

 A prospective observational study conducted by Silber et al. reported that there was no reduction in the time to clinical stability with the administration of antibiotics within 4 hours Bruns et al. conducted a study to evaluate the effect of minimizing the TFAD on the early clinical outcome Time to first antibiotic dose was however, not associated with early clinical failure. Hence, it is not advisable to consider TFAD as a performance indicator

 Metersky et al. determined the frequency of medicare patients who are discharged with a diagnosis of pneumonia with atypical presentation. This could lead to diagnostic uncertainty and a resultant appropriate delay in antibiotic administration. A fnding from a retrospective study of 548 patients by Welker et al. reported that there was a reduction in the accuracy of the initial diagnosis of CAP when the required TFAD was changed from 8 hours to 4 hours.

Concerns with the Administration of Antibiotics within 4 Hours

Overdiagnosis/misdiagnosis of CAP, inappropriate utilization of antibiotics, no association to mortality, length of hospital stay, time to clinical stability and pressure on clinicians to start the first dose of antibiotic despite diagnostic uncertainty, were the concerns with the administration of antibiotics within 4 hours

Ideal Time to Switch from Intravenous to Oral Antibiotics

The choice and timing of switch from intravenous (I.V.) to oral route of antibiotic administration depends of several factors.They are as follows: Absence of any contraindications to oral administration Availability of microbiological information pinpointing etiology of the pathogen Clear evidence that the patient is responding well to initial therapy

 Rhew et al. investigated the effectiveness of early switch and early discharge strategies in CAP patients Ten prospective, interventional, CAP-specifc studies that evaluated length of stay were included in the study. Early switch and early discharge strategies may signifcantly and safely reduce the mean length of stay (LOS) when the recommended LOS is shorter than the actual length of stay

 Athanassa et al. conducted a meta-analysis There was no difference in the treatment success, mortality and recurrence of CAP between the groups Shorter duration of hospitalization was observed in the early switch group. It was concluded that early switch to oral antibiotics can be as effective as continuous intravenous treatment in patients with moderateto-severe CAP

 Ramirez and Bordon conducted a study to evaluate the clinical outcomes while switching from intravenous to oral therapy in hospitalized patients with CAP. He used four criteria Improvement of cough and shortness of breath Patient being afebrile for a minimum of 8 hours White blood cell count reaching normal levels Adequate oral intake and gastrointestinal tract absorption It was concluded that it was safe to switch from intravenous to oral therapy in hospitalized patients with CAP after the patient was clinically stable

Recommendations
The timing of antibiotic therapy depends on the severity of the CAP at the time of hospital admission. Severe cases of CAP require immediate institution of therapy, which must be adjusted after confrming microbiological etiology. Switch from intravenous antibiotics to oral treatment is recommended in case of observed improvement in symptoms, improved respiratory rate and oxygen saturations, patient being afebrile for >24 hours, hemodynamic stability, reduction in white blood cell count (if elevated earlier) and absence of nausea/ vomiting.

Atypical organisms
Streptococcus pneumoniae causes up to 70% of community-acquired pneumonia cases and atypical pathogens are responsible for 3040% of cases Legionella, Mycoplasma pneumoniae and Chlamydia pneumoniae are the atypical agents the other bacteria which cause communityacquired pneumonia besides Streptococcus pneumoniae are Haemophilus infuenzae, Staphylococcus aureus and Gram-negative bacilli.

 Zaki and Godal reported that Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionella pneumophila, Coxiella burnetii, adenovirus, and infuenza virus were the pathogens responsible for CAP. Streptococcus pneumoniae (22%) Haemophilus infuenzae (18%). Mycoplasma pneumoniae (5%) and Legionella pneumophila (5%) were the most common isolated bacteria.

 Appropriate oral medications should be used without compromising on the spectrum of cover of the bacterial fora by the antibiotic. In the absence of a culture/sensitivity report identifying an organism and an appropriate oral antibiotic, following oral replacements are suggested. Special care and intensive management is required in some special population of patients like those with severe CAP, sepsis, hypotension and respiratory failure.

 In an Indian study conducted by Udwadia et al, the most common atypical organism causing CAP were Chlamydia pneumoniae and Mycoplasma pneumoniae

 Therapy for pneumonia is empiric because specifc pathogens usually are not identifed at the time the treatment is initiated. C. pneumonia and Legionella spp. are intracellular organisms and M. pneumonia lacks a cell wall, plactams are not effective. In Legionell infection erythromycin is effective as demonstrated in some trials and in case of Mycoplasma pneumonia, erythromycin and tetracycline are effective. They also reduce symptom duration in Chlamydia pneumonia infection.

 Azithromycin and clarithromycin are very effective against Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella spp. and show better tolerability profle as compared to erythromycin. Doxycycline is also effective and is associated with fewer gastrointestinal side-effects. Fluoroquinolones are highly effective against Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella spp. The advantage of fuoroquinolones is once-daily dosing and excellent bioavailability

 The combination of rifampin plus a macrolide or a quinolone can be used for initial treatment in severely ill patients with Legionnaires disease

 Initiation of empirical therapy of CAP is known to have two important concerns: Delayed initiation of anti-TB treatment Resistance to fuoroquinolone Dooley et al. , Yoon et al. Conducted studies indicate that newer fuoroquinolones should be restricted in tuberculosis endemicity because of its potential to mask active tuberculosis and emerging drug-resistant tuberculosis.

Impact of Empirical Therapy of CAP on Treatment of M. tuberculosis Infections

Recommendations
Atypical coverage is a must in moderate-to-severely ill patients with pneumonia requiring hospitalization and intensive care unit care. The only acute respiratory tract infection in which delayed antibiotic treatment has been associated with increased risk of death is CAP, hence prompt and accurate diagnosis of CAP is important. Tuberculosis should always be considered while treating CAP in India. Therefore fuoroquinolones (levofoxacin and moxifoxacin) though effective in the treatment of CAP should be used cautiously. Newer macrolides are the drug of choice for the treatment of CAP. Viral pneumonias, especially infuenza and H1N1 should be considered in the clinical setting.