Pneumonia

dr. Tjatur Winarsanto SpPD

 Definition
Pneumonia is an acute infection
of the parenchyma of the lung,
caused by bacteria, fungi, virus,
parasit etc.

Pneumonia may also be caused

by other factors including X-ray,
chemical, allergen
Classification
Classification of anatomy
Classification of pathogen
Classification of acquired environment
 Community Acquired
Pneumonia
Definition:
an 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. Clin Infect Dis 2000;31:347-82.

 Community Acquired
Pneumonia
Epidemiology:
4-5 million cases annually
~500,000 hospitalizations
~45,000 deaths
Mortality 2-30%
<1% for those not requiring
hospitalizatio

Bartlett. CID 1998;26:811-38.

 Community Acquired
Pneumonia

Epidemiology: (contd)
fewest cases in 18-24 yr group
probably highest incidence in <5 and
>65 yrs
mortality disproportionately high in
>65 yrs
Community Acquired
Pneumonia
Risk Factors for pneumonia
age
alcoholism
smoking
asthma
immunosuppression
institutionalization
COPD
PVD
dementia
ID Clinics 1998;12:723.
Am J Med 1994;96:313
 Community Acquired Pneumonia
Risk Factors (contd.)
Men: age and smoking, weight gain
RR 1.5 for age 50-54, 4.17 for > 70
Smoking, current: RR 1.5; heavy: 2.54;
Quit <10 yrs: 1.5
Weight gain >40 lbs since age 21
Women: smoking, BMI, weight gain
BMI 25-26.9, RR 1.53: BMI >30, RR 2.22
Exercise protective: RR 0.66 for most active
Alcohol consumption NOT associated with
increased risk in men or women
 Community Acquired
Pneumonia
Risk Factors in Patients Requiring
Hospitalization
older, unemployed, unmarried

common cold in the previous year

asthma, COPD; steroid or

bronchodilator use
Chronic disease

amount of smoking

alcohol NOT related to increased risk

Community Acquired
Pneumonia

Risk Factors for Mortality

age
bacteremia (for S. pneumoniae)
extent of radiographic changes
degree of immunosuppression
amount of alcohol
 Community Acquired
Pneumonia
Microbiology
Legionella spp.
S. pneumoniae: 20-60%

2-8%
H. influenzae: 3-10%
S. aureus: 3-5%
Chlamydia pneumoniae:
Gram negative
4-6%

bacilli: 3-5%
Mycoplasma pneumonaie:
Viruses: 2-13%
1-6%

40-60% - NO CAUSE IDENTIFIED

2-5% - TWO OR MORE CAUSES
Signs and Symptoms
Fever or hypothermia
Cough with or without sputum, hemoptysis
Pleuritic chest pain
Myalgia, malaise, fatigue
GI symptoms
Dyspnea
Rales, rhonchi, wheezing
Egophony, bronchial breath sounds
Dullness to percussion
Atypical Sxs in older patients
 Community Acquired
Pneumonia
Evaluation for CAP
History, PE, CXR

No infiltrate
manage/evaluate for alternate diagnosis
Infiltrate + clinical evidence of pneumonia

evaluate for admission

outpatient: hospitalize
empiric treatment with macrolide, doxycycline, FQ labs

medical ward:abx < 8 hrs ICU: abx < 8 hrs

no pathogen identified no pathogen identified

B-lactam + macrolide B-lactam + macrolide
FQ B-lactam + FQ
Community Acquired
Pneumonia
Laboratory Tests:
CXR
CBC with differential
BUN/Cr
glucose
liver enzymes
electrolytes
Gram stain/culture of sputum
pre-treatment blood cultures
oxygen saturation
 Community Acquired
Pneumonia
Diagnostic Evaluation
CXR
usually needed to establish diagnosis

prognostic indicator

rule out other disorders

may help in etiological diagnosis

Only 3% of outpatients and 28% of ER

patients with suggestive signs and symptoms
actually have pneumonia

J Chr Dis 1984;37:215-25

Community Acquired
Pneumonia
 Community Acquired
Pneumonia
PORT Publications:
Class I:
age < 50; 0/5 co-morbid conditions;
normal or mildly deranged VS; normal
mental status
Class II-V:
points assigned based on above, 5 co-
morbid conditions, 5 PE findings, 7 lab or
X-ray findings

Fine MJ. NEJM 1997;336:243-50

 Community Acquired
Pneumonia

Class I & II:

usually do not require hospitalization
Class III:
may require brief hospitalization
Class IV & V:
usually do require hospitalization

Fine MJ. NEJM 1997;336:243-50

Age:
Male Number of years
Female Number 10
Nursing home resident 10
Co-morbid illness
Neoplastic disease 30
Liver disease 20
CHF 10
Cerebrovascular disease 10
Renal disease 10
Physical Exam
Altered mental status 20
RR > 30 20
Systolic bp < 90 20
Temp <35oC or >40oC 15
Pulse >125 10
Lab/X-ray findings
Arterial pH <7.35 30
BUN > 30 20
Sodium < 130 20
Hematocrit <30% 10
Glucose > 250 10
PaO2 <60 10 Adeel A. Butt, MD
Pleural effusion 10
Risk Class Points Mortality

I Absence of 0.1%
predictors
II < 70 0.6%

III 71-90 2.8%

IV 91-130 8.2%

V > 130 29.2%

Adeel A. Butt, MD
 Community Acquired
Pneumonia
Severity of CAP
RR > 30
PaO2/FiO2 < 250, or PO2 < 60 on room air
Need for mechanical ventilation
Mulitlobar involvement
Hypotension
Need for vasopressors
Oliguria
Altered mental status
Community Acquired
Pneumonia
Management
Rational use of microbiology
laboratory
Pathogen directed antimicrobial

therapy whenever possible

Prompt initiation of therapy

Decision to hospitalize based on

prognostic criteria
Empiric therapy (1)
Outpatient<60 years A new generation
old and no comorbid macrolide
diseases A beta-lactam: the
Common pathogens: first generation
S pneumoniaes, cephlosporin
M pneumoniae, A fluoroquinolone
C pneumoniae,
H influenzae and
viruses
Empiric therapy (2)
Outpatient>65 years A fluoroquinolone
old or having comorbid A beta-lactam / beta-
diseases or antibiotic lactamase inhibitor
therapy within last 3 The second generation
months cephalosporin
Common pathogens: S or combination of a
pneumoniae(drug- macrolide
resistant), M
pneumoniae, C
pneumoniae, H
pneumoniae, H
influenzae, Viruses,
Gram-negative bacilli
and S aureus
Empiric therapy (3)
Inpatient : Not The second or third
severely ill. generation
Common cephalosporin plus
pathogen:S A macrolide
pneumoniae, H A beta-
influenzae, lactam/betalactamas
polymicrobial, e inhibitor.
Anaerobes, S aureus, A newer
C pneumoniae, fluoroquinolone
Gram-negative
bacilli.
Empiric therapy (4)
Inpatient severely ill The second or third
Common pathogens:S generation
pneumoniae, Gram- cephalosporin plus A
negative bacilli, M macrolide
pneumoniae, S aureus A beta-
and viruses lactam/betalactamase
inhibitor.
A newer
fluoroquinolone
Vancomycin
Empiric therapy (5)
Patients in ICU without The second or third
Pneudomonas generation
aeruginosa infection cephalosporin plus A
macrolide
A beta-
lactam/betalactamase
inhibitor.
A newer
fluoroquinolone
Vancomycin
Empiric therapy (6)
Patients in ICU with A antipneudomonas
Pneudomonas aeruginosa beta-
aeruginosa infection lactam/betalactamas
e inhibitor plus
fluoroquinolone
 Community Acquired
Pneumonia
Empiric Treatment
Outpatient:
macrolide
doxycycline
Fluoroquinolone
NOT IN ANY SPECIFIC ORDER

IDSA guidelines: Clin Infect Dis 2000;31:347-82

 Community Acquired
Pneumonia
Empiric Treatment
Patients in General Medical Ward:
3GC + macrolide
B/B-I + macrolide OR B/B-I + FQ
FQ alone

IDSA guidelines: Clin Infect Dis 2000;31:347-82

 Community Acquired
Pneumonia
Empiric Treatment
Patients in ICU:
3GC + macrolide
3GC + FQ
B/B-I + macrolide
B/B-I + FQ
IDSA guidelines: Clin Infect Dis 2000;31:347-82
 Deviation From Guidelines
Not many Studies done to assess this
Prospective study in a tertiary care hospital
Adherence to ATS guidelines was 88%
No significant difference in mortality or LOS
Mortality in Class V patients higher in
nonadherent treatments
Adherence to ATS associated with
decreased mortality
Mortality in Class I, II & III was ZERO.

Menendez. Chest 2002;122:612-617.

 Community Acquired
Pneumonia
Concerns about multiply resistant
pneumococcus:
25-40% overall penicillin resistance
intermediate resistance of questionable
significance
high level resistance associated with in
vitro macrolide and 3GC resistance
clinical failures not really documented

IDSA guidelines: Clin Infect Dis 2000;31:347-82

 Community Acquired
Pneumonia
Macrolide Resistance
Increased drug efflux Ribosomal methylase
coded by mefE coded by ermAM
susceptible to resistant to
clindamycin clindamycin
most cases in US mostly in Europe
may be overcome by not overcome by
achievable levels of standard doses
macrolides
 Community Acquired
Pneumonia
(Newer)Fluoroquinolones
Active against 98% of resistant
pneumococcus
Resistance has begun to increase

Chen DK. NEJM 1999;341:233-9

Ho PL. Antimicrob Agents Chemother 1999;43:1310-3.
Adeel A. Butt, MD
Wise R. Lancet 1996;348:1660
 FQ Resistance
4 cases from Canada with
pneumococcal pneumonia
1 died
2 developed resistance while on Rx
2 had resistant bugs to begin with
Authors suggested that recent FQ use
should be a contra-indication to using
a FQ for empiric treatment of CAP
Davidson. NEJM 2002;346:747-750
 FQ Resistance
In a case control study,
colonization or infection by FQ
resistant pneumococci was
independently associated with:
COPD
Nosocomial origin of bacteremia
Residence in a nursing home
Prior exposure to FQ
Ho. Clin Infect Dis 2001;32:701-707.
 Other Concerns
Delay in diagnosis and treatment of TB
Johns Hopkins study
33 patients with TB
16 received FQ for empiric Rx of CAP
TB treatment initiation time:
21 days in the FQ group
5 days in the non-FQ group

Dooley. Clin Infect Dis 2002;34:1607-1612.

 Community Acquired
Pneumonia
Choice of Initial Antimicrobial
Regimen
Second generation generation
cephalosporin plus a macrolide, non-
pseudomonal third generation
cephalosporin plus a macrolide, or a
fluoroquinolone alone were all
associated with a lower 30 day
mortality in patients with CAP.
Gleason. Arch Int Med 1999;159:2562-72. Adeel A. Butt, MD
 Community Acquired
Pneumonia

Macrolide Use and LOS:

Patients who received macrolides
within first 24 hours of admission had
a shorter LOS (2.8 days vs. 5.3 days)

Stahl. Arch Int Med 1999;159:2576-80.

 Community Acquired
Pneumonia

Azithromycin vs. Cefuroxime + Erythromycin

prospective, randomized trial

145 patients

Clinical cure 91% in each group.

4 S. pneumoniae strains with MIC 0.064-2

ug/ml: 1/1 in azithromycin group cured,

2/3 in cef/erythro group cured

Vergis. Arch Int Med 2000;160:1294-1300.

 Community Acquired
Pneumonia
IV followed by Oral Azithromycin
615 patients: Azithromycin given to 414
202 in a comparison trial with ATS
recommended cefuroxime +
erythromycin
77% vs 74% clinical cure or
improvement
Microbiological cure rates similar or
better in azithromycin group
 Cost-Effectiveness of IV-Oral
Switch Therapy

Azithromycin Cefuroxime +
Erythro
Mean cost - $4,104
Mean cost - $4,578
CE Ratio per
expected cure - CE Ratio per
$5,265 expected cure - $
6,145

Paladino. Chest Oct 2002;122:1271-1279.

 Clarithromycin ER

Head-to-head comparison with FQ

Vs. Levofloxacin1
252 patients
Clinical cure 88% in Clarithro; 86% levo
Radiographic success 95% vs. 88%
Vs. Trovafloxacin2
Clinical cure 87% vs. 95%
Radiographic success 95% vs. 95%
 Community Acquired
Pneumonia

Report from the DRSP Therapeutic Working

Group
Use a macrolide or doxycycline for outpatients

Beta-lactam for inpatient

Reserve FQ for:

if above fails
if allergic to any of the above
documented high level resistance (pen MIC >4)
 Summary

We have some really good drugs available

Use antibiotics judiciously
Do consider local and national resistance
patterns
For Class I, II and possibly III, first line
recommendations are a macrolide or doxycycline
Revise therapy based on clinical and
microbiological response
Consider prior exposure when choosing an Abx