PHILIPPINE CLINICAL PRACTICE GUIDELINES ON THE

DIAGNOSIS, EMPIRIC MANAGEMENT, AND PREVENTION REPORT

OF COMMUNITY-ACQUIRED PNEUMONIA (CAP)
IN IMMUNOCOMPETENT ADULTS 2010 AND 2016 UPDATE
OBJECTIVES
1. To review the criteria for the Clinical Diagnosis of CAP
2. To discuss the role of Chest Radiography in the diagnosis of CAP
3. To discuss risk stratification of CAP patients and the appropriate
site of care.
4. To review the indications and roles of microbiologic studies in the
diagnosis of CAP.
5. To discuss treatment strategies available in managing CAP
6. To enumerate approaches in the prevention of CAP
7. To discuss ethical principles appropriate for the management of
CAP
OUTLINE
1. Clinical Diagnosis
2. Chest Radiography
3. Site of Care Decisions
4. Microbiologic studies
5. Treatment
6. Prevention
CASE
58 year old man complaining of cough for 1 week duration. Cough
was described to be productive, tenacious yellowish sputum, continuous
throughout the day, but not distressing.
Associated with undocumented fever, mild shortness of breath and easy
fatiguability.
No other symptoms like colds, dyspnea, lightheadedness, throat
itchiness, frequent sneezing, anorexia, weight loss and night sweats.
Self medicated with Lagundi tablets TID without apparent relief.
Persistence of symptoms prompted consult.
PAST MEDICAL HISTORY
Hypertension: Negative
Diabetes: Negative
Kidney Disease: Negative
Bronchial Asthma: Negative
Tuberculosis: Negative
Other Diseases: Negative
Hospitalizations: Negative
Surgeries: Negative
Allergies: Negative
Immunizations: Negative
FAMILY MEDICAL HISTORY
Hypertension: Negative
Diabetes: Negative
Heart Disease Negative
Stroke: Negative
Kidney Disease: Negative
Thyroid Disorders: Negative
Bronchial Asthma: Negative
Tuberculosis: Negative
Skin Disease: Negative
Cancer: Negative
Others: Negative for any family member with the same
symptoms.
PERSONAL AND SOCIAL HISTORY
Tobacco Use in Pack Years 10
Alcohol intake 1L beer 2x/week
Illicit drug use Negative
Exercises None
Daily water intake 2 L/day
Coffee/ tea Negative
Carbonated drinks: Seldom
Skipping meals Yes, 3x / week
Binge Eating Occasional
Frequent NSAID Use No
Food Preference None
Occupation Helper
 PHYSICAL EXAM
General Survey Conscious, coherent, cooperative not in distress
VS 120/80, 18, 69, 36.7 C
HEENT
Conjunctivae Pink, no exudates
Sclerae Anicteric, no hemorrhages
Pupils Pupils equally round, reactive to light and accommodation
Nasal turbinates and Pink, moist
nasal septum
Tonsils and Pink, no petechiae
Pharyngeal walls
Neck Supple, no CLAD
 PHYSICAL EXAM
Chest/Lungs
Inspection Symmetrical Chest expansion, No retractions
Auscultation Coarse crackles on left lung base.
Heart
Inspection Adynamic precordium
Auscultation Regular, regular rhythm, no murmurs
Abdomen
Inspection Globular, no mass and lesions
Auscultation Normoactive bowel sounds
Palpation Soft, non-tender, negative murphy sign
Extremities No gross deformities, full equal pulses, CRT< 2secs
Other Exams
SALIENT FEATURES
Acute cough, fever and shortness of breath
smoker 10 pack years
Symmetrical Chest expansion, No retractions, Coarse crackles on left
lung base.
ASSESSMENT
Community Acquired Pneumonia – Low risk
PLANS
Start
Co-amoxiclav 1g/tab, 1 tab BID for 7 days
Paracetamol 500 mg/tab, 1 tab q4h PRN for fever
N-acetylcysteine 600 mg/tab, dissolve 1 tab in 200 ml glass of water
and drink ODHS
Cough etiquette
Increase oral fluid intake
Watch out for increasing shortness of breath, lightheadedness, chest
pain, ang high grade fever.
Follow up after 3 days.
Advised.
 CAP
acquired in the community within 24 hours to
less than 2 weeks.
presents with an acute cough
Abnormal vital signs
tachypnea (respiratory rate >20 breaths per
minute),
tachycardia (cardiac rate >100/minute)
fever (temperature >37.8ºC)

At least one abnormal chest finding of

diminished breath sounds, rhonchi, crackles, or
wheeze.
 CHEST RADIOGRAPHY
The chest x-ray is essential in the
diagnosis of CAP, assessing
severity, differentiating pneumonia
from other conditions, and in
prognostication. (Grade A)
A new parenchymal infiltrate in
the chest radiograph remains the
reference diagnostic standard for
pneumonia. A chest x-ray should be
done in patients suspected to have
CAP to confirm the diagnosis.
Standing posteroanterior and
lateral views of the chest in full
inspiration comprise the best
radiologic evaluation of a patient
suspected of having pneumonia.
(Grade A)
 CHEST RADIOGRAPHY

However, in settings with limited resources, a chest

x-ray may not be routinely done in patients strongly
suspected to have CAP with the following
conditions:
• Healthy individuals or those with stable co-morbid
conditions
• Normal vital signs and physical examination findings,
and
• Reliable follow-up can be ensured.
“RADIOGRAPHIC LAG PHASE”.
A “normal” chest radiograph connotes an absence of
any overt parenchymal lesion. It is possible to have a
“normal chest” in a background of significant
symptomatology specifically in an early phase of
pneumonia, that is referred to as a “radiographic lag
phase”.
For patients who are hospitalized for suspected
pneumonia but have initial negative chest
radiography findings, it may be reasonable to treat
their condition presumptively with antibiotics and
repeat the imaging in 24 to 48 hours.
SHOULD A CHEST RADIOGRAPH BE
REPEATED ROUTINELY?
Routine follow-up chest radiograph is not
needed for patients with low-risk CAP who are
clinically improving. (Grade B)
However, a repeat radiograph is recommended
during a follow-up office visit, approximately 4
to 6 weeks after hospital discharge. The repeat
radiograph will establish a new radiographic
baseline and to exclude the possibility of
malignancy associated with CAP, particularly in
older smokers.
 RISK STRATIFICATION
Low-risk CAP
Presence of:
Stable vital signs;
RR <30 breaths/min
PR <125 beats/min
Temp >36 C or <40 C
SBP >90 mmHg
DBP >60 mmHg mmHg
No altered mental state of
acute onset
No suspected aspiration
No or stable comorbid
conditions
Chest X-ray:
• localized infiltrates
• no evidence of pleural
effusion or abscess
Moderate-risk CAP High-risk CAP
Any of the following: Any of the criteria under
moderate- risk CAP category
plus
Unstable vital signs: Severe Sepsis and Septic Shock
RR >30 breaths/min
PR >125 beats/min shock
Temp >40 C or <36 C
SBP <90 mmHg
DBP <60 mmHg
Altered mental state of acute Need for mechanical
onset ventilation
Suspected aspiration
Decompensated co-morbid
condition
Chest X-ray:
• multilobar infiltrates
• pleural effusion, abscess
WHERE TO TREAT?
MICROBIOLOGIC STUDIES
Low Risk Cap Moderate Risk Cap High Risk CAP
Blood cultures Blood cultures
Gram stain and Gram stain and culture with antibiotic sensitivity tests
culture with antibiotic
sensitivity tests
• When possible, tests to document the presence of
Optional. (Grade B) Legionella pneumophila are recommended in hospitalized
patients with CAP. •Invasive procedures are options for
non-resolving pneumonia, immunocompromised patients
and patients in whom no adequate
respiratory specimens can be sent despite sputum
induction and routine diagnostic testing. (Grade B)
 POTENTIAL PATHOGENS
Low Risk Cap Moderate Risk Cap High Risk CAP

The most common Same as Low Risk Same as Moderate

etiologic agents are CAP risk CAP
bacterial
• S. Pneumoniae Plus Plus
• H. influenzae
• M. Pneumoniae L. Pneumophila Staphylococcus
• M. Catarhallis Anaerobes aureus
• C. pneumoniae (among those with Pseudomonas
risk of aspiration) aeruginosa
• Enteric Gram-
negative bacilli
( among those with
co-morbid illness)
ANTIBIOGRAM
WHEN TO SUSPECT FOR L. PNEUMOPHILIA

https://www.cdc.gov/legionella/downloads/fs-legionnaires.pdf
 L. PNEUMOPHILA

Among the atypical pathogens, L. pneumophila causes

severe pneumonia with the majority of patients requiring
intensive care. The associated case fatality rate is 5 to
30%. The greatest risk of death occurs in the elderly and
immunocompromised patients and delay in treatment is
associated with increased mortality. Thus, for hospitalized
patients with CAP, it is recommended that the presence
of L. pneumophila be documented through urine
antigen test (UAT) or direct fluorescent antigen test
(DFA) of respiratory secretions.
Diagnostic testing is recommended when the
results are likely to change the standard
empiric antibiotic management. The cost
effectiveness of the diagnostic tests should also
be taken into consideration.
 TREATMENT
Low Risk CAP
Without comorbid illness With stable comorbid illness
Amoxicillin1g TID OR B-lactam/B-lactamase inibitor
Extended macrolides combination
Azithromycin 500 mg OD Co-amoxiclav 1 g BID OR
Clarithromycin 500 mg BID Sultamicillin 750 BID OR
2nd Gen oral cephalosporins
Cefuroxime axetil 500 mg BID
With or without
Extended macrolides
Azithromycin 500 mg OD
Clarithromycin 500 mg BID
 Moderate Risk CAP – No risk for P. Aeruginosa
IV non- PLUS either
pseudomonal B- IV extended or IV respiratory
lactam (BLIC, macrolides fluoroquinolones
Cephalosporins)
Ceftriaxone 2g Azithromycin Levofloxacin 500
OD dihydrate 500 mg mg OD IV
OD IV Or Moxifloxacin
Or 400 mg OD IV

Ertapenem 1 gm
OD
ASPIRATION PNEUMONIA

If a regimen containing Ampicillin-Sulbactam 3g

q6h IV and or Moxifloxacin 400 mg OD PO is
used, there is no need to add another antibiotic
for additional coverage.
If another combination is used, may add
Clindamycin 600 mg q8h IV to the regimen to
cover microaerophilic streptococci.
HIGH RISK CAP
1. No Risk for P. Aeruginosa
2. Risk for P. Aeruginosa
3. Suspected MRSA
 High Risk CAP – NO RISK for P. Aeruginosa
IV non- PLUS either
pseudomonal B- extended or respiratory
lactam (BLIC, macrolides fluoroquinolones
Cephalosporins) (PO)
Ampicilin- Azithromycin 500 Levofloxacin 500
Sulbactam 1.5 gm mg OD PO mg OD PO
q6h IV Clarithromycin 500 Or Moxifloxacin
Or mg BID PO 400 mg OD PO

Cefuroxime 1.5 g
q 8h IV
Ceftriaxone 2g
OD
 High Risk CAP – RISK for P. Aeruginosa
IV PLUS
antipneumococcal IV extended or aminoglycoside
pseudomonal B- macrolides
lactam (BLIC,
Cephalosporins or
carbapenem)
Piperacillin- Azithromycin Gentamicin
tazobactam 4.5 dihydrate 500 mg 3mg/kg OD or
gm q6h IV OD IV Amikacin 15
Or mg/kg OD
Cefipime 2 gm
q8-12h
OR Meropenem 1
gm q8h
 High Risk CAP – RISK for P. Aeruginosa
IV PLUS
antipneumococcal IV Ciprofloxacin/ high dose levofloxacin
pseudomonal B-
lactam (BLIC,
Cephalosporins or
carbapenem)
Piperacillin- Levofloxacin 750 mg OD IV
tazobactam 4.5
gm q6h IV OR
Or
Cefipime 2 gm Ciprofloxacin 400 mg q8-12h IV
q8-12h
OR Meropenem 1
gm q8h
IF MRSA PNEUMONIA IS SUSPECTED, ADD

Vancomycin 15 mg/ kg q8-12h

OR
Linezolid 600 mg q12h IV
OR
Clindamycin 600 mg q8h IV
WHEN DO YOU START ANTI-MRSA?
1. Severe CAP: any of the following
a) Requirement for intensive care unit admission
b) Necrotizing or cavitary infiltrates
c) Empyema
Empirical therapy for MRSA is recommended
pending sputum and/or blood culture results. If
culture isolates revealed absence of MRSA,
may DC anti-MRSA Tx.
2. In patients with active influenza or with
history of influenza infection within 2 weeks
of development of CAP
RESPONSE TO THERAPY

Monitor: Temp, RR, HR, BP, Sensorium, O2

Sat, and inspired Oxygen concentration
Response to therapy: within 24- 72 hours
Failure to improve – repeat chest radiograph
Follow up cultures of blood and sputum are not
indicated for patients who are responding to
treatment.
STREAMLINE THERAPY
1. Resolution of fever > 24 hours
2. Less cough and resolution of respiratory distress (Normal
RR)
3. Etiologic agent is not a high-risk (virulent/ resistant)
4. No unstable comorbid conditions or life-threatening
complication such as MI, CHF, Complete heart block,
New AF, SVT etc.
5. No sign of Organ Dysfunction: hypotension, acute mental
changes, BUN:Crea >10:1, hypoxemia and metabolic
acidosis
6. Patient is clinically hydrated, taking oral fluids and able
to take oral medications.
 DURATION OF TREATMENT
Low Risk Moderate Risk High Risk
5-7 days 7-10 days

Gram neg, S. aureus, P. aeruginosa with Assoc

bacteremia- 28 days

Mycoplasma and Chlamydophila 10-14 days

Legionella- 14-21 days

FOR PATIENTS NOT IMPROVING

1. Review Clinical History, PE, and Results,

Reassess for possible resistance, Presence of M.
tuberculosis, viruses, parasites or fungi.
2. Follow up Chest Radiograph: pneumothorax,
cavitation, and extension, pleural effusion,
pulmonary edema, ARDS.
3. CT Scan: For undelying mass, bronchiectasis,
loculation, pulmonary abcess.
WHEN TO DISCHARGE?
1. No unstable co-morbids
2. Clinically stable and Oral therapy is
initiated
3. Clinically improving: no need for repeat
chest radiograph
4. Repeat chest radiograph may be repeated
after 4-6 weeks to establish a new
radiographic baseline and to exclude the
possibility of malignancy associated with
CAP, particularly in older smokers.
SYMPTOM IMPROVEMENT

1 week: fever should have resolved

4 weeks: chest pain and sputum production
should have substantially reduced
6 weeks: cough and breathlessness should
have substantially reduced
3 months: most symptoms should have
resolved but fatigued may still be present
6 months: most people will fell back to
normal
PREVENTION
Influenza vaccination is recommended for the prevention
of CAP. (Grade A)
Pneumococcal vaccination is recommended for the
prevention of invasive pneumococcal disease (IPD) in
adults. (Grade A)
the recommended age in the Philippines is 60 years
of age and older.
Smoking cessation is recommended for all persons with
CAP whosmoke. (Grade A)
Cigarette smoking, both active and passive, is a
recognized independent risk factor for CAP.
ETHICAL CONCEPTS

Autonomy
Beneficence
Non-maleficence
Justice