By- Dr. Armaan SinghBy- Dr. Armaan Singh

Community acquired pneumonia (CAP) Infection of the lung parenchyma in a person who is not hospitalized or living in

a long-term care facility for ≥ 2 weeks Hospital-acquired pneumonia (HAP)

Occurs 48 hours or more after admission, which was not incubating at the time of admission

Healthcare-associated pneumonia (HCAP) is defined as pneumonia that occurs in a non-hospitalized patient with extensive healthcare contact, as defined by one or more of the following: Intravenous therapy, wound care, or intravenous chemotherapy within the prior

30 days. Residence in a nursing home or other long-term care facility Hospitalization in an acute care hospital for two or more days within the prior 90

days Attendance at a hemodialysis clinic within the prior 30 days

Ventilator-associated pneumonia (VAP) Arises more than 48-72 hours after endotracheal intubation

• Common clinical features– Cough– Fever/Chills– Pleuritic chest pain– Dyspnea– Sputum production– Some may have GI symptoms including nausea,

vomiting and diarrhea• Physical Exam– Fever – Respiratory Rate >24– Tachycardia– Chest examination may reveal audible rales

A chest radiograph should be obtained in patients with suspected pneumonia when possible; a demonstrable infiltrate by chest radiograph or other imaging technique is required for the diagnosis of pneumonia, according to the 2007 consensus guidelines from the Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS)

The radiographic appearance of Pneumonia may include lobar consolidation, interstitial infiltrates, and/or cavitation.

• The 2007 IDSA/ATS consensus guidelines recommend for diagnostic testing:– For outpatients with CAP routine diagnostic tests

are optional.– Hospitalized patients should have CBC w/ diff,

blood cultures and sputum Gram stain and culture

– Patients with severe CAP requiring ICU admission should have blood cultures, urinary antigen tests, and sputum culture (either expectorated or endotracheal aspirate)

There are a Severity-of-illness scores that can help guide whether to admit or not but should not be used over clinical judgment of the patient and situation.

CURB-65 criteria (>2, more-intensive treatment) Confusion Urea 7 mmol/L (20 mg/dL) Increased respiratory rate >30 low blood pressure (SBP <90 or DBP <60)

Pneumonia Severity Index (PSI) uses demographics, the coexistence of co-

morbid illnesses findings on physical examination, vital signs and essential laboratory findings

American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388.

• No known risk factors for multidrug-resistant pathogens, early onset, and any disease severity– Streptococcus pneumoniae – MSSA– Haemophilus influenzae– Klebsiella pneumoniae– Enterobacter– Escherichia coli– Acinetobacter

• Has risk factors for Multidrug resistant pathogens– ESBL– Legionella pneumophila – MRSA– P aeruginosa *** consider especially with VAP

American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388.

American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388.

If patient does not improve on broad spectrum antibiotics may need to consider possibilities including Fungal Pneumonias, TB, PJP, Viral Pneumonias or even ARDs.

Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.

American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388.

Schuetz P, Christ-Crain M, Thomann R, et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA 2009; 302:1059.