Approach to

Community Acquired Pneumonia

Dr. Sajin Sunny Mathew
PG Resident
Community Acquired Pneumonia
 Historical Background:

1. Described as early as 400 BC by Hippocrates.

1. Described by William Osler in 1918 linking the infection

to a bacterial cause (“Captain of the men of death” –
Spanish flu of 1918)
Community Acquired Pneumonia
 Definition:

1. Inflammation & consolidation of lung tissue due to an

infectious agent.
2. Clinical definition is 2 or more of the following
symptoms/physical findings:
productive cough, purulent sputum, dyspnea, rigors
or chills, pleuritic chest pain,
in conjunction with
a new opacity on chest radiograph.
Community Acquired Pneumonia
 CAP has been defined as: (BTS Guidelines 2009)
1. Symptoms of an acute lower respiratory tract illness
(cough and at least one other lower respiratory tract
symptom).
2. New focal chest signs on examination.
3. At least one systemic feature (either a symptom
complex of sweating, fevers, shivers, aches and pains
and/or temperature of 38 0C or more).
4. No other explanation for the illness, which is treated as
CAP with antibiotics.
Community Acquired Pneumonia
 Clinical Manifestations:
1. Cough
- non productive or productive
2. Fever with chills
3. Pleuritic Chest Pain +/-
4. Non respiratory symptoms
- headache
- Nausea/vomting
- myalgia/arthralgia
- abdominal pain and diarrhea.
Community Acquired Pneumonia
 History:
1. Environmental:
- Legionella pneumophila
Contaminated air conditioning/contaminated potable water
in hospital
- Coccidiodes immitis
After windstorm in contaminated area
- Histoplasma capsulatum
Bat caves, excavation in endemic areas
Community Acquired Pneumonia
 History:
2. Animal Contact
- Coxiella burnetii
Infected cats, dogs, cattle, sheep.
- C. psittaci
Infected turkeys, chickens, ducks.
- Hantavirus
Mouse droppings.
Community Acquired Pneumonia
 History:
3. Travel History
- Burkholderia pseudomallei
South east Asian countries
- M.Tuberculsosis
Asia, India, Africa.
- Legionella species.
Travel almost anywhere.
Community Acquired Pneumonia
 History:
4. Occupational History:

- M. tuberculosis
Healthcare worker
- S. pneumoniae
Welding
Community Acquired Pneumonia
 History:
5. Host Factors
- Diabetic Ketoacidosis:
- S. pneumoniae
- Staph. Aureus
- Alcoholism
- S. pneumoniae
- Klebsiella pneumoniae
- S. aureus
Community Acquired Pneumonia
 History:
5. Host Factors
- COPD:
- S. pneumoniae
- Haemophilus influenza
- Moraxella catarrhalis
- Pseudomona aeruginosa
- Solid organ transplant (post 3 months):
- S. pneumoniae
- H. influenza
- Legionella spp.
- Pneumocysis jiroveci
Typical pathogens
 Streptococus pneumoniae
 Staph.aureus
 H. Influenaze
 Klebsella pneumoniae
 Morexella catarrhalis
 Pseudomonas aeroginosa
Classical Syptoms are Dominant
1. Sudden in Onset
2. High Grade Fever
3. Intense Chills
4. Productive Cough
5. Pleuritic Chest Pain ( Occasionally)
6. CBC Shows Leukocytosis with Neutrophillic Predominance
Atypical pathogens
 Mycoplasma Pneumoniae
 Chlamydia Pneumophila
 Legionella
Systemic Manifestations are Dominant
1. Generalized Myalgia
2. Muscle Ache
3. Arthralgia
4. Diarhhea
5. Nausea & Vomiting
6. Abdominal Pain
7. Gradual in Onset
8. Low Grade Fever
9. Dry Cough
10. CBC Shows Absent Leukocytosis
11. Do not respond to common Antibiotics
12. Do not form Lobar Consolidations rather restricted to Small Areas
Clinical Presentation
On General Physical Examination
 Hyperthermia
 Tachycardia
 Tachypnea
 Use of Accessory Muscles
 Central Cyanosis
 Altered Mental Status
Clinical Presentation
On Respiratory System Examination:
 Tracheal Deviation
 Decrease Chest Movements on Effected Side
 Increased tactile vocal fremitus
 Dull Percussion
 Coarse Crackles
 Reduced Breath Sounds
 Bronchial Breathing
 Pleural friction rub in 10% cases
Clinical Presentation
Physical findings:
Periodontal disease and foul smelling sputum
- Anaerobes
Bullous myringitis
- Mycoplasma pneumoniae
Erythema multiformae
- M. pneumonia
Ecthyma gangrenosum
- P. aeruginosa
- Serratia marcescens
Cutaneous nodules
- Nocardia spp.
Radiographic Diagnosis
1. All patients admitted to hospital with suspected CAP
should have a chest radiograph performed as soon as
possible to confirm or refute the diagnosis.

2. In 20% of patients with symptoms compatible with

pneumonia and a plain CXR read as normal, a CT Chest
will be compatible with pneumonia.
Radiographic Diagnosis
1. Asymmetric increase in lung
opacification with air
bronchogram
2. Presence of silhouette sign.
3. If only AP view available,
increased attenuation of cardiac
shadow.
4. For radiographs with widespread
airway disease, more asymmetric
or multifocal distribution of
opacification.
Radiographic Diagnosis
 Resolution of chest radiograph may lag behid clinical cure
during follow up and upto 50% of patients may not show
complete radiological resolution at 4 weeks

 A chest radiograph should be arranged after about 6

weeks for all those patients who have persistence of
symptoms or physical signs or who are at higher risk of
underlying malignancy (especially smokers and those aged
>50 years) whether or not they have been admitted to
hospital.
Diagnostic Work up
 Further investigations which may include bronchoscopy
should be considered in patients with persisting signs,
symptoms and radiological abnormalities at around 6
weeks after completing treatment.
Diagnostic Work up
 General investigations are not necessary for the majority
of patients with CAP who are managed in the community.
 Pulse oximeters allow for simple assessment of
oxygenation.
All patients should have the following tests
performed on admission: (BTS guidelines 2009)
1. Oxygenation saturations and, where necessary, arterial
blood gases in accordance with the BTS guideline for
emergency oxygen use in adult patients.
2. Chest radiograph to allow accurate diagnosis.
3. Urea and electrolytes to inform severity assessment.
4. C-reactive protein to aid diagnosis and as a baseline
measure. (not mandatory)
5. Full blood count. (Haemogram)
6. Liver function tests.
For patients managed in the community,
microbiological investigations are not
recommended routinely
 Examination of sputum should be considered for patients
who do not respond to empirical antibiotic therapy.

 Examination of sputum for Mycobacterium tuberculosis

should be considered for patients with a persistent
productive cough, especially if malaise, weight loss or
night sweats, or risk factors for tuberculosis (eg, ethnic
origin, social deprivation, elderly) are present.
Blood cultures
 Blood cultures are recommended for all patients with
moderate and high severity CAP, preferably before
antibiotic therapy is commenced.

 If a diagnosis of CAP has been definitely confirmed and a

patient has low severity pneumonia with no comorbid
disease, blood cultures may be omitted.
Sputum cultures
 Sputum samples should be sent for culture and sensitivity
tests from patients with CAP of moderate severity who
are able to expectorate purulent samples and have not
received prior antibiotic therapy.

 Sputum cultures for Legionella spp should always be

attempted for patients who are legionella urine antigen
positive in order to provide isolates for epidemiological
typing and comparison with isolates from putative
environmental sources.
Diagnostic Work up
 DEFINITE:
1. Blood culture positive for a pathogen
2. Pleural fluid positive for a pathogen
3. Presence of pneumocystis jiroveci in induced sputum or
BAL.
4. 4 fold rise in Ab titre to Mycoplasma, Chlamydia,
Coxiella for which serology testing available
5. Isolation of Legionella or 4 fold rise in Ab titre or
positive urinary antigen test for Legionella
6. Positive direct fluorescence test for Legionella
Diagnostic Work up
 DEFINITE:
7. Serum or urine positive for Streptococcus pneumoniae
antigen
8. Isolation of M. tuberculosis from sputum.
9. Amplification of nucleic acid Legionella from a
nasopharygeal swab specimen.
Diagnostic Work up
 PROBABLE:

1. Heavy growth of predominant bacterial pathogen on

sputum culture or gram stain.
2. Amplification of nucleic acid of Mycoplasma, Chlamydia,
influenza viruses A and B, parainfluenzae, RSV from
nasopharyngeal swab
3. Aspiration pneumonia as diagnosed on clinical grounds.
Admission decision
 Clinical judgement is essential in disease severity
assessment.
 The stability of any comorbid illness and a patient’s social
circumstances should be considered when assessing
disease severity.
 For all patients, clinical judgement supported by the
CURB65 score should be applied when deciding whether
to treat at home or refer to hospital.
Admission decision : CURB 65
Admission decision : PSI SCORE
Admission decision : PSI SCORE
Admission decision
Admission decision : ATS CRITERIA
THANK YOU