Community Acquired

Pneumonia:
2016 Philippine Clinical
Practice Guidelines

Cancino, Rafael S.
Mina, Diego Nathaniel D.
IM 251
Rationale

❖ Community-acquired Pneumonia is the leading

cause of death from an infectious etiology, and
sixth leading cause of death overall, worldwide
❖ New organisms have been discovered over time,
with an increase in resistance among these
pathogens
➢ Misuse and abuse of antimicrobial drugs
contribute to this rise in antimicrobial resistance
➢ Previous CPG on CAP was published in 2010
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Rationale

❖ Thus, it is necessary to publish a new standardized

approach based on best available evidences
➢ Regional differences, causative agents,
antibiotic resistance rates, drug licensing,
healthcare structure and available resources
are all considered in establishing the current
guidelines

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Sample Case

General Data
❖ CP
❖ 35/M
❖ Carpenter
❖ From Lemery, Batangas
❖ Chief complaint: cough
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Sample Case

History of Present Illness:

9 days PTC - had intermittent fever (low-grade,

undocumented), with cough and colds productive of whitish
phlegm. Took paracetamol for 2 days with relief of fever.

7 days PTC - fever and colds abated but cough persisted,

still productive of whitish phlegm. Started taking unrecalled
“cough syrup” with slight relief of cough

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Sample Case

History of Present Illness:

4 days PTC - fever recurred with temperatures ranging from

38-39°C. Self-medicated with paracetamol, with some
relief. Noted increase of yellowish-greenish phlegm

1 day PTC - still with fever and cough, developed chest pain
on deep breathing, and felt dizziness on standing. Went to
PGH ER the next day

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Sample Case

Past Medical History: No known history of asthma, allergies,

PTB, previous pneumonia, diabetes mellitus, hypertension,
past hospitalizations

Personal and Social History: No history of travel abroad, has

been smoking 4 sticks twice a week for the past 10 years (12
pack-years), drinks 3 to 4 beers once or twice a week

Family Medical History: Father died from complications of

stroke and hypertension 3 years ago at the age of 50
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Sample Case

Physical Examination
General Survey: alert, awake, oriented, not in
cardiorespiratory distress

Vital Signs: BP 90/60 mmHg, HR 130 bpm, RR 28 cpm,

T 40°C BMI 20 O2Sat 97%

Head and Neck: pink palpebral conjunctivae, anicteric

sclerae, no lymphadenopathies, no neck vein engorgement
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Sample Case

Physical Examination
Chest and Lungs: equal chest expansion, (+) decreased vocal
fremitus with dullness on percussion at left basal area, (+)
coarse crackles on left mid-to-basal area with decreased
breath sounds at the left basal area

Heart: tachycardic, regular rhythm, good S1 and S2, no S3

and S4, no heaves, no thrills, no murmurs appreciated (due
to coarse crackles), apex beat and PMI at 5th ICS LMCL
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Sample Case

Physical Examination
Abdomen: soft, flat, nontender abdomen, normoactive
bowel sounds, no organomegaly or masses

Extremities: pink nail beds, full and equal pulses, no

cyanosis, clubbing or edema

Neurological Exam: full sensorium, no focal neurological

deficits
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Sample Case

Chest X-ray: left lower zone is uniformly white, with a

meniscus sign; left heart border and hemidiaphragm are
obscured with blunting of left costophrenic angle

Complete Blood Count: Hgb 12.5; Hct 0.38; WBC 12,000

(increased; predominantly neutrophils) (Seg=90, Lym=14);
platelets 302

Chemistry: Creatinine 91 μmol/L; BUN 6.4 mmol/L

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Algorithm for the diagnosis and disposition of CAP in adults.

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 Diagnostic Criteria - Low Risk CAP

❖ Stable Vital Signs: ❖ No acute decrease in sensorium

➢ RR < 30 cpm ❖ No suspicion of aspiration
➢ PR < 125 bpm ❖ No or stable comorbid conditions
➢ SBP > 90 mmHg ❖ Chest X-ray shows localized
➢ DBP > 60 mmHg infiltrates and no evidence of
➢ Temp > 36 or < 40 C pleural effusion

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 Diagnostic Criteria - Moderate Risk CAP

❖ Unstable Vital Signs, ❖ Acute decrease in sensorium

indicated by any of the ❖ Suspicion of aspiration (must be
following: indicated in diagnosis)
➢ RR ≥ 30 cpm ❖ Unstable or decompensated
➢ PR ≥ 125 bpm comorbid conditions
➢ SBP ≤ 90 mmHg ❖ Chest X ray shows multilobar
➢ DBP ≤ 60 mmHg infiltrates or pleural effusion
➢ Temp ≤ 36 or ≥ 40 C

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Diagnostic Criteria - High Risk CAP

Any criteria for moderate risk CAP, plus any of the

following:

❖ Severe sepsis
❖ Septic shock
❖ Need for mechanical ventilation

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 Risk Stratification

Classification Rule In Rule Out

Low Risk RR 28 cpm, SBP 90 mmHg, T 38.8 Evidence of pleural effusion on

deg C CXR
No acute decrease in sensorium

Moderate Risk HR 130 bpm, DBP 50 mmHg, No unstable comorbids

evidence of pleural effusion on PE
and CXR

High Risk Features of MR-CAP No evidence of sepsis or septic

shock, no need for mechanical
ventilation

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Primary Working Impression

Moderate Risk Community-Acquired Pneumonia

with no suspicion of aspiration

The patient is classified at “Moderate risk CAP” because of at least 1

moderate risk feature, while having no high-risk feature.

What is the best management plan?

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Empiric Therapy

❖ Targets the most likely etiologic organisms based on clinical data

❖ Antibiotics should be started as soon as CAP is diagnosed;
however, this should still be properly directed at the most likely
etiologic organisms.
❖ The CAP CPG regimens concur with the National Antibiotic
Guidelines, with some exceptions as noted.
❖ Both present several options of treatment regimens per risk
stratification for CAP.

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 Empiric Therapy - Low Risk CAP

Potential Pathogens Antibiotic Regimen

❖ Streptococcus pneumoniae Without comorbid illness, either of the following:

❖ Haemophilus influenzae ❖ Amoxicillin 1g PO TID
❖ Chlamydophila pneumoniae
❖ Extended macrolides such as Clarithromycin 500mg PO
❖ Mycoplasma pneumoniae
❖ Moraxella catarrhalis
BID
❖ Enteric Gram-negative bacilli With stable comorbid illness:
(if with co-morbid illness) ❖ β-lactam/β-lactamase inhibitor combination (BLIC) (such
as Co-amoxiclav 1 g BID or Sultamicillin 750 mg BID) OR
2nd generation oral cephalosporin (such as Cefuroxime
axetil 500 mg BID)
❖ May add extended macrolides (such as Azithromycin 500
mg OD or Clarithromycin 500 mg BID)
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Empiric Therapy - Low Risk CAP

❖ Unlike amoxicillin, extended macrolides can be dosed once

a day and are safe for those allergic to β-lactam drugs
❖ Azithromycin may cause QT prolongation. Risk factors
include existing QT prolongation, hypokalemia,
hypomagnesemia, bradycardia, arrhythmias, arrhythmia
treatments
❖ Azithromycin increases risk of death only for those with a
high baseline risk (above risk factors or elderly)
❖ Unlike ampicillin, amoxicillin is more orally bioavailable,
causes less diarrhea, and has a longer half-life.
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Empiric Therapy - Low Risk CAP

❖ Fluoroquinolones have the side effects of QT prolongation,

tendinitis, tendon rupture, peripheral neuropathy,
phototoxicity, and hypersensitivity.
❖ Fluoroquinolones are not the first-line treatment for
low-risk CAP.
❖ If BLIC or cephalosporin with or without macrolides do not
cause improvement, patient should be reassessed.
❖ Oral 3rd generation cephalosporin is recommended only as
a step-down from IV 3rd generation cephalosporin.

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 Empiric Therapy - Moderate Risk CAP

Potential Pathogens Antibiotic Regimen

❖ Streptococcus pneumoniae Without aspiration risk, both of the following:

❖ Haemophilus influenzae
❖ IV non-antipseudomonal BLIC (such as
❖ Chlamydophila pneumoniae
❖ Mycoplasma pneumoniae
Ampicillin-Sulbactam 1.5 g q6h IV) OR Cephalosporin
❖ Moraxella catarrhalis such as Cefuroxime 1.5 g q8h IV or Ceftriaxone 2 g OD)
❖ Enteric Gram-negative bacilli ❖ Extended macrolides (such as Azithromycin 500 mg OD
❖ Legionella pneumophila PO or Clarithromycin 500 mg BID PO) OR Respiratory
❖ Anaerobes (among those fluoroquinolones (such as Levofloxacin 500 mg OD PO
with risk of aspiration) or Moxifloxacin 400 mg OD PO)

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 Empiric Therapy - Moderate Risk CAP

Potential Pathogens Antibiotic Regimen

❖ Streptococcus pneumoniae
With aspiration risk:
❖ Haemophilus influenzae
❖ Chlamydophila pneumoniae ❖ Ampicillin-sulbactam (in a higher dose of 3g
❖ Mycoplasma pneumoniae q6 IV) or Moxifloxacin (still at 400 mg OD
❖ Moraxella catarrhalis
❖ Enteric Gram-negative bacilli
PO) is enough if already part of the regimen
❖ Legionella pneumophila ❖ Otherwise, may add Clindamycin 600 g q8
❖ Anaerobes (among those IV
with risk of aspiration)

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 Empiric Therapy - High Risk CAP

Potential Pathogens Antibiotic Regimen

❖ Streptococcus pneumoniae Without risk of P. aeruginosa, both of the following:

❖ Haemophilus influenzae
❖ Chlamydophila pneumoniae ❖ IV non-antipseudomonal β-lactam (such as
❖ Mycoplasma pneumoniae Ceftriaxone 2 g OD or Ertapenem 1 g OD)
❖ Moraxella catarrhalis
❖ Enteric Gram-negative bacilli ❖ IV extended macrolides (Azithromycin
❖ Legionella pneumophila dihydrate 500 mg OD IV) or IV respiratory
❖ Anaerobes (among those
with risk of aspiration)
fluoroquinolones (such as Levofloxacin 500
❖ Staphylococcus aureus mg OD IV or Moxifloxacin 400 mg OD IV)
❖ Pseudomonas aeruginosa

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 Empiric Therapy - High Risk CAP

Risk factors for P. aeruginosa infection

❖ History of broad-spectrum antibiotic use for more than
7 days within the past month
❖ Severe underlying bronchopulmonary disease
❖ Malnutrition
❖ Chronic use of steroids > 15 mg/day for at least 2 weeks

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 Empiric Therapy - High Risk CAP

Potential Pathogens Antibiotic Regimen

❖ Streptococcus pneumoniae With risk of P. aeruginosa, all of the following:

❖ Haemophilus influenzae ❖ IV antipneumococcal antipseudomonal β-lactam such as
❖ Chlamydophila pneumoniae BLIC (eg, Piperacillin-tazobactam 4.5 gm q6h),
❖ Mycoplasma pneumoniae cephalosporin (eg, Cefepime 2 g q8h-12h), or carbapenem
❖ Moraxella catarrhalis (Meropenem 1 g q8h)
❖ Enteric Gram-negative bacilli ❖ IV extended macrolides (such as Azithromycin dihydrate
❖ Legionella pneumophila 500 mg OD IV) and Aminoglycoside (Gentamicin 3 mg/kg
❖ Anaerobes (among those OD or Amikacin 15 mg/kg OD)
with risk of aspiration) ➢ This may be substituted by Levofloxacin 750 mg OD
❖ Staphylococcus aureus IV or Ciprofloxacin 400 mg q8-12h IV
❖ Pseudomonas aeruginosa

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Empiric Therapy - High Risk CAP

Criteria to warrant empiric MRSA treatment

❖ Intensive care admission is required
❖ Necrotizing or cavitary infiltrates
❖ Empyema

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 Empiric Therapy - High Risk CAP

Potential Pathogens Antibiotic Regimen

❖ Streptococcus pneumoniae
With MRSA risk, any of the above PLUS:
❖ Haemophilus influenzae
❖ Chlamydophila pneumoniae ❖ Vancomycin 15 mg/kg q8-12h
❖ Mycoplasma pneumoniae
❖ Moraxella catarrhalis
❖ Linezolid 600 mg q12h IV (National Antibiotic
❖ Enteric Gram-negative bacilli Guidelines do not recommend
❖ Legionella pneumophila
❖ Anaerobes (among those
monotherapy)
with risk of aspiration) ❖ Clindamycin 600 mg q8h IV (disputed by
❖ Staphylococcus aureus
❖ Pseudomonas aeruginosa
National Antibiotic Guidelines)

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Empiric Therapy - Moderate and High Risk CAP
❖ Sulbactam increases bioavailability of oral ampicillin, but has
no effect on IV ampicillin.
❖ Carbapenems are best reserved when there is a risk of
potentially resistant strains (eg, ESBL producing
enterobacteriaceae), such as when there was prior use of 3rd
gen cephalosporins and fluoroquinolones.
❖ Non-PNDF carbapenems that may be used include
meropenem and imipenem.
❖ If there is active influenza or influenza within 2 weeks of
CAP onset, additional Vancomycin 15 mg/kg q8-12h or
Linezolid 600 mg q12h IV is administered.
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Course in the Wards

Given the patient’s initial diagnosis, appropriate work-up

was done; patient was started on an empiric therapy of
Ampicillin-sulbactam 1.5g IV q6 and Azithromycin 500
mg PO OD.

What is the next appropriate action to be taken?

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Response to Initial Therapy

❖ Response to therapy is expected within 24-72 hours of

initiating treatment. Failure to improve after 72 hours of
treatment is an indication to repeat the chest
radiograph.
❖ Temperature, respiratory rate, heart rate, blood
pressure, sensorium, oxygen saturation and inspired
oxygen concentration should be monitored to assess
response to therapy.
❖ Follow-up cultures of blood and sputum are not
indicated for patients who are responding to treatment.
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Response to Initial Therapy

❖ The lack of a response after 72 hours to seemingly

appropriate treatment in a patient with CAP should lead
to a complete reappraisal, rather than simply to
selection of alternative antibiotics.
❖ The clinical history, physical examination and the results
of all available investigations should be reviewed.
❖ Patients should be reassessed for possible resistance to
the antibiotics being given or for the presence of other
pathogens.
❖ Treatment should be revised according to culture result.
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Response to Initial Therapy

❖ Follow-up chest radiograph is recommended to

investigate for other conditions such as pneumothorax,
cavitation and extension to previously uninvolved lobes,
pleural effusion, pulmonary edema and ARDS.
❖ For suspicion of an underlying mass, bronchiectasis,
loculation, or pulmonary abscesses, a CT scan would
provide more information.
❖ Obtaining additional specimens for microbiological
testing should be considered.

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Response to Initial Therapy

❖ Reasons for a lack of response to treatment include:

➢ Correct organism but inappropriate antibiotic choice
or dose
➢ Resistance of organism to selected antibiotic
➢ Wrong dose (e.g., in a patient who is morbidly
obese or has fluid overload)
➢ Antibiotics not administered
➢ Correct organism and correct antibiotic but infection
is loculated (e.g., most commonly empyema)

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Response to Initial Therapy

❖ Reasons for a lack of response to treatment include:

➢ Obstruction (e.g., lung cancer, foreign body)
➢ Incorrect identification of causative organism
➢ No identification of causative organism and
empirical therapy directed toward wrong organism
➢ Non-infectious cause
➢ Drug-induced fever
➢ Presence of an unrecognized, concurrent infection

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Course in the Wards

PE on D1 of antibiotics:
General Survey: alert, awake, oriented, not in cardiorespiratory
distress
Vital Signs: BP 100/60 mmHg, HR 110 bpm, RR 20 cpm, T 37.9 C
O2Sat 96%
Head and Neck: pink palpebral conjunctivae, anicteric sclerae, no
lymphadenopathies, no neck vein engorgement
Chest and Lungs: equal chest expansion, (+) less coarse crackles
on left mid-to-basal area with improved breath sounds at the
left basal area

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Course in the Wards

PE on D1 of antibiotics:
Heart: tachycardic, regular rhythm, good S1 and S2, no S3 and S4, no
heaves, no thrills, no murmurs appreciated (due to coarse crackles),
apex beat and PMI at 5th ICS LMCL
Abdomen: soft, flat, nontender abdomen, normoactive bowel sounds,
no organomegaly or masses
Extremities: pink nail beds, full and equal pulses, no cyanosis, clubbing
or edema
Neurological Exam: full sensorium, no focal neurological deficits

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Course in the Wards

Labs on D1 of antibiotics:
Blood work up: Hgb 12.4; Hct 0.40; WBC 10,500
(Seg=74, Lym = 21); platelets 298,
Chemistry: Creatinine 72 μmol/L; BUN 5.6 mmol/L
Sputum culture: Positive for S. pneumoniae after 24
hours

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De-escalation of Therapy

Once the patient is clinically improving, hemodynamically

stable and has a functioning gastrointestinal tract,
de-escalation of initial empiric broad-spectrum antibiotic or
combination parenteral therapy to a single narrow spectrum
parenteral or oral agent based on available laboratory data is
recommended.

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De-escalation of Therapy

❖ Indications for de-escalation or streamlining include:

➢ Resolution of fever for > 24 hours
➢ Less cough and resolution of respiratory distress
(normalization of respiratory rate)
➢ Improving white blood cell count, no bacteremia
➢ Etiologic agent is not a high-risk (virulent/resistant)
pathogen e.g. Legionella, S. aureus or Gram negative
enteric bacilli

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De-escalation of Therapy

❖ Indications for de-escalation or streamlining include:

➢ No unstable comorbid condition or life-threatening
complication such as myocardial infarction,
congestive heart failure, complete heart block, new
atrial fibrillation, supraventricular tachycardia, etc.
➢ No sign of organ dysfunction such as hypotension,
acute mental changes, BUN to creatinine ratio of
>10:1, hypoxemia, and metabolic acidosis
➢ Patient is clinically hydrated, taking oral fluids and is
able to take oral medications
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De-escalation of Therapy

❖ The choice of oral antibiotics following initial parenteral

therapy is based on available culture results,
antimicrobial spectrum, efficacy, safety and cost.
❖ In general, when switching to oral antibiotics, either the
oral form of the parenteral antibiotic or an antibiotic
from the same drug class should be used.

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 De-escalation of Therapy

Dosages for commonly used oral agents for streamlining:

ANTIBIOTIC DOSAGE

Amoxicillin-clavulanic acid 625 mg TID or 1 g BID

Azithromycin 500 mg OD

Cefixime 200 mg BID

Cefuroxime axetil 500 mg BID

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 De-escalation of Therapy

Dosages for commonly used oral agents for streamlining:

ANTIBIOTIC DOSAGE

Cefpodoxime proxetil 200 mg BID

Levofloxacin 500-750 mg OD

Moxifloxacin 400 mg OD

Sultamicillin 750 mg BID

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Course in the Wards

After assessing the patient for a positive clinical response

to initial treatment, the patient’s therapy is de-escalated
to Azithromycin 500 mg PO OD after 48 hours of empiric
therapy.

How long should antibiotics be given? When can the patient

be discharged?

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Duration of Therapy
❖ Depends on the CAP classification and the etiology:
➢ Low-risk uncomplicated bacterial pneumonia
■ 5 to 7 days
➢ Moderate risk bacterial pneumonia
■ 7 to 14 days if MSSA
■ 7 to 21 days if MRSA
■ 14 to 21 days if P. aeruginosa
➢ Moderate-risk and high-risk CAP with bacteremia
■ Up to 21 days if MSSA
■ Up to 28 days if MRSA or P. aeruginosa
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Duration of Therapy
❖ Depends on the CAP classification and the etiology:
➢
➢
➢
Low-risk uncomplicated bacterial pneumonia - 5 to 7 days
Moderate risk bacterial pneumonia - 7-10 days
Moderate-risk and high-risk CAP or if with suspected or confirmed Gram-negative, S. aureus or P. aeruginosa pneumonia - Up to 28 days if with associated bacteremia

➢ Mycoplasma and Chlamydophila pneumonia

■ 10 to 14 days
➢ Legionella pneumonia
■ 14 to 21 days
❖ Newer agents like azalides have longer half-lives and
higher tissue levels, so treatment can be shortened (e.g.
3-5 days for low-risk, 10 days for Legionella)
❖ Patients should be afebrile for 48 to 72 hours with no
signs of clinical instability before discontinuation of
treatment.
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Discharge Plan

❖ In the absence of any unstable coexisting illness or other

life threatening complication, the patient may be
discharged once clinically stable and oral therapy is
initiated.

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Discharge Plan

❖ Recommended clinical criteria during the 24 hours

prior to discharge:
➢ Temperature of 36.5°C to 37.5°C
➢ PR < 100 bpm
➢ RR 16 to 24 cpm
➢ SBP > 90 mmHg
➢ O2 Sat > 90%
➢ Functional gastrointestinal tract

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Discharge Plan

❖ A repeat chest radiograph prior to hospital discharge is

not needed in a patient who is clinically improving.

❖ However, a repeat chest radiograph is recommended

during a follow-up visit, approximately 4 to 6 weeks
after hospital discharge to establish a new radiographic
baseline and to exclude the possibility of malignancy
associated with CAP, particularly in older smokers.

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Patient Education

❖ To improve adherence, patients should know what to

expect in terms of diagnosis prognosis.

❖ Symptoms are expected to improve after starting

treatment, but the rate of improvement varies with the
severity of pneumonia and adherence to the medical
regimen.

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 Patient Education
❖ Patients should be made aware that the usual course of
the disease is as follows:
hs
1 week 4 week
s
6 week
s 3 mont 6 mont
hs

Resolution Reduction Reduction Overall Return to

of fever of chest of cough resolution of normal
pain and and symptoms with function
sputum breathless- residual fatigue
production ness

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References:

Department of Health. (2017). National Antibiotic Guidelines. pp. 112 - 114.

Retrieved from
http://thepafp.org/website/wp-content/uploads/2017/05/2017-National-
Antibiotic-Guidelines-DOH.pdf

Philippine Society for Microbiology and Infectious Diseases, Philippine College of

Chest Physicians, Philippine Academy of Family Physicians, Philippine
College of Radiology. (2016). Diagnosis, Empiric Management and
Prevention of Community-Acquired Pneumonia In Immunocompetent
Adults - Treatment. Retrieved from
http://thepafp.org/website/wp-content/uploads/2017/05/2016-CAP-by-P
SMID.pdf

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