Mark Anthony A. Tom, M.D.

First Year Internal Medicine Resident

Davao Doctors Hospital
 PART ONE: CLINICAL DIAGNOSIS
Can CAP be diagnosed accurately by history and
physical examination?
Accuracy of predicting CAP by physicians’ clinical
judgment is between 60-76%. (Grade B)

Clinical prediction rules combining history and physical

examination findings may be utilized to presumptively
identify patients with pneumonia. (Grade B)
Is there any clinical feature that can predict CAP
caused by an atypical pathogen?

There is no clinical feature that can reliably

distinguish pneumonia due to a typical or an atypical
pathogen. (Grade A)
 PART TWO: CHEST RADIOGRAPHY
What is the value of the chest radiograph in the
diagnosis of CAP?

The chest x-ray is essential in the diagnosis of

CAP, assessing severity, differentiating pneumonia
from other conditions, and in prognostication.
(Grade A)
What specific views of chest radiograph should be
requested?

Standing postero-anterior and lateral views of the chest

in full inspiration comprise the best radiologic
evaluation of a patient suspected of having
pneumonia. (Grade A)
Are there characteristic radiographic features
that can predict the likely etiologic agent from the
chest radiograph?

There is no characteristic radiographic feature that

can predict the likely etiologic agent in CAP. (Grade B)
How should a clinician interpret a radiographic
finding of “pneumonitis”?

A radiographic reading of “pneumonitis” should always

be correlated clinically. (Grade C)
What is the significance of an initial “normal”
chest radiograph in a patient suspected to have
CAP?

An initial “normal” chest x-ray may connote a

radiographic lag phase.
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)
What is the role of chest CT scan in CAP?

The chest CT scan has no routine role in the

evaluation of CAP. (Grade B)
 PART THREE: SITE-OF-CARE DECISIONS
Which patients will need hospital admission?
A management-oriented risk stratification of CAP based on
the patient’s clinical presentation/condition, status of any
co-morbid condition and chest x-ray findings should be
utilized in the decision to determine the site of care for
patients. (Grade A)
Patients with low-risk CAP are considered suitable for
outpatient care in the absence of contraindications. (Grade
A)
These patients with moderate- and high-risk CAP need to be
hospitalized for closer monitoring and/or parenteral therapy.
(Grade A)
 CLINICAL VIGNETTE
PATIENT’S PROFILE
J.Y.
65, female, married
Filipino
Roman Catholic
Matina, Davao City
HISTORY OF THE PRESENT ILLNESS
Four days PTA
 fever at 40.7 degrees Celsius associated with chills, productive
cough with yellowish sputum
 Dyspnea noted after coughing
 Condition tolerated
On the day PTA
 Fever and cough persisted
 Right-sided chest pain on deep inspiration
 Occasional episodes of dyspnea
 Consult with AP was done – advised admission
PAST MEDICAL HISTORY
Hypertensive for 15 years with maintenance of
Amlodipine 5 mg OD and Telmisartan 40 mg OD
Diabetic for 7 years with fair compliance to Metformin
500 mg BID
Not a known asthmatic
PREVIOUS HOSPITALIZATION
Appendectomy last 1986
Dilatation and Curettage last 1996
FAMILY HISTORY
Hypertension and Diabetes Mellitus Type 2 on the
maternal side
PERSONAL/SOCIAL HISTORY
Non-smoker, non-alcoholic beverage drinker
No known food and drug allergies
PHYSICAL EXAMINATION
concious, febrile, tachypneic, tachycardic with the
following vital signs: Temp 39.9, BP 130/90 mmHg, HR
103/min, RR 30/min
Skin – warm, no lesions
HEENT – anicteric sclerae, pinkish palpebral
conjunctivae, no tonsilopharyngeal congestion
Chest/Lungs – symmetric lung expansion, crackles
over both lung bases, decrease breath sounds right
CVS – adynamic precordium, distinct heart sounds, no
heaves, no thrills
Abdomen – flabby, normoactive bowel sounds, no
tenderness
Extremties – strong pulses, CRT less that 2 seconds
CNS – within normal limits
IMPRESSION
Community Acquired Pneumonia – moderate risk
Diabetes mellitus type 2 – uncontrolled
Essential Hypertension
Upon admission:
Venoclysis started
CBC taken showed WBC of 16,000, segmenters 89%,
lymphocytes 11%, hgb 130, hct 0.40
CXR PA view showed bibasal pneumonia
Sputum GS/CS
Blood culture x 2 sites
FBS
Medications started:
 Ampicillin + sulbactam 1.5 grams IVTT q8 hours
 Azithromycin 500 mg tablet 1 tablet OD

 Erdosteine 300 mg cap 1 cap BID

 PART FOUR: MICROBIOLOGIC STUDIES
What microbiologic studies are necessary in CAP?
In low-risk CAP, microbiologic studies are optional.
(Grade B)
In moderate-risk and high-risk CAP, blood cultures and
Gram stain and culture with antibiotic sensitivity tests
of respiratory specimens should be done in laboratories
with quality assurance. (Grade A)
When possible, tests to document the presence of
Legionella pneumophila are recommended in
hospitalized patients with CAP. (Grade B)
Invasive procedures (i.e., transtracheal, transthoracic
biopsy, bronchoalveolar lavage, and protected brush
specimen) to obtain specimens for special microbiologic
studies for atypical pathogens (e.g., mycobacteria and
other microorganisms that will not grow on routine
culture) 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)
 PART FIVE: TREATMENT
When should antibiotics be initiated for the
empiric treatment of community-acquired
pneumonia (CAP)?

For patients requiring hospitalization, empiric therapy

should be initiated as soon as possible after diagnosis of
CAP is made. (Grade B)
For low-risk CAP, treatment may be delayed. (Grade C)
What initial antibiotics are recommended for the
empiric treatment of community-acquired
pneumonia?
First hospital day
S:
 Low grade fever, decreased appetite, occasional productive
cough, no dyspnea
O:
 Crackles over both lung bases, no wheeze
 FBS = 6.9 mmol/L
 Sputum GS – gram negative rods +
 Blood CS – no growth after 24 hours, left and right
Second hospital day
Afebrile
Occasional cough, non-productive
Clear breath sounds
Vital signs were stable and within normal limits
How can response to initial therapy be assessed?
Temperature, respiratory rate, heart rate, blood pressure,
sensorium, oxygen saturation and inspired oxygen
concentration should be monitored to assess response to
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.
(Grade A)
Follow-up cultures of blood and sputum are not indicated
for patients who are responding to treatment. (Grade A)
When should de-escalation of empiric antibiotic
therapy be done?
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 once the
patient is clinically improving, is hemodynamically
stable and has a functioning gastrointestinal tract.
(Grade B)
Third hospital day
Afebrile
No cough
Clear breath sounds
Unasyn IV shifted to Co-amoxiclav 1 gram BID
CBC showed WBC 9,600, seg 55%, lymph 45%, hgb 130,
hct 0.40
CXR PA view clearing of infiltrates on both lower lobes
Which oral antibiotics are recommended for de-
escalation or switch therapy from parenteral
antibiotics?
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
same agent as the parenteral antibiotic or an antibiotic
from the same drug class should be used.
How long is the duration of treatment for CAP?
Duration of treatment is 5 to 7 days for low risk
uncomplicated bacterial pneumonia. (Grade B)
For moderate-risk and high-risk CAP or for those with
suspected or confirmed Gram-negative, S. aureus or P.
aeruginosa pneumonia, treatment should be prolonged
to 14 to 21 days. (Grade B)
A treatment regimen of 10 to 14 days is recommended
for Mycoplasma and Chlamydophila pneumonia while
Legionella pneumonia is treated for 14 to 21 days. (Grade
B)
A 5-day course of oral or IV therapy for low-risk CAP and
a 10-day course for Legionella pneumonia is possible with
new agents such as the azalides, which possess a long
half-life and achieve high tissue levels that prolong its
duration of effect. (Grade B)
Patients should be afebrile for 48 to 72 hours with no
signs of clinical instability before discontinuation of
treatment. (Grade B)
What should be done for patients who are not
improving after 72 hours of empiric antibiotic
therapy?
The clinical history, physical examination and the
results of all available investigations should be reviewed.
The patient should be reassessed for possible resistance
to the antibiotics being given or for the presence of other
pathogens such as M. tuberculosis, viruses, parasites or
fungi. Treatment should then be revised accordingly.
(Grade B)
Follow-up chest radiograph is recommended to
investigate for other conditions such as pneumothorax,
cavitation and extension to previously uninvolved lobes,
pulmonary edema and ARDS. (Grade B)
Obtaining additional specimens for microbiologic
testing should be considered. (Grade B)
Fourth hospital day
Afebrile, comfortable
Stable vital signs
Minimal cough
Increasing appetite
Clear breath sounds
MGH
Home meds:
 Azithromycin 500 mg tab 1 tab x 1 more day
 Co-amoxiclav 1 gram tab BID x 7 more days
 Erdosteine 300 mg cap BID x 3 more days
 Telmisartan 40 mg tablet 1 tablet OD
 Amlodipine 5 mg tablet 1 tablet OD
 Metformin 500 mg tablet I tablet BID
When can a hospitalized patient with CAP be discharged?
In the absence of any unstable coexisting illness or other
lifethreatening complication, the patient may be discharged once
clinical stability occurs and oral therapy is initiated. (Grade A)
A repeat chest radiograph prior to hospital discharge is not
needed in a patient who is clinically improving. (Grade B)
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. (Grade B)
 PART SIX: PREVENTION
How can CAP be prevented?
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)
Smoking cessation is recommended for all persons with
CAP who smoke. (Grade A)
THANK YOU!