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Diagnosis Community Aquired Pneumonia ( CAP) and

Current Management

Yunita Arlini

Pulmunology and Respiratory Medicine Department, Faculty of Medicine

Syiah Kuala University

preliminary

Pneumonia is clinically defined as an inflammation of the lungs caused by

microorganisms, namely bacteria, viruses, fungi and parasites, but does not include

those caused by bacteria.

M.tuberculosis. Community pneumonia or community acquired

pneumonia ( CAP) is community-acquired pneumonia. Pneumonia epidemiology can

occur in all countries but data to compare it are very few, especially in developing

countries. In the United States pneumonia is the leading cause of death among

infectious diseases, with 5-6 million cases of CAP with each year

1.1 million patients treated and 45 thousand patients died from pneumonia. In

Indonesia, based on RISKESDAS data in 2013, it is stated that the incidence and

prevalence of pneumonia is 1.8 percent and 4.5 percent. Pneumonia can affect all

age groups, but the mortality rate is higher in the age group over 60 years

compared to those aged 50 years, which is 2-4 times higher. Meanwhile,

pneumonia is the main cause of death in children under five

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under five in the world, it is estimated that there are 2 million under-five deaths due to

pneumonia out of 9 million deaths among children under five. Due to the high mortality rate

due to pneumonia, but often not realized, pneumonia gets the nickname " the forgotten

pandemic ".

Definition

The definition of CAP according to the Infectious Diseases Society of America

(IDSA) is an acute lung parenchymal infection characterized by the presence of new

infiltrates on chest X-ray or the discovery of changes in breath sounds and / or local wet

radiographs on lung physical examination consistent with pneumonia in patients who are

not being treated at home. hospital or other place of care within 14 days before the onset

of symptoms. A more complete definition is given by BTS, namely the appearance of

symptoms of a lower respiratory tract infection, namely: cough plus at least one other

symptom of lower respiratory tract infection; changes in the results of physical examination

of the lungs; at least one of the systemic signs (sweating, fever, chills, and / or temperature

≥38 0 C); response after antibiotics.

Etiology

Several prospective studies conducted to investigate the etiology of CAP

failed to identify the causative agent in 50 percent of cases. Some of the most

common causes of germs are

Streptococcus pneumonia which causes two thirds of pneumonia cases. Several

other causes of germs, namely Haemophilus influenza, Klebsiella pneumonia,

staphylococcus aureus, Pseudomonas spp, Mycoplasma pneumonia, Chlamydia, Moraxella

catarrhalis,

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Legionella and influenza viruses. Mycoplasma, Chlamydia, Moraxella and Legionella

are atypical germs. Some of the most common causes of CAP are shown in the

table below:

Table 1. Etiology of CAP according to ATS / IDSA 2007

Patient type Etiology

Outpatient S. pneumonia
H. influenza
M. pneumoniae
Chlamydia
Respiratory virus

Inpatient (non ICU) S. pneumonia

H. influenza
M. pneumoniae
Chlamydia
Legionella Sp
Respiratory virus
aspirations

Inpatient (ICU) S. pneumoniae

Staphylococcus aureus
Legionella species
Gram-negative bacilli
H. influenza

Data from several hospitals in Indonesia shows that the most common

cause of CAP in the inpatient room of sputum is gram-negative bacteria such as Klebsiella

pneumonia, Acitenobacter

baumanii, Pseudomonas aeruginosa while gram-positive germs like S. pneumoniae,

S. viridans, S.aureus found in small quantities. This shows that in the last 10 years it

happened

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changes in the pattern of germs that cause CAP in Indonesia so that this needs further

research.

The 2010 SARI (Severe Acute Respiratory Infection) sentinel survey data

conducted by the Indonesian Health Research and Development Agency obtained

results from sputum cultures of CAP patients, namely K. pneumoniae ( 29%), A.baumanii

( 27%), S.aureus

(16%), S. pneumoniae (), A.calcoaticus ( 8%), P. aeruginosa ( 6%) and

E. coli ( 2%). In chronic lung diseases such as bronchiectasis, cystic fibrosis and COPD,

usually when there is an infection it is usually associated with gram-negative bacteria such

as P.aeruginosa.

Risk Factors

The risk factors for pneumonia include being over 60 years of age; there are

comorbidities such as diabetes mellitus, COPD, cardiovascular, malignancy, kidney

failure, chronic liver disease and neurological disorders;

alcoholism; malnutrition; smoking habit;

immunosuppression and infection caused by gram negative. CAP with comorbidities

will increase the mortality rate. The American Thoracic Society classifies risk factors

based on modifying factors, namely:

• Resistant Streptococcus pneumonia

• Age over 65 years

• History of use of beta-lactam antibiotics within 3 months

• Immunosuppression (long history of corticosteroid use)

• Multiple comorbid disease

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 • Alcoholism

• Enteric gram negative

• History of antibiotic use

• Cardiovascular disease

• History lives in nursing home

• Multiple comorbid diseases

• Pseudomonas aeruginosa:

• Bronchiectasis

• Use of broad spectrum antimicrobials in 7 days in the last month

• Corticosteroid use of at least 10 mg prednisone per day

• malnutrition

Diagnosis

The diagnosis of CAP is obtained from history, clinical symptoms, physical

examination, chest X-ray and laboratory. A definite diagnosis of community pneumonia is

made if on the chest X-ray there is a new infiltrate or progressive infiltrate plus 2 or more

of the following symptoms:

• Increased cough

• Changes in sputum / purulent characteristics Body

• temperature> 38 0 C (axillary) / history of fever

• Examination: found signs of consolidation, bronchial breath sounds and

crackles

• Leukocytes> 10,000 or <4500

Blood gas, electrolyte, urea and liver function analysis tests are performed

to determine the severity of CAP. Microbiological test

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of sputum should be done in patients with moderate and severe CAP, whereas in

patients with mild CAP, microbiological examination should be based on clinical

factors such as age, comorbid disease and indicators of the severity of CAP as well

as epidemiological factors and history of previous antibiotics used. If the results of

microbiological examination find the causative bacteria, the antibitiok given must be

replaced with antibiotics that are more specific to the causative bacteria. Sputum

examination for detection of M.Tb (BTA) is performed if there is no improvement

after antibiotic administration which is characterized by persistent productive cough

and other clinical symptoms associated with TB. Based on the IDSA guidelines, a

sputum culture examination accompanied by a Gram sputum examination is a

routine examination that must be performed on every CAP patient but this is not a

routine examination if there is no risk of infection by resistant germs according to

ATS guidelines because pathogens that cause CAP are only found 40-50% of all

patients. ATS and IDSA recommend performing pleural puncture if the lateral

decubitus chest X-ray shows fluid thickness> 10 mm to rule out empyema and

parapneumonia effusion.

Assessment of disease severity

The assessment of the degree of severity of the CAP can use several scores,

namely CURB-65 (confusion, uremia, respiratory rate, low blood pressure, age 65 years

or greater) as shown in Figure 1 below:

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 Image 1. Assessment of pneumonia severity with a CURB- score
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Pneumonia patients who got a score of 0 with a score of CURB65 could be

outpatient with oral antimicrobials for 5 days. Moderate pneumonia if the CURB-65

score is 1 or 2 and the patient must be referred to hospital, a score of 3-4 is classified as

severe pneumonia and should receive empiric antimicrobials immediately. The severity

of CAP can also be assessed by a pneumonia severity index (PSI) score. The

parameters used in the PSI score and the interpretation of the results are shown in

Figure 2.

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 Figure 2. Assessment of the severity of pneumonia is based on the PSI score

Based on the PDPI agreement, the criteria used for indication of CAP

hospitalization are:

1. PORT / PSI score over 70

2. If the PORT / PSI score is less than <70 then the patient still needs to be hospitalized if

one of the following criteria is found:

• Respiratory rate> 30 / minute

• Pa02 / FiO2 less than 250 mmHg

• Chest X-ray shows bilateral abnormalities

• Chest X-ray involving> 2 lobes

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 • Systolic pressure <90 mmHg

• Diastolic pressure <60 mmHg

3. Pneumonia in drug users

According to the ATS the criteria for severe pneumonia if there are 'one or more' of the

following criteria:

Minor criteria:

• Respiratory rate> 30 / min Pa02 / FiO2

• less than 250 mmHg

• Chest X-ray showing bilateral abnormalities Chest chest

• radiograph involving> 2 lobes

• Systolic pressure <90 mmHg Diastolic

• pressure <60 mmHg

The major criteria are as follows:

• Requires mechanical ventilation

• Infiltrates increase> 50%

• Requires a vasopressor> 4 hours (septic shock)

• Serum creatinine> 2 mg / dl or an increase of> 2 mg / dI, in patients with a

history of kidney disease or kidney failure requiring dialysis

Patients who require treatment in an intensive care room are patients who

have at least 1 of 2 certain major symptoms (require mechanical ventilation and

require a vasopressor.

> 4 hours [shock as]) or 2 of 3 certain minor symptoms (Pa02 / FiO2 less than 250
mmHg, chest X-ray shows bilateral abnormalities,

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and systolic pressure <90 mmHg). The other minor and major criteria are not

indications for intensive care.

Management
Management of CAP is in the form of antibiotic and supportive therapy.

Supportive therapy with fluids to prevent dehydration as well as electrolytes and

nutrition. In addition, anti-pyretics can also be given if needed and mucolytics.

Antibiotics are given regularly

empiric and should be administered in less than 8 hours. The reason for giving the

initial therapy with empiric antibiotics is because the disease is serious and can be

life-threatening, requires a long time to wait for cultures to identify the causative

bacteria and it is not certain that the results of the germ culture are the germs that

cause CAP.

Current CAP management guidelines recommend stratifying patients into

risk groups, selecting appropriate empiric antimicrobial therapy based on germ

pattern maps, pharmacokinetics and pharmacodynamics of drugs, presence or

absence of drug allergy, history of previous antibiotic use, drug side effects, local

pathogens, price. The purpose of giving antimicrobials is to reduce and eradicate

germs, reduce morbidity and mortality and minimize resistance.

Empirical therapy for CAP (PDPI)

Outpatient Antibiotics
Patients who were previously healthy or without a • Β-lactam group or β-lactam
history of antibiotic use 3 months plus anti β-lactamase
previous • New macrolides

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 Patient with comorbid or Respiratory fluoroquinolones (levofloxacin
have a history of using antibiotics 750mg or 3 months before moxifloxacin) or
The β-lactam group is added anti β -
lactamase or
β-lactam plus macrolides;

Non ICU Inpatient Respiratory fluoroquinolone (levofloxacin

750mg or moxifloxacin) or β -
lactams plus macrolides

Intensive wards Not there is factor risk infection

pseudomonas β-lactam (cefotaxime, ceftriaxone,
or ampicillin - sulbaktam)
plus macrolides new or
Respiratory fluoroquinolone (levofloxacin
750mg or moxifloxacin)
Special considerations If there are risk factors for pseudomonas infection:
antipneumococcal, antipseudomonas
lactam (piperacillin-tazobactam, cefepime,
imipenem, or meropenem) plus
ciprofloxacin or levofloxacin
(750mg) Or β-lactam as mentioned above plus
aminoglycosides and azithromycin or β-lactams
as mentioned above are added
aminoglycosides and
antipneumococcal fluoroquinolones (for
allergic patients penicillin, β-lactam
replaced with aztreonam)
If suspected accompanied by CA-MRSA infection Add vancomycin or linezolid

The duration of giving antibiotics by oar or intravenously is at least 5 days

and there is no fever for 48-72 hours. Before the therapy is stopped the patient is in

the following circumstances: not

require supplemental oxygen (except for the underlying disease) and have no more

than one sign of clinical instability such as:

• Pulse rate> 100 x / minute

• Respiratory rate> 24 x / minute

• Systolic blood pressure ≤ 90 mmHg

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 After getting improvement with intravenous antibiotics in hospitalized patients, if the

therapy is immediately changed to oral on condition; stable hemodynamics, improved clinical

symptoms, can take medication orally and gastrointestinal function is good. Replacement therapy

or switch therapy can be done in 3 ways, namely sequential, switch over, and step down.

The patient will be discharged if within 24 hours none of the following is found:

• Temperature> 37, 80 C

• Pulse> 100 minutes

• Respiratory rate> 24 / minute

• Distolic <90 mmHg

• oxygen saturation <90% can

• not eat orally

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