CAP MANAGEMENT

UPDATE BASED ON NEW GUIDELINES

Dr. dr. Irawaty Djaharuddin, Sp.P(K), FISR

Department of Pulmonology and Respiratory Medicine, Faculty of Medicine Universitas Hasanuddin

Mortality by cause, world, 2019
Mortality from pneumonia, 2019
The annual number of deaths from pneumonia per 100,000 people
 CAP Epidemiology
USA
Mortality from
CAP 6,5%, and
increase by age

Indonesia
Prevalence of pneumonia in all age 2,21%; 2,5% in 55-64 years old
people, 3% in 65-74 years old people, and 2,9% in 75 years and older

Konsensus PDPI, CAP. 2022

 Definition
Community-Acquired
Pneumonia Pneumonitis
Pneumonia
An acute infection of Inflammation of An acute infection of
pulmonary parenchyma pulmonary parenchyma pulmonary parenchyma
caused by microorganism caused by non-infection acquired outside health
(bacterial, virus, fungi, (chemical, radiation, toxic care settings or in
parasite), yet not include inhalation, drugs, etc.) community
M. tuberculosis

Konsensus PDPI, CAP. 2022

 Risk Factors of CAP
1 Age 7 Asthma bronchiale

2 Smoking 8 Fungsional disorders

3 Exposure to environment 9 Bad oral hygiene

4 Malnutrition 10 Imunosupressive therapy

5 History of CAP 11 Oral steroid therapy

6 Chronic bronchitis/COPD 12 Gastric acid inhibitor drugs

Konsensus PDPI, CAP. 2022

 Type of patients Etiology
Outpatients Streptococcus Pneumoniae
CAP Etiology Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydia pneumoniae
Respiratory virus
Inpatients (non-ICU) S. Pneumoniae
Mycoplasma pneumoniae
Chlamydia pneumoniae
Haemophilus influenzae
Legionella spp.
Anaerobes (+aspiration)
Respiratory virus
ICU S. Pneumoniae
Staphylococcus aureus
Legionella spp.
Negative gram bacilli
H. influenza
Konsensus PDPI, CAP. 2022
 Diagnosis of CAP
Chest radiography or other chest imaging demonstrating an infiltrate
or air-bronchogram confirms the diagnosis, plus acute onset of:

• Cough (productive or nonproductive)

• Changes in sputum characteristics, usually purulent
• Axilla temperature >38oC or history of fever
• Chest pain with inspiration and coughing
• Dyspnea
• Signs of consolidation, bronchial breath sound and rales
• Leucocyte ≥10.000 cells/mm3 or <4.500 cells/mm3 with
neutrophilia segment/immature
Konsensus PDPI, CAP. 2022
 2 major principles
Diagnosis of CAP

1 Define if severe
or nonsevere 2 Presence of risk factors
for MRSA or PSA

MRSA = Methicillin-resistant S. aureus

PSA = Pseudomonas aeruginosa

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

2007 Infectious Diseases Society of America/ American
Thoracic Society Criteria for
Defining Severe CAP
Validated definition includes either 1 major criterion or 3 or more minor criteria
Minor criteria Respiratory rate >30 breaths/min
PaO2/FiO2 ratio <250
Multilobar infiltrates
Confusion/disorientation
Uremia (BUN level >19 mg/dl)
Leukopenia* (white blood cell count <4,000 cells/ul)
Thrombocytopenia (platelet count <100,000/ul)
Hypothermia (core temperature <36oC)
Hypotension requiring aggressive fluid resuscitation
Major criteria Septic shock with need for vasopressors
Respiratory failure requiring mechanical ventilation
*Due to infection alone (i.e., not chemotherapy induced)
Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019
 Strong risk factors associated with
MRSA or PSA CAP
1. Prior isolation of MRSA/PSA, especially from
respiratory tract
2. Recent hospitalization in the last 90 dys
3. Exposure to parenteral antibiotics in the last 90 days

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

 Typical vs Atypical Pneumonia
Atypical pneumonia caused by nondetectable on gram stain microorganisms or
cultivatable on standard bacteriologic culture media
Sign and symptom Atypical pneumonia Typical pneumonia
Onset Gradual Acute
Temperature Low-grade High fever, shivering
Cough Nonproductive Productive
Sputum Mucoid Purulent
Other symptoms Headache, myalgia, sore throat, Rare
hoarse voice, otalgia
Extrapulmonary symptoms Common Rare
Gram stain Normal flora or specific Gram +ve or –ve coccus
Radiography Patchy or normal Lobar infiltrate
Laboratory Normal leukocyte or low count Leukocytosis
Liver disfunction Common Rare
Konsensus PDPI, CAP. 2022
 CAP: Define Severity-Prognosis

Clinical
Clinical Need for
prediction hospitalization
judgment
rule

Defining severe Validated:

CAP CURB-65
PSI

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

 Validated clinical prediction rules for prognosis:
CURB-65
Clinical factor
Confusion (mental test score <8)
Blood Urea Nitrogen >19 mg/dL
(Ureum >40 mg/dL)
Respiratory rate ≥30 breaths/min
Blood pressure: systolic <90 mmHg
or diastolic ≤60 mmHg
Age >65 years
Total
*0=no sign, 1=presence
Points*
1 Score, risk of death, management:
1 0-1 low risk (1.5%), ambulatory care
2 medium risk (9.2%),
1 admit to non-ICU ward
1 >3 high risk (22%),
manage as severe case
1 4-5 high risk, admit to ICU
?
Konsensus PDPI, CAP. 2022
Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019
Validated clinical prediction rules for prognosis:
Pneumonia Severity Index (PSI)
PSI capable to identifies large proportions of patients at lower
risk and has high discriminative power in predicting mortality

PDPI recommendation of hospitalization if:

PSI score >70
PSI score <70 with 1 criterion of:
Respiratory rate >30 breaths/min
PaO2/FiO2 <250 mmHg
Multilobar infiltrate on radiology
Blood pressure: systolic <90 mmHg or diastolic <60 mmHg

Total points Risk Class Mortality Management

Unpredicted Low I 0.1 % Ambulatory care
<70 Low II 0.6 % Ambulatory care
71-90 Low III 2.8 % Ambulatory/hospitalization
91–130 Medium IV 8.2 % Hospitalization
>130 High V 29.2 % Hospitalization
Konsensus PDPI, CAP. 2022
Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019
Etiology Examination in CAP Diagnosis(1)
Pre-treatment respiratory secretion gram-stain or
culture, and blood culture for:
Severe CAP, especially if intubated
Being empirically treated for MRSA/PSA, or
Prior MRSA/PSA infection in respiratory tract
History recent hospitalization and parenteral antibiotics use
within last 90 days

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

Etiology Examination in CAP Diagnosis(2)
Urine Pneumococcal antigen in adults with severe CAP

Urine Legionella antigen in adults with severe CAP

and outbreak or recent travel

Influenza testing during periods of high influenza

activity

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

 Inflammatory Markers in CAP Diagnosis
Procalcitonin (PCT) level
• Increase in inflammation and
infection
• Level of >2 ng/mL is predictor of
bacteremia, sepsis, septic shock
and MODS
• Not recommended to
determine need for initiation of
empirical antimicrobial therapy
C-Reactive Protein (CRP) level
• Normal value 3 mg/L, level of 10
mg/L is predictor of inflammation
• Level of >100 mg/L is predictor of
poor prognosis and the need for
mechanical ventilation
Konsensus PDPI, CAP. 2022
Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019
CAP Diagnosis and Management Algorithm
Anamnesis, Physical examination, radiology, routine blood test

Radiology not Radiology & symptoms

suggestive pneumonia suggestive pneumonia

Consider other diagnosis PSI/CURB-65 score

Microbiology test Hospitalization Ambulatory

Definitive antibiotics Admit to med floor Define severity Progression

Empirical tx
>1 major criterion >3 minor criterias

Empirical antibiotics ICU Consider ICU Continue

Empirical tx

Konsensus PDPI, CAP. 2022

 Principles in CAP Treatment

Early initial antibiotics Evaluation of In suggestive sepsis,

following established antibiotics therapy antibiotics
pneumonia diagnosis within 72 hours, administration within
continue if clinical 1 hour after
improvement emergency admission
observed, and change (Sepsis bundle, 2021)
when progressive

Konsensus PDPI, CAP. 2022

 CAP Treatment: Outpatient setting
No co-morbidities or
risk factors for MRSA/PSA
Amoxicillin 1 g tid
Doxycycline 100 mg bid
Macrolide (if local pneumococcal
resistance <25%):
Azithromycin 500 mg day 1
then 250 mg qd
Clarithromycin 500 mg bid
Clarithromycin ER 1 g qd
With co-morbidities
Combination therapy:
Amoxicillin/clav 500 mg/125 mg tid or amoxicillin/clav
875 mg/125 mg bid or 2 gr/125 mg bid or cephalosporin
(cefditoren 400 mg bid or cefixime 200 mg bid or
cefpodoxime 200 mg bid or cefuroxime 500 mg bid);
AND
Macrolide (azithromycin 500 mg day 1 then 250 mg qd,
clarithromycin (500 mg bid or ER 1 gr qd) or doxycycline
100 mg bid;
OR
Monotherapy:
Respiratory fluoroquinolone (levofloxacin 750 mg qd,
moxifloxacin 400 mg qd or gemifloxacin 320 mg qd)
Konsensus PDPI, CAP. 2022
Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019
CAP Treatment: Inpatient setting/Nonsevere
Standard regimen Risk factors Management
Prior respiratory isolation + MRSA coverage
of MRSA Obtain nasal PCR or cultures

Prior respiratory isolation + PSA coverage

of PSA Obtain cultures
Beta-lactam + Macrolide
or FQ
Recent hospitalization Obtain culture or nasal PCR,
IV antibiotics use withhold MRSA coverage
Other risk for MRSA unless above positive

Recent hospitalization Obtain cultures

IV antibiotics use Withhold coverage unless
Other risk for PSA culture positive

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

 CAP Treatment: Inpatient setting/Nonsevere
Standard regimen options
Combination B-Lactam + Macrolide:
Ampicillin-sulbactam 1.5-3 g q6h, cefotaxime 1-
2 g q8h, ceftriaxone 1-2 g daily, ceftaroline 600
mg q12h;
AND
Azithromycin 500 mg daily, clarithro 500 mg bid;
OR
Monotherapy respiratory FQ:
Levofloxacin 750 mg daily, moxi 400 mg daily
MRSA coverage
Vancomycin 15 mg/kg q12h, adjust based on
levels
Linezolid 600 mg q12h
Alternative regimen options
If contraindicated to both Macrolide and FQ
Combination B-Lactam + Doxycycline:
Ampicillin-sulbactam 1.5-3 g q6h, cefotaxime
1-2 g q8h, ceftriaxone 1-2 g daily, ceftaroline
600 mg q12h;
AND
Doxycycline 100 mg bid
PSA coverage
Piperacillin-tazobactam 4.5 g q6h, cefepime 2 g
q8h, ceftazidime 2 g 18h, imipenem 500 mg
q6h, meropenem 1 g q8h, aztreonam 2 g q8h
Management of Adults with HAP and VAP. ATS/IDSA. 2016
Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019
 CAP Treatment: Inpatient setting/Severe
Standard regimen Risk factors Management
Prior respiratory isolation + MRSA coverage
of MRSA Obtain nasal PCR or cultures

Prior respiratory isolation + PSA coverage

of PSA Obtain cultures
Beta-lactam + Macrolide
or Beta-Lactam + FQ
Recent hospitalization
IV antibiotics use + MRSA coverage
Obtain nasal PCR or cultures
Other risk for MRSA

Recent hospitalization
IV antibiotics use + PSA coverage
Obtain cultures
Other risk for PSA

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

 CAP Treatment: Inpatient setting/Severe
Standard regimen options
Combination B-Lactam + Macrolide:
Ampicillin-sulbactam 1.5-3 g q6h, cefotaxime 1-
2 g q8h, ceftriaxone 1-2 g daily, ceftaroline 600
mg q12h;
AND
Azithromycin 500 mg daily, clarithro 500 mg bid;
OR
Combination B-Lactam (as above) + FQ:
Levofloxacin 750 mg daily, moxi 400 mg daily
MRSA coverage
Vancomycin 15 mg/kg q12h, adjust based on
levels
Linezolid 600 mg q12h
Alternative regimen options
If contraindicated to both Macrolide and FQ
Combination B-Lactam + Doxycycline:
Ampicillin-sulbactam 1.5-3 g q6h, cefotaxime 1-
2 g q8h, ceftriaxone 1-2 g daily, ceftaroline 600
mg q12h;
AND
Doxycycline 100 mg bid
PSA coverage
Piperacillin-tazobactam 4.5 g q6h, cefepime 2 g
q8h, ceftazidime 2 g 18h, imipenem 500 mg
q6h, meropenem 1 g q8h, aztreonam 2 g q8h
Management of Adults with HAP and VAP. ATS/IDSA. 2016
Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019
 CAP Treatment: Antibiotics Duration
Type of CAP Duration
Outpatient 5 days for most patient
Hospitalized patients that are improving 5-7 days
MRSA/PSA 7 days
Pneumonia + deep seated infections Longer duration depending on
(i.e., meningitis, endocarditis) pathogen or source control
Infection with less common pathogen Longer duration depending on
e.g. endemic fungi pathogen

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

 Atypical Pneumonia Treatment
Antibiotic therapy for Legionella, Chlamydophila, and Mycoplasma
Medication Dose
Azithromycin 1.5 g over 5 days (500 mg day 1 then 250 mg for 4 days)
Clarithromycin 500 mg bid for 10 days
Doxycycline 100 mg bid for 7-21 days
Tetracycline 250 mg qid for 7-21 days
Levofloxacin 750 mg for 5-10 days or 500 mg for 7-14 days
Moxifloxacin 400 mg for 10 days
Nemonoxacin* 500 mg or 750 mg for 7 days
Slorithromycin* 800 mg day 1 then 400 mg for 4 days
*Still in the trial phase and are not yet FDA approved

Sharma. Pneumonia Updates on Legionella, Chlamydophila, and Mycoplasma Pneumonia. Clin Chest Med. 2017 March; 38(1): 45–58.
 Switch Therapy and Clinical Stability Criteria
Switch therapy criteria Clinical stability criteria
• Stable haemodynamic • Temperature <37.8oC
• Clinical improvement • Pulse rate <100 beats/min
• Ability to take oral • Respiratory rate <24
medication breaths/min
• Normal gastrointestinal • Systolic BP >90 mmHg
function • SaO2 >90% atau PO2 >60
mmHg

Konsensus PDPI, CAP. 2022

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019
 Switch Therapy
Type of Switch Therapy Description
Sequential Same drugs, same potency
(levofloxacin, moxifloxacin)
Switch over Different drugs, same potency
(ceftazidime iv into ciprofloxacin po)
Step down Same or different drugs, lower potency
(amoxicillin, cefuroxime, cefotaxime iv
into cefixime po)

Konsensus PDPI, CAP. 2022

CAP Treatment: Corticosteroid use and Follow-up

Corticosteroid Follow-up
The use of corticosteroids Chest imaging not routinely
may be considered in obtain In adults with CAP
patients with CAP and whose symptoms have
refractory septic shock resolved within 5-7 days

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. ATS/IDSA. 2019

ATS/IDSA CAP Guidelines

Differences between the 2019 and 2007
Type, Pattern, and Evaluation of unresponsive CAP patients
Failure to recover, Progression, Late response

Unresponsive to empirical therapy

Misdiagnosis Correct diagnosis

Heart failure
Emboli
Malignancy
Patients factor Drugs factor Pathogen factor
Sarcoidosis Local abnormality Incorrect drugs of DR pathogen
Drug reaction (sumbatan benda choice Other bacterial
Bleeding asing) Wrong doses/route Mycobateria or
Inadequate respons Complication Nocardia
Complication i.e., Drug reactions Nonbacterial (fungi
lung superinfection, or virus
empyema
Konsensus PDPI, CAP. 2022
 CAP Preventive Treatment
Nutrition
Improve environment
Vaccination
Pneumococcal conjugate vaccine (PCV) or PCV13
Pneumococcal polysaccharide vaccine (PPV) or PPSV23

Konsensus PDPI, CAP. 2022

 Take home message
• Diagnosis of pneumonia established by radiology infiltrate, with
symptoms of cough, fever and dyspnea
• Majority of CAP patients can be adequately treated with old regimens
despite raising concerns for MDRs
• Principles of CAP mangement are defining severity and prognosis
prediction based on CURB-65 and PSI
• Prevention of pneumonia by good nutritional intake, environmental
improvement and vaccination
TERIMA KASIH