THE LOWER RESPIRATORY

TRACT INFECTION:
Pneumonia

IDA BAGUS NGURAH RAI

PNEUMONIA
COMMUNITY-ACQUIRED PNEUMONIA
HOSPITAL-ACQUIRED (NOSOCOMIAL)
PNEUMONIA
COMMUNITY-ACQUIRED
PNEUMONIA
30-Day Mortality Data by Risk Class of CAP

Total Score Risk Recommended Mortality Range

Class Site of observed in
Treatment Validation
Cohort, %
None I Outpatient 0.1

≤ 70 II Outpatient 0.6

71-90 III Outpatient 0.9-2.8

91-130 IV Inpatient 8.2-9.3

> 130 V Inpatient 27.0-29.2

Ramsdell et al. Chest 2005; 127:1752-1763

 PATIENT WITH SUSPECT
CAP

DIAGNOSIS
1.
PSI
CURB-65

THE SITE OF INITIAL

2.
TREATMENT

OUT PATIENT IN PATIENT

3. EMPIRICAL ANTIMICROBIAL
(EFFECTIVITY, COMPLIANCE, COST)
Community-acquired pneumonia
(CAP)
• Pneumonia in community
• New infiltrates or progressively infiltrates
with two or more:
- increased cough,
- change in sputum characteristic,
- temperature 380C or history of fever,
- sign of consolidation (bronchial sound,
creackles),
- leucocyte 10.000 or ≤4.5000
 INPATIENT vs OUTPATIENT
• The cost of inpatient is 25 times greater¹
• Outpatients are able to resume normal
activity sooner²
• 80% of patient prefer outpatient therapy³
• Hospilization increase the risk of
thromboembolic events and superinfection by
more-virulent or resistant hospital bacteria⁴

1. Niederman et al. Clin Ther 1998; 20:820-37

2. Coley et al. Arch Intern Med 1996; 156:1565-71
3. Carratala at al. Ann Intern Med J 2005; 142:165-72
4. Alikhan et al. Arch Intern Med 2004; 164:963-8
 (IDSA, 2000, ATS,2001, PDPI,2003)
Patient characteristic Points assigned
Demographic factor:
Age
- Male No. of years of age
- Female No. of years of age – 10
Nursing home resident +10
Comorbid illnesses:
Neoplactic disease +30
Liver disease +20
Congestive heart disease +10
Renal disease +10
Cerebrovascular disease +10
Physical examination finding:
Altered mental status +20
Respiratory rate >30 breaths/min +20
Systolic blood pressure <90 mmHg +20
Pulse >125 beat/min +10
Body temperature <35°C or 40°C +15
Laboratory or radiographic finding:
Arterial pH <7.35 + 30
BUN >30 mg/dL +20
Sodium <130 mgEq/L +20
Glucose >250 mg/dL +10
Hematocrit <30% +10
PaO2 <60 mmHg or O2 sat <90% +10
Pleural effusion +10

Patient Outcome Research System (PORT) Severity Index

 How the PSI is derived
• Step 1: determine of weather patients meet the
following criteria for class I: age <50 yrs, with 0
of 5 comorbid conditions, normal or mildy
deranged vital sign, and normal mental status
• Step 2: patients not assigned to risk class I are
stratified into class II-V on the basis of points
assigned:
Class II ≤70 : OUTPATIENT
Class III: 71-90 : OUTPATIENT or BRIEF
INPATIENT
Class IV: 91-130 : INPATIENT
Class V:>130 : INPATIENT
 Any of
- Confusion*
- Respiratory rate ≥30/min
- Blood pressure (SBP <90 mm Hg or DBP ≤60 mmHg)
- Age ≥65 years
Score 1 point for each feature present

CRB-65
0 1 or 2 3 or 4
score

Likely suitable Consider Urgent

for home hospital hospital
treatment referral admission

* Defined as a Mental Test Score of 8 or less, a new disorientation in person, place or time

Severity assessment used to determine the management of CAP in patient

community (CRB-65 score) updated 2004 (BTS, 2004)
 Selection of Antimicrobial Regimens

• Based on prediction of most likely

pathogens
• Knowledge of local susceptibiliy patterns
Most common etiologies of CAP
Streptococcus pneumoniae
Outpatient Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydophilia pneumoniae
Respiratory viruses
Inpatient (non- S. Pneumoniae
M. Pneumoniae
ICU)
C. Pneumoniae
H. Influenza
Legionella species
Aspiration
Respiratory viruses
Inpatient (ICU) S. Pneumoniae
Staphylococcus auereus
Legionella species
Gram-negative bacilli
H. influenza
OUTPATIENTS: Previously healthy and
no risk factors for DRSP infection:

• A macrolide (azithromycin, clarithromycin, or

erythrommycin) (strong recommendation;
level I evidence)
• Doxycycline (weak recommendation; level III
evidence)
OUTPATIENTS: Presence of comorbidities, such as chronic
heart, lung, liver, or renal disease; diabetes mellitus; alcoholism;
malignancies; asplenia; immunosuppressing conditions or use of
immunosupressing drugs; use of antimicrobials within the
previous 3 moths (in which case an alternative from different class
should be selected); or other risk for DRSP infection:

A respiratory flouroquinolone (moxifloxacin, gemifloxacin, or

lefofloxacin [750 gm}](strong recommendation; level I evidence)

A beta-lactam plus a macrolide (strong recommendation; level I

evidence) (High-dose amoxicillin {e.g., 1 g 3 times daily] or
amoxicillin-clavulanate [2 g 2 times daily] is preferred; alternative
include ceftriaxone, cefpodoxime, and cefuroxime [500 mg 2 times
daily]; doxycycline [level II evidence] is an alternative to the
macrolide)
 Inpatient, non-ICU treatment
• A respiratory flouroquinolone (strong recommen-
dation; level I evidence)
• A beta-lactam plus macrolide (strong recommen-
dation; level I evidence) (Preferred beta-lactam
agents include cefotaxime, ceftriaxone, and
ampicillin; ertapenem for selected patients; with
doxycycline [level III evidence) as an alternative
to the macrolide. A respiratory flouroquinole
should be used for penicillin-allergic patients)
 Inpatient, ICU treatment
Minimal recommended treatment:
• A beta-lactam (cefotaxime, ceftriaxone, or
ampicillin-sulbactam) plus either azithromycin
(level II evidence) or a flouroquinole (level I
evidence) (strong recommendation) ( For
penicillin-allergic patients, a respiratory
flouroquinole and aztreonam are
recommended.)
Criteria for clinical stability
Temperature ≤37.8°C
Heart rate ≤100 beats/min
Respiratory rate ≤24 breaths/min
Systolic blood pressure ≥90 mm Hg
Arterial oxygen saturation ≥90% or pO₂ ≥60 mmHg on room air
Ability to maintain oral intake
Normal mental status
Death or readmission:
- 10.5% with no instability
- 13.7% with 1 instability
- 46.2% with ≥2 instabilities
(Halm et al. Arch Intern Med 2002; 162:1278-84)
Patients should be switched from intravenous to
oral therapy when they are hemodynamically
stable and improving clinically, are able to
ingest medications, and have a normally
functioning gastrointestinal tract.
(Strong recommendation; level II evidence)

Patients should be discharged as soon as they

are clinically stable, have no other active
medical problems, and have safe environment
for continued care. Inpatient observation while
receiving oral therapy is not necessary.
(Moderate recommendation; level II evidence)
Patients with CAP should be treated for a
minimum of 5 days (level I evidence), should be
afebrile for 48-72 h, and should have no more
than 1 CAP-associated sign of clinical instability
before discontinuation or therapy
(level II evidence) (Moderate recommendation)
A longer duration of therapy may be needed if
initial therapy was not active against the identified
pathogen or if it was complicated by
extrapulmonary infection, such as meningitis or
endocarditis
(Week recommendation; level III evidence)
 HOSPITAL-ACQUIRED
(NOSOCOMIAL) PNEUMONIA
Hospital-acquired pneumonia (HAP): pneumonia occurs
48 hours or more after admission, which was not
incubating at the time of admission

Ventilator-associated pneumonia (VAP): pneumonia

that arise more than 48-72 hours after endotracheal
intubation

Healthcare-associated pneumonia (HCAP) includes any

patients who was hospitalized in acute care hospital for
two or more days within 90 days of the infection; resided in
a nursing home or long-term care facility; received recent
IV antibiotic therapy, chemotherapy, or wound care within
the past 30 days of the current infection; or attended a
hospital or hemodialysis clinic
 EPIDEMIOLOGY
• The incidence of HAP is usually between 5
and 15 cases per 1000 hospital admission
• The incident of VAP is 6-to-20 fold greater
than nonventilated patients
• HAP and VAP are frequent cause of
nosocomial infection that is associated
with a higher crude mortality than other
hospital-acquired infections.
• The crude mortality rate for HAP: 30-70%
 HAP, VAP or HCAP Suspected

Obtain Lower Respiratory Tract (LRT) Sample for Culture

(Quantitative or Semi-quantitative) & Microscopy

Unless There is Both A Low Clinical Suspicion for

Pneumonia & Negative Microscopy of LRT Sample, Begin
Empiric Antimicrobial Therapy Using Algorithm & Local
Microbiologic Data

Day 2 & 3: Check Cultures & Assess Clinical Response:

(Temperature, WBC, Chest X-ray, Oxygenation, Purulent
sputum, Hemodynamic Changes & Organ Function)

Clinical Improvement at 48-72 hours

ATS. AJRCCM 2005; 171:388-416
 Clinical Improvement at 48-72 hours

No Yes

Culture - Culture + Culture - Culture +

Search for other Consider

Pathogens, Stopping
Complication, Antibiotic
Other Diagnoses
or Other Sites of
Infection
De-escalate
Adjust Antibiotic
Antibiotics, if
Therapy, Search for
Possible. Treat
Other Pathogens,
ATS. AJRCCM Selected Patients
Complication, Other
2005; 171:388- for 7-8 Days &
416 Diagnoses or Other
Reassess
Sites Infection
 EMPIRIC ANTIBIOTIC THERAPY
FOR HAP
HAP, VAP, or HCAP Suspected
(All Disease Severity)
Late onset ( 5 days) or
Risk Factors for MDR Pathogens
ATS.
AJRCCM

No Yes 2005;
171:388-
416

Limited Spectrum Broad Spectrum

Antibiotic Therapy Antibiotic Therapy for
MDR Pathogens
RISK FACTORS FOR MDR PATHOGENS CAUSING HAP,
HCAP, AND VAP

◙ Antimicrobial therapy in preceding 90 d

◙ Current hospitalization of 5 d or more
◙ High frequency of antibiotic resistance in the
community or in the specific hospital unit
◙ Presence of risk factors for HCAP:
Hospitalization for 2 d or more in the preceding 90 d
Residence in a nursing home or extended care facility
Home infusion therapy (including antibiotics)
Chronic dialysis within 30 d
Home wound care
Family member with MDR pathogen
◙ Immunosuppressive disease and/or therapy

ATS. AJRCCM 2005; 171:388-416

A INITIAL EMPIRIC ANTIBIOTIC THERAPY FOR HAP, VAP
IN PATIENTS WITH NO KNOWN RISK FACTORS FOR
MDR, EARLY ONSET, AND ANY DISEASE SEVERITY

POTENTIAL PATHOGEN RECOMMENDED ANTIBIOTIC

♣ Streptococcus pneumoniae Ceftriaxone

♣ Haemophilus influenza or
♣ Methicillin-sensitive Levofloxacin,
Staphylococcus aureus moxifloxacin, or
♣ Antibiotic-sensitive enteric ciprofloxacin
gram-negative bacillii or
Escherichia coli Ampicillin/sulbactam
Klebsiella pneumoniae or
Enterobacter species Ertapenem
Serratia marcessens

ATS. AJRCCM 2005; 171:388-416

INITIAL EMPIRIC ANTIBIOTIC THERAPY FOR HAP, VAP, AND HCAP IN
PATIENTS WITH LATE-ONSET DISEASE OR RISK FACTORS FOR MDR
PATHOGENS AND ALL DISEASE SEVERITY
POTENTIAL PATHOGEN COMBINATION ANTIBIOTIC TH/
Antipseudomonal cephalosporin
♣ Pathogens list in table A and MDR (cefepime, ceftazidime)
pathogens
or
Pseudomonas aeruginosa
Antipseudomonal carbepenem
Klebsiella pneumoniae (ESBL)
(imipenem or meropenem)
Acinetobacter species
or
-Lactam/-lactamase inhibitor
(piperacillin-tazobactam)
plus
Antipseudomonal fluiroquinolone
(ciprofloxacin or levofloxacin)
or
Aminoglycoside (amikacin,
gentamicin. or tobramycin)
Methicillin-resistant plus
Staphylococcus aureus (MRSA) Linezolid or vancomycin
♣ Legionella pneumophila ATS. AJRCCM 2005; 171:388-416
 INITIAL IV, ADULTS DOSES OF ANTIBIOTICS FOR EMPIRIC THERAPY OF
HAP, INCLUDING VAP, AND HCAP IN PATIENTS WITH LATE ONSET DISEASES
OR RISK FACTORS FOR MDR PATHOGENS
Antibiotic Dosage
Antipseudomonals cephalosporin
Cefepime 1-2 g every 8-12h
Ceftazidine 2 g every 8 h
Carbepenems
Imipenem 500 every 6 h or 1 g every 8h
Meropenem 1 g every 8 h
Beta-lactam/beta-lactamase inhibitor
Piperacillin-tazobactam 4.5 g every 6 h
Aminoglycosides
Gentamicin 7 mg/kg per d
Tobramycin 7 mg/kg per d
Amicain 20 mg/kg per d
Antipseudomonal quinolones
Levofloxacin 750 mg every d
Ciprofloxacin 400 mg every 8 h
Vancomycin 15 mg/kg every 12 h
Linezolid 600 mg every 12 h

ATS. AJRCCM 2005; 171:388-416

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