CREATIVE ANALYTICAL DISCUSSION:

COMMUNITY-ACQUIRED PNEUMONIA
CASE V10

Salvador, Chelsea S. Sharma, Rabindra Thapa, Dipika

Outline
01 Case & Discussion

02 Salient Points

03 Patient Education & Family Intervention

04 Social Relevance

05 Collaborative Management

06 Valid and Relevant Evidences

I. Case

Florencio, a 72-year-old farmer, was brought to the

clinic because of fever, cough, and dyspnea of 5 days
duration. He was given on his first consult with
levofloxacin, guaiphenesin, and paracetamol which
gave temporary relief. Upon follow-up, DOB
worsened, chest radiograph requested revealed
diffuse infiltrates over his lower lung fields.
 Differential Diagnosis
Rule in Rule out
(+) fever (-) tiredness
(+) cough (-) body aches and pain
COVID-19 (+) dyspnea (-) sore throat
(-) diarrhea
(-) loss of taste or smell

(+) cough (-) body malaise

(+) dyspnea (-) chest discomfort
(-) wheezing
Acute bronchitis presence of lung infiltrates

(+) cough (-) worsening of symptoms

(+) dyspnea
Acute exacerbation of
chronic bronchitis
(+) dyspnea (-) fatigue and weakness
(-) edema
(-) rapid or irregular heartbeat
(-) increased need to urinate at
Heart failure night
(-) nausea, lack of appetite
 Differential Diagnosis
Rule in Rule out
(+) dyspnea (-) chest pain
(+) cough (-) dizziness,
lightheadedness
Pulmonary embolism
(-) irregular heartbeat,
palpitations
occupation (-) muscle or joint pain
(+) fever (-) anorexia, weight loss
Hypersensitivity
(+) cough (-) fatigue
Pneumonitis (+) dyspnea (-) lung fibrosis
(-) clubbing of fingers or
toes

Radiation (+) fever (-) chest pain

(+) cough (-) chest congestion
Pneumonitis (+) dyspnea
Clinical Impression:
Community-acquired
pneumonia, mild risk
 Discussion

Pneumonia is an infection of the pulmonary parenchyma.

Community-acquired pneumonia (CAP)

Hospital-acquired pneumonia (HAP)

Ventilator-associated pneumonia (VAP)

Health care-associated pneumonia (HCAP)

Source: Harrison’s Principle of Internal Medicine 20 th edition

 Pathophysiology
Pneumonia results from the proliferation of microbial pathogens at the
alveolar level and the host's response to those pathogens.

hematogenous
spread co
n
t io e ex nti
ira t h n x te gu
p y ns o
as rom ar1 io us
f ph n
o
or

Source: Harrison’s Principle of Internal Medicine 20 th edition

 Pathophysiology
Mechanical factors Killing of pathogens
• hairs and turbinates of When these barriers are
the nares overcome or when
• branching architecture microorganisms are small
of the tracheobronchial enough to be inhaled to
tree the alveolar level, resident
• gag and cough reflexes alveolar macrophages are
• normal flora adhering extremely efficient at
to mucosal cells of the clearing and killing
oropharynx pathogens.
release of inflammatory
mediators resulting to
fever
release of neutrophils and
their attraction to the
Clinical manifestation lung producing both
peripheral leukocytosis
Only when the capacity of and increased purulent
the alveolar macrophages secretions
to ingest or kill the
microorganisms is alveolar capillary leak
exceeded does clinical resulting to radiographic
pneumonia manifest. infiltrate and rales
some bacterial pathogens
interfere with the
hypoxemic vasoconstriction
which can result to
hypoxemia
Source: Harrison’s Principle of Internal Medicine 20 th edition
 Pathology

• presence of a proteinaceous exudate in the alveoli

a
em
Ed

• erythrocytes in the cellular intraalveolar exudate

n
io

• neutrophil influx
at d
at
ep Re
iz

• bacteria are occasionally seen

• no new erythrocytes are extravasating, and those already present have been lysed and
H

degraded
io
at ay

• neutrophil is the predominant cellfibrin deposition is abundant, and bacteria have

at
ep Gr
iz

disappeared
• macrophage reappears as the dominant cell type in the alveolar space
H

n
io

• the debris of neutrophils, bacteria, and fibrin has been cleared, as has the inflammatory
ut

response
sol
Re

Source: Harrison’s Principle of Internal Medicine 20 th edition

Etiology

Source: Harrison’s Principle of Internal Medicine 20 th edition

Classification and Disposition
Low-risk CAP Moderate-risk CAP High-risk CAP
Vital Signs Stable Unstable Any of the criteria
• RR <30/min • RR ≥30/min under moderate-risk
• PR <125 bpm • PR ≥125 bpm CAP, PLUS any of the
• Temp 36-40 C • Temp ≥40 C or ≤36 C following:
• BP ≥ 90/60 mmHg • BP < 90/60 mmHg • Severe sepsis and
septic shock, or
Features • No altered mental • Altered mental state
• Need for
state of acute onset of acute onset
mechanical
• No suspected • Suspected aspiration
ventilation
aspiration • Decompensated
• No or stable comorbids
comorbids
Chest X-ray • Localized infiltrates • Multilobar infiltrates
• No pleural effusion • Pleural effusion
• No abscess • Abscess
Disposition Outpatient Ward admission ICU admission

Source: IM Platinum, 3rd edition

II. Salient Points

Florencio, a 72-year-old farmer, was brought to

the clinic because of fever, cough, and dyspnea
of 5 days duration. He was given on his first
consult with levofloxacin, guaiphenesin, and
paracetamol which gave temporary relief. Upon
follow-up, DOB worsened, chest radiograph
requested revealed diffuse infiltrates over his
lower lung fields.
 History - Identifying Data

Given Data Missing Points

• Florencio • Marital status
• 72 yrs old • Address
• Male • Religion
• Farmer • Date and time of history
• No. of times admitted in the
institution
• Reliability
 History - Chief Complaint

Given Data Missing Points

• Fever, cough, dyspnea of 5 days
duration
 History - Present Illness
Given Data
• Acute onset
• 5 days duration
• Patient was given levofloxacin,
guaifenesin, and paracetamol
which offered temporary relief.
• Upon follow up, difficulty of
breathing worsened
Missing Points
• Fever grade and presence of
other associated symptoms
• Characteristic of cough
• Dose and frequency of use of
the medications
• The interim between prior and
current consultation
• Compliance to medications
 History - Past Medical

Given Data Missing Points

• None • Presence of medical conditions
such as asthma, cardiovascular
diseases, and other
comorbidities
• Health maintenance:
immunizations (Pneumococcal
and influenza vaccinations)
 History - Family History

Given Data Missing Points

• None • History of respiratory diseases
and other heritable illnesses
 History - Personal & Social

Given Data Missing Points

• Occupation • Exercise and diet
• History of alcohol intake
• Smoking history
 History - Review of Systems

Given Data Missing Points

• None • Gastrointestinal symptoms
such as nausea, vomiting,
and/or diarrhea.
• Other symptoms may include
fatigue, headache, myalgias,
and arthralgias.
• Neurologic: new-onset or
worsening confusion
 Physical Examination
General Survey
The general condition of the patient should be noted. Observe the patient’s general
state of health.

Vital Signs
No data regarding vital signs were indicated
• RR <30/min
• PR <125 bpm
• Temp 36-40 C
• BP ≥ 90/60 mmHg

Chest and Lungs

Inspection: use of accessory muscles of respiration is common.
Palpation: increased or decreased tactile fremitus
Percussion: can vary from dull to flat, reflecting underlying consolidated lung and
pleural fluid, respectively.
Auscultation: Crackles, bronchial breath sounds, and possibly a pleural friction
rub may be heard
 Supporting Diagnostics
• The sensitivity and specificity of the findings on physical examination are less than ideal,
averaging 58% and 67%, respectively.

• Chest radiography is essential in the diagnosis of CAP, in assessing severity, and in

differentiating pneumonia from other conditions, and in prognostication.

• For outpatients, the clinical and radiologic assessments are usually all that is done before
treatment for CAP is started since most laboratory results are not available soon enough to
influence initial management significantly.

• Other diagnostic procedures can be done such as sputum gram stain and culture to identify
the etiologic agent.

• Further procedures than can be requested are blood culture and invasive procedures, but
the said procedures are indicated in severe CAP or in critically-ill CAP patients.

Source: Harrison’s Principle of Internal Medicine 20 th edition

 Primary care skills and tools
1. Complete and proper history

2. Proper physical examination

3. Request for laboratory examinations such as gram’s stain and culture

of sputum, blood cultures, serology, biomarkers, urinary antigen test,
polymerase chain reaction to rule out etiologic diagnosis

4. Request for chest radiography which is often necessary to differentiate

CAP from other conditions to rule out differential diagnosis.

Source: Harrison’s Principle of Internal Medicine 19 th edition

III. Patient Education and Family Intervention
Risk factors

Several risk factors for CAP are recognised, including age >65years,
smoking, alcholism, immunosuppressive conditions, and conditions
such as COPD, cardiovascular disease, cerebrovascular disease,
chronic liver or renal disease, diabetes mellitus & dementia.

Source: Harrison’s Principle of Internal Medicine 19 th edition

Source: Harrison’s Principle of Internal Medicine 19 th edition
Diagnosis

Source: Harrison’s Principle of Internal Medicine 19 th edition

Diagnosis

Source: Harrison’s Principle of Internal Medicine 19 th edition

 Management
Since the etiology of CAP is rarely
known at the outset of treatment,
initial therapy is usually empirical,
designed to cover the most likely
pathogens.

Source: Harrison’s Principle of Internal Medicine 20 th edition

 Management
In addition to appropriate antimicrobial therapy, certain adjunctive
measures should be used. Adequate hydration, oxygen therapy for
hypoxemia, vasopressors, and assisted ventilation when necessary
are critical to successful treatment.

Source: Harrison’s Principle of Internal Medicine 20 th edition

 How would you communicate the risks
diagnosis and interventions?
• Explain risk factor diagnosis and all possible interventions to the
patient and family in simple undterstandable manner

• Explain the impact of alcohol, and encourage them to avoid

alcoholism

• Maintaining a healthy diet, staying hydrated, drinking plenty of water

to help prevent mucus building up

• Encourage patient & family to be vaccinated; Influenza and

Pneumococcal vaccination
Source: Harrison’s Principle of Internal Medicine 19 th edition
 How would you communicate the risks
diagnosis and interventions?
• Explain them to avoid exposure to bats, birds, rabbit, sheep, goats,
cats

• Smokers should be strongly encouraged to stop smoking

Source: Harrison’s Principle of Internal Medicine 19 th edition

 Managing psychosocial issues
• Patients with CAP can have psychosocial issues such as
depression or anxiety, in such case first of all make patient
comfortable, support him /her by listening to his/her
concerns so that patient can feel encouraged, show empathy
towards patient & his/her family.
 IV. Social Relevance
Will there be any advocacies for family & community?

As our patient is suffering from CAP with mild risk, home treatment can
be applied is getting plenty of bed rest, drinking plenty of fluids
especially water to help loosen mucus in the lungs & can take oral
antibiotic like doxycycline. If no idea for self medication, primary health
care team should be informed.

In addition,public awareness health campaigns should be launched to

raise awareness about every detail information about CAP & its impact
on personal health as well as community.
 IV. Social Relevance
How would you conduct these?

• Public awareness on good health hygiene

• Health campaigns for vaccinations
• Nutritious diet policy
• Smoking use policy
V. Collaborative Management
If there was need for referral, how would you prepare the
patient?

• Explain the patient why referral is needed.

• Allow patient to ask questions if he/she is willing to ask &

answer calmly.

• Contact the specialist about the referral & discuss about the
patient .
V. Collaborative Management
To what discipline shall you refer?

Pulmonologist
Cardiologist
Palliative care
Geriatric care
 VI. Research
Methods
Clinical and imaging data of 165 COVID-19 patients
from seven hospitals in China, aged 5 to 91 years with an
average age of 45.1 ± 17.6 years and 118 patients with CAP
aged 1 to 76 years with an average age of 15.6 ± 21.4 years
were recorded and compared.

Age, white blood cell count, and ground-glass

Conclusion
opacity in CT have high accuracy in the early diagnosis of
COVID-19 and the differential diagnosis from CAP.

You can simply impress your audience and add a

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Liu, K. C., Xu, P., Lv, W. F., Chen, L., Qiu, X. H., Yao, J. L., ... & Wei, W. (2020). Differential diagnosis of coronavirus disease 2019 from community-acquired-pneumonia by computed tomography
scan and follow-up. Infectious diseases of poverty, 9(1), 1-11.
Methods
337 patients with CAP who received nemonoxacin
monotherapy (500 mg orally once daily) were selected from
outpatients. Their characteristics, pneumonia-related
symptoms, treatment effects, and adverse reactions were
recorded.

In the current situation of severe drug resistance,

Conclusion
nemonoxacin is an emerging option for the treatment of
CAP. Specifically, in outpatients with mild to moderate
CAP, it can be used to effectively control the disease
without the need for intravenous administration or
inpatient treatment. Moreover, as it is associated with
relatively few adverse reactions and is well tolerated, it can
be safely and effectively used for treating CAP.
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Zhao, B., Yu, X., Chen, R., & Zheng, R. (2020). Efficacy and Safety of Nemonoxacin in Outpatients with Community-Acquired Pneumonia. Infection and Drug Resistance, 13, 2099.
Methods
Different databases were used to gather randomized
controlled trials evaluating nemonoxacin and levofloxacin
in the treatment of CAP.

The clinical and microbiologic efficacy of

Conclusion
nemonoxacin is comparable to that of levofloxacin in the
treatment of CAP, and this agent is as well tolerated as
levofloxacin.

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Chang, S. P., Lee, H. Z., Lai, C. C., & Tang, H. J. (2019). The efficacy and safety of nemonoxacin compared with levofloxacin in the treatment of community-acquired pneumonia: a systemic review
and meta-analysis of randomized controlled trials. Infection and Drug Resistance, 12, 433.
Methods
The clinical efficacy of lefamulin in patients with CAP has been
evaluated in two multicentre, randomized, double-blind, double-dummy,
phase 3 trials, the Lefamulin Evaluation Against Pneumonia (LEAP 1 and
2) trials.
• LEAP 1 study evaluated the efficacy and safety of iv-to-oral lefamulin
compared to moxifloxacin ± linezolid in adult patients with moderate
to severe CAP.
• LEAP 2 study: compared the safety and efficacy of 600 mg of oral
lefamulin twice daily for 5 days versus 400 mg of oral moxifloxacin
once daily for 7 days in 738 adult patients with moderate CAP.

Conclusion
Lefamulin is a novel antibiotic for the empirical treatment of
patients with CAP. Its particular mechanism of action, affecting
ribosomal protein synthesis, provides a low probability of cross-
resistance to other commonly used antibiotics in CAP. Its antimicrobial
activity, pharmacokinetic parameters and safety profile makes it a good
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alternative for patients with CAP.
unique zing and appeal to your Presentations. Get
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Falcó, V., Burgos, J., & Almirante, B. (2020). An overview of lefamulin for the treatment of community acquired bacterial pneumonia. Expert Opinion on Pharmacotherapy, 21(6), 629-636.
 References
Harrison’s Principles of Internal Medicine, 20th ed. 2018.

Liu, K. C., Xu, P., Lv, W. F., Chen, L., Qiu, X. H., Yao, J. L., ... & Wei, W. (2020). Differential diagnosis of
coronavirus disease 2019 from community-acquired-pneumonia by computed tomography scan and
follow-up. Infectious diseases of poverty, 9(1), 1-11.

Zhao, B., Yu, X., Chen, R., & Zheng, R. (2020). Efficacy and Safety of Nemonoxacin in Outpatients with
Community-Acquired Pneumonia. Infection and Drug Resistance, 13, 2099.

Chang, S. P., Lee, H. Z., Lai, C. C., & Tang, H. J. (2019). The efficacy and safety of nemonoxacin compared
with levofloxacin in the treatment of community-acquired pneumonia: a systemic review and meta-
analysis of randomized controlled trials. Infection and Drug Resistance, 12, 433.

Falcó, V., Burgos, J., & Almirante, B. (2020). An overview of lefamulin for the treatment of community
acquired bacterial pneumonia. Expert Opinion on Pharmacotherapy, 21(6), 629-636.
Thank you!