Current Diagnosis & Management of CAP in the UK

• CAP vs HAP

  CAP

  • pnuemonia acquired outside hospital or healthcare facilities

  HAP

  • pneumonia acquired ≥ 48 hours into hospital admission that wasn't incubating on admission
  • recently hospitalised patients can be treated as CAP unless additional risk factors for multiple drug resistance (HAP)
• DDx of respiratory tract infection

  Tachietis

  Acute bronchitis

  Infective exacerbation COPD

  Bronchiolitis

  Infective exacerbation bronchiectasis

  Pneumonia

  Lung abscess

  Empyema
• What is the pathological definition of pneumonia?

  Inflammation of lung parenchyma leading to consolidation

  Doesn't have to be infectious or bacterial
• What is the clinical definition of pneumonia?

  Symptoms of lower respiratory tract infections with CXR changes

  Usually treated as due to bacterial infection
• Pneumonia disproportionally affects…

  • Old - co-morbidities, frality, immunosensescence
  • Disadvantaged - socioeconomic deprivation
• Pneumonia has more hospital admissions & bed days than any other lung disease.

  3rd commonest cause of death from lung disease (after cancer & COPD)

  15% mortality within 30 days

  Most common source of sepsis presenting in ED

  Most common cause of acute respiratory distress syndrome
• What are the 4 typical bacterial pathogens thay cause pneumonia?

  Streptococcus pneumoniae

  Haemophilus influenza

  Moraxella catarrhalis

  Staphylococcus aureus
• What are 4 atypical bacterial pathogens that cause pneumonia?

  Mycoplasma pneumoniae

  Chlamydophilia pneumoniae

  Chlamydia psittaci

  Legionella pneumoniae
• What are 3 'other' bacterial pathogens that can cause pneumonia?

  Psudomonas aeruginosa

  Enterobacteriaceae

  Group A streptococcus
• What are atypical pathogens?

  Usually pathogens that don't response to penicillins
• What are most cases of HAP caused by?

  Bacteria (esp, gram -ve)

  E.g.

  • Pseudomonas aeruginosa
  • E.coli
  • Klebsiella pneumoniae
  • Acinetobacter MRSA
• What are the risk factors for pneumonia?

  Age > 65

  Residence in healthcare setting

  COPD

  HIV infection

  Cigarette smoke exposure

  Alcohol abuse

  Poor oral hygiene

  Contact with children

  Drugs - ICS, opioids etc.

  Diabetes mellitus

  Chronic liver disease

  CKD

  Sickle cell disease

  Splenectomy
• What are the differential diagnosis of pneumonia?

  Left ventricular failure

  PE

  Infective exacerbation COPD

  Infective exacerbation bronchiectasis

  Acute asthma

  TB

  Empyema

  Lung neoplasm

  Oesophageal rupture
• When should you consider 'atypical pathogens'?

  Foreign travel

  Prior antibiotics

  Hyponatraemia (mycoplasma)

  Air conditioning exposure

  Diarrhoea

  Abnormal LFTs

  Neurological symptoms

  Headache (chlamydophila pneumoniae)

  Sub-acute presentation

  Likely to have aspirated
• How does a pneumonia pts often present?

  Fever

  Cyanosis

  Tachypnoea

  Dyspnoea

  Localising signs (dullness to percussion, bronchial breathing, crackles)
• A CXR is needed to confirm a diagnosis of pneumonia.
• What are the BTS audit standards for CXR?

  CXR within 4 hours of admission

  CXR taken & CAP confirmed within 4 hours of admission
• Apart from a CXR, what other investigations should be done for pneumonia?

  Bloods - FBC, U&Es, LFTs, CRP, ABG?

  Blood cultures

  Sputum cultures

  Pneumococcal/legionella urinary antigen testing

  HIV testing - in younger pts or if known risk factors (has to be done with patient consent)
• What is the British Thoracic Society Community Acquired Pneumonia Care Bundle?

  Perform CXR within 4hrs of admission

  Assess O2 sats & prescribe O2 according to appropriate target range

  Calculate CURB-65 in all pts where CXR demonstrates pneumonia

  Administer antibiotics within 4hrs of diagnosis appropriate to CURB-65 score
• What is the role of a microbiologist?

  Antimicrobial stewardship

  Infection control

  Monitoring of organ prevelence

  Antibiotic sensitivity testing

  Antimicrobial advice

  A sounding board - helpful
• What is done if the pneumonia is not getting better?

  Consider differential diagnosis

  • empyema
  • lung abscess
  • lung cancer

  Consider different organism & antimicrobial resistance

  • reculture, discuss with microbiology
• What is shown in the image?

  Empyema (new pleural effusion)

  
• What is shown in the image?

  Lung abscess

  
• What is shown in the image?

  Lung cancer

  
• What are the viral pathogens that can cause CAP?


  Influenza A

  Influenza B

  Parainfluenza

  Rhinovirus

  Metapneumovirus

  Respiratory syncytial virus

  Corona virus (SARS, MERS, COVID-19)
• What is a usual presentation of pneumonia?

  Chills

  SOB

  Cough (productive)

  Pleurtic chest pain

  Haemoptysis

  Malaise (overall weakness)

  Arthralgia (pain in joint)

  Myalgia (muscle aches & pain)
• How might penumonia present in elderly/immunocompromised pts?

  Atypical presentation

  Confusion
• How might pneumonia present with legionella infection?

  Confusion

  GI upset

  Hyponatraemia

  Transaminitis (elevated, LFTs)

  Lymphopaenia (low lymphocytes)
• How might pneumonia present wirth mycoplasma infection?

  Myringitis (inflammation of tympanic membrane)

  Uveitis

  Iritis

  Encephalitis (inflammation of brain)

  Myocarditis
• A CXR is needed to confirm a pneumonia diagnosis, until then it is ony 'suspected CAP/HAP'
• What is shown on a CXR for pneumonia?

  Consolidation
• What is CURB-65?

  Confusion (AMTS </= 8/10)

  Urea (> 7 mmol/L)

  Resp rate (>/= 30 breaths/min)

  BP (SBP < 90 mmHg, DBP </= 60 mmHg)

  Age (> 65 years)

  Gives a score out of 5, can use to predict 30 day mortality risk

  • 0-1 = low severity < 3%
  • 2 = moderate severity = 9%
  • 3-5 = high severity = 15-40%
• Apart from CXR & CURB-65, what other investigations should be done for pneumonia pts?

  FBC

  U&Es

  LFTs

  CRP

  ABG (if low O2 sats)

  Blood cultures (severe)

  Sputum cultures (severe)

  Consider HIV testing
• What is the management of pnuemonia?

  Depends on severity

  CURB-65 = 0-1

  • home treatment (unless other unstable co-morbidities)

  CURB-65 >/= 2

  • hospital treatment

  CURB-65 >/= 3

  • escalation decision/critical care review
• What are the contraindications to outpatient therapy?

  Inability to maintain oral intake

  Hx of substance abuse

  Severe co-morbid illnesses

  Cognitive impairment

  Impaired functional status

  Availability of support at home
• What is the management for ALL pneumonia pts?

  O2 (to keep sats in normal range)

  IV fluid (if hypotensive/acute kidney injury)

  VTE prophylaxis (LMWH)

  Nutritional support (if prolonged illness)

  Get out of bed & walking (at least 20 mins on 1st day & increase every day)

  Chest physio (if need to clear sputum)
• What antibiotics should be used for mild CAP (CURB-65 = 0-1)?

  1st line - amoxicillin

  Alternatives - clarithromycin OR doxycycline
• What antibiotics should be used for mild-moderate CAP (CURB-65 = 0-2)?

  1st line = amoxicillin

  Alternative = clarithromycin
• What antibiotics should be used in severe CAP (CURB-65 ≥ 3)?

  1st line = co-amoxiclav (IV)

  Alternative = cefuroxime (IV)
• What should you do to medication if an atypical pneumonia is suspected?

  Add in clarithromycin

  Regardless of CURB-65 score