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Community-acquired Pneumonia

Definition. Community-acquired pneumonia (CAP) is defined as an acute infection of the lung parenchyma accompanied by symptoms of acute illness, which is not acquired in hospitals or other long-term care facilities.-Clin. infect Dis. 2000;31:347-82. Epidemiology. One of the most common infectious diseases in the world.12/1,000/year, about 600,000 hospitalization cases per year (in the U.S.).The 6th leading cause of death in the U.S. (7th in Taiwan).The most common cause of death d9447

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Community-acquired Pneumonia

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    1. Community-acquired Pneumonia Ri ??? 2003/10/27

    2. Definition Community-acquired pneumonia (CAP) is defined as an acute infection of the lung parenchyma accompanied by symptoms of acute illness, which is not acquired in hospitals or other long-term care facilities. -Clin. infect Dis. 2000;31:347-82

    3. Epidemiology One of the most common infectious diseases in the world. 12/1,000/year, about 600,000 hospitalization cases per year (in the U.S.). The 6th leading cause of death in the U.S. (7th in Taiwan). The most common cause of death due to infectious disease. -N Engl J Med 1995; 333:1618-24

    4. Epidemiology

    5. Pathology Primarily involve the interstitium or the alveoli. Lobar pneumonia bronchopneumonia Necrotizing pneumonia Lung abscess -Harrison’s Principles of Internal Medicine, 15th edition (2001)

    6. Clinical Manifestations Typical presentation Atypical presentation Syndromes of the two presentation sometimes might be overlapping -Harrison’s Principles of Internal Medicine, 15th edition (2001)

    7. Clinical Manifestations Typical presentation Cough (>90%) Sudden onset of fever (80%) SOB (66%) Sputum production (66%) Pleuritic pain (50%) Signs of pulmonary consolidation (dullness, increased fremitus, egophony, bronchial breatathing sound, rales) -N Engl J Med 2002; 347:2039-45

    8. Clinical Manifestations Atypical presentation More gradual onset Dry cough Extrapulmonary symptoms Legionella-CNS, heart, liver, GI and GU M.pneumoniae- upper RT, GI, skin The point that extrapulmonary organ involvement separate atypical from typical pneumonia cannot be overemphasized! -Eur J Clin Microbiol Infect Dis (2003) 22: 579-583

    9. Diagnosis

    10. Diagnosis Prompt and accurate diagnosis of CAP is important, since it is the only acute respiratory tract infection in which delayed antibiotic treatment has been associated with increased risk of death. -JAMA 1997;278:2080-4

    11. Diagnosis History and physical examination Image study Laboratory-based approach Invasive procedures

    12. History and Physical Examination

    13. Image Study CxR, hrCT…… CxR: the “imperfect” gold standard Sensitivity/specificity Cost Availability Expertise -Ann Intern Med. 2003;138:109-118

    14. Laboratory-based approach WBC count C-reactive protein Sputum culture and smear Blood culture Pleural effusion analysis Serology PCR -Thorax 2002; 57:267-271

    15. Invasive Procedures Bronchoscopy Upper airway flora contamination Protected specimen brush (PSB) Pathogen yield rate: 13~48% Bronchoalveolar lavage (BAL) Pathogen yield rate: 12~30% -Thorax 2002; 57:267-271

    16. Conclusion Careful choice and combination of multiple diagnostic methods would yield optimal result.

    17. Treatment

    18. The Importance of Empirical Antibiotic Treatment Despite the improvement in diagnostic methods, some cases of CAP (may up to 30%) can’t isolate a specific pathogen. -Thorax 2002; 57:267-271 The availability of diagnostic methods -Chest 2001; 120:2021-2034

    19. The Menace of Drug-Resistance About 34% of pneumococcal isolates are penicillin-resistant. -Diagn Microbiol Infect Dis 1997; 29:249-257 The mechanism of resistance: altered penicillin-binding protein Resistant to amoxicillin-clavulanate -Antimicrob Agent Chemother 1990;34:2075-2080 Resistance to other antibiotic classes is higher among penicillin-resistant strains. -J Antimicrob Chemother 1996;38(suppl):71-84

    20. Role of Fluoroquinolones DNA gyrase inhibitors Potency Favorable pharmacokinetics Broad spectra of antimicrobial activities Excellent respiratory tissue penetration and activities against respiratory pathogens Drug resistance is uncommon -Chest 2001; 120:2021-2034

    21. Strategy of Management- the PORT Score Assessment

    22. Empirical Treatment for Out-Patient Macrolide (clarithromycin or azithromycin for H. influenzae) Fluoroquinolones Doxycycline Amoxicillin-clavulanate 2nd generation cephalosporin -Chest 2001; 120:2021-2034

    23. Empirical treatment for In-patient (General Ward) 3rd generation cephalosporin plus a macrolide or doxycycline Antipneumococcal fluoroquinolones Beta-lactam-beta-lactamase inhibitor plus a macrolide or doxycycline -N Engl J Med 2002; 347:2039-45

    24. Empirical treatment for In-patient (ICU) No risk of P. aeruginosa infection 3rd generation cephalosporin plus an anti-pneumococcal fluoroquinolones or a macrolide Beta-lactam-beta-lactamase inhibitor plus anti-pneumococcal fluoroquinolones or macrolide -N Engl J Med 2002; 347:2039-45

    25. Empirical treatment for In-patient (ICU) With risk of P. aeruginosa infection Antipseudomonal beta-lactam plus amino-glycoside plus macrolide or antipneumococcal fluoroquinolones Antipseudomonal beta-lactam plus ciprofloxacin -N Engl J Med 2002; 347:2039-45

    26. Pathogen-specific Treatment

    27. Pathogen-specific Treatment

    28. Poor Prognostic Factors

    29. When Can In-Patient Discharge?

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