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Ri 2003/10/27
Definition
CommunityCommunity-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. long-Clin. infect Dis. 2000;31:347-82 2000;31:347-
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; 333:1618-24 333:1618-
Epidemiology
Pathogens that cause CAP
Pathology
Primarily involve the interstitium or the alveoli. Lobar pneumonia bronchopneumonia Necrotizing pneumonia Lung abscess
-Harrisons Principles of Internal Medicine, 15th edition (2001) Harrison
Clinical Manifestations
Typical presentation Atypical presentation Syndromes of the two presentation sometimes might be overlapping
-Harrisons Principles of Internal Medicine, 15th edition (2001) Harrison
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; 347:2039-45 347:2039-
Clinical Manifestations
Atypical presentation
More gradual onset Dry cough Extrapulmonary symptoms
LegionellaLegionella-CNS, heart, liver, GI and GU M.pneumoniae- upper RT, GI, skin M.pneumoniae
The point that extrapulmonary organ involvement separate atypical from typical pneumonia cannot be overemphasized!
-Eur J Clin Microbiol Infect Dis (2003) 22: 579-583 579-
Diagnosis
Does this patient have CAP?
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 1997;278:2080-
Diagnosis
History and physical examination Image study Laboratory-based approach LaboratoryInvasive procedures
Image Study
LaboratoryLaboratory-based approach
WBC count C-reactive protein Sputum culture and smear Blood culture Pleural effusion analysis Serology PCR
-Thorax 2002; 57:267-271 57:267-
Invasive Procedures
Bronchoscopy
Upper airway flora contamination Pathogen yield rate: 13~48% Pathogen yield rate: 12~30%
-Thorax 2002; 57:267-271 57:267-
Conclusion
Careful choice and combination of multiple diagnostic methods would yield optimal result.
Treatment
Despite the improvement in diagnostic methods, some cases of CAP (may up to 30%) cant can isolate a specific pathogen.
-Thorax 2002; 57:267-271 57:267-
Resistance to other antibiotic classes is higher among penicillin-resistant strains. penicillin-J Antimicrob Chemother 1996;38(suppl):71-84 1996;38(suppl):71-
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 120:2021-
Macrolide (clarithromycin or azithromycin for H. influenzae) influenzae) Fluoroquinolones Doxycycline Amoxicillin-clavulanate Amoxicillin2nd generation cephalosporin
-Chest 2001; 120:2021-2034 120:2021-
3rd generation cephalosporin plus a macrolide or doxycycline Antipneumococcal fluoroquinolones Beta-lactam-betaBeta-lactam-beta-lactamase inhibitor plus a macrolide or doxycycline
-N Engl J Med 2002; 347:2039-45 347:2039-
PathogenPathogen-specific Treatment
PathogenPathogen-specific Treatment