COMMUNITY

ACQUIRED
PNEUMONIA
BORLAGDAN / CONCEPCION /
GALANG / MALUYO
 OUTLINE
I. OBJECTIVES
II. GENERAL DATA
III. CHIEF COMPLAINT
IV. HISTORY OF PRESENT ILLNESS
V. REVIEW OF SYSTEMS
VI. PAST MEDICAL HISTORY
VII. FAMILY HISTORY (GENOGRAM, APGAR)
VIII. PERSONAL SOCIAL HISTORY
IX. PHYSICAL EXAMINATION
X. SALIENT FEATURES
XI. DIFFERENTIAL DIAGNOSIS
XII. WORKING IMPRESSION
XIII. LABORATORY AND IMAGING
OBJECTIVES
1. Discuss a case seen at DFCM ER
2. Form a diagnosis and plan for
the patient
3. Discuss the patient’s disease and
ideal diagnosis and
management
GENERAL DATA
● J.A.
● Age/Sex: 71/Female
● DOB: January 26, 1952
● Nationality: Filipino
● Religion: Catholic
● Concepcion Uno, Marikina
CHIEF COMPLAINT

Difficulty of Breathing
HISTORY OF PRESENT ILLNESS
● 1 week PTC: Productive cough with yellowish phlegm with associated
undocumented fever. No colds, no headache, no sore throat, no diarrhea,
no vomiting and no loss of appetite. Patient denies recent travel history
and exposure to PUIs or confirmed COVID-19 positive patients. No
medications taken no consult done.
● During the interim patient still experienced the productive cough and
undocumented intermittent fever.
● Few hours PTC: Experienced sudden difficulty of breathing while drying
kitchen utensils, associated with generalized body weakness, bouts of
coughing and hoarseness of voice. No colds, no headache, no fever, no
sore throat, no diarrhea, no vomiting and no loss of appetite and denies
recent travel history and exposure to PUIs or confirmed COVID-19 positive
patients. Due to progression of symptoms hence consult
 REVIEW OF SYSTEMS
General (-) weight gain/loss, (-) easy fatigability, (-) night sweats

Cutaneous (-) rash, (-) pigmentation, (-) hair loss, (-) pruritus

HEENT Head: (-) headache, (-) dizziness

Eyes: (-) conjunctival redness, (-) excessive lacrimation
Ears: (-) aural discharge, (-) decreased hearing
Nose: (-) nasal discharge, (-) itching
Throat: (-) sore throat

Cardiovascular (-) chest pain, (-) orthopnea

Abdominal (-) diarrhea, (-) constipation, (-) melena, (-) hematochezia

Genitourinary (-) dysuria, (-) urinary frequency

Endocrine (-) cold/heat intolerance, (-) polydipsia, (-) polyphagia

Musculoskeletal (+) joint pain, (-) limitation of motion

PAST MEDICAL HISTORY
● (+) Hypertension - 30 years
○ Telmisartan 40 mg OD, compliant
○ Amlodipine 10 mg OD, compliant
○ Usual bp: 120-130/80 mmHg
○ Highest bp: 140/80 mmHg
● (+) Dyslipidemia - 30 years
○ Rosuvastatin 20 mg OD, compliant
● (-) DM, (-) PTB, (-) Cancer, (-) prev. Covid-19 infection
● (-) Previous surgeries and hospitalizations
● Fully vaccinated with Pfizer (2x, no booster)
● (-) Flu and Pneumococcal vaccines
FAMILY HISTORY/GENOGRAM
PERSONAL AND SOCIAL HISTORY
● Non-smoker
● Non-alcoholic beverage drinker
● No illicit drug use
● Usual diet:
○ Vegetables, fish, chicken, fruits
● ADL: Taking care of grandchildren, watching TV
● Lives with husband, daughter and 4 grandchildren
PHYSICAL EXAMINATION
General Survey Awake, Alert, Not in cardiorespiratory distress.

Vital Signs BP 140/90 mmHg, HR:105 bpm, RR 19 cpm , Temp. 37.0*C,

SP02 97% at room air

Skin No jaundice, no cyanosis, warm to touch, moist, good skin

turgor, no lesions

HEENT Anicteric sclera, Pink palpebral conjunctiva, no nasoaural

discharge, (-) CLADS
PHYSICAL EXAMINATION
Chest/Lung Symmetrical chest expansion, (-) Retractions (+) Crackles,
right lower lung,

Heart Adynamic precordium, (+) tachycardic, Regular rhythm, no

murmur.

Abdomen Nondistended abdomen, normoactive bowel sound, soft,

nontender abdomen.

Extremities Normally gross extremities, No cyanosis, no edema, CRT <2

seconds.
SALIENT FEATURES

SUBJECTIVE OBJECTIVE

● (+) 71 year old ● (+) Crackles, right lower lung

● (+) Productive cough ● (+) Tachycardic at 105 bpm
● (+) Fever (undocumented) ● (-) chest retractions
● (+) Hoarseness ● (-) BP 140/90mmHg
● (+) Dyspnea (on exertion) ● (-) RR 19 cpm
● (+) Generalized body weakness ● (-) Temp. 37 *C
● (+) Hypertensive for 30 years ● (-) SpO2 97% at room air
● (+) Dyslipidemic ● (-) GCS15
DIFFERENTIAL DIAGNOSIS

RULE IN RULE OUT

● (+) Crackles, right lower
lung.
● (+) Productive cough
Can not totally rule out
● (+) Fever
COVID-19 INFECTION
● (+) Hoarseness
No exposure
● (+) Dyspnea
● (+) With comorbidities
DIFFERENTIAL DIAGNOSIS

RULE IN RULE OUT

● (-) Weight loss

● (+) Productive cough
● (-) Night sweats
● (+) Fever
● (-) Loss of appetite
PULMONARY TUBERCULOSIS ● (+) Dyspnea
● (-) 1 week
● (+) Generalized body
symptoms
weakness
● No exposure
DIFFERENTIAL DIAGNOSIS

RULE IN RULE OUT

● (+) Crackles, right lower
lung.
● (+) Productive cough
COMMUNITY ACQUIRED ● (+) Fever
Can not totally rule out
PNEUMONIA ● (+) Dyspnea
● (+) 71 y/o
● (+) Body weakness
PRIMARY WORKING IMPRESSION:
COMMUNITY ACQUIRED PNEUMONIA,
LOW RISK; COVID-19 SUSPECT, MODERATE
RISK, SYMPTOMATIC, HYPERTENSION -
CONTROLLED (1993), DYSLIPIDEMIA
(1993)
MANAGEMENT DONE AT ER:
● Chest x-ray
● 12 lead ECG
● CBC
● BUN
● Crea
● Na
● K
● ALT
● AST
● Rapid Antigen Test
LABORATORY AND IMAGING
CBC

WBC 11.7 10^3/uL Segmenters 70.1 %

Red blood cells 4.50 10^6/uL Lymphocytes 20.7 %

Monocyte 6.5 %
Hemoglobin 12.5 g/dL
Eosinophil 1.7 %
Hematocrit 39.4 %
Basophil 1.0 %
MCV 87.6 fL

MCH 27.9 pg

MCHC 32.1 g/dL

Platelet count 319 10^3/uL

LABORATORY AND IMAGING
Blood Chemistry

BUN 5.18 mmol/L

Creatinine 65.22 umol/L

SGOT/ AST 47.43 mmol/L

SGPT/ ALT 41.28 mmol/L

Sodium 139.2 mmol/L

Potassium 4.08 mmol/L

eGFR :77 mL/min/1.73m2

LABORATORY AND IMAGING
RAPID TEST SARS-COV-2 Antigen NEGATIVE
CHEST XRAY (05/12/23)
ECG (05/12/23)
FINAL DIAGNOSIS:
COMMUNITY ACQUIRED PNEUMONIA,
LOW RISK; COVID UNLIKELY (RAT
NEGATIVE 05/12/23), HYPERTENSION -
CONTROLLED (1993), DYSLIPIDEMIA
(1993)
Take home medications
● CEFUROXIME 500 MG/TAB BID X 7 DAYS
● AZITHROMYCIN 500 MG/ TAB OD X 3 DAYS
● NAC 600 MG/SACHET OD
● VIT C + ZINC TAB OD

Advised RT-PCR for confirmation, follow up at

Telehealth for interpretation of other lab results
and after course of treatment
DISCUSSION
I. INTRODUCTION
II. EPIDEMIOLOGY
III. PATHOPHYSIOLOGY
IV. CLINICAL MANIFESTATIONS
V. DIAGNOSTICS
VI. TREATMENT
VII. PREVENTION
VIII. PROGNOSIS
IX. DISCHARGE CRITERIA
X. PATIENT EDUCATION
 INTRODUCTION:
COMMUNITY-ACQUIRED PNEUMONIA
● Lower respiratory tract infection (pulmonary parenchyma) acquired in
the community within 24 hours to less than 2 weeks
● Aspiration- most common access of microorganisms to lower respiratory
tract
● Etiologic agents:
○ Typical organisms
■ S. pneumoniae- most common
■ Haemophilus influenzae
■ S. aureus
■ Klebsiella pneumoniae
■ Pseudomonas aeruginosa
○ Atypical organisms
■ Mycoplasma pneumoniae
■ Chlamydia pneumoniae
■ Legionella species
■ Respiratory viruses (influenza viruses, adenoviruses, human
metapneumovirus, and respiratory syncytial viruses)

Source: Harrison’s Principles of Internal Medicine, 20th edition

Lifted from Harrison’s Principles of Internal Medicine 20th edition
 EPIDEMIOLOGY
● In the United States,
○ CAP is the number one cause of death from infection among patients >65
years of age
○ CAP results in more than 1.2 million hospitalizations and more than 55,000
deaths annually
● In the Philippines,
○ the DOH recognizes CAP as a significant cause of morbidity and mortality
among adults.
○ It is the top medical claims reimbursed as reported by PhilHealth.

Sources: Harrison’s Principles of Internal Medicine, 20th edition & Management and Prevention of Adult Community Acquired Pneumonia Practice Guidelines 2020
RISK FACTORS
● alcoholism
● asthma
● immunosuppression
● age of ≥70 years
● In the elderly:
○ decreased cough and gag reflexes
○ reduced antibody and Toll-like
receptor responses

Source: Harrison’s Principles of Internal Medicine, 20th edition

 ACCESS OF MICROORGANISMS TO LOWER
RESPIRATORY TRACT:
● Aspiration from oropharynx
○ Most common mechanism
● Inhalation as contaminated droplets
● Hematogenous spread
● Contiguous extension from an infected
pleural or mediastinal space

Source: Harrison’s Principles of Internal Medicine, 20th edition

PHYSIOLOGY
● Defenses of the pulmonary system:
○ Mechanical factors
■ hair and turbinates of the nares- capture larger inhaled particles before
they reach the lower respiratory tract
■ branching architecture of the tracheobronchial tree- traps microbes on
the airway lining
■ mucociliary clearance and local antibacterial factors- clear or kill the
potential pathogen
○ Gag reflex and cough mechanism- prevents aspiration
○ Local proteins (e.g., surfactant proteins A and D)- have intrinsic opsonizing
properties, antibacterial or antiviral activity
○ Resident alveolar macrophages
○ Normal flora adhering to mucosal cells of oropharynx

Source: Harrison’s Principles of Internal Medicine, 20th edition

PATHOLOGY
● Edema
○ a proteinaceous exudate and of bacteria in the alveoli
● Red hepatization phase
○ presence of erythrocytes in the cellular intra-alveolar exudate gives this
second stage its name, but neutrophil influx is more important with regard to
host defense
● Gray hepatization phase
○ neutrophil is the predominant cell, fibrin deposition is abundant, and
bacteria have disappeared.
○ corresponds with successful containment of the infection and improvement
in gas exchange
● Resolution
○ the macrophage reappears as the dominant cell type in the alveolar space,
and the debris of neutrophils, bacteria, and fibrin has been cleared, as has
the inflammatory response
Source: Harrison’s Principles of Internal Medicine, 20th edition
PATHOLOGY

Source: https://www.amboss.com/us/knowledge/Pneumonia
PATHOPHYSIOLOGY
CLINICAL MANIFESTATIONS:
SYMPTOMS PE FINDINGS

● non-productive/productive cough ● increased respiratory rate

● SOB ● use of accessory muscles
● pleuritic chest pain ● tachycardia
● nausea ● increased/decreased tactile
● vomiting fremitus
● diarrhea ● dull to flat percussion note
● fatigue ● crackles
● myalgia
● arthralgia

Source: Harrison’s Principles of Internal Medicine, 20th edition

DIAGNOSIS
LABORATORY AND IMAGING
GSCS
● Recommend for patients with moderate to high risk
CAP, or with risk factors for MDRO infection

Blood Culture
● Recommended for patients with moderate and high
risk CAP.
LABORATORY AND IMAGING
Influenza Test
● Recommended for patients with high risk CAP preceded
by influenza-like illness symptoms (sore throat,
rhinorrhea, body malaise, joint pains) and any of the
following risk factors:

1. Aged 60 years and above

2. Pregnant
3. Asthmatic
4. Other comorbidities: uncontrolled diabetes mellitus, active
malignancies, neurologic disease in evolution, congestive heart failure
class II-IV, unstable coronary artery disease, renal failure on dialysis,
uncompensated COPD, decompensated liver disease
LABORATORY AND IMAGING
Legionella test
● May be considered for patients with high risk CAP.

CHEST XRAY
● Essential diagnosis of CAP, assessing severity,
differentiating pneumonia from other conditions and
in prognostication
● Posttreatment chest x-rays after a minimum of 6 to 8
weeks among patients with CAP to establish baseline
and to exclude other conditions.
LABORATORY AND IMAGING
CRP
● We do not recommend the use of CRP to monitor
treatment response among patients with CAP

PROCALCITONIN
● Procalcitonin may be used to guide antibiotic
discontinuation among patients with moderate or
high risk CAP.
PNEUMONIA RISK SCORE
TREATMENT
● Initiation
○ Antibiotic therapy should be initiated within 4 hours of
diagnosis establishment
● Duration of Treatment
○ Low to Moderate risk CAP - 5 days duration if stable
○ Extension
■ Pneumonia not resolving
■ Complicated by sepsis, meningitis, endocarditis and
other deep seated infection
■ Infection with less common pathogens
■ Infection with drug resistant pathogens
TREATMENT
● De-escalation
○ Clinically improving
○ Hemodynamically stable
○ Able to tolerate oral medications

Initial empiric broad spectrum/extended spectrum

antibiotic for MRSA, Pseudomonas or ESBL
↓
Targeted/Oral antibiotics based on culture results
TREATMENT
● Monitoring Response with Chest x-ray
○ Follow-up chest x-ray is NOT routinely performed to
monitor response to treatment
○ Post treatment chest x-rays after 6-8 weeks to
establish baseline and exclude other conditions
● Monitoring Response with CRP
○ Not recommended
● Monitoring Response with Procalcitonin
○ Not recommended for monitoring treatment response
○ May be used to guide antibiotic discontinuation in
moderate to high risk CAP
TREATMENT
● Patients not improving after 72hrs of empiric antibiotic treatment:
○ Review history, PE, and results of all investigations
○ Reassess patient for
■ Possible antibiotic resistance or
■ Presence of other pathogens (M.tb, viruses, parasites, or fungi)
○ Revise treatment
○ Follow-up CXR to investigate other conditions (pneumothorax,
cavitation, and extension to previously uninvolved lobes, pulmonary
edema, and acute respiratory distress syndrome)
○ Consider obtain additional specimens for microbiological testing
TREATMENT - LOW RISK CAP
Empiric Treatment
● Without comorbidities
○ Amoxicillin 1g TID or
○ Clarithromycin 500mg BID or
○ Azithromycin 500mg OD
● With comorbidities
○ Co-amoxiclav 500mg/125mg TID or 875mg/125mg BID or
○ Cefuroxime 500mg BID
Plus/Minus
○ Clarithromycin 500mg BID or Azithromycin 500mg OD or
○ Doxycycline 100mg BID
TREATMENT - MODERATE RISK CAP
Empiric Treatment
● Without Multiple Drug Resistant Organism
(MDRO)
○ Ampicillin-Sulbactam 1.5-3g q6 or
○ Cefotaxime 1-2g q8 or
○ Ceftriaxone 1-2g OD
Plus
○ Azithromycin 500mg OD/ Clarithromycin
500mg BID
TREATMENT - HIGH RISK CAP
Empiric Treatment
● Without MDRO infection
○ 1st line
■ Ampicillin-Sulbactam 1.5-3g IV q6 or
■ Cefotaxime 1-2g IV q8h or
■ Ceftriaxone 1-2g IV OD
Plus
■ Azithromycin 500mg PO/IV OD or
■ Erythromycin 500mg PO q6 or
■ Clarithromycin 500mg PO BID
TREATMENT - HIGH RISK CAP
Empiric Treatment
● Without MDRO infection
○ Alternative
■ Ampicillin-Sulbactam 1.5-3g IV q6 or
■ Cefotaxime 1-2g IV q8h or
■ Ceftriaxone 1-2g IV OD
Plus
■ Levofloxacin 750mg PO/IV OD or
■ Moxifloxacin 400mg PO/IV OD
TREATMENT - MODERATE TO HIGH RISK CAP
Empiric Treatment
● With MDRO and Risk Factors
○ Routine anaerobic coverage for
suspected aspiration pneumonia is
NOT recommended, unless lung
abscess or empyema is suspected
TREATMENT
Empiric Treatment for MDROs
● Methicillin Resistant Staphylococcus aureus (MRSA)
○ Non-pseudomonal Beta-lactam antibiotic
Plus
○ Macrolide or Respiratory Fluoroquinolone
Plus
○ Vancomycin 15mg/kg IV q12 or
○ Linezolid 600mg IV q12 or
○ Clindamycin 600mg IV q8
TREATMENT
Empiric Treatment of High Risk CAP
● Extended-spectrum beta-lactamases (ESBL)
○ Replace Non-pseudomonal Beta lactam
antibiotic with
■ Ertapenem 1g IV q24 or
■ Meropenem 1g IV q8 (if Ertapenem is not
available)
Plus
○ Macrolide or Respiratory Fluoroquinolone
TREATMENT
Empiric Treatment of High Risk CAP
● Pseudomonas aeruginosa
○ Replace Non-pseudomonal Beta lactam antibiotic with
■ Piperacillin-Tazobactam 4.5g IV q6 or
■ Cefepime 2g IV q8 or
■ Ceftazidime 2g IV q8 or
■ Aztreonam 2g IV q8 or
■ Meropenem 1g IV q8
Plus
○ Macrolide or Respiratory Fluoroquinolone
TREATMENT
Treatment of High Risk CAP
● Antiviral treatment
○ If with any of these factors and test positive for
influenza virus
■ Aged ≥60yrs
■ Pregnant
■ Asthmatic
■ Other comorbidities
○ Empiric treatment with antibacterial therapy during
periods of high influenza activity (July to January)
with high risk CAP preceded by influenza-like illness (sore
throat, rhinorrhea, body malaise, joint pains)
PREVENTION
● Pneumococcal polysaccharide Vaccine (PPSV) or
Pneumococcal conjugate vaccine (PCV) - adults ≥50 years
● PPSV to prevent
○ pneumococcal pneumonia
○ mortality from IPD or pneumonia
○ pneumonia among high-risk groups and adults ≥50 years
● Influenza vaccine in all adults
○ To prevent influenza
○ Influenza-like illness and hospitalization
Schedule of Pneumococcal Vaccination
● PCV13 1st then after at least 1 year, PPSV23. No revaccination needed
● >50 years who were previously given PPSV23, may be given PCV13 at
least 1 year after
● Adults who were previously given PPSV23 at <50 years old, but who are
now ≥50 years old may receive 1 dose of PCV13 at least 1 year after, then
another dose of PPSV23 after 1 year after PCV13 dose
● Adults >50 years old who were previously given PPSV23, WITHOUT
previous PCV13, may opt to be given another dose of PPSV23 after 5
years. No re-vaccination
DISCHARGE CRITERIA
● Temperature of 36-37*C
● Pulse <100/min
● Respiratory rate between 16-24/ min
● Systolic BP >90 mmHg
● Blood oxygen saturation >90%
● Functioning gastrointestinal tract.
COMPLICATIONS
● Metastatic infection
● Lung abscess
● Complicated pleural effusion
● Respiratory failure,
● Shock and multiorgan failure,
● Coagulopathy,
● Exacerbation of comorbid illnesses.
PROGNOSIS
● Young patients without comorbidity do well and usually recover fully
after ~2 weeks.
● Older patients and those with comorbid conditions can take several
week longer to recover fully.
● The overall mortality rate for the outpatient group is <5%.
● For patients requiring hospitalization, the overall mortality rate ranges
from 2 to 40%.
PATIENT EDUCATION
1 Week Fever

4 Weeks Chest pain & Sputum

production

6 Weeks Cough & Breathlessness

3 Months Most symptoms resolved,

fatigue may still be present

6 Months Back to normal

REFERENCES
● Harrison's Principles of Internal Medicine, Twentieth Edition
● Clinical Practice Guidelines Management and Prevention of Adult Community
Acquired Pneumonia, 2020.
THANK
YOU!