Severe Community Acquired Pneumonia (SCAP)

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Review Article

Severe Community Acquired Pneumonia (SCAP) Ajit Vigg a,b,c,d,e,* a

Head Dept. of Respiratory Medicine, Apollo Hospitals, Hyderabad, India Former Governor, American College of Chest Physicians (ACCP), South India Chapter, India c Former President, Indian Association of Bronchology, India d Member, Steering Committee, Sleep Network, ACCP, India e Member, American Academy of Sleep Medicine, India b

article info

abstract

Article history:

Although there are no large epidemiological studies from India, mortality data on total

Received 28 January 2015

number of deaths from lower respiratory tract infection are available. Whereas the world

Accepted 6 February 2015

wide mortality of CAP in hospitalised patients varies from 14%e50%, the reported mortality

Available online xxx

in India varies from 3.3% to 40% with higher rates in elderly & in those requiring intensive care unit (ICU) care. Use of clinical scores like CURB-65, & CRB 65 help to stratify risk of

Keywords:

severe disease & need for hospitalisation & ICU care. Early initiation of appropriate anti-

Severe community acquired

biotic based upon the knowledge of local resistant patterns of existing pathogens is the key

Pneumonia

for successful treatment.

Streptococcus pneumoniae

Pneumonia is the seventh leading cause of death in United States.1 It is estimated that

Clinical scores

there are 4 million cases of community-acquired pneumonia (CAP)/yr in the United States

Initial early appropriate antibiotic

which result in approximately 10 million physician visits, 1 million hospitalizations, and 45,000 deaths.2 There are no large studies from India on incidence of CAP3; however, mortality data on total number of deaths are available related to lower respiratory tract infection (LRTI).4 Number of deaths due to LRTI was 35.1/100,000 population in 2008 compared to 35.8/100,000 population for tuberculosis & deaths related to gastro intestinal infections & parasitic diseases was 194.9/100,000 population. As per the WHO data overall mortality due to LRTI is around 20% in our country.4 Worldwide mortality of CAP in hospitalised patients is 14% but increases to 20%e50% in those requiring Intensive Care Unit (ICU)care. The reported mortality from CAP in India is similar to that reported elsewhere in the world. In one Indian series of admitted patients with CAP, 8% had hospital mortality & 2.7% had 30 day mortality.5 In a recent study decrease in mortality in Severe Community-Acquired Pneumococcal Pneumonia was seen with early antibiotic and combined therapeutic intervention.6 Another study of 72 Indian patients with CAP showed mortality of 35% in elderly & 14% in young Indian patients.7 Mortality has varied from 3.3% to 11% in several other Indian studies.8,9 Pneumonia is characterized by the presence of fever, altered general well-being, and respiratory symptoms such as cough (90%), expectoration (66%), dyspnoea (66%), pleuritic pain (50%), and haemoptysis (15%).3 Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.

* Vigg Villa 553, Rd No 3, Banjara Hills, Hyderabad 500034, India. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.apme.2015.02.010 0976-0016/Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.

Please cite this article in press as: Vigg A, Severe Community Acquired Pneumonia (SCAP), Apollo Medicine (2015), http:// dx.doi.org/10.1016/j.apme.2015.02.010

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Community Acquired Pneumonia presents with mild to severe symptoms which can be treated in outpatient or inpatient (ward or ICU) depending on the severity. The common pathogens which cause CAP are: Outpatient setting: Streptococcus pneumonia, Mycoplasma pneumonia, Haemophilus influenza, Chlamydia pneumoniae and Respiratory viruses. Inpatient (non-ICU) Streptococcus Pneumonia, M. Pneumoniae, C. Pneumoniae, H. Influenzae, Legionella species, and Respiratory viruses. Inpatient (ICU) Streptococcus Pneumonia, Staphylococcus aureus, Legionella species, Gram-negative bacilli, H. Influenza.2 There are very few Indian reports on aetiological agents of CAP. In a study of Blood cultures performed in CAP, Streptococcal Pneumoniae was the most common isolate (35.3%), followed by staphylococcus aureus (23.5%), klebseilla pneumonia (20.5%) & Hemophilus influenzae (8.8%).8 Another Indian study published a decade ago found Mycoplasma Pneumoniae in 15% of their cases with CAP.7,9 Legionella pneumophilia was detected with high serological titres in 27% of patients with CAP in one more Indian study.10 Severe Community Acquired Pneumonia is one which requires ICU admission The severity of CAP can be assessed with the help of different scores like Pneumonia severity index (PSI), CURB-65 Score & CRB 65 score in primary settings. All the Scores help in making decision on site of care and indicate the risk of mortality.11 PSI score consists of 20 variables, Patients who have a PSI score of 70 or less (class I or II) risk of death of less than 1% and require outpatient treatment. Patients with a PSI score of 71e90 (class III) have a risk of mortality of 2.8% and may benefit from brief hospitalization. Hospital care is appropriate for patients with scores of 91e130 (class IV), who have a 30-day risk of

Minor criteriaa Respiratory rateb  30 breaths/min PaO2/FiO2 ratiob 250 Multilobar infiltrates Confusion/disorientation Uremia (BUN level, 20 mg/dL) Leukopeniac (WBC count, <4000 cells/mm3) Thrombocytopenia (platelet count, <100,000 cells/mm3) Hypothermia (core temperature, <36  C) Hypotension requiring aggressive fluid resuscitation Major criteria Invasive mechanical ventilation Septic shock with the need for vasopressors Note. BUN, blood urea nitrogen; PaO2/FiO2, arterial oxygen pressure/fraction of inspired oxygen; WBC, white blood cell. a Other criteria to consider include hypoglycemia (in nondiabetic patients), acute alcoholism/alcoholic withdrawal, hyponatremia, unexplained metabolic acidosis or elevated lactate level, cirrhosis, and asplenia. b A need for noninvasive ventilation can substitute for a respiratory rate >30 breaths/min or a PaO2/FiO2 ratio <250. c As a result of infection alone. Adapted Mandell LA, Wunderink RG, Anzueto A, et al.: Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 44(Suppl 2):S27eS72, 2007.

death of 8.2%e9.3%, and for patients with a score of more than 130 (class V), who have a 30-day risk of death of 27.0%e31.1%.12 CURB-65 Score- 1 point for each of the criteria present:- (1) confusion; (2) urea higher than 7 mmol/L; (3) respiratory rate of 30/min or more; (4) low systolic (<90 mm Hg) or low diastolic (60 mm Hg) blood pressure; and (5) age 65 years or older. CURB- 65 score of 0e1 be treated as outpatients; those with a score of 2 be admitted to the wards, and those patients with a score of 3 often require ICU care.13,14 The IDSA and the ATS ICU admission criteria for patients with CAP: According to this criteria patient with 3 minor criteria or one major criterion qualifies for ICU admission.15 Many guidelines have been formed for the management of community acquired pneumonia. The widely used guidelines are the ones from American Thoracic Society (ATS)/Infectious disease society of America (IDSA), British thoracic society (BTS), National institute for health and care excellence (NICE). Recently Indian guidelines have been formed by ICS/NCCP.9 They are in line with the international guidelines. The diagnosis of severe community acquired is based on the clinical features like fever, cough, sputum production and pleuritic chest pain with chest radiography and physical examination of rales or bronchial breath sounds. In elderly patient clinical features or physical finding might be less or altered. Chest radiography helps in knowing etiological agent, alternative diagnosis, prognosis of the patient etc. Pulse oximetry helps in identifying hypoxemia in a diagnosed patient.

1. Management of Severe Community Acquired Pneumonia15e18 Microbiological investigation of severe community acquired pneumonia (CAP) 1. Blood cultures (minimum 20 ml) 2. Sputum or other respiratory sample for routine culture and sensitivity tests 3. Pleural fluid, if present, for microscopy, culture and pneumococcal antigen detection. 4. Pneumococcal urine antigen test 5. Investigations for legionella pneumonia: (a) Urine for legionella antigen (b) Sputum or other respiratory sample for legionella culture and direct immunofluorescence (if available) 6. Investigations for atypical and viral pathogens: (a) If available, sputum or other respiratory sample for PCR or direct immunoflourescence (or other antigen detection test) for Mycoplasma pneumonia, Chlamydia species, Influenza A and B, Parainfluenza 1e3, adenovirus, respiratory syncytial virus, Pneumocystis jirovecii (if at risk) 7. (b) Consider initial and follow-up viral and “atypical pathogen” serology Appropriate antimicrobials are the main stay of treatment; it helps in eradicating the infecting agent and resolution of clinical disease. Antibiotics should be started as soon as possible once admitted to Hospital. (within one hour ideally). Local knowledge of drug resistant patterns in the community

Please cite this article in press as: Vigg A, Severe Community Acquired Pneumonia (SCAP), Apollo Medicine (2015), http:// dx.doi.org/10.1016/j.apme.2015.02.010

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& hospital play an important role in selecting empircal antibiotic initially. 1) Empirical Antibiotic therapy in Severe Community Acquired Pneumonia  b-lactam (cefotaxime, ceftriaxone, or ampicillinsulbactam) plus either azithromycin or a fluoroquinolone (For penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are recommended.)  For Pseudomonas infection, use an antipneumococcal, antipseudomonal b-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750-mg dose) or  the above b-lactam plus an aminoglycoside and azithromycin or  the above b-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone. (For penicillin-allergic patients, substitute aztreonam for the above b-lactam.) 2) Shift to Specific antibiotic once the culture and sensitivity report is available. 3) If there is no improvement in 48e72 h the patient should be evaluated for non responsive pneumonia e atypical pathogen and drug resistant pathogen. 4) Switch from intravenous to oral therapy once the patient is heamodynamically stable and clinically improving and able to take medication orally. 5) Steroids are not recommended routinely for treatment of severe CAP. 6) CAP with ARDS and CAP leading to severe sepsis and septic shock should be treated with ARDS net trial protocol and surviving sepsis campaign protocol respectively. 7) Preventive measures i. Smoking Cessation in smokers ii. Influenza vaccination iii. Pneumococcal vaccination for the people at risk of developing invasive pneumococcal pneumonia.

Conflicts of interest The author has none to declare.

references

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Please cite this article in press as: Vigg A, Severe Community Acquired Pneumonia (SCAP), Apollo Medicine (2015), http:// dx.doi.org/10.1016/j.apme.2015.02.010