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Differential diagnosis
The differential diagnosis includes acute bronchitis, COPD exacerbation, left
ventricular failure, pulmonary embolism, TB, exacerbation of pulmonary fibrosis
and rare lung disorders (e.g. pulmonary eosinophilia).
Microbial aetiology and resistance
The same 10 pathogens commonly cause CAP worldwide, with Streptococcus
pneumoniae being the most common overall and the most important cause of
severe illness and death. Mycoplasma pneumoniae is also a common cause of
mild illness, especially in young adults. Severe illness is most likely to be
associated with S. pneumoniae, Legionella, staphylococcal or Gram-negative
bacterial infection. Legionella infection may occur in outbreaks associated with a
water aerosol source, such as showers or decorative fountains.
Staphylococcal infection is especially common following influenza virus infection
and in intravenous drug abusers. Influenza occurs in seasonal outbreaks during
the winter months and occasional pandemics. It is the most common viral cause
of CAP.
Bacterial antibiotic resistance varies in frequency between countries. Clinically
significant resistance to penicillins in S. pneumoniae is rare but clinically
significant macrolide resistance is more common,
especially in Southern Europe.
Nosocomial pneumonia is most commonly caused by Gram-negative
enterobacteria or Staphylococcus aureus. Pseudomonas aeruginosa and
multiresistant bacteria (e.g. methicillin-resistant S. aureus (MRSA) are important
causes of VAP.
Severity assessment
Severity assessment is the key to deciding the place of care and should also
guide diagnostic tests and antimicrobial therapy. This should be done through
clinical judgement guided by objective severity scores. There are many of these,
but the best validated for CAP are CURB65 (and its derivative CRB65) and the
pneumonia severity index (PSI). The latter is based on a score from 20 variables
and is often not practical in routine practice. The former is simpler and based on
the number of severity variables present.
Management
Correction of gas exchange and fluid balance abnormalities, and the provision of
appropriate antimicrobial therapy are the cornerstones of management. Outside
hospital, rest, oral fluids and an oral antibiotic may be all that is required. In
hospital, oxygen at a concentration to maintain SaO2 (9295%) should be
delivered. If this cannot be achieved, CPAP may be helpful. If there is an
unacceptable rise in PaCO2, then assisted ventilation should be considered. A
place for NIV in pneumonia management has yet to be proven.
Initial antibiotic therapy must be empirical and directed by illness severity
according to national or international guidelines.
Empirical antibiotics for CAP should always include pneumococcal coverage.
Treatment for nosocomial pneumonia should be guided by knowledge of local
microbial causes and that for pneumonia in the immunocompromised by the
type of immune suppression and likely pathogens. Duration of therapy is usually
7 days in uncomplicated cases but may need to be prolonged in severe illness.
Failure to respond should prompt a re-evaluation of the correct diagnosis and a
more detailed search for microbial cause, for example by bronchoscopy, as long
as gas exchange function will allow.
Below, from:
Richard G. Wunderink, M.D., and Grant W. Waterer, M.B., B.S., Ph.D. CommunityAcquired Pneumonia. N Engl J Med 2014;370:543-51.
Richard G. Wunderink, M.D., and Grant W. Waterer, M.B., B.S., Ph.D. CommunityAcquired Pneumonia. N Engl J Med 2014;370:543-51.
Richard G. Wunderink, M.D., and Grant W. Waterer, M.B., B.S., Ph.D. CommunityAcquired Pneumonia. N Engl J Med 2014;370:543-51.
Richard G. Wunderink, M.D., and Grant W. Waterer, M.B., B.S., Ph.D. CommunityAcquired Pneumonia. N Engl J Med 2014;370:543-51.
From: J. Gonzlez-Castillo, et al.Guidelines for the management of communityacquired pneumonia in the elderly patient. Rev Esp Quimioter 2014;27(1): 69-86.
From: J. Gonzlez-Castillo, et al.Guidelines for the management of communityacquired pneumonia in the elderly patient. Rev Esp Quimioter 2014;27(1): 69-86.