1. .
INSTITUTE OF HEALTH SCIENCE
DEPARTMENT OF NURSING AND MIDWIFERY
PROGRAM OF ADULT HEALTH NURSING
Community Acquired Pneumonia (CAP)
BY AHN MSc student’s
Aug ,2022
Wollega
Ethiopia
2/5/2023 1
2. Group members
S/No Students name Track ID NO
1 Ashenafi Tesfaye AHN 1400225
2 Demiso Geneti AHN 1400227
3 Kidane Dinku AHN 1400228
4 Mulata Kanate AHN 1400283
5 Nasira Jamal AHN 1400229
6 Takele Mitiku AHN 1400230
7 Zewude Mulatu AHN 1400231
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3. Objectives of the presentation
At the end of the presentation the students will be
able to:-
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4. Pneumonia
• Pneumonia refers to acute inflammation of the distal
lung-terminal airways, alveolar spaces, and interstitial.
• Common illness which occurs in all age group
• Leading cause of M&M in Infants and Older People
& people who are chronically & terminal ill.
• Occur in 7% (450 million) of global population per
year.
• One of top 10 outpatient & inpatient Dx.
• Results in 4 million deaths in developing world
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5. Pneumonia….
Normally, lungs are well protected
For pneumonia to occur, at least one of the following
three conditions must occur:
1. Failure or defect in host defenses
2. Exposure to very virulent pathogens
3. Exposure to an overwhelming load of pathogens
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6. Predisposing factors
Decrease level of consciousness
Tracheal intubation
Malnutrition
Alcohol
Cigarette smoking, air pollution, viral URTIs
Advanced age
Immunosuppressive disease &/or therapy
Advanced age
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7. Classification
Primary benefit of classification schemes is to
guide appropriate management and empiric
treatment
Based on causative agent
A. Bacterial:- Typical and atypical pneumonia
B. Viral
C. Fungal
Pneumonia may be either infectious or non-
infectious
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8. Classification….
According to the X-ray appearance (anatomic
classification)
1. Lobar pneumonia- Typically involves an entire lobe
of a lung, homogeneous consolidation of one or more
lung lobes
2. Bronchopneumonia- characterized by multiple-
patchy consolidation. Exudate tends to remain
primarily in the bronchi and bronchioles.
3. Interstitial pneumonia- the inflammatory process
primarily involves the interstitium: the alveolar walls
and connective tissue supporting the bronchial tree.
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10. Classification …
According to the setting or clinical and environment in
the past, pneumonia was typically classified as :-
1. Community-acquired pneumonia
2. Hospital-acquired pneumonia
Because of vast presence of patients with multidrug
resistant (MDR) pathogens, hospital-acquired
pneumonia revised to medical care-associated
pneumonia
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11. Classification …
Medical care-associated pneumonia encompasses three
forms of pneumonia:
1. Hospital-associated pneumonia:- acquired during or
after hospitalization -at least 48 hours after admission.
2. Ventilator-associated pneumonia :- refers to pneumonia
that occurs more than 48 hours after endotracheal
intubation.
3. Healthcare-associated pneumonia :- occurs in a non-
hospitalized pts, due to frequent contact with health
care environment.
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13. Community-acquired pneumonia (CAP)
CAP is commonly defined as an acute infection of the
pulmonary parenchyma that is associated with at least
some symptoms of acute infection and is accompanied
by the presence of an acute infiltrate on a CXY or
auscultator findings consistent with pneumonia
CAP occurs in a patient who is not hospitalized or
residing in a long term care facility for > 14 days before
the onset of symptoms
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14. CAP………
Infectious pneumonia in a person who has not
recently been hospitalized & within the first
48 hours after hospitalization.
Common type of pneumonia.
Infection usually spread by droplet inhalation.
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15. Cont…
The clinical presentation and the etiology vary greatly
depending on the:-
Patient’s age
Immune status of the patient
Presence of comorbid conditions
Sites the infection has involved
Place of acquisition of infection
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16. Etiology of CAP
Streptococcus pneumoniae :- is the most common cause
Accounted for over 80 % of cases of CAP.
May associated with viral URTI in winter season
The atypical bacteria:- Legionella ( in elderly and smokers),
Mycoplasma pneumoniae & Chl. Pneumonia account for 10-20 %
of all cases of pneumonia.
Mycoplasma pneumoniae among hospitalized adults with CAP
ranges from 1-8 %, and it is much higher for young adults who
are treated as outpatients
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17. Etiology of CAP….
Other bacteria commonly encountered in cultures of
expectorated sputum are:-
H.influenzae, Staph. aureus, and gram-negative bacteria
(mainly in alcoholics & during aspiration), Moraxella
catarrhalis, Strep. pyogenes, & Neisseria meningitides
H. influenza - frequently affects elderly people and those
with comorbid illnesses e.g., COPD, alcoholism, D/M.
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18. Etiology of CAP…
Viral agents :- account for 2 to 15 % of cases,
Most common causative organisms in elderly adults and
children
Most commonly influenza virus ,para influenza virus and
adenovirus.
Tuberculosis usually accounts for 1 to 2 % of cases
Legionella is 1 to 5 % of hospitalized adults with CAP
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19. Pathophysiology of CAP
Routes of infection:
1. Aspiration from the oropharynx (commonest)
Gross aspiration (Post op, CNS abnormality)
Micro aspiration (inhaled droplet -commonest )
2. Hematogenous spread (endocarditis, UTI)
3. Direct (from pleura, mediastinum)
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20. Pathophysiology of CAP…..
Once inside, bacteria may invade the spaces b/n cells
and b/n alveoli through connecting pores.
Invasion triggers the immune system to send
neutrophils
Neutrophils & macrophages engulf and kill the
offending organisms
The alveolar macrophages also initiate the
inflammatory response
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21. Pathophysiology of CAP…..
It releases cytokines, causing a general activation of
the immune system.
Neutrophils, bacteria and fluid from surrounding blood
vessels fill the alveoli.
As alveoli and respiratory bronchioles fill with
exudate, blood cells, fibrin and bacteria, consolidation
(solidification) of lung tissue occurs.
Interrupt normal oxygen transportation and venous
blood entering the lungs passes through the under
ventilated area.
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22. Pathophysiology of CAP…..
Bacteria often travel from an infected lung into the
bloodstream, causing serious or even fatal illness
such as septic shock
Bacteria can also travel to the area between the lungs
and the chest wall (the pleural cavity) causing a
complication called an empyema
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23. Pathophysiology of CAP…..
• Four stage of pathophysiological change occur due to
pneumonia
1. Congestion: - occurs during the first 24 hrs
Out pouring of fluid from tissue to alveoli- b/se of
inflammatory process.
Only a few neutrophils are seen at this stage.
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24. Pathophysiology of CAP…..
2. Red hepatization:- Lungs look like the liver
There is massive capillary dilation
Characterized microscopically by the presence of many
RBC, neutrophils, micro-organisms, fibrins in the
alveolar spaces
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25. Pathophysiology of CAP…..
3. Gray hepatization
The lung is dry, friable and gray-brown to yellow as a
consequence of a persistent fibrino-purulent exudates
WBC and fibrin consolidate the alveoli and lung
Second and third stages last for 2 to 3 days each
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26. Pathophysiology of CAP…..
4. Resolution
Characterized by enzymatic digestion of the alveolar
exudate
Resorption, phagocytosis or coughing up of the
residual debris and
Restoration of the pulmonary architecture
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27. Clinical manifestations
Cough producing greenish or yellow sputum
High fever that may be accompanied by shaking chills
Shortness of breath
Tachypnea
Pleuritic chest pain
Headaches
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28. Clinical manifestations…
Sweaty and clammy (moist) skin,
Loss of appetite
Fatigue
Blueness of the skin
Nausea, vomiting
Joint pains or muscle aches
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29. Clinical manifestations…
Typical
Acute onset of fever,
Cough with purulent sputum,
Pleuritic chest pain, dyspnea
Signs of consolidation on CXR
Fatigue
E.g. . S.pneumoniae,
H.influenzae
Atypical
Culture negative
Insidious onset of dry cough,
Extra-pulmonary symptoms :-
diarrhea, headache, myalgia,
sore throat
Patchy interstitial pattern on
CXR
E.g.. Mycoplasma, Chlamydia,
Legionella, viral
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30. Diagnosis
Diagnosis is based on combination of clinical findings,
physical examination and CXR
History ( CAP Clinical + CXR )
Characteristic symptoms and physical findings:
Fever(acute onset ), chills, productive cough,
Pleuritic chest pain, dyspnea & BBS with
Percussive dullness and egophony.
Signs of Consolidation on CXR
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31. Diagnosis ….
Physical examination
Inspection
Increase respiratory rate
Cyanosis, may be use of accessory muscle
Palpation
Increase tactile fremitus
Decrease chest expansion in affected side
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33. Diagnosis….
Chest x-ray:-this is the cardinal investigation.
Chest x-rays can reveal areas of opacity (seen as white)
which represent consolidation.
Area of consolidation on chest x-ray makes the diagnosis,
but x-ray is a poor guide to the likely pathogen.
Chest CT scan :- to distinguish pneumonia from other illness.
PCR for specific viruses (e.g.SARSCOV 2):in the right
epidemiologic setting.
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34. Figure of CXR
Pneumonia as seen on chest x-ray A: Normal chest x-ray. B: Abnormal chest x-ray 34
35. Sputum microscopy and culture
• There is debate about the value of sputum samples in
diagnosis of CAP.
• Oral flora rather than the offending pathogen may
dominate a sputum Gram stain and culture.
• Nevertheless, we believe that an attempt should be
made to obtain a sputum sample before beginning
antibiotic therapy, as this is sometimes the best
opportunity to identify pathogens that need special
treatment.
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36. Blood chemistry and hematology
• All patients with CAP being assessed in emergency
departments or admitted to hospital should have Oxymetry,
measurement of serum electrolytes and urea levels, and a
full blood count to assist in assessing severity (CBC may
show a high WBC count)
• Blood gas measurement is also recommended, as it provides
prognostic information pH and Pao2 and chronic Paco2
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37. Blood culture
Blood cultures are the most specific diagnostic test for
the causative organism, but are positive in only around
10% of patients admitted to hospital with CAP.
The more severe the pneumonia, the more likely blood
cultures are to be positive.
We recommend that blood be cultured from all patients,
except those well enough to be managed at home with
oral antibiotics
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38. Risk Group
Factors that increase risk of CAP are
COPD, dementia, HF, immunosuppressant,
Age over 50, asthma, alcoholism,
Indigenous background institutionalization,
Seizure disorders, smoking, stroke
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39. Risk…..
Factors that increased risk of death from CAP are:
Hypothermia (temperature 370C),
Hypotension (SBP<100mmhg)
More than one lobe involved on chest x-ray,
Tachypnea (RR > 20 bpm),
Existing neoplastic disease, leukopenia, confusion
Neurological disease and bacteremia.
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40. Medical Treatment
Combination antibiotic therapy achieves a better outcome
compared with monotherapy,
Identify high risk patients for CAP and require
hospitalization:-
Outpatients with co morbidities
Previous antibiotic therapy
Nursing home patients with CAP, hospitalized patients
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41. Medical Treatment….
Objectives of treatment
Achieve clinical cure
Prevent complications and associated morbidity and
mortality.
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42. .CURB-65 criteria
The CURB-65 scoring systems decided to evaluate
the prognosis and determine subsequent management
of patient with CAP.
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C Confusion - 1 point
U Uremia BUN >19mg/dl 1 point
R Respiratory rate RR >= 30/min 1 point
B Blood pressure BP <=90/60 1 point
65 Age > =65 Age >65 1 point
46. Medical management…
Pharmacologic
Initially be treated with a broad-spectrum antibiotic
regimen aimed at covering all likely bacterial
pathogen
This regimen should subsequently be narrowed,
according to the result of culture
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47. Empiric antibiotic
Two parameters before starting empiric antibiotic
1.Look for risk factors include of MRSA (Methicillin
Resistant Staphylococcus aureus) or P.aeruginosa
Recent hospitalization
Receipt of parenteral antibiotics in the last 90days
Prior isolation of the organisms from the respiratory
samples
2.Comorbidities:- Organ failure, D/M, Ca, alcoholism
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48. Empiric antibiotic…..
The duration of antibiotic therapy is generally 5 to 7
days; however, it needs to be guided by clinical
response as well
The antibiotic should be continued until the patient
achieves stability but for no less than a total of 5days.
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49. New Treatment Paradigm
Hit hard and early with appropriate antibiotic &
Short Rx. Duration; De-escalate where possible
Appropriate Duration of Therapy
Minimum of 5 days
Afebrile for at least 48 to 72hr
Longer duration of therapy- If initial therapy was
not active against the identified pathogen or
complicated by extra pulmonary infection
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50. For CAP ambulatory(Outpatient) patient
Mild pneumonia
No recent antibiotics use
No co-morbidities/previously healthy;
No risk factors for drug-resistant & S. pneumoniae, H.Influenza
Clarithromycin 500mg P.O., BID for 5-7 days OR 2nd line
Azithromycin 500mg P.O first day then 250mg P.O for 4days OR
Doxycycline 100mg P.O., BID for 7-10 days
Amoxicillin 500mg Po TID/5-7day ---1st line
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51. For CAP ambulatory(Outpatient) patient…
If recent antibiotic use within 3months:
Out patient with co-morbidities
Clarithromycin, 500mg P.O. BID for 5-7 days OR
Azithromycin,500mg PO first day then 250mg P.O for 4d.
PLUS
Amoxicillin, 1000mg P.O., TID for 5 to 7 days. OR
Amoxicillin-clavulanate, 625mg P.O., TID for 5-7days
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52. For CAP hospitalized (severe pneumonia)
Non-Drug treatment:
Bed rest
Frequent monitoring of temperature, B/P and PR.
Give attention to fluid & nutritional replacements.
Administer Oxygen
Analgesia for chest pain
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53. CAP for hospitalized patients mgt
• The Antibiotic choice should be aimed at the most
likely causative agent.
• Empiric treatment for pneumonia due to common
organisms:
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54. CAP for hospitalized mgt…
For Gram positive and negative and
Atypical microorganism
Ceftriaxone, 1g I.V or I.M every 12-24 BID/7days OR
Benzyl penicillin, 2-3 million IU I.V. QID for 7-10 days.
PLUS
Azithromycin, 500mg on day 1 followed by 250mg/day on
day 2 – 5 OR
Clarithromycin, 500mg P.O., BID for 7-10 days
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55. CAP for hospitalized mgt…
For Coverage MRSA and P. aeruginosa
For P.aeruginosa coverage:
Cefepime 2g IV 8-12 hours
Ceftazidime 2g Iv q 6-8 hours
For MRSA coverage:
Vancomycin 1g IV BID
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57. Nursing intervention
Encourage increased fluid intake (at least 2 L/day)
Lung expansion maneuvers- deep breathing, direct coughing
Administers oxygen therapy as prescribed.
Limited activity and encourage rest
Teaching good health habits; such as proper diet & hygiene
Frequent monitoring schedule for population at risk.
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58. Prevention CAP
In addition to treating any underlying illness , also
Smoking cessation, because cigarette smoke interferes
with many of the body’s natural defenses against CAP.
Vaccination is important in both children and adults,
against H. influenza and S.pneumoniae
Other infection prevention measures
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60. References
1. Standard treatment guideline for general Hospitals in
Ethiopia 4thedition, 2021
2. Community Acquired Pneumonia by Sonia Akter,
ETL.March 21, 2015
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