Community-Acquired Pneumonia (CAP)

Written By Danial Mirza

Definition

Community-acquired pneumonia (CAP) is defined as an acute infection of the lung parenchyma in a person who has acquired the infection in the community, as distinguished from a hospital or long-term care facility setting (1). The clinical diagnosis requires evidence of an acute lower respiratory tract illness along with new radiological infiltrates on a chest X-ray (1).

Epidemiology

In Malaysia, pneumonia represents a significant public health burden. In 2023, it was reported as the leading cause of death in the country (4). It stands as the second leading cause of overall mortality, responsible for 11.4% of all deaths, underscoring its clinical significance (1). CAP drives a substantial volume of healthcare utilization, with an estimated 20% of diagnosed patients requiring hospitalization. Of those admitted, approximately 1% will develop severe disease necessitating ICU admission (5). The condition disproportionately affects vulnerable groups, particularly older adults and individuals with chronic comorbidities (1).

Pathophysiology

The development of CAP results from a failure of the host's lung defense mechanisms to prevent microbial invasion (1). The most common route of infection is the microaspiration of oropharyngeal secretions, which introduces pathogens into the lower airways (1). The outcome depends on the interplay between the virulence of the microorganism and the integrity of the host's defenses, which include the cough reflex, the mucociliary escalator, and alveolar macrophages (1). Pathogens like Streptococcus pneumoniae possess virulence factors, such as a polysaccharide capsule, that help them evade these defenses (1). Other pathogens, like Mycoplasma pneumoniae or Influenza virus, damage the respiratory epithelium, impairing clearance mechanisms and creating a window for infection (1).

Clinical Presentation

The classic presentation of CAP involves an acute onset of respiratory and systemic symptoms.

Diagnostic Clues: A rusty-colored sputum is a classic, though not always present, sign associated with pneumococcal pneumonia (19).

Common Symptoms (>50%):

  • Cough, which may be productive of purulent (yellow/green) sputum (19)

  • Fever, often accompanied by chills and rigors (19)

  • Shortness of breath (dyspnoea) (19)

  • Pleuritic chest pain (sharp pain on inspiration) (19)

Less Common Symptoms (10-50%):

  • Profound fatigue and malaise (19)

  • Loss of appetite (19)

  • Headache (19)

  • Night sweats (19)

⚠️ Red Flag Signs & Symptoms:

  • New confusion or disorientation (the 'C' in the CURB-65 score) (8)

  • Respiratory rate ≥ 30 breaths/minute (the 'R' in the CURB-65 score) (8)

  • Hypotension (Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg) (the 'B' in the CURB-65 score) (8)

  • Central cyanosis, indicating severe hypoxemia (20)

  • Inability to speak in full sentences, a sign of significant respiratory distress (20)

Complications

Complications of CAP can be severe and are often what necessitate hospitalization and intensive care.

  • Respiratory: Acute respiratory failure (Type 1 or Type 2), parapneumonic effusion, empyema, and lung abscess (3, 82).

  • Cardiovascular: Septic shock, cardiac arrhythmias, and exacerbation of underlying heart failure (8, 38).

  • Systemic: Sepsis, acute kidney injury, and multi-organ dysfunction (8, 41).

Prognosis

The prognosis of CAP is directly linked to its severity, which is best assessed using the CURB-65 score. For patients with a score of 0-1 (mild CAP), the 30-day mortality risk is less than 3% (8). This risk climbs to 3-15% for a score of 2 (moderate CAP) and exceeds 15% for a score of 3 or more (severe CAP) (8). Key factors that worsen prognosis include advanced age, the presence of comorbidities, and the development of complications like sepsis or respiratory failure (1).

Differential Diagnosis

  • Acute Bronchitis. This is a primary differential due to the shared symptom of cough (27). However, acute bronchitis is less likely if the patient presents with high fever, systemic illness, and signs of consolidation on examination. The chest X-ray in bronchitis is characteristically clear of new infiltrates (27).

  • Pulmonary Embolism (PE). Consider PE in patients with a sudden onset of dyspnoea and pleuritic chest pain (33). It is less likely in the presence of a productive cough and high fever. A history lacking risk factors for venous thromboembolism (e.g., recent surgery, immobility, malignancy) also points away from PE (33).

  • Acute Heart Failure (AHF). This is a common mimic, especially in the elderly (38). AHF is more probable given a history of cardiac disease, orthopnoea, or paroxysmal nocturnal dyspnoea. Key distinguishing signs include a raised jugular venous pressure (JVP), an S3 gallop, and bilateral basal fine crackles on auscultation, in contrast to the focal, coarser crackles of pneumonia (38).

Investigations

Immediate & Bedside Tests

  • Pulse Oximetry: This is a mandatory "fifth vital sign" to rapidly detect hypoxemia (the rationale), a key marker of severity that requires immediate oxygen supplementation (the action) (2).

  • Arterial Blood Gas (ABG): Indicated for any patient with significant respiratory distress or hypoxemia (SpO2 <92%) to precisely measure oxygenation (PaO2) and acid-base status (the rationale), which is critical for identifying respiratory failure and guiding respiratory support (the action) (2).

Diagnostic Workup

  • First-Line Investigations: A Chest X-ray (CXR) is the essential first-line investigation. It is required to confirm the diagnosis by identifying new parenchymal infiltrates (the rationale) and to assess severity and detect complications (the action) (1).

  • Gold Standard: While often elusive, the definitive "gold standard" is the isolation of a pathogen from a sterile site, such as blood or pleural fluid culture (11). This provides a definitive microbiological diagnosis and antibiotic susceptibilities (the rationale), enabling the de-escalation of antibiotics to targeted therapy (the action) (22).

Monitoring & Staging

  • Full Blood Count (FBC): A baseline FBC is essential to look for neutrophilic leukocytosis, a common sign of bacterial infection, or leukopenia (the rationale), which is an ominous sign indicating overwhelming sepsis and a poor prognosis (the action) (2).

  • Renal Profile and Electrolytes: This is mandatory as a blood urea level >7 mmol/L is a core component of the CURB-65 score (the rationale). It is also vital for assessing renal function for drug dosing and detecting acute kidney injury from sepsis (the action) (8).

  • Inflammatory Markers (CRP/PCT): While C-reactive protein (CRP) is non-specific, it is almost always elevated in bacterial pneumonia (26). Procalcitonin (PCT), though not recommended to initiate antibiotics, can be valuable for monitoring response and guiding antibiotic de-escalation (40).

Management

Management Principles

The management of CAP is centered on three core principles: prompt and appropriate antibiotic therapy, maintenance of physiological stability through supportive care, and vigilant monitoring for complications (8, 54).

Acute Stabilisation (The First Hour)

  • Airway/Breathing: Administer supplemental oxygen to maintain SpO2 between 94-98% (or 88-92% for patients at risk of hypercapnic respiratory failure) (the action) to correct hypoxemia and prevent tissue hypoxia (the rationale) (8).

  • Circulation: Secure intravenous access. For patients with hypotension or signs of septic shock, begin rapid administration of 30 ml/kg of crystalloid fluid (the action) to restore tissue perfusion, a key component of the sepsis care bundle (the rationale) (41).

  • Disability: Formally assess for new confusion or altered mental status (the action), as this fulfills the 'C' criterion of the CURB-65 score and signifies severe illness requiring urgent escalation (the rationale) (8).

Definitive Therapy

Antibiotic choice is dictated by the Malaysian National Antimicrobial Guideline (NAG), stratified by severity.

  • First-Line Treatment (Moderate CAP, CURB-65 Score 2): The recommended regimen is IV Amoxicillin/clavulanate 1.2g q8h PLUS Azithromycin 500mg IV/PO q24h (8). This combination covers typical pathogens (S. pneumoniae, H. influenzae) with the beta-lactam and atypical pathogens with the macrolide, reflecting the local pathogen landscape (15, 68).

  • Second-Line/Escalation (Severe CAP, CURB-65 Score ≥3 or Pseudomonas risk): For severe CAP, the same combination is used (8). However, if risk factors for Pseudomonas aeruginosa are present (e.g., bronchiectasis, recent hospitalization with IV antibiotics), therapy should be escalated to an anti-pseudomonal agent like IV Piperacillin/tazobactam 4.5g q6-8h plus Azithromycin (8).

Supportive & Symptomatic Care

  • Analgesia: Provide regular paracetamol or other simple analgesics to manage pleuritic chest pain (the action), which improves comfort and facilitates effective coughing and deep breathing (the rationale) (54).

  • Antipyretics: Use paracetamol to control high fever (the action), thereby reducing metabolic demand and improving patient comfort (the rationale) (54).

  • VTE Prophylaxis: For all hospitalized patients with reduced mobility due to acute illness, administer prophylactic anticoagulation (e.g., LMWH) (the action) to prevent venous thromboembolism, a significant risk in this population (the rationale) (8).

Key Nursing & Monitoring Instructions

  • Monitor vital signs, including respiratory rate and SpO2, at least 4-hourly or more frequently if unstable.

  • Maintain a strict fluid balance chart (input/output).

  • Immediately escalate to the medical team for any of the following: systolic BP <90 mmHg, respiratory rate >30, SpO2 <92% on oxygen, new confusion, or urine output <0.5mL/kg/hr.

Long-Term Plan & Patient Education

Discharge planning is a critical phase focused on ensuring a safe recovery and preventing recurrence (88). A follow-up chest X-ray should be arranged for 6-8 weeks post-discharge, particularly for smokers, the elderly, or those with severe disease, to ensure radiological resolution and to exclude an underlying pathology like lung cancer (26). Patients must be educated on the importance of completing their full course of antibiotics, what to expect during recovery (persistent fatigue is common), and clear red flag symptoms that warrant immediate medical attention (88, 89). This is a vital opportunity to provide strong advice on smoking cessation and to recommend vaccination against S. pneumoniae and annual influenza (25).

When to Escalate

Call Your Senior (MO/Specialist) if:

  • The patient has a CURB-65 score of ≥ 3, indicating severe CAP (8).

  • The patient shows signs of impending or established respiratory failure (worsening hypoxemia, increasing work of breathing, exhaustion, or hypercapnia) (3).

  • The patient develops septic shock (persistent hypotension requiring vasopressors and elevated lactate despite fluid resuscitation) (41).

  • There is a failure to respond to appropriate antibiotic therapy within 48-72 hours, which may suggest a complication (e.g., empyema) or a resistant organism (82).

Referral Criteria:

  • Refer to the ICU team for any patient with severe CAP requiring invasive or non-invasive ventilation, or vasopressor support for septic shock (8).

  • Refer to the Cardiothoracic Surgery team for confirmed empyema or a complicated parapneumonic effusion that requires drainage via chest tube or video-assisted thoracoscopic surgery (VATS) (82, 84).

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Danial Mirza
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