CAP remains a leading cause of morbidity and mortality worldwide. Clinical signs of an infectious lung process include fever, production of sputum (which is often purulent), leukocytosis, and hypoxia, but presentations can vary and the provider's index of suspicion for pneumonia should be high when evaluating any respiratory illness. No symptom or set of symptoms is adequate for the diagnosis of pneumonia without chest imaging.
In the United States, CAP accounts for over 4.5 million emergency room and outpatient visits annually, accounting for 0.4% of encounters. It is the most common infectious cause of death and the second most common cause for hospitalization, with 1.5 million CAP hospitalizations annually. Rates of CAP and associated hospitalization increase with increasing age, particularly with each decade over the age of 65 years. Globally and locally, the true incidence of CAP is difficult to determine accurately due to differences in reporting and case definition. Incidence also varies significantly by geographic location, study population, and season, with rates almost doubling in winter months.
The microbiologic etiology of CAP has evolved over time. Historically, in the pre-antibiotic era, almost all cases (95%) were caused by Streptococcus pneumoniae. Since the advent of antibiotics as well as the widespread use of pneumococcal conjugate vaccines in children and pneumococcal polysaccharide vaccines in adults, the rate of S pneumoniae pneumonia in the United States has dropped to 10%-15% of cases. Other bacterial etiologies include Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus, and Pseudomonas aeruginosa, as well as other gram-negative bacilli. Etiologies categorized as "atypical" include Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella pneumophilia, which have a wide variability in reported incidence in part due to their inability to grow on standard culture media and variable diagnostic techniques. Of note, respiratory viruses, including COVID-19, have been identified in up to a third of CAP cases when studied using molecular techniques. The exact impact of this finding – whether viral infection can be the primary pathogen, a co-factor for infection, or a trigger for a dysregulated immune response – is unknown and warrants further study.
Risk factors for CAP include age; the incidence of hospitalization with CAP in those 65 years and older is 3 times that of the general population. Medical comorbidities also increase the risk of hospitalization for CAP, with chronic obstructive pulmonary disease (COPD) placing patients at the highest risk. Chronic heart disease, diabetes mellitus, immunocompromised states, malnutrition, and other chronic lung diseases all increase the risk of severe CAP. Lifestyle factors such as smoking and excess alcohol consumption also increase risk for CAP. Finally, impaired airway clearance states due to altered mental status in the context of neurologic injury, medication and illicit substance use, and dysphagia can result in aspiration and increased rates of CAP as well. Preceding viral infection increases the risk for bacterial superinfection, classically seen with respect to influenza and subsequent risk for pneumonia attributed to S aureus.
CAP is classified as severe if it meets 1 major criterium or 3 minor criteria.
- Septic shock with need of vasopressors
- Respiratory failure necessitating mechanical ventilation
- Respiratory rate ≥ 30 breaths per minute
- PaO2/FiO2 ≤ 250 mmHg
- Multilobar infiltrates
- Altered mental status
- Uremia (blood urea nitrogen [BUN] ≥ 20 mg/dl)
- Leukopenia (< 4000 WBC)
- Thrombocytopenia (platelets < 100 000)
- Hypothermia (< 36°C / 96.8°F)
- Hypotension requiring aggressive fluid resuscitation
Note: To view x-rays and other imagery, see individual diagnoses.
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