Nosocomial Pneumonias

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• Nosocomial
• Pneumonias

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Nosocomial Pneumonias

• Hospital-acquired pneumonia - pneumonia 48 hours
  or more after admission, and was not incubating
  at the time of admission
• Ventilator-associated pneumonia - pneumonia that
  arises more than 48-72 hours after endotracheal
  intubation
• Health Care Associated Pneumonia (HCAP)
• i. hospitalized in an acute care hospital
  2days in
• preceding 90 days
• ii. nursing home or long-term care facility
  resident
• iii. recent iv chemotherapy, or wound care
  within
• past 30 days
• iv. attended a hospital or hemodialysis clinic

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HOST Impaired immune function Comorbid
illness Prior surgery/antibiotics
ENVIRONMENT Infected air,water, fomites,instrument
s Cross-contamination

• PATHOGEN
• Inoculum
• - Virulent strain (MDR)

PATHOGENESIS NOSOCOMIAL PNEUMONIA
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DIAGNOSIS OF HAP


Clinical
Microbiology
Chest X ray

• New onset fever
• Purulent expectoration
• Tachycardia
• Tachypnoea
• Leukocytosis /
• Leukopenia
• Need of higher FiO2

• Microbiology
• To identify etiology
• De-escalate therapy
• Decide duration of therapy

• Clinical diagnosis,
• high sensitivity,
• low specificity
• empiric treatment

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Drug Resistance Factors

•  Sicker inpatient population
• Immuno-compromised patients
• New procedures instrumentation
• Emerging pathogens
• Complacency regarding antibiotics
• Ineffective infection control and compliance
• Increased antibiotic use

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Principles of therapy

• Start empiric therapy pending reports of culture
  and drug-sensitivity test
• Choose antibiotics based on probable organisms as
  cause of infection
• Combination therapy is preferred
• Parenteral route should be chosen
• Adequate dosages must be used
• Change the drug/s after culture and sensitivity
  reports
• Monitor for effects side efffects of drugs

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SUMMARY

• Nosocomial Pneumonias are frequent associated
  with excess mortality ?initiate prompt
  appropriate adequate therapy
• Pathogens distinct from one hospital to another,
  specific sites within the hospital, and from one
  time period to another
• Avoid overuse of antibiotics, focus on accurate
  diagnosis, tailor therapy to recognized pathogen
  and shorten duration of therapy to the minimum
  effective period
• Apply prevention strategies aimed at modifiable
  risk factors

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Suppurative Lung Disease

• Lung Abscess
• Bronchiectasis
• Empyema

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Lung Abscess

• Localized collection of pus in the lung
  parenchyma surrounded by a fibrous tissue wall.
• Single or Multiple
• Necrotizing pneumonia may simulate an abscess
  it lacks a wall
• May precede lung abscess development

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Classification

• Primary Lung Abscess (Usually single)
• Occurs in healthy individuals, e.g. following
  aspiration, pneumonia (cavitation)
• Secondary Abscess (May be multiple)
• Pre-existing lung disease, e.g. Bronchogenic
  cancer, COPD, lung cysts etc
• Systemic Immunosuppression
• Metastatic (eg. Infective endocarditis)

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Factors contributing to thedevelopment of lung
abscess

• 1. Oral cavity disease
• Periodontal disease
• Gingivitis
• 2. Altered consciousness
• Alcoholism Coma
• Drug abuse Anesthesia
• Seizures
• 3. Immunocompromise
• Steroid therapy
• Chemotherapy
• Malnutrition
• Multiple trauma

• 4. Esophageal disease
• Achalasia
• Reflux disease
• Esophageal obstruction
• 5. Bronchial obstruction
• Tumor
• Foreign body
• Stricture
• 6. Generalized sepsis

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Pathogenesis

• Aspiration of infectious material
• i. Poor oro-dental hygiene (infected gums,
  tonsils, etc)
• ii. Predisposition to aspiration Dysphagia,
  Alcoholism, seizure, stroke, trauma,
  unconsciousness
• Colonization of organisms in the lung.
• Cellular infiltration and exudation
• Local liquefaction necrosis, destruction
• Bronchial communication, air in the abscess
  cavity.
• May extend to pleural cavity - pyopneumothorax
• Repair mechanisms and fibrosis - containment

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Microorganisms responsible for lung abscess

• 1. Aerobic Klebsiella, Pseudomonas
• Staphylococci,
  others
• Anaerobic Bacteroides, Clostridia
• Fungal Aspergillus
• Mycobacterial
• Parasitic Entamoeba
• Echinococcus
  (Hydatid Cyst)

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Clinical Features

• Symptoms
• - Acute or insidious onset
• - Fever with rigors, night sweats, Chest pain/
  dullness, Cough, Sputum production
• (Sputum is large volume, thick, muco-purulent or
  purulent blood stained, foul smelling)
• Signs
• - Presence of per/sidontal disease, other
  risk-factor
• - Febrile, toxic patient, Finger clubbing
• Chest exam
• - May be normal.
• - Localized impairment of percussion note
• - Breath sounds diminished bronchial breathing,
  egophony, Crackles

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Differential diagnosis (cavitary lung lesion)

• 1. Cavitating lung cancer
• 2. Localized empyema
• 3. Infected bulla containing a fluid level
• 4. Infected bronchogenic cyst or sequestration
• 5. Pulmonary hematoma
• 6. Cavitating
• pneumoconiosis

• 7. Hiatus hernia
• 8. Lung parasites (e.g. hydatid cyst, Paragonimus
  infection)
• 9. Actinomycosis
• 10. Wegeners granulomatosis and other
  vasculitides
• 11. Cavitating lung infarcts
• 12. Cavitating sarcoidosis

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Investigations

• Polymorphonuclear leukocytosis
• Sputum examination Smear and culture for
  different etiological agents
• Chest radiography CXR, CT scans
• Bronchoscopy for bronchial assessment
  (Obstruction, ulceration etc) br secretions for
  microbiology

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Radiographic findings

• CXR
• - Smooth or irregularly walled cavity, fluid
  level dependent part commonly.
• - Klebsiella abscess mostly in upper lobe,
  bulging fissure sign.
• - Staph abscesses Multiple, sometimes thin
  walled
• CT scans
• Clear demonstration of wall, localization of site
  within the lung, pleural communication
• - presence of empyema other underlying lung
  problem.
• - CT is also helpful for guidance for
  per-cutaneous aspiration

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Pulmonary Samples For
Microbiological Demonstration (Uncontaminated)

• Transtracheal aspirate
• Transthoracic pulmonary aspirate
• Fiberoptic bronchoscopy with protected specimen
  brush
• Bronchoalveolar lavage fluid for quantitative
  culture
• Surgical specimens
• Pleural fluid (if empyema present)

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Lemierres Syndrome

• Rare cause of lung abscesses
• Infection with anaerobe
• (F. necrophorum)
• Cl Features
• - Sore throat, fever, rigors, neck-swelling,
  hemoptysis, dyspnea
• - Thrombophlebitis thrombosis of neck veins,
• - Metastatic spread to other organs.

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Complications

• Erosion/ rupture Broncho-pleural fistula and
  empyema formation
• Spread into surroundings
• Metastatic spread Brain, Liver, Spleen
• Sepsis
• Long-term sequelae Bronchiectasis, Fibrosis
• Systemic
  amyloidosis

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Management

• General measures
• Antibiotic therapy parenteral
• Aspiration pn. Co-amoxiclav
• Metronidazole
• Staphylococcal
• CA-MSSA Oral co-amoxilav
• CA-MRSA Clindamycin, Linezolid,
  Vancomycin etc
• Surgical management

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Bronchiectasis

• Definition
• Permanent destructive dilatation of the bronchi
  (following infection, destruction and fibrosis)
• Types
• Cystic
• Cylindrical
• Localized or diffuse

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Etiology of bronchiectasis

• Post-infectious, e.g. tuberculosis, pneumonia
  childhood infection such as measles, mumps,
  whooping cough
• Connective tissue diseases, e.g. SLE, rheum
  arthritis, Sjögrens syndrome, relapsing
  polychondritis
• Secondary to inhalation or aspiration, e.g.
  a foreign body
• Inflammatory bowel disease, e.g. ulcerative
  colitis
• Allergic bronchopulmonary aspergillosis
• Immune deficiency e.g. Secondary to ch lymphatic
  leukemia

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Congenital causes of Bronchiectasis

• Cystic fibrosis
• Ciliary defects, e.g. primary ciliary dyskinesia,
  Youngs syndrome
• Kartageners syndrome
• Immune deficiency, e.g. IgA deficiency,
• X-linked agammaglobulinemia,
• Common variable immunodeficiency
• Congenital defects e.g. tracheobronchomegaly
  (Mounier-Kuhn syndrome), pulmonary sequestration

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Clinical Features

• Chronic cough and expectoration
• Sputum Purulent/ muco-purulent, foul-smelling,
  large volume, thick and tenacious
• Haemoptysis, sometimes massive
• Recurrent exacerbations
• SIGNS - General malnutrition, pallor, edema
• - Digital clubbing,
  osteoarthropathy
• Chest
• - Depends on site and extent of involvement
• - If large, signs of lung volume reduction
• - May be areas of bronchial breathing
• - Coarse crepitations, Occasional rhonchi

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Investigations

• General Anemia, Hypoglobulinemia
• Chest radiography CXR, CT scan (HRCT)
• Bronchography
• Sputum examination For exacerbations.
• - AFB to exclude TB, if suspected
• Smear for culture
• - ECG, ECHO for cardiac evaluation in suspected
  chronic cor-pulmonale

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Differential Diagnosis

• Pulmonary tuberculosis
• Cystic fibrosis
• COPD
• Allergic broncho-pulmonary aspergillosis
• Interstitial lung diseases
• Eosinophilic lung diseases
• Hypersensitivity pneumonias

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Radiological features

• CXR
• May appear normal in early, limited disease,
  left lower lobe hidden behind the heart in PA
  film.
• Thickened bronchial lines- tram lines
• Cystic shadows/ cavities with fluid levels
• HRCT
• Almost diagnostic.
• Clear demonstration of site of involvement,
• Type of lesions, surrounding lung parenchyma,
  focal pneumonitis, areas of atelectasis.
• Clue to the underlying etiology (eg ABPA)

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Complications

• Recurrent pneumonias
• Recurrent hemoptysis, sometimes massive
• Local lung destruction and cavitation
• Aspergilloma formation (fungal ball) in a cavity
• Metastatic spread
• Pulmonary hypertension and chronic cor pulmonale
• Chronic malnutrition
• Amyloidosis
• Chronic respiratory failure if extensive lung
  destruction and fibrosi

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Management

• Bronchial hygiene Postural drainage, Chest
  physiotherapy
• Antibiotics for infections
• Expectorant and mucolytics
• Management of complications, e.g hemoptyis,
  pulmonary hypertension (Chronic or pulmonale),
  respiratory failure
• Nutritional supplementation
• Surgical management - Resection, if localized
• -
  Management of hemoptysis
• - Lung
  transplantation

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Recommendation for antibiotics use

• Bacterial infection
  First choice Second
  line
• Haemophilus influenzae
  
  Doxycycline,
• or Moraxella catarrhalis
  Co-amoxiclav ciprofloxacin
• Streptococcus pneumoniae
  Amoxicillin
  Clarithromycin
• MRSA
  Rifampicin and Rifampicin
  and
• 
  trimethoprim
  doxycycline or
• 
  or IV vancomycin
  linezolid
• 
  or teicoplanin
• Ps aeruginosa
  Ciprofloxacin Ceftazidime
• 
  
  and tobramycin
• 
  
  or colistin

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Prevention of infections

• Preventive vaccinations
• Bronchial hygiene measures
• - Chest physiotherapy
• - Nebulization/steam inhalation
• - Respiratory muscle exercises
• Long term antibiotic use - Oral
• 
  Nebulized

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Kartageners Syndrome

• Ciliary dyskinesia i.e. abnormal ciliary
  movements
• Genetic abnormality
• Clinical features
• - Bronchiectasis
• - Situs inversus, dextrocardia
• - Chronic sinusitis
• - Infertility

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Allergic Broncho Pulmonary Aspergillosis

• Hypersensitivity to aspergillus in the
  tracheo-bronchial tree in patients with chronic
  asthma.
• Clinical Features Severe attacks, sputum
  production hard brown plugs hemoptysis
• Radiology CXR and HRCT Fleeting opacities,
  typical patterns bronchiectasis proximal
  bronchi
• Diagnosis Skin test Immediate delayed ve
• Sputum for aspergillus ve
• Serology ve Total Asperg
  specific IgE levels
• Treatment Anti-inflammatory drugs (steroids),
• Anti-biotics, anti-fungals

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Cystic Fibrosis

• A common condition in Caucasians 1 in 2500 live
  births
• Genetic anomaly Autosomal recessive mutation on
  chromosome 7 leads to protein Cystic Fibrosis
  Transmembrane Regulator, CFTR) abnormality
• Clinical Features Multi-organ problem
• Bronchiectasis thick viscid sputum
• Pancreatic insufficiency - diarrhoea
• Liver disease biliary cirrhosis
• Sweat glands function abnormality
• Infertility
• Low bone mass

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