Pneumonia

1
Pneumonia

• Very common (1-10/1000), significant mortality
• Severity assessment, aided by score, is a key
• management step
• Caused by a variety of different pathogens
• Antibiotic treatment initially nearly always
  empirical, local
• guidelines and microbial resistance rates may
  support it

2
2009.05.18
3
2009.05.26
4
2009.10.26
5
2009.11.02
6
2009.11.02
7
Evidence-based health policy (Science 1996
274740-743.)
8
Definition

• Acute, infectious inflammation of the lower
  respiratory tract parenchyma (distal to
  bronchiolus terminalis).

9
Pathogens

• Bacteria /aerobic,anaerobic, atypical/
• Virus /influenza ,parainfluenza, adenovirus,
  herpesvirus,cytomegalovirus, RSV/
• Fungi /Aspergillus,Candida/
• Parasites /Pneumocystis jiroveci, Toxoplasma
  gondii,Ascaris lumbricoides/

10
Clinical classification

• Community-acquired, CAP
• Nosocomial, hospital-acquired, HAP, VAP
• Aspiration and anaerobic
• Pneumonia in the immuncompromised host
• AIDS-related
• Reccurent
• Pneumonias peculiar to specific geographical
• areas

11
Epidemiology of CAP
Mycoplaspa pn. Chlamydia pn.
12
Pathogenesis

• Inhalation of infected droplets
• Aspiration /residents from nasopharynx/
• Spread through bloodstream
• Direkt spread (concomittant)

13
Risk factors

• Prolonged supine position
• Antibiotics, antacids
• Patient contact
• Decreased defense mechanisms
• Infected health care materials

14
Etiology

• 1. Streptococcus pneumoniae 40-60
• 2. Mycoplasma pneumoniae 10-20
• 3. Haemophilus influenzae 6-10
• 4. Influenza A 5-8

15
Clinical features I.

• General symptoms
• malaise, anorexia
• sweating, rigors
• myalgia, arthralgia
• headache
• fast (bacteremia) vs. slow (Mycoplasma)
  progression
• marked confusion (Legionella, psittacosis)
• acute abdominal or urinary problem (lower lobe,
  age!)

16
Clinical features II.

• Respiratory symptoms
• - cough, dsypnea, pleural pain
• - purulent sputum, hemoptysis
• Physical signs
• - high fever and rigor (Pneumococus)
• - little or no fever (elderly, seriously
  ill)
• - herpes labialis (Pneumococcus)
• - dullness, inspiratory crackles,
  bronchial breathing
• - upper abd. tenderness (lower lobe)
• - rash (antibiotic, mycoplasma,
  psittacosis)

17
Differential diagnosis

• Pulmonary infarction
• Atypical pulmonary oedema
• Less common pulmonary eosinophilia, acute
  allergic alveolitis, lung tumours
• Diseases below the diaphragm hepatic abscess,
  appendicitis, pancreatitis, perforated ulcer

18
Investigations

• Chest x-ray (lateral!, neoplasm) compulsory
• WBC ?, gt30 or lt 4 G/L poor prognosis
• Sputum Gram stain and culture
• Blood culture (20-25 positive)
• Pleural fluid (25, exclude empyema pH!)
• Serology (atipical, viral), antigen detection
  (Legionella, Pneumococcus)
• Invasive tests uncontaminated LRT secretions
  (BAL,PBS) or lung biopsies

19
Radiological features

• Lobar or segmental opacification
• Patchy shadows
• Small pleural effusions
• Cavitation (infrequent, Staphylococcus,
  Pneumococcus serotype 3)
• Spread to more than one lobe (Legionella.
  Mycoplasma)
• Clearance of shadow may last for months

20
Treatment at home or in hospital ?
21
CAP PORT (NEJM 1997, 40 000beteg)

• male age
• female age 10
• elderlys home 10
• Neoplasia 30
• Liver dis. 20
• CHF 10
• Cerebrovasc. 10
• Renal dis. 10
• Confusion 20
• Pleuriy 10

• Resp.rate gt 30 20
• RRlt90 20
• Temp.lt35 v. gt40 15
• Pulsegt125 10
• pHlt7,35 30
• UNgt11 20
• Nalt130 20
• Se glucosegt13,9 10
• Htklt30 10
• PaO2lt60 Hgmm 10

22
PORT categories

• I.-II. lt70, mortality lt 1, outpatient
• III. 70-90, mortality 2,8, short hospital,
  sequential ATB
• IV. 91-130, mortality 8,2, hospital
• V. gt130, mortality 29,2, consider ICU

23
CURB65 score (1-1point)
C Mental confusion
U UN gt 7 mM/L
R Respiratory rate gt 30/min
B RRlt90/60 mmHg
65 Age gt 65 years
Mild 0-1point, 1.5 mortality Moderate 2point,
9 mortalility Severe 3-5 point, 22 mortalitty
24
Ten commandments of CAP treatment
Severe
All

• Only a few pathogens are involved
• Always cover Pneumococcus
• Consider epidemiology, age and health status
• Mycoplasma during epidemics, Staph.aur. in flu
• Do not delay starting antibiotics

• Assess prognostic factors and severity early
• Establish etiology quickly
• Adequate oxygen, hydration and nutrition
• Careful monitoring transfer early to ICU
• Initial antibiotics must cover all the likely
  pathogens

25
Treatment of CAP

• 1) lt65 year, no comorbidity, home macrolide,
  doxycyclin,
• amoxycillin/clavulanic acid, 2. gen.
  cephalosporin
• 2) gt65 year, comorbidity, home
  amoxycillin/clavulanic acid, 2-3 gen.
  cephalosporin - macrolide, respiratory
  fluoroquinolon (levofloxacin, moxifloxacin)
• 3) hospital amoxycillin/clavulanic acid, 2-3
  gen. cephalosporin macrolide,
  resp.fluoroquinolon
• 4) ICU ceftriaxon/cefotaxim, cefepim,
  carbapenemes (imipenem, meropenem),
  piperacillin/tazobactam
• macrolides, resp. fluoroquinolon

26
Risk factors of nosocomial pneumonia, HAP
27
Pathogens and treatment of non-severe HAP
Core pathogens Core antibiotics
Gram-neg. Enterobacteriaceae E. coli, Klebsiella spp., Proteus spp, Serratia marcescens, Enterobacter spp. Usual community pa- thogensPneumococcus, H.influenzae,Staph.aureus 2nd- or 3 rd- gen cephalosporins, beta-lactam/lactamase inhibitor, fluoroquinolones
28
Pathogens and treatment of non-severe HAP with
additional risk factors
Core path. plus Risk factor Core ant. plus
Anaerobes Surgery, impaired swal- loing, aspiration, dental sepsis clindamycin,beta- lactam inhibitor, moxifloxacin
Staph.aureus Diabetes,renal failure, coma, head trauma, neurosurgery add vancomycin if MRSA susp.
Legionella spp High dose steroid, endemic in hospital macrolides -fluo- roquinolones- rifam.
Pseuodomonas aeruginosa prior ant., high dose ster. ICU, CF,bronchiectasia ciprofloxacin,amino- glycoside,3rd gen ceph. with antipseud. act.
29
Pathogens and treatment of severe HAP
Core pathogens plus Core antibiotics
Pseudomonas aeruginosa, Acinetobacter spp, MRSA ciprofloxacin or aminoglycoside, plus one of antipseudomonal beta-lactam, meropenem, vancomycin
30
Reccurent pneumonia (GERD)
31
Streptococcus pneumoniae

• Most common bacterium in adults
• Significant morbidity and mortality
• Polysaccharide capsule impairs phagocytosis ?
• need of opsonization ? risk population
  lymphoma,
• hyposplenia, hypogammaglobulinaemia
• Abrupt onset, cough, rigors, high fever,
  tachycardia, tachypnoe, sticky pink sputum, focal
  crackles,
• Sputum Gram stain diplococcus, blood culture
  (20 pos.)
• Good sputum sample LRT gt 25 PMN, lt 10 EC (low
  power field)
• X-ray homogenouos consolidation
• Complications pleura, pericardium, meninges,
  joints, endocardium, Type 3 abscess, lung
  scarring

32
Streptococcus pneumoniae
33
Streptococcus pneumoniae II.

• Treatment
• Penicillin, ampicillin, amoxycillin
• Cephalosporins 2-3 gen.
• Macrolides
• Carbapenems (imipenem, meropenem)
• Prevention
• 23-valent vaccine, 90 adult types
• Chronic lung, heart, liver, renal disease, HIV
• Diabetes, after spelenctomy, sickle-cell disease

34
Mycoplasma pneumoniae(Atypical pneumonia)

• Atypical pathogen, moderate morbidity, low
  mortality
• Close communities (schools, barracks,
  dormitories)
• Intracellular pathogen (Chlamydia, Legionella)
• Patchy shadowing on X-ray
• Extrapulmonary manifestations lymphadenopathy,
  cardiac, neurological, skin lesions,
  gatrointestinal,haematological, musculoskeletal
• Treatment macrolides, tetracyclin,
  fluoroquinolones

35
Mycoplasma pneumoniae
36
Legionella pneumophila
37
Staphylococcus aureus

• High morbidity and mortality (30-70 in
  bacterae-mia)
• 30 of adults carry in the anterior nares
• Intravascular tubes (catheters, cannules)
• Usually follows influenza infections
• Toxins ? tissue necrosis ? abscess
• Treatment beta-lactamase resistant penicillins
  (oxacillin), cephalosporins, MRSA vancomycin

38
Staphylococcus aureus
39
Lung abscess
Key points

• many other cavitating lesions than abscess
• careful review of chest x-ray to distinguish from
  empyema
• most are secondary to aspiration of oropharyngeal
  secretions
• exclude malignancy or other cause, bronchoscopy!
• a single microbe is unusual unless abscesses
  developed after bacterial pneumonia. More
  commonly, there is a mixed growth, including
  anaerobes

40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
Causes of lung abscess

• Aspiration from the oropharynx
• Bronchial obstruction
• Pneumonia
• Blood-borne infection
• Infected pulmonary infarct
• Trauma
• Transdiagphragmatic spread

46
Diff. dg of lung abscess

• Cavitated tumour
• Infected bulla or cyst
• Localised saccular bronchiectatsis
• Aspergilloma
• Wegeners granulomatosis
• Hydatid cyst
• Coal workres pneumoconiosis
• - progressive massive fibrosis
• - Caplans sy
• Cavitated rheumatoid nodule
• Gas-fluid level in oesophagus, stomach or bowel

47
Treatment of lung abscess

• Based on bacteriologic findings
• Penicillin (amoxicillin/clavulanic acid)
• Clindamycin aminoglycosid (mixed flora)
• moxifloxacin