COMMUNITY ACQUIRED PNEUMONIA -OLD ENEMY

1
COMMUNITY ACQUIRED PNEUMONIA -OLD
ENEMY RECENT FOE

• Dr. Md. Sayedul Islam
• Consultant
• pulmonologist intensivist
• King Saud Chest Hospital

2
DEFINITION

• ?An acute infection of the pulmonary parenchyma
  that is associated with at least some symptoms of
  acute infection,
• ?accompanied by the presence of an acute
  infiltrate on a chest radiograph, or auscultatory
  findings consistent with pneumonia,
• ?in a patient not hospitalized or residing in a
  long term care facility for gt 14 days before
  onset of symptoms.

Adeel A. Butt, MD
Bartlett. Clin Infect
Dis 200031347-82.
3
EPIDEMIOLOGY
EPIDEMIOLOGY
4
Current CAP burden

• 6Th leading cause of death.

CID 2007 44 (supl 2), s27
5
ETIOLOGY
6
Pneumococcal burden
7
PATHOLOGY
8
PATHOLOGY
9
Assessment of pneumonia

• Pneumonia with complication
• Pneumonia with co morbid illness
• Pneumonia with risk factors
• Pneumonia with unstable vital sign

10
Complication of Pneumonia

• Parapneumonic effusion
• Pneumothorax
• Lung abscess/Metastasis abscess
• Septicemia /ARDS
• Hepatitis, pericarditis, Myocarditis,
  meningoencephalitis.

11
Co morbid illness

• COPD
• Congestive heart failure
• Malignancy
• Diabetes Mellitus
• Hepatic or renal disease

12
Risk factors

• Risk factors for DRSP
• Agegt65years
• Recent antibiotics within 1 months (DRSP)
• Immunosupressive therapy within 3 months
• HIV/ Immunocompromized patient

• Unstable Vital sign
• Altered level of conciousness
• Heart rate gt125
• Respiratory rate gt30/m
• Systolic BPlt90 mmHg
• Temperature lt35 or gt400 C

13
Maximize the outcome of CAP

• Site of care decision
• Time of first antibiotics
• Proper choice of antibiotics

14

SITE OF CARE

• PORT PEDICTION RULE
• CURB- 65
• FINES PSI SCORING

15
PORT Prediction Rule
Items Score
Neoplastic disease 30
CLD 20
CCF 10
CVD 10
Renal 10
Altered mentation 20
Respiratory rate gt30/m 20
Systolic BP lt90mmHg 20
Temperature lt35ºC 15
Patients outcome research team
16
PORT Prediction Rule-contd
Items Score
Na 10
PH lt7.35 30
Urea 30mg/dl 20
Glucose gt250 mg/dl 10
HCT lt 30 10
Pao2 lt60 mmHg 10
Pleural effusion 10
17
PORT Prediction Rule - contd

• Risk class

Class Predictor level Mortality rate
I Absence of predictor 0.1- 0.4
II 70 0.6-0.7
III 71- 90 0.9-2.8
IV 91- 130 8.2-9.3
V gt 130 29-31
Low
Mod
high
CMD 2005
18
Pneumonia severity scoring index
system (CURB-65 scoring)

• CURB-65 score (Updated 2004.)
• Confusion
• Urea gt 7 mmol/l
• Respiratory rate 30/min
• Blood pressure (SBP lt 90mmHg or DBP 60mmHg)
• Age 65 years
• Score 1 point for each feature present

19
Pneumonia severity scoring index
system (Fines PSI scoring)

• Age
• Co morbidity
• Unstable vital sign

Group-I No to all, Low mortality risk,
eligible for OPD management of
CAP Group-II Yes to 1-2 of three questions,
Intermediate mortality
risk, close monitoring or
hospitalization for up to 48
hours, Group III Yes to all, Moderate to high
mortality risk, proceed to
hospitalization
20
(No Transcript)
21
DIAGNOSTIC TOOLS
HISTORY PHYSICAL EXAMINATION IMAGING- CXR,
CT LABORATORY
22
CAP EARLY
23
Diagnosis
Does this patient have CAP?
24
CAP after 12 hours
25
CAP AFTER 12 HOURS
26
X-ray Swine flu
27
LAB Evaluation

• SPUTUM CULTURE
• BLOOD CULTURE
• ANTIGEN DETECTION
• ACUTE PHASE SEROLOGY
• PCR

28
LAB Evaluation
Bacteriological
CID 2003 37(1 December)
29
(No Transcript)
30
PNEUMONIA IN ER
Sign clinical symptoms suggestive of pneumonia
Risk stratification
Mod/High
Yes
Low
Obtain CXR
OPD
Inpatient
Infiltration suggestive pneumonia ?
No
Out of guideline
31
Empirical Rx of CAP-
ATS- Guideline

• OPD

Evidence Level- I Alternative
Young otherwise healthy Macrolide Doxycycline (Evidence level-?)
Comorbid illness or risk factor 2nd Ceph Macrolide Res FLQ. (Evidence level-II)
CID
CID 200744 (1supl 2) s27
32
Empirical Rx of CAP-
ATS Guideline

• Hospitalized patient

Evidence level- I Alternative
Ordinary cases 2nd/ Ceph Macrolide B-lactam Doxy (Evidence level- III)
Suspected aspiration 3rd/ cephaclinda Clinda macrolide (Evidence level III)
With bronchiactesis Anti-Pseudomonal 3rd/4th ceph macrolide RFQ macrolide (Evidence level- II)
CID 200337 (1 December)
33
Empirical Rx of CAP-
Therapeutic Guideline

• Severe Pneumonia (ICU)

First line Alternative
No pseudomonas risk 3rdCephmacrolide Carbipenem Macrolide
Pseudomonas risk Antipseudomonas 3rdcephaminoglymacrolide AntiPseudomonal pencilline aminoglymacrolid
CID 200337 (1 December)
34
Head to head comparison of first line Abx

• MOXIRAPID study group

For adult hospitalized Patient with CAP, MxF
therapy is clinically equivalent to high dose
Ctrx clari
Clin Infect Dis.2005 Dec 15 41(12)1697-705
35
PROBLEM OF CAP

• DRSP
• MDRSP
• EPIDEMIC AND PANDEMIC FLU

36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
De-Escalation

• De- Escalation is use of EITHER OR BOTH-
• Fewer drugs,
• Narrower spectrum
• De Escalation reduced drug resistance and
  decrease mortality

43
VACCINE
INFLUENZA VACCINE PNEUMOCOCCAL VACCINE
44
Conclusion

• S. pneumonae and H. influenzae are important
  pathogens in CAP
• Resistant in S. pneumoae is increasing worldwide.
• -Fatal pandemic H1N1 cases had bacterial
  coinfection,esp Spn
• Risk stratification by prediction scoring,
  appropriate ABx, De-excalation may reduce the
  resistance pattern
• Moxifloxacin has excellent activity against
  typical RTI pathogene, including PRSP.

45
Thanks for Your Attention!
THANK YOU
46
(No Transcript)
47
The Abbreviated Mental Test (each question scores
1 mark, total 10 marks) Age Date of birth
Time (to nearest hour) Year Hospital name
Recognition of two persons (e.g. doctor, nurse)
Recall address (e.g. 42 West Street) Date of
First World War Name of monarch Count
backwards 20 1
48
Duration of treatment
Place/severity or pathogen Duration of
treatment (days) Home treated, not severe
(microbiologically undefined)
7 Hospital treated, not severe (microbiologically
undefined) 7 Hospital treated,
severe (microbiologically undefined)
10 Legionella infection

1421 Atypical pathogen

14 Pneumococcal infection (uncomplicated)
7 Staphylococcal
infection
1421 Gram negative
enteric bacilli
1421
49
ABx Choice
50
(No Transcript)
51
(No Transcript)
52
Drug category

• Advanced macrolide
• Clarithromycine
• Azithromycine
• Roxithromycine

• Respiratory quinolones
• Moxifloxacine
• Gatifloxacine
• Gemifloxacin
• Levoloxacin

53
AntiPseudomonal drugs

• Antipseudomonal Ceph
• Ceftazidime- 3rd generation
• Cefipime- 4th generation

• Carbapenem
• Imipenem
• Meropenem

• Antipseudomonal penicillin
• Piperacilline
• Tazocine
• Ticarcilline-Clavulonic acid

54
Pseudomonas Risk Factor

• Severe structural lung disease (bronchiactesis)
• Recent antibiotic therapy
• Stay in hospital (ICU)

55
Importance of guideline of empirical therapy

• Ideally the first dose of antibiotic should be
  administered within 6 hours of initial medical
  assessment to improve the outcome
• CAP is the evolving process and patient may shift
  between risk groups. The physician must be
  responsive to these changes and can only do so
  when the patient is managed in appropriate
  setting.
• Timely therapy can only be given when disease is
  recognized severity is appropriately assessed.

56
(No Transcript)
57
(No Transcript)
58
(No Transcript)
59
(No Transcript)
60
(No Transcript)
61
(No Transcript)
62
(No Transcript)
63
EPIDEMIOLOGY
64
CAP PRODUCING ORGANISM
65
Deference between Typical Atypical
Features Typical Atypical
Cough Present, productive May be absent, when present dry, hacking
Main complain Fever, chest pain Fever, body ache
Physical finding Typical physical finding Of consolidation Feature out of proportion to physical finding
culture 60 culture positive Usually culture ve/ serology diagnostic
TLC Usually very high May be normal
CxR Lober consolidation Variable
66
(No Transcript)
67
COMMUNITY ACQUIRED PNEUMONIA - Old enemy
recent foe

• Dr. Md. Sayedul Islam
• Consultant
• pulmonologist intensivist
• King Saud Chest Hospital

68
(No Transcript)
69

DEFINITION

• Commonly defined as-
• An acute infection of the lower respiratory tract
  
• In patient who has not resided in a hospital or
  health care facilities in the previous 14 days.

70
COMMUNITY ACQUIRED PNEUMONIA

• Infection is usually spread by droplet inhalation
  
• Most patients affected are previously well.
• -Smoker
• -Alcoholic more susceptible
• -Steroid therapy

71
EPIDEMIOLOGY
EPIDEMIOLOGY
72
EPIDEMIOLOGY
73
Current CAP burden

• 6Th leading cause of death.

CID 2007 44 (supl 2), s27
74
ETIOLOGY
75
Pneumococcal burden
76
AGE DISTRIBUION
77
PATHOLOGY
78
PATHOLOGY
79
PNEUMONIA TYPES

• Community Acquired Pneumonia (CAP)
• Hospital Acquired Pneumonia (HAP)
• Hospitalized community Acquired Pneumonia (HCAP)
• Ventilator Associated Pneumonia (VAP)
• Pneumonia in immunocompromized patient

80
Assessment of pneumonia

• Pneumonia with complication
• Pneumonia with co morbid illness
• Pneumonia with risk factors
• Pneumonia with unstable vital sign

81
Complication of Pneumonia

• Parapneumonic effusion
• Pneumothorax
• Lung abscess/Metastasis abscess
• Septicemia /ARDS
• Hepatitis, pericarditis, Myocarditis,
  meningoencephalitis.

82
Co morbid illness

• COPD
• Congestive heart failure
• Malignancy
• Diabetes Mellitus
• Hepatic or renal disease

83
Risk factors

• Risk factors for DSRP
• Agegt65years
• Recent antibiotics within 3 months (DRSP)
• Immunosupressive therapy within 3 months
• HIV/ Immunocompromized patient

• Unstable Vital sign
• Altered level of conciousness
• Heart rate gt125
• Respiratory rate gt30/m
• Systolic BPlt90 mmHg
• Temperature lt35 or gt400 C

84
Maximize the outcome of CAP

• Site of care decision
• Time of first antibiotics
• Proper choice of antibiotics

85

SITE OF CARE

• PORT PEDICTION RULE
• CURB- 65
• FINE,S PSI SCORING

86
PORT Prediction Rule
Items Score
Neoplastic disease 30
CLD 20
CCF 10
CVD 10
Renal 10
Altered mentation 20
Respiratory rate gt30/m 20
Systolic BP lt90mmHg 20
Temperature lt35ºC 15
Patients outcome research team
87
PORT Prediction Rule-contd
Items Score
Na 10
PH lt7.35 30
Urea 30mg/dl 20
Glucose gt250 mg/dl 10
HCT lt 30 10
Pao2 lt60 mmHg 10
Pleural effusion 10
88
PORT Prediction Rule - contd

• Risk class

Class Predictor level Mortality rate
I Absence of predictor 0.1- 0.4
II 70 0.6-0.7
III 71- 90 0.9-2.8
IV 91- 130 8.2-9.3
V gt 130 29-31
Low
Mod
high
CMD 2005
89
Pneumonia severity scoring index
system (CURB-65 scoring)

• CURB-65 score (Updated 2004.)
• Confusion
• Urea gt 7 mmol/l
• Respiratory rate 30/min
• Blood pressure (SBP lt 90mmHg or DBP 60mmHg)
• Age 65 years
• Score 1 point for each feature present

90
Pneumonia severity scoring index
system (Fines PSI scoring)

• Age
• Co morbidity
• Unstable vital sign

Group-I No to all, Low mortality risk,
eligible for OPD management of
CAP Group-II Yes to 1-2 of three questions,
Intermittent mortality
risk, close monitoring or
hospitalization for up to 48
hours, Group III Yes to all, Moderate to high
mortality risk, proceed to
hospitalization
91
The Abbreviated Mental Test (each question scores
1 mark, total 10 marks) Age Date of birth
Time (to nearest hour) Year Hospital name
Recognition of two persons (e.g. doctor, nurse)
Recall address (e.g. 42 West Street) Date of
First World War Name of monarch Count
backwards 20 1
92
Duration of treatment
Place/severity or pathogen Duration of
treatment (days) Home treated, not severe
(microbiologically undefined)
7 Hospital treated, not severe (microbiologically
undefined) 7 Hospital treated,
severe (microbiologically undefined)
10 Legionella infection

1421 Atypical pathogen

14 Pneumococcal infection (uncomplicated)
7 Staphylococcal
infection
1421 Gram negative
enteric bacilli
1421
93
CAP PRODUCING ORGANISM
94
(No Transcript)
95
Deference between Typical Atypical
Features Typical Atypical
Cough Present, productive May be absent, when present dry, hacking
Main complain Fever, chest pain Fever, body ache
Physical finding Typical physical finding Of consolidation Feature out of proportion to physical finding
culture 60 culture positive Usually culture ve/ serology diagnostic
TLC Usually very high May be normal
CxR Lober consolidation Variable
96
(No Transcript)
97
DIAGNOSTIC TOOLS
HISTORY PHYSICAL EXAMINATION IMAZING- CXR,
CT LABORATORY
98
CAP EARLY
99
CAP AFTER 12 HOURS
100
X-ray Swine flu
101
LAB evaluation

• SPUTUM CULTURE
• BLOOD CULTURE
• ANTIGEN DETECTION
• ACUTE PHASE SEROLOGY
• PCR

102
LAB evaluation
Bacteriological
CID 2003 37(1 December)
103
(No Transcript)
104
PNEUMONIA IN ER
Sign clinical symptoms suggestive of pneumonia
Risk stratification
Mod/High
Yes
Low
Obtain CXR
OPD
Inpatient
Infiltration suggestive pneumonia ?
No
Out of guideline
105
ABx Choice
106
Antibiotic treatment

• Antibiotic should be given as soon as clinical
  diagnosis of pneumonia is made.
• If possible culture specimen should be sent prior
  to starting antibiotic.
• Treatment shouldnt be delayed if a sputum
  sample is not readily available

107
(No Transcript)
108
(No Transcript)
109
Empirical Rx of CAP-
ATS- Guideline

• OPD

Evidence Level- I Alternative
Young otherwise healthy Macrolide Doxycycline (Evidence level-?)
Comorbid illness or risk factor 2nd Ceph Macrolide Res FLQ. (Evidence level-II)
CID
CID 200744 (1supl 2) s27
110
Empirical Rx of CAP-
ATS Guideline

• Hospitalized patient

Evidence level- I Alternative
Ordinary cases 2nd/ Ceph Macrolide B-lactam Doxy (Evidence level- III)
Suspected aspiration 3rd/ cephaclinda Clinda macrolide (Evidence level III)
With bronchiactesis Anti-Pseudomonal 3rd/4th ceph macrolide RFQ macrolide (Evidence level- II)
CID 200337 (1 December)
111
Empirical Rx of CAP-
Therapeutic Guideline

• Severe Pneumonia (ICU)

First line Alternative
No pseudomonas risk 3rdCephmacrolide Carbipenem Macrolide
Pseudomonas risk Antipseudomonas 3rdcephaminoglymacrolide AntiPseudomonal pencilline aminoglymacrolid
CID 200337 (1 December)
112
Drug category

• Advanced macrolide
• Clarithromycine
• Azithromycine
• Roxithromycine

• Respiratory quinolones
• Moxifloxacine
• Gatifloxacine
• Gemifloxacin
• Levoloxacin

113
AntiPseudomonal drugs

• Antipseudomonal Ceph
• Ceftazidime- 3rd generation
• Cefipime- 4th generation

• Carbapenem
• Imipenem
• Meropenem

• Antipseudomonal penicillin
• Piperacilline
• Tazocine
• Ticarcilline-Clavulonic acid

114
Pseudomonas Risk Factor

• Severe structural lung disease (bronchiactesis)
• Recent antibiotic therapy
• Stay in hospital (ICU)

115
Importance of guideline of empirical therapy

• Ideally the first dose of antibiotic should be
  administered within 6 hours of initial medical
  assessment to improve the outcome
• CAP is the evolving process and patient may shift
  between risk groups. The physician must be
  responsive to these changes and can only do so
  when the patient is managed in appropriate
  setting.
• Timely therapy can only be given when disease is
  recognized severity is appropriately assessed.

116
Head to head comparison of first line Abx

• MOXIRAPID study group

For adult hospitalized Patient with CAP, MxF
therapy is clinically equivalent to high dose
Ctrx clari
Clin Infect Dis.2005 Dec 15 41(12)1697-705
117
Moxi-Rapid trial
Fever resolution
Days
ECCMID (European congress of clinical
Microbiology and infectious Disease)
118
CAPRIE study
Clinical cure Day 5-21 post therapy

Cure of patients
119
Bacterial co-infection from fatal
pandemic H1N1

• During May - august 2009, 77 us patients with
  
• fatal cases of confirmed H1N1
• ? Of the 77 cases, gt 30 cases had bacterial
  coinfection--
• -10 cases with S.
  pneumoniae,
• -6 with S. pyogenes,
• -7 cases with S. aureus,
• -2 with S. mitis, and
• -1 with H influenzae,
• -rest of the cases were
  involved with
• multiple pathogen.
• 
  MMWR,Sep29,2009

120
(No Transcript)
121
(No Transcript)
122
(No Transcript)
123
(No Transcript)
124
(No Transcript)
125
(No Transcript)
126
(No Transcript)
127
(No Transcript)
128
(No Transcript)
129
(No Transcript)
130
(No Transcript)
131
(No Transcript)
132
(No Transcript)
133
(No Transcript)
134
(No Transcript)
135
(No Transcript)
136
(No Transcript)
137
(No Transcript)
138
Duration of treatment

• Uncomplicated pneumonia 7-10 days
• Legionella, Staph, Klebsiella needs 14 days or
  more
• Pneumonia with complication needs treatment for
  4wks or longer

139
De-Escalation

• De- Escalation is EITHER OR BOTH
• Fewer drugs,
• Narrower spectrum
• De Escalation reduced drug resistance and
  decrease mortality

140
VACCINE
141
Conclusion

• S. pneumonae and H. influenzae are important
  pathogens in CAP
• Resistant in S. pneumoae is increasing worldwide
• -In Asia, macrolides resistance was higher
  than in other areas
• -Penicilln and macrolides resistance were
  clinically significant
• -Fatal pandemic H1N1 cases had
  bacterialcoinfection,esp Spn
• Prevalence of BLANR in H. influenza bring concern
  in Japan.
• Moxifloxacin has excellent activity against
  typical RTI pathogene, including PRSP.

142
(No Transcript)
143
Pneumonia in ER
144
(No Transcript)
145
Atypical Pneumonia
146
(No Transcript)
147
THANK YOU
148
MRSA -Pneumonia

• National Nosocomial Infection Surveys
  report
• 1975 2-3 of all S. aureus isolation
• 1997-1999 Over 34 of all S. aureus
• 1999 Incidence of MRSA, CAP is 25 of
  
• all S. aureus

149
MRSA- Risk Factors (CAP)

• Intravenous drug use
• Chronic antimicrobial therapy
• Hemodialysis
• The major route of MRSA spread is direct patient
  to patient contact
• Via the hand of medical personnel.

150
Sites of colonization

• Anterior nares
• Wound, burns or other areas of decrease skin
  integrity.
• The perineal area
• Upper respiratory tract.
• Skin adjacent to- invasive device, gastrostomy
  tube, tracheostomies.

151
Hospital Acquired Pneumonia

• Occur at least 2 days after admission in hospital
• Usually developed in patients with
• Chronic lung disease
• General disability
• Receiving assisted ventilation
• Endotracheal Intubation / tracheostomy

152

• Infected ventilator
• nebulisers
• bronchoscops
• Dental or sinus injections
• Intra venous cannula injection

153
Organism involved

• Commonly gram negative organism
• Escherichia .
• Pseudomonas.
• Klebsiella
• Gram positive organism
• Staph. aureus commonly
• multidrug resistant variety.
• Anaerobic organism are more
• common than cap.

154
Management

• Adequate Gram-negative coverage obtained
• third generation cephalosporin cefotaxime plus
  aminoglycoside- gentamycin
• Imipenem or
• Aztreomam plus flucloxacillin.
• Aspiration pneumonia.
• Amoxiclav 1.2g 8-hrly plus metronidazol 500mg
  8hrly

155
Suppurative Aspirational Pneumonia (including
pulmonary abscess

• Organism involved
• If healthy lung tissue
• Staph. aureus
• Klebsiella Pneumonia
• In pulmonary infarct or collapsed lobe.
• Step pneumoniae
• Staph. Aureaus
• Strep pyogenes H. inflenzae

156
Antibiotic treatment

• Amoxycillin 500mg 6hrly orally plus
• Metronidazole 400 mg 8 hrly
• If anaerobic infection suspected
• Antibiotic therapy modified according to CS

157

• Removal or treatment of endobronchial obstruction
  if any.
• Duration 4-6 weeks.

158
Pneumonia in immunocompromised patient

• In AIDS disease
• Disseminated infection
• Cytomegalovirus (CMV) infection
• Bacterial septicemia
• Pneumococcal
• salmonella

159
(No Transcript)
160
Atypical Pneumonia
161
(No Transcript)
162
THANK YOU
163
MRSA -Pneumonia

• National Nosocomial Infection Surveys
  report
• 1975 2-3 of all S. aureus isolation
• 1997-1999 Over 34 of all S. aureus
• 1999 Incidence of MRSA, CAP is 25 of
  
• all S. aureus

164
MRSA- Risk Factors (CAP)

• Intravenous drug use
• Chronic antimicrobial therapy
• Hemodialysis
• The major route of MRSA spread is direct patient
  to patient contact
• Via the hand of medical personnel.

165
Sites of colonization

• Anterior nares
• Wound, burns or other areas of decrease skin
  integrity.
• The perineal area
• Upper respiratory tract.
• Skin adjacent to- invasive device, gastrostomy
  tube, tracheostomies.

166
Hospital Acquired Pneumonia

• Occur at least 2 days after admission in hospital
• Usually developed in patients with
• Chronic lung disease
• General disability
• Receiving assisted ventilation
• Endotracheal Intubation / tracheostomy

167

• Infected ventilator
• nebulisers
• bronchoscops
• Dental or sinus injections
• Intra venous cannula injection

168
Organism involved

• Commonly gram negative organism
• Escherichia .
• Pseudomonas.
• Klebsiella
• Gram positive organism
• Staph. aureus commonly
• multidrug resistant variety.
• Anaerobic organism are more
• common than cap.

169
Management

• Adequate Gram-negative coverage obtained
• third generation cephalosporin cefotaxime plus
  aminoglycoside- gentamycin
• Imipenem or
• Aztreomam plus flucloxacillin.
• Aspiration pneumonia.
• Amoxiclav 1.2g 8-hrly plus metronidazol 500mg
  8hrly

170
Suppurative Aspirational Pneumonia (including
pulmonary abscess

• Organism involved
• If healthy lung tissue
• Staph. aureus
• Klebsiella Pneumonia
• In pulmonary infarct or collapsed lobe.
• Step pneumoniae
• Staph. Aureaus
• Strep pyogenes H. inflenzae

171
Antibiotic treatment

• Amoxycillin 500mg 6hrly orally plus
• Metronidazole 400 mg 8 hrly
• If anaerobic infection suspected
• Antibiotic therapy modified according to CS

172

• Removal or treatment of endobronchial obstruction
  if any.
• Duration 4-6 weeks.

173
Pneumonia in immunocompromised patient

• In AIDS disease
• Disseminated infection
• Cytomegalovirus (CMV) infection
• Bacterial septicemia
• Pneumococcal
• salmonella