Pneumonia. Definition: Acute infectious inflammation of the distal lung paranchyme (Distal to terminal bronchioles) with clinical and radiological signs.

Pneumonia

Pneumonia

• Definition: Acute infectious inflammation of the distal lung paranchyme (Distal to terminal bronchioles) with clinical and radiological signs of consolidation

• Pneumonitis: Noninfectious inflammation

Classifications

– Community Acquired

– Nosocomial (Hospital acquired)

– Pneumonia in immuncompromised host

• Anatomic– Lober– Bronchopneumonia– Interstitial pneumonia

• Etiologic– Bacterial– Viral– Fungal

• The microorganism reaches the lungs by:– Inhalation or aspiration– Hematogenious way– Direct invasion from the neighbouring tissues

• The amount of the organism inoculated, the virulance factors and the immunity of the host are important factors

Most frequent

• S. Pneumonia (50%)

• H. İnfluenzae

• Moraxella catarrhalis

• Mycoplasma pneumonia

• Chlamydia pneumonia

• Legionella pneumophilia

• Virus (10-20%)

Atypical pn

Community acquired pneumonia

• The symptoms of pneumonia are usually nonspecific but generaly include:– Fever (chills)– Cough– Sputum production (purulent)– Thoracic pain– Dyspnea

• Typical pneumonia is characterised by abrubt onset high fever, chills, productive cough, thoracic pain, focal clinical signs, lobar or segmental radiographic findings, leukocytosis– Strep. Pneumonia

• Rast colored (pink) sputum• Labial herpes lesions• Lober infiltration

– H. influenzae

Different presentation

• Confusion, tachypnea, hypotermia can be the presenting symptom in old age groups

• Unusual presentation can be seen in immunocompromised patients

• Atypical pneumonias are characterised by progressive onset, fever without chills, a cough without sputum, headache, myalgia, diffuse crackles, modest leukocytosis, interstitial infiltrates on chest radiographs.– Mycoplasma pneumonia– Legionella (bradicardia, hyponatremia)– Chlamydia

Physical examination

• High fever, tachicardia, tachypnea, hypotension, confusion, drowsiness, altered mental status

• Respiratory system:• Inspection:

– Usually normal– Ortopnea– Cyanosis– Respiratory disstress

• Palpation– İncreased Vibration thoracic (lober pneumonia)– Decreased hemithoracal movement

• Percution– Normal sonority– Dullness (Matite)

• Oscultation– End inspiratory fine crackles– Local diminished breath sounds– Bronchial voice

Diagnosis

• History and symptoms

• Physical examination

• PA Chest x-ray

• Microbiologic examination

• Routine laboratory tests– CBC,ESR,CRP,Hepatic enzymes,Renal functions

• Blood gas

PA Chest x-ray

• Consolidation – Lobar or patchy

nonhomogenious infiltrations

– Air bronchogram– Round opacity– Fine reticular density

• Complications– Pleural effusion– Cavitation– Abscess– Pneumatocell– Pneumothorax

Microbiologic examination(identification of the causative pathogen)

• The causative pathogen can not be isolated in 30-50% of CAP (Not always necessary)

• Sputum– Gram Staining (more specific than culture but less

sensitive)

In microscopic examination sputum shoud show <10 epithelial cell , and >25 PNL – Culture (Staining and culture shoud be consistent)

• Blood culture (Hospitalised patients)• Pleural fluid

• Serology (Urine, sputum or blood: pneumococcal antigen, urine: Legionella antigen, DFA, 4 fold increase in specific antibody titers (cold agglutinins) between acute and covalescent period

• İnvasive techniques (Shoud be performed in severe

cases and immunocompromised patients) (FOB, BAL, Protected-brush, TBB, PCFNA)

Approach to the patient

• Is it pneumonia?

• How severe is the illness? – Outpatient treatment?– Hospitalization?– Intensive care?

– Risk factors– Severe condition

Risk Factors

• Age>65• Comorbid illness• Alcoholism• Aspiration?• Recurrent pneumonia

<1year• Mental problems• Spleenectomy• Malnutrition

• Social problems• CS use >10 mg

prednisolone for 3 months

• Immunosuppressive treatment

• Pneumonia following influensa

Signs of Severe condition• Respiratory rate >30/min• BP <90/60 mmHg• Fever>38,3 C• Extrapulmonary disease (menegitis, artritis,

myocarditis etc)• WBC <4000 or >30000 / mm3 • Htc <30% or Hb<9 gr/dl• ABG PaO2<60 mmHg

PCO2>50 mmHg• BUN >20 mg/dl• Multilober infiltration, cavity, effusion, rapid

progression• Sepsis or multisystem disfunction

CURB-65 Score

• Confusion• Urea>42.8 mg/dl; BUN>20 mg/dl• RR>30/min• BP<90/60 mmHg• Age>65

Predicting mortality, each is 1 point. A score >2 points Hospitalization

Group I A

• Probable microorganism– S. pneumoniae– M. pneumoniae– Chlamydia

pneumoniae– H. influensa– Virus– Other

• Empirical Treatment– Amoksisilin 1gr/8hr– Macrolid (Klaritromycine,

azitromycine) or Doksisiklin

(According to clinical signs (atypical?) or allergic conditions)

Risk factor(-)

Severe condit ion (-)

Outpatient treatment

Group I B

• Probable microorganism– S. pneumoniae– M. pneumoniae– Chlamydia pneumoniae– Mikst infeksiyon– H. İnfluensa– Enterik Gr (-)– Virus– Other

Risk factor (+)

Severe condition (-)Send to hospital

Outpatient treatment

• Empirical Treatment– 2-3. line sephalosporin

(nonpseudomonal)– Beta-laktamase inhibiting

aminopenisilin

±– Macrolid veya Doksisiklin– (In case of intolerability,

allergy only florokinolon Moksifloksasin, Levofloksasin)

Group 2

• Probable microorganism– S. pneumoniae– H. İnfluensa – M. pneumoniae– Chlamydia pneumoniae– Mixed infection– Aerob Gr (-) – Anaerobic– Legionella– Virus

Severe condition (+)and/or Risk factor (+)

Hospitalized

Empirical treatment:

3. line nonpseudomonal sephalosporin or beta laktamase inhibiting aminopenisilin

+

Macrolid /Doksisiklin

Or

Florokinolon alone

Intensive Care Indications– RR>30 – PaO2/FiO2 ≤250– Confusion/ disorientation– BP<90/60 mm Hg– Urine <20 ml/st,(BUN>20

mg/dl) ARF– WBC<4000/mm3

– PLT<100 000/mm3

– Temp<360C– Bilateral, multilober

infiltration or progression >50% in 48 hrs

– Hypotension that needs heavy iv support

• Indications for mechanical ventilation

• Septic shock (need for vasopressor drugs)

Group 3

• Probable microorganism– S. Pneumoniae– Legionella– H. İnfluensa– Enteral Gr (-) – S aureus– M pneumonia– Virus– Other

• Probable microorganism– P aureginosa– Grup A pathogens

Intensive care tr. indication (+)

A Pseudomonas risk(-)

B Pseudomonas risk(+)

Empirical treatment:

3. Line nonpseudomonal sephalosporin or beta laktamase inhibiting aminopenisilin

+

Macrolid or Florokinolon

(Add rifampicin if documented legionella+)

Antipseudomonal betalaktam

+

Ciprofloksasin/ofloksasin or aminoglikozid

+

Macrolid (in non Kinolon combined group)

Risk for Pseudomonas

– Underlying lung disease (Bronchiectasis, C. Fibrozis, severe COPD)

– Steroid (>10 mg/gün)– Antibiotic use (>7 days in the previous month)– Malnutrition

Certain risk-pathogen relations

• Gr (-) enteral bacillei– Nursing home residency– Concomitant CVS

disease– Multipl concomitant

disease– Recent antibiotic use– 3rd generation

cephalosporines, fluorokinolones (3-4 weeks)

– Antipseudomonal penicillines, ceftazidime +aminoglicoside for pseudomonas

• Anaerob bacteria– Poor oral hygen

– Probability of aspiration (alcoholism, epileptic atack, gingivitis, esophageal obstruction

– iv drug abuse

– Obstructive bronchial pathologies

– Fusobacterium, bacteroides, peptostreptococcus, actinomyces

– Sputum with bad smell,

– Betalactamase inh aminopenicilins, penicillin G, clindamycine, metranidazole, ornidazole (4-6 weeks if necrosis is present)

• Legionella pneumophila– Age >65– Malignancy– COPD– Steroid treat.– Smoking– Recent travel (hotel)– Water supply system

reconstruction– Macrolide (21 days)– Rifampicine, kinolones

• S. Aureus (rapid progression, cavitation, severe illness)

– Concurrent influensa epidemic,

– Nursing home resident– Iv drug abuse– Vancomycine,

Teikoplanin (min 3 weeks, 6 weeks if abscess is formed)

• C. psittachi– Recent bird contact– At risk occupation

Follow up

• Parenteral to oral tr. shift:– Afebril period of 24 hours – Decreased neutrophylia– Clinical stability– Decreased CRP>50%

• Treatment response:– Evaluated in 72 hours

unless a resistant bacillei is shown or clinical deteoriation

– Radiologic control in 7-10 days

– Radiologic complete resolution may take 4 weeks, can be longer in elderly, alcoholics, COPD patients

• Treatment period– Pnomococ 7-10 days– Mycoplasma, Clamydia

10-14 days– Legionella 14-21days– Unknown 2-3 weeks

Prevention

• Influensa vaccine• Pneumococ vaccine• General hygene

– Staff education (hand washing, glowes)– Avoid invasive procedures if possible– Sucralphate for gastric prophylaxis– Enteral feeding as much as possible– Avoid narcotics – Early mobilization– Early discharge from IC or hospital

CAP

Nasocomial

Certain Definitions

• Recurrent pneumonia:A second pneumonia that occurs after the

complete healing of a first attack (>1 month). At least 2 times a year.

• Late resolution:A pneumonia that resolves <50% in 2 weeks or

incomplete regression in 4 weeks• Nasocomial Pneumonia:Pneumonia seen after 48 hours of hospitalization

or within 48 hours after being discharged from hospital

Risk factors for late resolution:– Age– COPD– Alcoholism– Smoking– D mellitus– Malignancy– Renal or cardiac

failure– CS use

– S pneumonia– Legionella– Viral– H influensae

Complications of pneumonia

• Pleural effusion (parapneumonic)• Emphyema• Bronchopleural fistule• Mediastinitis, pericarditis, chest wall infection• Necrosis, cavitation• Pneumatocel• Pneumothorax• ARDS• Fibrosis• Bronchiectasis• Late resolution or recurrens