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