Puru Koirala
Resident, Division of Pulmonary, Critical and Sleep Medicine
Department of Internal Medicine
BPKIHS
Pneumonias

BPKIHS
72/F, Dharan-7
Presenting Complaints-
– Fever- 2 days
– Cough-2 days
– Chest pain-2 days
– Increased sleepiness since 24 hours

 Past History:
– No similar illness in the past
– No known DM,PTB, HTN or other known co-morbidity
 Personal History:
– Current smoker, 5 cigarettes/day, 12 pack year
– Chronic Alcohol Consumer
• Daily consumed 150ml home made alcohol

Physical Examination
• GCS E4 M6 V4(Oriented to person not to
place and time)
• BP:90/60 mmHg with Ionotropic support
,Rt arm supine
• Pulse: 112/min normal volume, regular
Dorsalis Pedis Palpable bilaterally
• RR:32/min, thoraco-abdominal type,
shallow
• Temperature: afebrile
• SpO2:98% with O2 by facemask @ 6L/min
• No pallor
• No Icterus
• No Lymphadenopathy
• No Cyanosis
• No Clubbing
• No Odema
• Dehydration

• Chest:
– Expansion of Rt. Hemithorax less than Lt.
– Tactile fremitus increased in Rt.Infra-axillary &
infrascapular area
– Dullness on percussion
– B/L equal intensity of VBS
– Fine end inspiratory crepitations in Rt. Infrascapular and
infra-axillary area
– No pleural rub
• CVS
– AB 5th ICS
– S1+, S2+ No murmur
• Abdomen
– Soft, non tender
– No organomegaly
– BS normoactive

Investigation
• Hb-13.8 gm/dl
• PCV-41.1
• TLC- 220005700/ml
• DLC-N80L17M 2 E1
• Platelet- 59000134000/ml
• PT/INR-20/13/1.87
• RBS 102mg/dl
• Urea- 5723mg/dl
• Creatinine 2.40.9mg/dl
• Na/K:140/3.4 144/4.6 mmol/lt
• ECG:Sinus Tacycardia
• CXR PA-view: Rt. Lower zone
inhomogenous opacity
ABG
• Ph;7.527.46
• Pco2:2336
• PO2: 82--151
• HCO3-2022
• Lac : 3.21.1
• ESR-51 mm/hr
• Mantoux< 5mm
• Sputum for AFB *3 Negative
• Sputum C/S:Normal respiratory flora
• Blood culture:Sterile in 48 hrs
• D-dimer; O.4 ng/dl

Impression
• Acute Febrile Illness with Right lower lobe
Community Acquired Pneumonia with CURB-
65- 5/5 ( Severe Pneumonia) presented in
sepsis with septic shock with Multi-organ
Dysfunction Syndrome(MODS) with
AKI
Lactic Acidosis
Thrombocytopenia

Management
• ICU admission
• O2 therapy:FiO2 @40%, flow rate 6-8LPM via
facemask
• Inj. 1000ml( 20ml/kg) NS stat.
• Inj. Hydrocort. 50mg iv stat &QID* 7days.
• Inj. Nordrenaline @ 10ugm/min tapered in 3days.
• Inj. Ceftriaxone 1gm iv BD * 7days
• Inj. Levofloxacin 750mg iv OD * 5 days

Topic Review
Community- Acquired Pneumonia
(CAP)

Definition
• Pneumonia is an infection of the pulmonary
parenchyma
• CAP: An infection that begins outside of the
hospital or is diagnosed within 48 h after
admission to the hospital in a patient who has
not been hospitalized or visited health care
facility in last 3 month
Current Diagnosis and Treatment in Pulmonary Medicine 2008

Definition
HCAP= Pneumonia in a patient with at least one of the following risk factors:
1. Hospitalization for two or more days in the last 90 days
2. Residence in a nursing home or long-term care facility in the last 90 days
3. Receiving outpatient intravenous therapy (like antibiotics or
chemotherapy) within the past 30 days
4. Receiving home wound care within the past 30 days
5. Attending a hospital clinic or dialysis center in the last 30 days
6. Having a family member with known multi-drug resistant pathogens

Definition
• HAP: Infection of lung parenchyma occurring
more than 48 h after admission to a hospital
• VAP: When HAP occurs in the subset of
patients receiving mechanical ventilation,
it is termed VAP

• Aspiration pneumonitis (Mendelson's syndrome) is a
chemical injury caused by the inhalation of sterile gastric
contents, whereas aspiration pneumonia is an infectious
process caused by the inhalation of oropharyngeal secretions
that are colonized by pathogenic bacteria
• The term “aspiration pneumonia,” refers specifically to the
development of a radiographically evident infiltrate in
patients who are at increased risk for oropharyngeal
aspiration
• Anaerobes play a significant role only when an episode of
aspiration has occurred days to weeks before presentation for
pneumonia
Aspiration Pneumonitis and Aspiration Pneumonia Paul E. Marik, M.B., B.Ch. N Engl J Med
2001; 344:665-671March 1, 2001

Epidemiology
• CAP, together with influenza, remains the seventh leading
cause of death especially in the extremes of ages
• 80% of the 4 million CAP
– an outpatient basis
• 20% in the hospital
• Responsible for
– 600,000 hospitalizations
– 64 million days of restricted activity
– 45,000 deaths
• 55% AKI patients presented with diagnosis of CAP.
– Outcomes of Acute Kidney Injury:A Hospital Based Study, 2009-10;
Koirala P et al

PATHOPHYSIOLOGY
• Pneumonia results from
– Proliferation of microbial pathogens at the alveolar level
– Host's response to those pathogens
• Modes of Acquisition
– Inhalation of infected Nasopharayngeal secretions
– Aspiration from the oropharynx
• sleep (in the elderly)
• decreased levels of consciousness
– Hematogenous spread (e.g., from tricuspid endocarditis)
or by contiguous extension from an infected pleural or
mediastinal space

Pulmonary Clearance of Infectious Agents
 Mechanical Defenses:
 Nasopharyngeal Airways
 Conducting Airways
 Hairs and turbinates of the nares
 Normal flora adhering to mucosal
cells of the oropharynx
 Gag reflex and the cough
mechanism
 Branching architecture of the
Tracheobronchial tree
 Mucociliary clearance and local
antibacterial factors
 Innate Immunity:
 Innate Immune Recognition
 Resident alveolar
macrophages
 NK Cells
 Complement
 Alveolar Epithelial Cells (e.g.,
surfactant proteins A and D)

PATHOPHYSIOLOGY
Capacity of the alveolar macrophages exceeded
The inflammatory response
• The host Inflammatory Response, rather than
the proliferation of microorganisms, triggers
the clinical syndrome of pneumonia
• Adaptive Immune Response

PATHOPHYSIOLOGY
Macrophage
• IL-1, TNF alpha IL-8 and G-CSF
• Fever Peripheral leukocytosis
Purulent secretions
Respiratory alkalosis
Alveolar filling( Rales,Hypoxemia)

PATHOLOGY
1. Edema or Congestion
2. Red hepatization
3. Gray hepatization
4. Resolution

PATHOLOGY

Etiology
Bacteria, Fungi, Viruses, and Protozoa
Hantaviruses, Metapneumoviruses, the
Coronavirus responsible SARS and
community-acquired strains MRSA

• Typical bacterial pathogens
– S. pneumoniae,
– Haemophilus influenzae,
– S. aureus
– Gram-negative bacilli such as Klebsiella
pneumoniae and Pseudomonas aeruginosa.
• Atypical organisms
– Mycoplasma pneumoniae
– Chlamydia pneumoniae
– Legionella spp.
– Respiratory viruses

Epidemiologic Factors Suggesting Possible Causes of
Community-Acquired Pneumonia
Alcoholism Streptococcus pneumoniae, oral anaerobes,
Klebsiella
pneumoniae, Mycobacterium tuberculosis
COPD and/or smoking Haemophilus influenzae, Pseudomonas
aeruginosa, Legionella
spp
Structural lung disease (e.g.,
bronchiectasis)
P. aeruginosa, Staphylococcus aureus
Dementia, stroke, decreased
level of consciousness
Oral anaerobes, gram-negative enteric bacteria
Lung abscess CA-MRSA, oral anaerobes, endemic fungi, M.
tuberculosis,
Stay in hotel or on cruise ship in
previous 2 weeks
Legionella spp.
Local influenza activity Influenza virus, S. pneumoniae, S. aureus

Epidemiologic Factors Suggesting Possible Causes of
Community-Acquired Pneumonia
Exposure to bats or birds H. capsulatum
Exposure to birds Chlamydia psittaci
Exposure to rabbits Francisella tularensis
Exposure to sheep, goats,
cats
Coxiella burnetii
SOURCE: Harrison's Principles of Internal Medicine, 18th Ed.

SYMPTOMS
• Fever
• Chills and/or sweats
• Cough; nonproductive or productive of mucoid, purulent, or blood-
tinged sputum
• May be able to speak in full sentences or may be very short of
breath
• Pleuritic chest pain(If pleura involved)
• Nausea, vomiting, and/or diarrhea in 20%
• Constitutional symptoms fatigue, headache, myalgias, and
arthralgias in 30%

Physical Examination
• Elderly  confusion
• Use of accessory muscles of respiration &
Tachypnea
• Increased or decreased tactile fremitus
• Percussion note can vary from dull to flat,
reflecting underlying consolidated lung and
pleural fluid, respectively
• Crackles, bronchial breath sounds, and possibly a
pleural friction rub

Differential Diagnosis
• The sensitivity and specificity signs & symptoms is 58% and
67% respectively
– Acute bronchitis
– Acute exacerbations of chronic bronchitis
– Heart failure
– Pulmonary embolism
– Radiation pneumonitis
• In addition to a constellation of suggestive clinical features,
a demonstrable infiltrate by chest radiograph or other
imaging technique, with or without supporting
microbiological data  diagnosis of pneumonia

Investigations
• Except for the 2% of CAP patients who are
admitted to ICU, no data exist to show that
treatment directed at a specific pathogen is
statistically superior to empirical therapy

Investigation
• Gram's Stain
The main purpose of the sputum Gram's stain
– To ensure sample is suitable for culture
– To be adequate for culture, sample must have >25
neutrophils and <10 squamous epithelial cells/lpf
– may also identify S. pneumoniae, S. aureus, and
gram-negative bacteria

Blood Cultures
• Only 5–14% of cultures positive
• The most frequently isolated pathogen S. pneumoniae
• Since all provide pneumococcal coverage, a positive blood culture 
little, if any, significance
• Because of the low yield and the lack of significant impact on
outcome, blood cultures are no longer considered de rigueur for all
hospitalized CAP patients
• Certain high-risk patients—including those with neutropenia,
asplenia, or complement deficiencies; chronic liver disease; or severe
CAP—should have blood cultured

Other Tests
• Urine Antigen Tests
– Pneumococi and Legionella
– Sensitivity and specificity >90%
– Influenza & RSV
• PCR
– Legionella, Mycoplasma, Mycobacteria, Chlamydia
• Serology
– A fourfold rise diagnostic of infection
– Fallen out of favour

Treatment
SITE OF CARE
There are currently two sets of criteria
1. The Pneumonia Severity Index (PSI)
2. The CURB-65 criteria
Time to first antibiotic dose
• For patients admitted through the emergency
department (ED), the first antibiotic dose should
be administered while still in the ED

Pneumonia Severity Index(PSI)

CURB-65

Infectious Diseases Society of America/American Thoracic Society Consensus
Guidelines on the Management of Community-Acquired Pneumonia in Adults

Infectious Diseases Society of America/American Thoracic Society Consensus
Guidelines on the Management of Community-Acquired Pneumonia in Adults

Empirical Antibiotic Treatment of
Community-Acquired Pneumonia
• Outpatients
 A macrolide [clarithromycin (500 mg PO bid) or azithromycin (500 mg PO
once, then 250 mg qd)]
or
• Doxycycline (100 mg PO bid)
 Comorbidities or antibiotics in past 3 months: select an alternative from a
different class
• A respiratory fluoroquinolone [moxifloxacin (400 mg PO qd), gemifloxacin
(320 mg PO qd), levofloxacin (750 mg PO qd)]
or
• A B-lactam [preferred: high-dose amoxicillin (1 g tid) or
amoxicillin/clavulanate (2 g bid);
• alternatives: ceftriaxone (1–2 g IV qd), cefpodoxime (200 mg PO bid),
cefuroxime (500 mg PObid)]
Plus
A macrolide

Inpatients, Non-ICU
• A Respiratory Fluoroquinolone [moxifloxacin
(400 mg PO or IV qd), gemifloxacin (320 mg PO
qd),levofloxacin (750 mg PO or IV qd)]
OR
• A B-lactam [cefotaxime (1–2 g IV q8h), ceftriaxone
(1–2 g IV qd), ampicillin (1–2 g IV q4–6h), ertapenem (1
g IV qd in selected patients)]
plus
• A Macrolide [oral clarithromycin or azithromycin
(as listed above for previously healthy patients) or
IV azithromycin (1 g once, then 500 mg qd)]

Inpatients, ICU
• A B-lactam [cefotaxime (1–2 g IV q8h),
ceftriaxone (2 g IV qd), ampicillin-sulbactam (2
g IV q8h)]
plus
• Azithromycin or a Fluoroquinolone (as listed
above for inpatients, non-ICU)

Special Concerns
 If Pseudomonas is a consideration
• An Antipneumococcal, Antipseudomonal B-lactam
[piperacillin/tazobactam (4.5 g IV q6h), cefepime (1–2 g IV
q12h), imipenem (500 mg IV q6h), meropenem (1 g IV q8h)]
plus either Ciprofloxacin (400 mg IV q12h) or
Levofloxacin (750 mg IV qd)
OR
• The above B-lactams plus an Aminoglycoside
[amikacin (15 mg/kg qd) or tobramycin (1.7 mg/kg
• qd)] plus Azithromycin/Antipneumococcal
Fluoroquinolone

Special Concerns
 If CA-MRSA is a concern
• Add linezolid (600 mg IV q12h)
OR
• Vancomycin (1 g IV q12h).

When to Switch from
intravenous to oral therapy?
• Hemodynamically stable and improving
• Clinically able to ingest medications
• Have a normally functioning gastrointestinal
tract

When to Switch from intravenous to
oral therapy?
Ramirez JA, Srinath L, Ahkee S, Huang A, Raff MJ. Early switch from
intravenous to oral cephalosporins in the treatment of hospitalized
patients with community-acquired pneumonia. Arch Intern Med
1995; 155:1273–6.

Duration of Antibiotic Therapy
• Minimum of 5 days
• Afebrile for 48–72 h
• No more than 1 CAP-associated sign of clinical
instability
• A longer duration of therapy needed
– if initial therapy was not active against the
identified pathogen
– Complications: extrapulmonary infection, such as
meningitis or endocarditis

When to Discharge?
• Patients should be discharged as soon as they
are
– Clinically stable
– Have no other active medical problems
– Have a safe environment for continued care

GENERAL CONSIDERATIONS
• Adequate hydration
• Oxygen therapy for hypoxemia
• Patients with severe CAP who remain
hypotensive despite fluid resuscitation may
have adrenal insufficiency and may respond
to glucocorticoid treatment
• Assisted ventilation when necessary

Ventilation in Pneumonia
• Patients with hypoxemia or respiratory
distress should receive a cautious trial of non-
invasive ventilation unless immediate
intubation needed
– PaO2/FiO2 < 150
– Bilateral alveolar infiltrates
• Low-tidal-volume ventilation (6 cm3/kg of
ideal body weight) should be used

Failure to Improve
• Nonresponding Pneumonia
– Situation in which an inadequate clinical response
despite antibiotic treatment
– Lack of a clear-cut and validated definition
– Re-evaluated at about day 3 (sooner if condition
is worsening)

Failure to Improve
• Lack of Response
– Correct drug at the wrong dose or frequency
– Nosocomial superinfections—both pulmonary and
extrapulmonary
– Resistant,unsuspected pathogen, or a sequestered
focus ( lung abscess or empyema)
– Missed diagnosis
• In all cases of delayed response or deteriorating
condition, the patient must be carefully
reassessed and appropriate studies initiated

Complications
• Respiratory Failure
• Lung abscess
• Complicated Pleural Effusion
• Metastatic infection, (e.g., Brain abscess or
Endocarditis)
• Shock
– Multiorgan failure
– Coagulopathy
– Exacerbation of Comorbid Illnesses

Follow Up
• Fever and leukocytosis resolve in 2–4 days
• Other physical findings may persist
• Chest radiograph requires 4–12 weeks to clear
• Follow-up radiograph advised after 4–6 weeks
If relapse or recurrence, particularly in the same
lung segment occurs, the possibility of an
underlying neoplasm must be considered

Prognosis
• Young patients without comorbidity recover
fully in 2 weeks
• Mortality rate for the outpatient <1%
• In-hospital mortality rate is 10% with 50%
deaths directly attributable to pneumonia

Prevention
• Smoking Cessation
• Vaccination

Pneumococcal
polysaccharide vaccine
• All persons 65 years of age
• Current smoker
• Chronic cardiovascular, pulmonary, renal, or
liver disease
• Diabetes mellitus
• Alcoholism
• Asplenia
• Immunocompromising conditions
• Long-term care facility residents

Inactivated
Influenza Vaccine
• All persons 50 years &above
• Household contacts
• Health care providers
• Children 6–23 months of age
• Chronic cardiovascular or
pulmonary disease (including
asthma)
•
• Chronic metabolic disease
(including diabetes mellitus)
• Renal dysfunction
• Hemoglobinopathies
• Immuno-compromised conditions
• Compromised respiratory
function or increased aspiration
risk
• Pregnancy
• Residence in a long-term care
facility
• Aspirin therapy in persons< 18
years of age

References:
•Harrison’s Principles of Internal Medicine, 18th edition, Anthony S.
Fauci, MD, Eugene Braunwald, MD, Dennis L. Kasper, MD, Stephen L.
Hauser, MD, Dan L. Longo, MD, J. Larry Jameson, MD, PhD, Joseph
Loscalzo, MD, PhD
•Infectious Diseases Society of America/American Thoracic Society
Consensus Guidelines on the Management of Community-Acquired
•Pneumonia in Adults Lionel A. Mandell et al, Clinical Infectious Diseases
2007; 44:S27–72 2007 by the Infectious Diseases Society of America
•Robbins and Cotran Pathologic Basis of Disease 7th Ed.
•Current Diagnosis Treatment in Pulmonary Medicine 2008.
•Aspiration Pneumonitis and Aspiration Pneumonia Paul E. Marik, M.B.,
B.Ch. N Engl J Med 2001; 344:665-671 March 1, 2001
•Crofton and Douglas’s Respiratiory Diseases 5th Edition S.Anthony, S.
Douglas

Thank You!