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Pneumonia
- 2. Pneumonia – Definition An acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, accompanied by some auscultatory findings consistent with pneumonia and radiological pulmonary shadowing
- 3. What happens ??? • Inflammatory condition where alveoli are filled with fluid and blood cells • Begins with infection of alveoli followed by inflamed pulmonary membrane and becomes highly porous • Whole lobe or sometimes whole lungs is consolidated
- 4. Pneumonia I. Reduction in the total available surface area of the respiratory membrane II. Decreased ventilation-perfusion ratio These two causes Hypoxemia hypercapnia
- 5. Pneumonia • The major cause of death in the world • The 6th most common cause of death in the U.S. • Annually in U.S.: 2-3 million cases, ~10 million physician visits, 500,000 hospitalizations, 45,000 deaths, with average mortality ~14% inpatient and <1% outpatient
- 6. Risk factors • Old age • Recent influenza infection • Pre-existing lung disease • Lowered immune system due to corticosteroid therapy, • Alcohol,smoking
- 7. Pneumonia - Symptoms • Cough (productive or non-productive) • Dyspnea • Pleuritic chest pain • Fever or hypothermia • Myalgias • Chills/Sweats • Fatigue • Headache • Diarrhea (Legionella) • Sinusitis • Loss of appitite
- 8. Findings on Exam • Physical: Vitals: Fever or hypothermia Pyrexia,techicardia,hypoxamia Lung Exam: Crackles, rhonchi, dullness to percussion • Labs: Elevated WBC Hyponatremia – Legionella pneumonia Positive Cold-Agglutinin – Mycoplasma pneumonia
- 9. Investigations • Chest X-ray ▫ Pulmonary shadow • Microbiological investigation ▫ Strep. pneumo urinary antigen ▫ Legionella urinary antigen ▫ < 10 Squamous Epithelial Cells • Arterial blood gas measurements ▫ PO2 • General blood test ▫ High neutrophil leucocytes
- 10. Investigation objectives • To obtain a radiological conformation of the diagnosis • To exclude other condition that may mimic pneumonia • To obtain microbiological diagnosis • To assess the severity of the pneumonia
- 12. Chest X-ray – Pneumonia
- 13. Chest X-ray - Pneumonia
- 14. Chest X-ray -- Pneumonia
- 15. Types of Pneumonia • Community-Acquired (CAP) • Hospital-Acquired Pneumonia (HAP) ▫ Pneumonia that develops after 5 days of hospitalization ▫ Includes: Ventilator-Associated Pneumonia (VAP) Aspiration Pneumonia
- 16. Common Bugs for Pneumonia Community-Acquired • Streptococcus pneumoniae • Mycoplasma pneumoniae • Chlamydophila psittaci or pneumoniae • Legionella pneumophila • Haemophilus influenzae • Moraxella catarrhalis • Staphylococcus aureus • Nocardia • Mycobacterium tuberculosis • Influenza • RSV • CMV • Histoplasma, Coccidioides, Blastomycosis HCAP or HAP • Pseudomonas aeruginosa • Staphylococcus aureus (Including MRSA) • Klebsiella pneumoniae • Serratia marcescens • Acinetobacter baumanii
- 17. Special Clues on Chest X-ray • Lobar pneumonia – Strep. Pneumonia • Diffuse interstitial infiltrates – Pneumocystis • RUL infiltrate – Tuberculosis • Diffuse interstitial infiltrates – Tuberculosis in HIV
- 18. PORT Score
- 19. PORT Score
- 20. Antibiotics treatment • Amoxillin 500mg 8-hourly orally • If patient allargic to penicilin ▫ Clarithromycin 500mg 12 hourly orally ▫ Erythromycin 500mg 6 hourly orally • If staphylococcus is cultured ▫ Flucoxamin 1-2g 6 hourly orally ▫ Clarithromycin 500mg 12 hourly orally
- 21. Severe CAP ▫ Clarithromycin 500mg 12 hourly orally ▫ Erythromycin 500mg 6 hourly orally ▫ Amoxillin 500mg 8-hourly orally ▫ Co-amoxiclav 1.2mg 8 hourly i.v
- 22. Treatment of HCAP, HAP, VAP • Antipseudomonal cephalosporin (Cefepime, Ceftazidime) + Vancomycin • Anti-pseudomonal Carbapenem (Imipenem, Meropenem) + Vancomycin • Beta-Lactamase/Beta-Lactamase Inhibitor (Pip-Tazo – Zosyn) + Pseudomonal Fluoroquinolone (Cipro) + Vancomycin • Aminoglycoside (Gentamycin, Amikacin) + Vancomycin
- 23. HAP – Failure of Therapy Incorrect diagnosis – it is not pneumonia – Atelectasis, CHF, PE with infarction, lung contusion, chemical pneumonitis, ARDS, pulmonary hemorrhage Pathogen resistance Host factors that increase mortality – Age > 60, prior pneumonia, chronic lung disease – immunosuppression Antibiotic resistance
- 24. HAP - Prevention Hand washing Vaccination – Influenza – Pneumococcus Isolation of patients with resistant respiratory tract infections Enteral nutrition Choice of GI prophylaxis Subglottoc secretion removal?
- 25. Special Cases! • HIV Pneumocystis jirovecii Mycobacterium tuberculosis Cryptococcus Histoplasmosis • Transplant Patients Fungi (Aspergillosis, Cryptococcus, Histoplasmosis) Nocardia CMV • Neutropenic Patients Fungi ( Aspergillosis) Gram-negatives
- 26. More Special Cases • Smokers: S. pneumo, H. influenzae, M. catarrhalis • Alcoholics: S. pneumo, Klebsiella, anaerobes • IV Drug User: S. aureus, Pneumocystis, anaerobes • Splenectomy: encapsulated organisms (S. pneumo, H. influenzae) • Cystic fibrosis: Pseudomonas, S. aureus • Deer mouse exposure: Hantavirus • Bat exposure: Histoplasma capsulatum • Rat exposure: Yersinia pestis • Rabbit exposure: Francisella tularensis • Bird Exposure: C. psitacci, Cryptococcus neoformans • Bioterrorism: Bacillus anthracis, F. tularensis, Y. pestis
- 27. Pneumococcal Vaccine • What does it cover? Protects against 23 serotypes of Strep. Pneumoniae (90% of invasive pneumonia infections) • Who should get it? Anyone over age 65 Anyone with chronic medical problem such as cancer, diabetes, heart disease, lung disease, alcoholism, cirrhosis, sickle cell disease, kidney failure, HIV, damaged spleen or no spleen, CSF leaks Anyone receiving cancer therapy, radiation, steroids Alaskan natives and certain Native American populations • How often to get it? Give second dose if >5 years from first dose if > 65, cancer, damaged spleen, kidney disease, HIV or any other condition lowering immune system function
- 28. Thank You