presentation on CAP AND NOSCOMIAL PNEUMONIA... U LL FIND IT HELPFULL : )

1. PNEUMONIA
BY
DR USSAMA MUNIR

2. Defination
 PATHOLOGICAL:- Infection of alveoli, distal
airways and interstitium of the lung that is
manifested by increased weight of the
lungs, replacement of the normal lung’s
sponginess by consolidation and alveoli
filled withWBC, RBC and fibrin.
 CLINICAL:- Pneumonia is a constellation of
symptoms and signs in combination with at
least one opacity on chest radiography.

3. Classification
 BY SOURCE :
 Community acquired
 Noscomial
 Aspiration
 Immunocompromised host
 Pathological
 Lobar
 bronchopneumonia

4.  By Infectious Agents
 Bacterial
 Atypical
 Viral
 Fungi
 Others
 On basis of previous health status
 Primary
 Secondary

5. HOST DEFENCES IN LUNGS
Upper airway:-
 Nasal turbinates and angulation of pharynx
 Mucociliary transport system
 Mucins
 Decreased mucosal pH
 Natural bacterial & epithelial cell binding
analogues
 Secretory IgA
 Constant desquamation of epithelial cells
 Nonpathogenic bacteria

6. LOWERTRACT:-
 Protected by glottis
 Clearing by coughing
 Nonspecific defenses – macrophages,
fibronectin, lysozymes, Lactoferrin etc
 Surfactant
 Alveolar macrophages
 Epithelial cells
 Lymphocytes

7. ROUTES OF INFECTION
Microaspiration of oropharyngeal secretions
colonized with pathogenic microorganisms
(e.g., S. pneumoniae, H. influenzae) is the
most common route.
Gross aspiration –
More common in patients with impaired level of consciousness:
alcoholics, IVDA, seizures, stroke, anesthesia, swallowing disorders,
NG tubes, ETT
Gram positive and anaerobes: Strep pneumo, H flu, Mycoplasma,
Moraxella,Actinomyces
Gram negatives:
 more likely with hospitalization, debility, alcoholism, DM, and
advanced age
 Source may be stomach which can become colonized with these
organisms with use of H2blockers

8. Aerosolization –
TB, fungi, Legionella,Coxiella
Hematogenous spread –
Staph aureus
Fusobacterium infections of the retropharyngeal tissues
Direct spread
stab wound, ETT

9. Community-Acquired Pneumonia

10.  DEFINATION
 Community-acquired pneumonia (CAP) is an
infection of the alveoli, distal airways, and
interstitium of the lungs that occurs outside
the hospital setting in ambulatory patients or
previously ambulatory patients within 48hrs
after admission in hospital.

11. Etiology
 Most cases of CAP are caused by a few
common respiratory pathogens, including:
 Streptococcus pneumoniae
 Accounts for ~50% of all cases of CAP
requiring hospital admission

12.  Haemophilus influenzae
 Staphylococcus aureus
 Mycoplasma pneumoniae
 Chlamydia pneumoniae
 Moraxella catarrhalis
 Legionella spp.
 Aerobic gram-negative bacteria
 Influenza viruses
 Adenoviruses

13. Condition Organism
Alcoholism
Streptococcus pneumoniae, oral
anaerobes, Klebsiella pneumoniae,
Acinetobacter species, Mycobacterium
tuberculosis
COPD and/or smoking
Haemophilus influenzae, Pseudomonas
aeruginosa, Legionella species, S.
pneumoniae, Moraxella catarrhalis,
Chlamydophila pneumoniae
Lung abscess
CA-MRSA, oral anaerobes, endemic
fungal pneumonia, M. tuberculosis,
atypical mycobacteria
Exposure to bat or bird droppings Histoplasma capsulatum
Exposure to birds
Chlamydophila psittaci (if poultry: avian
influenza)

14. Exposure to birds
Chlamydophila psittaci (if poultry:
avian influenza)
Exposure to rabbits Francisella tularensis
Exposure to farm animals or parturient
cats
Coxiella burnetti (Q fever)
HIV infection (early)
S. pneumoniae, H. influenzae, M.
tuberculosis
HIV infection (late)
Pneumocystis jirovecii, Cryptococcus,
Histoplasma, Aspergillus, atypical
mycobacteria (especially
Mycobacterium kansasii), P. aeruginosa,
H. influenzae
Hotel or cruise ship stay in previous 2
weeks
Legionella species
Injection drug use
S. aureus, anaerobes, M. tuberculosis, S.
pneumoniae

15.  Bacteria are the most common cause of CAP and
have traditionally been divided into two groups,
"typical" and "atypical" agents:
 "Typical" organisms include S. pneumoniae,
Haemophilus influenzae (H. influenzae), S.
aureus, Group A streptococci, Moraxella
catarrhalis, anaerobes, and aerobic gram-
negative bacteria.
 "Atypical pneumonia” refers to pneumonia
caused by Legionella spp, M. pneumoniae,
Chlamydophila (formerly Chlamydia)
pneumoniae, and C. psittaci, and is a term that
should no longer be used.

16. Symptoms & Signs
 History
 Most typical signs/symptoms
 Fever
 Cough (nonproductive or productive of
purulent sputum)
 Pleuritic chest pain
 Chills and/or rigors
 Dyspnea

17.  Headache
 Nausea
 Vomiting
 Fatigue
 Arthralgia/myalgia
 Falls and new-onset or worsening confusion
(in elderly patients)

18. Physical findings pneumonia
 Fever
 Tachypnea
 Tachycardia
 Dullness to percussion
 Increase vocal fremitus
 Increase vocal resonance
 Crackles
 Pleural friction rub

19. Diagnostic Approach
 Assess pneumonia severity.
 Pay attention to vital signs, including oxygen
saturation.
 Always count the respiratory rate yourself for
1 min.
 The single most useful clinical sign of severity
is a respiratory rate of > 30/min in a person
without underlying lung disease.
 Ensure adequate oxygenation and support of
circulation during the evaluation

20.  Consider possible etiologies.
 Carefully collect information on:
 Travel
 Occupational and other exposures
 Underlying illnesses
 Prior infections
 Never forget tuberculosis and Pneumocystis
infection as possible etiologies.
 Consider pulmonary embolus in all patients
with pleuritic chest pain.

21.  Perform etiologic workup.
 Chest x-ray
 Sputum stains and cultures
 Blood cultures, if bacteremia is likely
 Urine antigen tests for S. pneumoniae and
Legionella pneumophila type 1 can be helpful.
 Serology can be helpful in identifying certain
pathogens.

22. Laboratory Tests
 Assessment of the severity of pneumonia and
coexisting disease
 Arterial blood gas
 Complete blood count
 Serum electrolyte and glucose measurements
 Blood urea nitrogen (BUN) and creatinine
measurements
 Sputum stains and culture
 Gram’s stain

23.  Stains for
 Acid-fast bacilli
 Pneumocystis
 Fungi
 Cytology
 Rapid antigen testing for viral pathogens
(e.g., influenza)

24.  All patients admitted to the hospital for CAP
should have 2 sets of blood cultures done
before initiation of antibiotic therapy
 Detection of antigens of pulmonary
pathogens in urine for
 Legionella pneumophilia
 S pneumoniae

25.  Serology
 Detection of IgM antibody or demonstration of a 4-fold rise
in titer of antibody to a particular agent between acute-
and convalescent-phase serum samples.
 M. pneumoniae
 C. pneumoniae
 Chlamydia psittaci
 Legionella spp.
 Coxiella burnetii
 Adenovirus
 Parainfluenza viruses
 Influenza virus A


26. Imaging
Chest x-ray
 Diagnostic test of choice for pneumonia
 May show lobar consolidation, interstitial infiltrates,
cavitation, associated pleural fluid, etc.
 Occasionally, an etiologic diagnosis is suggested by
chest radiography findings.
 A cavitating upper-lobe lesion raises the likelihood of
tuberculosis.
 Pneumatoceles suggest S. aureus pneumonia.
 An air-fluid level suggests a pulmonary abscess,
which often is polymicrobial.
 In the immunocompromised host, a crescent
(meniscus) sign suggests aspergillosis.

27.  If pneumonia is strongly suspected on clinical
grounds and no opacity is seen on the initial
chest radiograph, it is useful to repeat the
radiograph in 24–48 hours or to perform CT.
 High-resolution CT
 Occasionally detects pulmonary opacities in
patients with symptoms and signs suggestive
of pneumonia and negative chest x-ray

28. Special Examinations
 DiagnosticThoracocentesis
the fluid should be sampled for studies
including Gram’s stain, culture, cell counts,
and measurements of protein, lactate
dehydrogenase (LDH), glucose, and pH.
 SPUTUM INDUCTION AND FIBEROPTIC
BRONCHOSCOPY
 PROCALCITONIN
 PCR

29. DIFFERENTIAL DIAGNOSIS
 URTIs
 Reactive Airway Disease
 CCF
 LUNG ABSCESS
 PTE
 PULMONARYVASCULITIS

30. INDICATIONS FOR ADMISSION
 PSI
 CURB 65
 Confusion (based upon a specific mental test or disorientation to person, place,
or time)
 Urea (blood urea nitrogen in the United States) >7 mmol/L
 Respiratory rate >30 breaths/minute
 Blood pressure [BP] (systolic <90 mmHg or diastolic <60 mmHg)
 Age >65 years
CURB-65 report suggested that patients with a CURB-
65 score of 0 to 1 were at low risk and could probably
be treated as outpatients; those with a score of 2
should be admitted to the hospital, and those with a
score of 3 or more should be assessed for ICU care,
particularly if the score was 4 or 5.

31. ATS/IDSA Criteria for ICU Rx
 Minor criteriaa
 Respiratory rateb 30 breaths/min
 PaO2/FiO2 ratio less then 250
 Multilobar infiltrates
 Confusion/disorientation
 Uremia (BUN level more then 7mmol/l)
 Leukopeniac (WBC count, less then 4000 cells/mm3)
 Thrombocytopenia (platelet count, less 100,000 cells/mm3)
 Hypothermia (core temperature, less then 36C)
 Hypotension requiring aggressive fluid resuscitation
 Major criteria
 Invasive mechanical ventilation
 Septic shock with the need for vasopressors

32. Empiric Therapy
 Outpatient treatment
 1. Previously healthy and no use of antimicrobials within the previous 3
months: A macrolide (azithromycin, clarithromycin, or erythromycin)
OR Doxycyline
 2. Presence of comorbidities such as chronic heart, lung, liver or renal
disease; diabetes mellitus; alcoholism; malignancies; asplenia;
immunosuppressing conditions or use of immunosuppressing drugs; or
use of antimicrobials within the previous 3 months (in which case an
alternative from a different class should be selected): A respiratory
fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])
 OR
 A beta-lactam (first-line agents: high-dose amoxicillin, amoxicillin-
clavulanate; alternative agents: ceftriaxone, cefpodoxime, or
cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, or
erythromycin)*
 3. In regions with a high rate (>25 percent) of infection with high-level
(MIC ≥16 µg/mL) macrolide-resistant Streptococcus pneumoniae,
consider use of alternative agents listed in (2) above.

33.  Inpatients, non-ICU treatment
 A respiratory fluoroquinolone (moxifloxacin,
gemifloxacin, or levofloxacin [750 mg])
 OR
 An antipneumococcal beta-lactam (preferred
agents: cefotaxime, ceftriaxone, or
ampicillin-sulbactam; or ertapenem for
selected patients)• PLUS a macrolide
(azithromycin, clarithromycin, or
erythromycin)*Δ

34.  Inpatients, ICU treatment
 An antipneumococcal beta-lactam (cefotaxime,
ceftriaxone, or ampicillin-sulbactam) PLUS
azithromycin
 OR
 An antipneumococcal beta-lactam (cefotaxime,
ceftriaxone, or ampicillin-sulbactam) PLUS a
respiratory fluoroquinolone (moxifloxacin,
gemifloxacin, or levofloxacin [750 mg])
 OR
 For penicillin-allergic patients, a respiratory
fluoroquinolone (moxifloxacin, gemifloxacin, or
levofloxacin [750 mg]) PLUS aztreonam

35.  Special concerns
 If Pseudomonas is a consideration: An antipneumococcal,
antipseudomonal beta-lactam (piperacillin-tazobactam,
cefepime, imipenem, or meropenem) PLUS either
ciprofloxacin or levofloxacin (750 mg)
 OR
 The above beta-lactam PLUS an aminoglycoside PLUS
azithromycin
 OR
 The above beta-lactam PLUS an aminoglycoside PLUS a
respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or
levofloxacin [750 mg]); for penicillin-allergic patients,
substitute aztreonam for above beta-lactam
 IfCA-MRSA is a consideration: Add vancomycin or linezolid

36. Clinical Response
 Most patients with CAP will have an adequate
response within 3 days. Switch to oral antibiotics
after
 Resolution of fever for >24 hrs.
 Resolution of tachypnoea
 Pulse < 100 beats /min
 Resolution of hypotension
 Hydrated and taking oral fluidsAbsence of hypoxia
 Improving white cell count
 Non-bacteremic infection
 No concern over GI absorption

37. Duration of therapy
 Patients managed in community and admitted
non-severe uncomplicated pneumonia:
07 DAYSTHERAPY IS ENOUGH
 Patients with severe microbiologically undefined
pneumonia:
10 DAYSTHERAPY IS PROPOSED
 Patients suffering from legionella, staphylococcal, or
Gram negative enteric bacilli pneumonia:
 14-21 DAYSTHERAPY IS RECOMMENDED

38. COMPLICATIONS
 Usually result of direct spread of bacterial
infection within thoracic cavity.
(pleural effusion- empyema- pericarditis)
 bacteremia and hematologic spread
meningitis suppurative arthritis osteomyelitis

39. Non Resolving Pneumonia
Consider other diagnosis
 TB
 Lung Cancer
 Fungal pneumonia
 Foreign body inhalation
 Eosinophilic pneumonias, Sarcoidosis
 Pulmonary embolism
 Pulmonary hemorrhage
 Heart failure

40. Correct Diagnosis but Fail
to Respond
 Host: Obstruction, Foreign body,
Superinfection, Empyema
 Drug: Error in drug selection, dose or route,
Compliance, Drug interaction
 Pathogen: Nonbacterial, Resistant

41. SOME FACTS ABOUT CAP
 The etiologic agent causing CAP cannot be
accurately predicted from clinical or
radiological features
 The term ‘atypical pneumonia’ should be
abandoned
 Elderly patients with CAP more frequently
present with non specific symptoms and are
less likely to have fever
 Radiological resolution may take upto 6
weeks
 Radiological resolution is slow in the elderly
and cases of multilobar involvement.

42. Prevention
 23-valent polysaccharide pneumococcal
vaccine
 Target hosts at greatest risk for
pneumococcal disease
- > 65 yrs
- Chronic cardiovascular and pulmonary
disease
- Metabolic diseases, alcoholism,
cirrhosis, nephrotic syndrome
- Immunosuppression, asplenia
- Lymphoma, multiple myeloma

43.  Influenza vaccine
 Younger patients at risk
- Chronic cardiovascular and pulmonary
diseases
- Renal and metabolic disease
- Immune deficiency
- Nursing home residents and health care
workers

44. NOSCOMIAL PNEUMONIA

45.  The 2005 AmericanThoracic Society/Infectious Diseases Society
of America (ATS/IDSA) guidelines:
 Hospital-acquired (or nosocomial) pneumonia (HAP) is
pneumonia that occurs 48 hours or more after admission and did
not appear to be incubating at the time of admission.
 Ventilator-associated pneumonia (VAP) is a type of HAP
that develops more than 48 to 72 hours after endotracheal
intubation.
 Healthcare-associated pneumonia (HCAP) is defined as
pneumonia that occurs in a non-hospitalized patient with
extensive healthcare contact, as defined by one or more of the
following:
 - Intravenous therapy, wound care, or intravenous
chemotherapy within the prior 30 days
 - Residence in a nursing home or other long-term care facility
 - Hospitalization in an acute care hospital for two or more days
within the prior 90 days
 - Attendance at a hospital or hemodialysis clinic within the
prior 30 days

46. DIFFERENCE B/W CAP & NP
 DIFFERENT INFECTIOUS CAUSES
 DIFFERENTANTIBIOTIC SUSCEPTIBILITY
PATTERNS
 PATIENTS UNDERLYING HEALTH STATUS

47. PNEUMONIA ORGANISM
HAP SAUREUS,MRSA,P
AERUGINOSA,GRAM –VE RODS
VAP ACTINOBACTER,
HCAP S PNEUMONIAE, H INFLUENZA
Common pathogens include aerobic gram-negative bacilli
(eg, Escherichia coli, Klebsiella pneumoniae, Enterobacter
spp, Pseudomonas aeruginosa, Acinetobacter spp) and
gram-positive cocci (eg, Staphylococcus aureus, including
methicillin-resistant S. aureus [MRSA], Streptococcus spp).
Nosocomial pneumonia due to viruses or fungi is
significantly less common, except in the
immunocompromised patient.

48. S/S
 The clinical diagnosis of HAP,VAP, and HCAP is difficult in part
because the clinical findings are nonspecific.The 2005 ATS/IDSA
guidelines concluded that HAP,VAP, or HCAP should be
suspected in patients with a new or progressive infiltrate on lung
imaging as well as clinical characteristics such as
 Fever
 Purulent sputum
 Leukocytosis
 Decline in oxygenation
 The presence of a new or progressive radiographic infiltrate plus
at least two of the three clinical features (fever >38ºC,
leukocytosis or leukopenia, and purulent secretions) represents a
clinically relevant combination of criteria for starting empiric
antimicrobial therapy.

49. LAB FINDINGS
 BLOOD CULTURES FROM 2 DIFFERENT
SITES
 ABGs
 THORACOCENTESIS
 SPUTUM EXAMINATION

50. IMAGING
 NON SPECIFIC

51. SPECIAL EXAMINATION
 ENDOTRACHEALASPIRATION
 FIBEROPTIC BRONCHOSCOPYWITH BAL
 PROCALCITONIN

53. Risk factor for MDR
• Antimicrobial therapy in preceding 90 d
• Current hospitalization of 5 d or more
• High frequency of antibiotic resistance in the community or
in the specific hospital unit
 • Presence of risk factors for HCAP:
 Hospitalization for 2 d or more in the preceding 90 d
 Residence in a nursing home or extended care facility
 Home infusion therapy (including antibiotics)
 Chronic dialysis within 30 d
 Home wound care
 Family member with multidrug-resistant pathogen
 • Immunosuppressive disease and/or therapy

54. Treament empiricle
 LOW RISK , USE
 Ceftriaxone
 Gamifloxocin
 Moxi-
 levo-
 Ciprofloxocin
 Tanzo

55. High risk use 1 frm each
 1) anti pseudomonal
 Cefepime,imipenem,tanzo,aztreonam
 2)2nd anti pseudomonal
 Levofloxocin,ciprofloxocin,aminoglycosides
 3) coverage for MRSA with either
 Vancomycin or linezolid

56. Thank you