4. *HCAP: diagnosis made < 48h after hospitalization with any of the following risk factors:
(1)hospitalized in an acute care hospital for > 48h within 90d of the diagnosis; (2) resided in a nursing home or long-term care facility; (3) received recent IV antibiotic therapy, chemotherapy, or wound care within the 30d preceding the current diagnosis; and (4) attended a hospital or hemodialysis clinic
HCAP
5. Infection of the lung parenchyma in a person who is not hospitalized or living in a long-term care facility for ≥ 2 weeks. This pneumonia develops in the outpatient setting or within 48 hours of admission to a hospital.
Definition of CAP
6. Symptoms:
• Respiratory: Cough dry or productive, mucopurulent sputum , sometimes rusty, dyspnea, sometimes pleuritic chest pain
• Non-respiratory: Fever, body aches, altered mental state, vomiting or diarrhea.
The clinical diagnosis of CAP
7. Signs:
Generally: Fever, sometimes hypothermia, tachycardia, tachypnea.
Local: signs of consolidation
The clinical diagnosis of CAP
8. 8 CAP – The Two Types of Presentations Classical
•Sudden onset of CAP
•High fever, shaking chills
•Pleuritic chest pain, SOB
•Productive cough
•Rusty sputum, blood tinge
•Poor general condition
•High mortality up to 20% in patients with bacteremia
•S.pneumoniae causative
•Gradual & insidious onset
•Low grade fever
•Dry cough, No blood tinge
•Good GC – Walking CAP
•Low mortality 1-2%; except in cases of Legionellosis
•Mycoplasma, Chlamydiae, Legionella, Ricketessiae, Viruses are causative Atypical
9. Sputum Gram stain:
is a rapid and inexpensive test that can help a lot:
• Differentiate Gm –ve from Gm +ve bacteria.
• Excess pus cells without organism suspect atypical infection.
The Bacteriological Diagnosis of CAP
10. Cultures to identify the causative organism:
Sputum cultures are not recommended in cases of CAP except in certain occasions:
• Patients admitted in hospital or ICU.
• Patients who do not respond to empirical antibiotic therapy.
• Suspection of resistant strains of S.pneumoniae.
The Bacteriological Diagnosis of CAP
11. Blood Culture:
Recommended for all patients with moderate and high severity CAP, preferably before antibiotic therapy is commenced.
Examination of sputum for Mycobacterium TB
The Bacteriological Diagnosis of CAP
12. 12
CAP – Pathogenesis Inhalation Aspiration Hematogenous
13.
14. 14 PORT Scoring – PSI
Clinical Parameter
Scoring
Age in years
Example
For Men (Age in yrs)
50
For Women (Age -10)
(50-10)
NH Resident
10 points
Co-morbid Illnesses
Neoplasia
30 points
Liver Disease
20 points
CHF
10 points
CVD
10 points
Renal Disease (CKD)
10 points
Clinical Parameter
Scoring
Clinical Findings
Altered Sensorium
20 points
Respiratory Rate > 30
20 points
SBP < 90 mm
20 points
Temp < 350 C or > 400 C
15 points
Pulse > 125 per min
10 points
Investigation Findings
Arterial pH < 7.35
30 points
BUN > 30
20 points
Serum Na < 130
20 points
Hematocrit < 30%
10 points
Blood Glucose > 250
10 points
Pa O2
10 points
X Ray e/o Pleural Effusion
10 points Pneumonia Patient Outcomes Research Team (PORT)
15. 15 Classification of Severity - PORT Predictors Absent Class I 70 Class II 71 – 90 Class III 91 - 130 Class IV > 130 Class V
16. 16
CAP – Management based on PSI Score
PORT Class
PSI Score
Mortality %
Treatment Strategy
Class I
No RF
0.1 – 0.4
Out patient
Class II
70
0.6 – 0.7
Out patient
Class III
71 - 90
0.9 – 2.8
Brief hospitalization
Class IV
91 - 130
8.5 – 9.3
Inpatient
Class V
> 130
27 – 31.1
IP - ICU
17. 17
CURB 65 Rule – Management of CAP CURB 65 Confusion BUN > 30 RR > 30 BP SBP <90 DBP <60 Age > 65 CURB 0 or 1 Home Rx CURB 2 Short Hosp CURB 3 Medical Ward CURB 4 or 5 ICU care
18.
19. 19
CAP – Criteria for ICU Admission
Major criteria
Invasive mechanical ventilation required
Septic shock with the need of vasopressors
Minor criteria (least 3)
Confusion/disorientation
Blood urea nitrogen ≥ 20 mg%
Respiratory rate ≥ 30 / min;
Core temperature < 36ºC
Severe hypotension;
PaO2/FiO2 ratio ≤ 250
Multi-lobar infiltrates
WBC < 4000 cells;
Platelets <100,000
21. 21
CAP – Value of Chest Radiograph •Usually needed to establish diagnosis •It is a prognostic indicator •To rule out other disorders •May help in etiological diagnosis
J Chr Dis 1984;37:215-25
22. 22 Infiltrate Patterns and Pathogens
CXR Pattern
Possible Pathogens
Lobar
S.pneumo, Kleb, H. influ, Gram Neg
Patchy
Atypicals, Viral, Legionella
Interstitial
Viral, PCP, Legionella
Cavitatory
Anerobes, Kleb, TB, S.aureus, Fungi
Large effusion
Staph, Anaerobes, Klebsiella
38. S Curve of Golden
When there is a mass adjacent to a fissure, the fissure takes the shape of an "S". The proximal convexity is due to a mass, and the distal concavity is due to atelectasis. Note the shape of the transverse fissure.
This example represents a RUL mass with atelectasis
45. Pneumonia
Posterior intercostal scan shows a hypoechoic consolidated area that contains multiple echogenic lines that represent an air bronchogram.
46. Post-stenotic pneumonia
Posterior intercostal scan shows a hypoechoic consolidated area that contains anechoic, branched tubular structures in the bronchial tree (fluid bronchogram).
47. Contrast-enhanced ultrasonography of pneumonia
A: Baseline scan shows a hypoechoic consolidated area
B: Seven seconds after iv bolus of contrast agent, the lesion shows marked and homogeneous enhancement
C: The lesion remains substantially unmodified after 90 s.
50. MECHANISMS OF ACTION OF ANTIBACTERIAL DRUGS
Mechanism of action include:
Inhibition of cell wall synthesis
Inhibition of protein synthesis
Inhibition of nucleic acid synthesis
Inhibition of metabolic pathways
Interference with cell membrane integrity
51. EFFECTS OF COMBINATIONS OF DRUGS
Sometimes the chemotherapeutic effects of two drugs given simultaneously is greater than the effect of either given alone.
This is called synergism. For example, penicillin and streptomycin in the treatment of bacterial endocarditis. Damage to bacterial cell walls by penicillin makes it easier for streptomycin to enter.
52. EFFECTS OF COMBINATIONS OF DRUGS
Other combinations of drugs can be antagonistic.
For example, the simultaneous use of penicillin and tetracycline is often less effective than when wither drugs is used alone. By stopping the growth of the bacteria, the bacteriostatic drug tetracycline interferes with the action of penicillin, which requires bacterial growth.
53. EFFECTS OF COMBINATIONS OF DRUGS
Combinations of antimicrobial drugs should be used only for:
1.To prevent or minimize the emergence of resistant strains.
2.To take advantage of the synergistic effect.
3.To lessen the toxicity of individual drugs.
55. The Ideal Drug*
1.Selective toxicity: against target pathogen but not against host
LD50 (high) vs. MIC and/or MBC (low)
2.Bactericidal vs. bacteriostatic
3.Favorable pharmacokinetics: reach target site in body with effective concentration
4.Spectrum of activity: broad vs. narrow
5.Lack of “side effects”
Therapeutic index: effective to toxic dose ratio
6.Little resistance development
57. Resistance Physiological Mechanisms
4. Altered target
RIF – altered RNA polymerase (mutants)
NAL – altered DNA gyrase
STR – altered ribosomal proteins
ERY – methylation of 23S rRNA
5. Synthesis of resistant pathway
TMPr plasmid has gene for DHF reductase; insensitive to TMP
(cont’d) REVIEW
58. Empirical Treatment is the recommended strategy in treatment of CAP and shouldn’t be delayed.
59. 59 CAP – Special Features – Pathogen wise
Typical – S.pneumoniae, H.influenza, M.catarrhalis
Blood tinged sputum - Pneumococcal, Klebsiella, Legionella
H.influenzae
CAP has associated of pleural effusion:S.Pneumoniae – commonest – penicillin resistance problem
S.aureus, K.pneumoniae, P.aeruginosa
S.aureus causes CAP in post-viral influenza; Serious CAP
K.pneumoniae primarily in patients of chronic alcoholism
P.Aeruginosa causes CAP in pts with CSLD or CF, Nosocom
Aspiration CAP only is caused by multiple pathogens
Extra pulmonary manifestations only in Atypical CAP
60. Outpatient treatment: Oral Respiratory Fluroquinolones OR Oral B-Lactam/ B-Lactamase + Oral New Macrolide OR IM 3rd Generation Cefalosporines + New Macrolide Recommendations for the Empirical Treatment:
61. In-patient treatment: Non-ICU:
Intravenous ( IV )Respiratory fluoro- quinolone OR IV B-Lactam/ B-Lactamase + IV New Macrolide OR IV 3rd Generation Cephalosporin + IV New Macrolide Recommendations for the Empirical Treatment:
62. In-patient treatment: ICU:
No Monotherapy.
IV Respiratory fluoroquinolone + 3rd or 4th generation cephalosporin
OR IV Imipenem + IV New Macrolide
Recommendations for the Empirical Treatment:
63. Special entities in ICU:
Aspiration:
As Before + i.v. Clindamycin OR Metronidazole
Risk of Pseudomonas Infection:
Antipseudomonal beta-lactam (3rd or 4th generation cephalosporin OR Piperacillin-tazobactam OR carbapenem) Plus (aminoglycoside OR antipseudomonal fluoroquinolone) For community-acquired methicillin-resistant Staphylococcus aureus infection (MRSA): Add Teicoplanin OR linezolid Alternative: Vancomycin (considering its renal side effects) Recommendations for the Empirical Treatment:
64. 64 Duration of Therapy
•Minimum of 5 days
•Afebrile for at least 48 to 72 h
•Longer duration of therapy
If initial therapy was not active against the identified pathogen or complicated by extra pulmonary infection
65. 65
Strategies for Prevention of CAP
•Cessation smoking
•Influenza Vaccine It offers 90% protection and reduces mortality by 80%
•Pneumococcal Vaccine (Pneumonia shot)
It protects against 23 types of Pneumococci
70% of us have Pneumococci in our RT
It is not 100% protective but reduces mortality
Age 19-64 with co morbidity of high for pneumonia
Above 65 all must get it even without high risk
•Starting first dose of antibiotic within 4 h & O2 status
66. 66 Switch to Oral Therapy
Four criteria
Improvement in cough, dyspnea & clinical signs
Afebrile on two occasions 8 h apart
WBC decreasing towards normal
Functioning GI tract with adequate oral intake
If overall clinical picture is otherwise favorable, hemodynamically stable; can switch to oral therapy while still febrile.
67. 67 Management of Poor Responders
Consider non-infectious illnesses
Consider less common pathogens
Consider serologic testing
Broaden antibiotic therapy
Consider bronchoscopy
68. 68 CAP – Complications
Hypotension and septic shock
3-5% Pleural effusion; Clear fluid + pus cells
1% Empyema thoracis pus in the pleural space
Lung abscess – destruction of lung - CSLD
Single (aspiration) anaerobes, Pseudomonas
Multiple (metastatic) Staphylococcus aureus
Septicemia – Brain abscess, Liver Abscess
Multiple Pyemic Abscesses
69. 69 CAP – So How Best to Win the War?
Early antibiotic administration within 4-6 hours
Empiric antibiotic Rx. as per guidelines (IDSA / ATS)
PORT – PSI scoring and Classification of cases
Early hospitalization in Class IV and V
Change Abx. as per pathogen & sensitivity pattern
Decrease smoking cessation - advice / counseling
Arterial oxygenation assessment in the first 24 h
Blood culture collection in the first 24 h prior to Abx.
Pneumococcal & Influenza vaccination; Smoking cessation
70. Broncho-Vaxom is an extract of different bacterial species frequently responsible of respiratory infections. It stimulates the immune system in order to increase the body’s natural defences against a wide spectrum of respiratory pathogens. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .
71. Broncho-Vaxom prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular sinusitis, rhinopharyngitis and middle ear infection, in adults and children. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .
72. Immunostimulating agent In animals, an increased resistance towards experimental infections, a stimulation of macrophages and B lymphocytes as well as an increase in immunoglobulins secreted by the respiratory mucosal cells have been reported. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .
73. Immunostimulating agent In humans, an increase in the rate of circulating T lymphocytes, in salivary IgA, in the non-specific response to polyclonal mitogens and in the mixed lymphocyte reaction have been observed. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .
74. Safety Extensive toxicity studies have not revealed any toxic effect. Effects on ability to drive and use machines:
Broncho-Vaxom is presumed to be safe and unlikely to produce an effect.
BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .
75. Safety Reproduction studies in animals have not demonstrated any risk to the fetus, but controlled studies in pregnant women are not available. As regards breast-feeding, no specific studies have been performed and no data have been reported up to now. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .
76. Side effects The overall incidence of adverse effects in clinical trials lies between 3 and 4%. Gastrointestinal troubles (nausea, abdominal pain, vomiting), dermatologic reactions (rash, urticaria), and respiratory disorders (coughing, dyspnea, asthma), as well as generalized problems (fever, fatigue, allergic reactions) are the most frequent complaints reported. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .
77. Interaction No drug interaction is known up to now.. BRONCHO-VAXOM
Broncho-Vaxom ® prevents and/or reduces the severity of acute attacks of chronic bronchitis and recurrent infections of the respiratory tract, in particular .