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Pneumonia Liza

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  • 1. ADULT PNEUMONIA LIZA D. MARIPOSQUE, M.D. July 1, 2008
  • 2.  
  • 3.  
  • 4.  
  • 5.           b Histoplasma , Coccidioides , and Blastomyces spp. a Influenza virus, cytomegalovirus, respiratory syncytial virus, measles virus, varicella-zoster virus, and hantavirus.   Pneumocystis carinii M. tuberculosis S. pneumoniae H. influenzae Enteric aerobic gram-negative bacilli Pseudomonas aeruginosa S. aureus Oral anaerobes Mycoplasma pneumoniae Streptococcus pneumoniae Haemophilus influenzae Chlamydia pneumoniae Legionella pneumophila Oral anaerobes Moraxella catarrhalis Staphylococcus aureus Nocardia spp. Viruses a Fungi b Mycobacterium tuberculosis Chlamydia psittaci   HIV Infection-Associated Hospital-Acquired Community-Acquired Table 255-1. Microbial Pathogens That Cause Pneumonia
  • 6. DEFENSE MECHANISMS
    • Ciliary movements
    • Epithelial lining fluids- lyse microbial pathogens
    • Alveolar macrophages, lymphocytes & polymorphonuclear leukocytes
    • Sneeze & cough reflex
  • 7. Routes of Infection
    • Microaspiration
    • Gross Aspiration
    • Aerosolization/inhalation
    • Hematogenos route
    • Contiguous spread
  • 8. Microaspiration
    • Oropharyngeal secretions colonized with pathogenic microorganisms.
    • The most common route.
    • Most common: S. pneumonia, H. influenzae
    • Anaerobic organism from gingival crevices & dental plaque.
  • 9. Gross aspiration
    • Occurs in patient with CNS disorders that affect swallowing- stroke, seizure
    • In those with impaired consciousness – alcoholic, IV drug users
    • During anesthesia or intubation.
    • Anaerobic organisms & gram negative bacilli.
  • 10.  
  • 11.  
  • 12. PATHOLOGY
  • 13. PNEUMONIA is an infection of the alveoli, distal airways, and interstitium of the lungs.
    • LOBAR PNEUMONIA: involvement of the entire lung lobe.
    • BRONCHOPNEUMONIA: patchy consolidation in 1 or several lobes, usually in dependent lower or posterior portions centered around bronchi & bronchioles.
  • 14.
    • INTERSTITIAL PNEUMONIA: Inflammation of the interstitium, including the alveolar walls and connective tissue around the bronchovascular tree.
    • MILIARY PNEUMONIA: Numerous discrete lesions due to hematogenous spread.
  • 15. CLINICAL MANIFESTATION
  • 16.
    • Community Acquired Pneumonia
    • - typical pneumonia
    • - atypical pneumonia
    • Nosocomial Pneumonia
    • Aspiration Pneumonia
  • 17. CAP:COMMUNITY-ACQUIRED PNEUMONIA
    • More common among patients with severe underlying illness, those with defects in phagocytosis or ciliary function, and those with anatomical defects such as bronchiectasis.
    • Factors that influence the types of pathogens.
    • Most causes by S. pneumonia (50% hosp.)
  • 18.
    • Most typical symptoms: fever, cough, pleuritic chest pain, chills or rigors, and dyspnea.
    • Frequent symptoms: HA, N/V, diarrhea, fatigue and confusion.
    • PE: tachypnea, dullness to percussion, inc. tactile & vocal fremitus, egophony, whispering pectoriloquy, crackles, and pleural friction rub.
    • RR>30/min – the most useful sign of severe pneumonia in a person without underlying lung disease.
  • 19. Not prominent Prominent (HA,myalgia, fatigue, N/V, diarrhea Extra-pulmonary symptoms Purulent Scanty Sputum Productive cough Dry cough Cough Abrupt gradual Onset S.pneumonia, H. influenza, Klebsiella, mixed aerobic & anaerobic oral flora M.pneumonia, Legionellasp.C. pneumonia, Mycoplasma, viruses Etiology TYPICAL PNEUMONIA ATYPICAL PNEUMONIA
  • 20.
    • the less frequently encountered pathogens C. psittaci , Coxiella burnetii , Francisella tularensis , H. capsulatum , and Coccidioides immitis .
    Atypical pneumonia
  • 21.
    • Certain viruses also produce pneumonia that is usually characterized by an atypical presentation:
    • Primary viral pneumonia can be caused by influenza virus (usually as part of a community outbreak in winter).
    • - respiratory syncytial virus (in children and immunosuppressed individuals)
    • - measles or varicella-zoster virus (accompanied by the characteristic rash)
    • - cytomegalovirus (in patients immunocompromised by HIV infection or by therapy given in association with organ transplantation).
  • 22.  
  • 23.
    • ANY OF THE FF:
    • DM
    • Neoplastic dse
    • Neurologic dse
    • Chf, copd
    • Renal insufficiency
    • Chronic liverdse
    • alcoholism
    Unstable LOWRISK CAP II OPD MINIMAL RISK CAP I MODERATE RISK CAP III WARD
  • 24.
    • Demographic Fc:
    • -age-men age yr
    • women age-10
    • Nursing home res. +10
    • Coexisting illness
    • Neosplatic dse +30
    • liver dse +20
    • CHF +10
    • CVD +10
    • Renal dse +10
    • PE Findings:
    • -altered ms +20
    • -RR>30 +20
    • SBP <90 +20
    • T<35/>40C +15
    • PR>125 +10
    • Labs:
    • -art.pH<7.35 +30
    • -BUN>30mg/dl +20
    • -Na<130 +20
    • -glucose>250 +10
    • -hct<30 +10
    • -PPA <60/O2 Sat +10
    • -pleural effusion
    PORT SCORE:Criteria for hosp.of Px with pneumonia
  • 25. ICU >130 V ICU 91-130 IV IN PATIENT 71-90 III OPD <70 II OPD No prediction I Recommendations for site of care No. of points Risk class
  • 26.  
  • 27. HAP:HOSP.-ACQUIRED (NOSOCOMIAL) PNEUMONIA
    • Defined as a new or progressive infiltrate on CXR plus at least two of the ff: T>37.8C, WBC>10T and production of purulent sputum.
    • Pneumonia develop at least 48 hrs after hospital admission.
    • Occurs most frequently in ICU patients on mechanical vent.
    • The highest morbidity and mortality rates of all nosocomial infections
  • 28.
    • the patients at greatest risk for nosocomial pneumonia are most likely to be heavily colonized with potential pulmonary pathogens in the oropharyngeal or tracheobronchial mucosa.
    • the presence of these organisms in gram-stained preparations or cultures of respiratory tract secretions does not necessarily confirm the diagnosis of pneumonia .
  • 29.  
  • 30.  
  • 31. Diagnosis
    • History & P.E.
    • - 60% accuracy
    • B. CXR
    • C. Sputum examinaton
  • 32.  
  • 33.
    • Oral anaerobes, S. aureus, S. pneumoniae serotype III, aerobic gram-negative bacilli, M. tuberculosis , and fungi as well as certain noninfectious conditions can produce tissue necrosis and pulmonary cavities.
    • H. influenzae , M. pneumoniae , viruses, and most other serotypes of S. pneumoniae almost never cause cavities.
    • Apical disease, with or without cavities, suggests reactivation tuberculosis.
  • 34.
    • Anaerobic abscesses are located in dependent, poorly ventilated, and poorly draining bronchopulmonary segments and characteristically have air-fluid levels, unlike the well-ventilated, well-drained upper-lobe cavities caused by M. tuberculosis , an obligate aerobe.
    • Air-fluid levels may also be present in cavities due to pulmonary necrosis of other infectious etiologies, such as S. aureus and aerobic gram-negative bacilli.
    • Mucor and Aspergillus invade blood vessels and cause pleural-based, wedge-shaped areas of pulmonary infarction.
  • 35.
    • In the patient with an uncomplicated course, chest radiographs need not be repeated before discharge, since the resolution of infiltrates may take up to 6 weeks after initial presentation.
    • In patients who do not respond clinically, who have a pleural effusion on admission, who may have postobstructive pneumonia , or who are infected with certain pathogens (e.g., S. aureus , aerobic gram-negative bacilli, or oral anaerobes) need more intensive surveillance.
  • 36.  
  • 37.  
  • 38.
    • Expectorated sputum usually is easily collected from patients with a vigorous cough but may be scant in patients with an atypical syndrome, in the elderly, and in persons with altered mental status.
    • If the patient is not producing sputum and can cooperate, respiratory secretions should be induced with ultrasonic nebulization of 3% saline
    • Gram's staining is more specific and probably more sensitive than the sputum culture.
    • The finding of mixed flora on Gram's staining of an uncontaminated sputum specimen suggests an anaerobic infection.
  • 39.  
  • 40.  
  • 41.   d The new macrolides azithromycin and clarithromycin are more active against H. influenzae than erythromycin and are equally or more active against other respiratory pathogens.   c In the United States, about 42% of strains are currently resistant to penicillin (15% with high-level penicillin resistance), 20% to amoxicillin and cefuroxime, 20-30% to trimethoprim-sulfamethoxazole, 7-10% to doxycycline (tetracycline), 14% to erythromycin, and <4% to the newer fluoroquinolones.   b Levofloxacin, gatifloxacin, moxifloxacin, and sparfloxacin.   a +, effective; -, ineffective; ±, sometimes effective.   + + + ± ± - - - Legionella pneumophila   + + + + - - - - Chlamydia pneumoniae   + + + + - - - - Mycoplasma pneumoniae   ± - - - - ± + ± Anaerobes   + + + + + + + - Moraxella catarrhalis   + + - d + + + + - Haemophilus influenzae   + c ± ± c + c ± c ± c ± c ± c Streptococcus pneumoniae   Newer Fluoroquinolones b Ciprofloxacin Erythromycin Doxycycline Trimethoprim- Sulfamethoxazole Cefuroxime Amoxicillin/ Clavulanate Penicillin G Pathogen Value of Indicated Antimicrobial a   Table 255-5. Empirical Oral Antimicrobial Therapy for Outpatient Management of Community-Acquired Pneumonia
  • 42. EMPIRIC Rx FOR CAP: Clarithromycin 500mg BIDx10 days; Azithromycin 500mg PO 1 dose then 250 mg/d x 4 days; Doxycyline 100mg BID x 10 days. OPD, no CP disease, no risk factors Regimen Rx Settings
  • 43. Quinolone with enhanced activity against S. pneumonia- Levox, Moxifloxacin; B-Lactam (cefpodoxime, amox, co-amox.); Telithromycin OPD, CP disease and/or risk factors; high prevalence in the comunity Regimen Rx Settings
  • 44.   d In the United States, about 42% of strains are currently resistant to penicillin (15% with high-level penicillin resistance; ampicillin slightly less active than penicillin), 20% are resistant to cefuroxime (similar activity displayed by the first-generation cephalosporin cephalothin), 4-5% are highly resistant to third- or fourth-generation cephalosporins, 20-30% are resistant to trimethoprim-sulfamethoxazole, 7-10% are resistant to doxycycline (tetracycline), 14% are resistant to erythromycin, and <4% are resistant to the newer fluoroquinolones.   c Levofloxacin, gatifloxacin, moxifloxacin, and sparfloxacin.   b Ceftriaxone, cefotaxime, and cefepime.   a +, effective; -, ineffective; ±, sometimes effective.   + - + - - - - - Mycoplasma pneumoniae   + - + ± - - - - Legionella pneumophila   + - + - - - - - Chlamydia pneumoniae   ± + - - + - - - Anaerobic gram-negative bacilli   ± + ± - ± + + + Anaerobic gram-positive cocci   + + + + - + + - Moraxella catarrhalis   + + - + - + + - Haemophilus influenzae   + + + + - + + - Staphylococcus aureus   + d ± d ± d ± d - + d ± d ± d Streptococcus pneumoniae   Newer Fluoro- quinolones c Ampicillin/ Sulbactam Erythromycin Trimethoprim- Sulfamethoxazole Metronidazole Third- and Fourth- Generation Cephalosporins b Second- Generation Cephalosporins Penicillin G Pathogen Value of Indicated Antimicrobial a   Table 255-6. Empirical Antimicrobial Therapy for the Management of Hospitalized Patients with Community-Acquired Pneumonia
  • 45. a Dosage must be modified for patients with renal failure. Guidelines on the duration of therapy for each pathogen are given in the text of this chapter and of chapters on specific infecting agents.   1 g (15 mg/kg) IV q12h Vancomycin   3.1 g IV q4h Ticarcillin/clavulanate   4.5 g IV q6h Piperacillin/tazobactam   3 million units IV q4-6h Penicillin G   2 g IV q4h Nafcillin   500 mg IV or PO q6h Metronidazole   500 mg IV or PO q24h Levofloxacin   500 mg IV q6h Imipenem   5 mg/kg/d in 3 equally divided doses IV q8h Gentamicin (or tobramycin)   0.5-1.0 g IV q6h Erythromycin   600-900 mg IV q8h Clindamycin   400 mg IV or 750 mg PO q12h Ciprofloxacin   750 mg IV q8h Cefuroxime   1-2 g IV q12h Ceftriaxone   2 g IV q8h Ceftazidime   1-2 g IV q8-12h Cefotaxime, ceftizoxime   2 g IV q8h Cefepime   1-2 g IV q8h Cefazolin   2 g IV q8h Aztreonam   3 g IV q6h Ampicillin/sulbactam   Dosage Drug Table 255-7. Dosage of Antimicrobial Agents for the Treatment of Pneumonia in Hospitalized Patients a
  • 46. e Add vancomycin if methicillin-resistant S. aureus is present in the institution. d Metronidazole must be combined with vancomycin or another antimicrobial that covers microaerophilic and anaerobic gram-positive cocci. c Use when chromosomally encoded, inducible b-lactamase producers are endemic in the institution. b Use when extended-spectrum b-lactamase producers are endemic in the institution. a If methicillin-resistant S. aureus is known to exist in the institution, use vancomycin; otherwise, use an antistaphylococcal b-lactam such as nafcillin or cefazolin.   1. Ceftazidime or cefepime + clindamycin (or metronidazole) ± aminoglycoside e 2. Ticarcillin/clavulanate or piperacillin/tazobactam ± aminoglycoside e 3. Aztreonam + clindamycin (or metronidazole d ) ± aminoglycoside e 4. Imipenem b ± aminoglycoside e 5. Fluoroquinolone c + clindamycin (or metronidazole d ) ± aminoglycoside or b-lactam Mixed flora   1. Ceftazidime or cefepime ± aminoglycoside 2. Ticarcillin/clavulanate or piperacillin/tazobactam ± aminoglycoside 3. Aztreonam ± aminoglycoside 4. Imipenem b ± aminoglycoside 5. Fluoroquinolone c ± aminoglycoside or b-lactam Presumptive enteric aerobic gram-negative bacilli or Pseudomonas aeruginosa   Nafcillin or vancomycin a Presumptive Staphylococcus aureus   Regimen Etiology Table 255-8. Empirical Antimicrobial Therapy, Based on Gram's Staining of Sputum, for Institutionally Acquired Pneumonia
  • 47. Imipenem/meropenem 500mg q6h or Piperacillin/tazobactam 3.375g q6h + ciproflox ICU; risk factors Azithromycin 1G iv then 500mg OD + ceftriaxone or cefotaxime or quinolone ICU; no risk factors for P.aeruginosa infxn Regimen Rx Settings
  • 48. Wait 24H; if symptoms persist, give antibiotic Aspiration pneumonitis Metronidazole or Piperacillin/tazobactam 3.375 g q6h or Imipenem 500mg q6h or Levofloxacin, ceftri,or cefotaxime aspiration pneumonia Regimen Rx Settings
  • 49.  
  • 50.  
  • 51. PROGNOSIS >50% High risk 5 – 25% Moderate risk 1 – 5% Low Risk MORTALITY RATE CATEGORY