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Pneumonia Diagnosis and treatment
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Pneumonia Diagnosis and treatment

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  • 1. Introduction 0 Pneumonia is an inflammation of the lung parenchyma (i.e. alveoli rather than the bronchi) of infective origin.12/12/2011 Pneumonia 2
  • 2. 0 It is the most common infectious cause of death. 0 It is usually characterized by consolidation. 0 Consolidation is a pathological process in which the alveoli are filled with a mixture of inflammatory exudate, bacteria & WBC12/12/2011 Pneumonia 3
  • 3. EPIDEMIOLOGY 0Occurs throughout the year 0Results from different etiological agents varying with the seasons 0Occurs in persons of all ages 0Clinical manifestations severe in very young, elderly & in chronically ill patients12/12/2011 Pneumonia 4
  • 4. CLASSIFICATION Classified based on two types 1. Type 1 0 Lobar pneumonia 0 Bronchopneumonia 2. Type 2 0 Community- acquired pneumonia (CAP) 0 Hospital-acquired pneumonia (HAP)12/12/2011 Pneumonia 5
  • 5. Lobar pneumonia 0 Lobar pneumonia is acute bacterial infection of a part of lobe the entire lobe, or even two lobes of one or both the lungs.12/12/2011 Pneumonia 6
  • 6. Bronchopneumonia 0 Bronchopneumonia is infection of the terminal bronchioles that extends into the surrounding alveoli resulting in patchy consolidation of the lung.12/12/2011 Pneumonia 7
  • 7. Community Acquired Pneumonia (CAP) Pneumonia which develops in an otherwise healthy person outside of hospital or have been in hospital for less than 48hrs12/12/2011 Pneumonia 8
  • 8. Nosocomial pneumonia (HAP) Pneumonia that was not incubating upon admission developing in a patient hospitalized for greater than 48 hrs.12/12/2011 Pneumonia 9
  • 9. PATHOPHYSIOLOGY Microbial invasion of the normally sterile lower respiratory tract Three routes- 0 Inhaled as aerosolized particles 0 Haematogenous spread from an extrapulmonary site of infection 0 Aspiration of oropharyngeal contents12/12/2011 Pneumonia 10
  • 10. Various defence mechanisms that protects lung from infection 0 Anatomic barriers –epiglottis, larynx 0 Cough reflexes 0 Tracheobronchial secretions 0 Mucocilliary lining 0 Cell & humoral mediated immunity 0 Dual phagocytic system-alveolar macrophages & neutrophils12/12/2011 Pneumonia 11
  • 11. Invasion occurs as a result of 0 Defect in host defence mechanism 0 Overwhelming inocculum 0 Lung infection with viruses suppress the antibacterial activity of the lung by impairing alveolar macrophage function & mucocilliary clearance thus setting the stage for secondary bacterial pneumonia.12/12/2011 Pneumonia 12
  • 12. Clinical Manifestations 0 Indolent to fulminant in presentation 0 Mild to fatal in severity 0 Typical symptoms – • Fever • Chills • Cough • Rust coloured sputum • Mucopurulent sputum • Dyspnea ( shortness of breath) • Pleuritic chest pain 0 Elevated WBC 0 Bacteraemic12/12/2011 Pneumonia 13
  • 13. Chest X-ray For Lobar Pneumonia Consolidation confined to one or more lobes (or segments of lobes) of lungs. Lobarpneumonia12/12/2011 Pneumonia 14
  • 14. Chest X-ray For Bronchopneumonia •Patchy consolidation usually in the bases of both lungs. Bronchopneumonia12/12/2011 Pneumonia 15
  • 15. Diagnosis Clinical diagnosis 0 History 0 Signs & symptoms 0 Chest x-ray 0 CT12/12/2011 Pneumonia 16
  • 16. Diagnosis Etiological diagnosis 0 Grams Stain and Culture of Sputum 0 Blood Cultures 0 Antigen Tests 0 Polymerase Chain Reaction 0 Serology 0 Bronchoalveolar lavage 0 Bronchoscopy12/12/2011 Pneumonia 17
  • 17. Complications Possible complications include: 0 Acute respiratory distress syndrome (ARDS) 0 Fluid around the lung (pleural effusion) 0 Lung abscesses 0 Respiratory failure (which requires a breathing machine or ventilator) 0 Sepsis, which may lead to organ failure12/12/2011 Pneumonia 18
  • 18. COMMUNITY ACQUIRED PNEUMONIA Pneumonia is most common in winter because of seasonal increase in viral infections Mortality 1%- Non hospitalized patients 13.7%-Hospiatalized patients 19.6%-Bacteremic patients <36.5%- Intensive care unit12/12/2011 Pneumonia 19
  • 19. Risk factors 1. Comorbidity- Neoplastic disease, neurological problem 2. Alcoholism 3. Advanced age 4. Asthma 5. Immunosuppression12/12/2011 Pneumonia 20
  • 20. Etiology Potential etiologic agents in CAP - Bacteria Viruses Fungi Protozoa Potential bacteriologic causes can be divided into two types 0 Typical bacterial pathogens 0 Atypical bacterial pathogens12/12/2011 Pneumonia 21
  • 21. Typical bacterial pathogens 0 Streptococcus pneumoniae – 30% to 60% ,Severe illness, death 0 Haemophilus influenzae - 10% 0 S. aureus (in selected patients) 0 gram-negative bacilli – Klebsiella pneumoniae Pseudomonas aeruginosa12/12/2011 Pneumonia 22
  • 22. Atypical bacterial pathogens 0 Mycoplasma pneumoniae 0 Chlamydophila pneumoniae 0 Legionella pneumophillia 0 These organisms are intrinsically resistant to all - B lactam agents macrolide, a fluoroquinolone, or a tetracycline. 0 Poor dental hygiene-anaerobes 0 HIV- p.carnii 0 Birds- Chlamydia psittaci 0 Cattle or parturient cat-Coxiella burnetti12/12/2011 Pneumonia 23
  • 23. HOSPITAL ACQUIRED PNEUMONIA 0 Pneumonia that was not incubating upon admission developing in a patient hospitalized for greater than 48 hrs 0 10-15% of all hospital acquired pneumonia, usually presenting with sepsis or&/or respiratory failure 0 50% acquired on ICU12/12/2011 Pneumonia 24
  • 24. Predisposing features Reduced host defence against bacteria 0 Reduced immune defences (Corticosteroid treatment, diabetes, malignancy) 0 Reduced cough reflux (Post operative) 0 Disordered mucocilliary clearance (Anaesthetic agents) Aspiration of nasopharyngeal or gastric secretions 0 Immobility or reduced conscious level 0 Vomiting, Dysphagia, 0 Nasogastric intubation12/12/2011 Pneumonia 25
  • 25. 0 Most bacterial nosocomial infection occur by microaspiration of bacteria colonizing the patients oropharynx or upper GI tract 0 Most common pathogen – Aerobic gram negative bacilli 0 Most commonly exposed to multiresistant hospital pathogen 0 86% nosocomial infection-mechanical ventilation 0 Mortality-0 to 50%12/12/2011 Pneumonia 26
  • 26. Bacterial introduction into LRT Endotracheal intubation Infected ventillatiors / nebuliser /bronchoscopy Dental or sinus infection Bacteraemia Abdominal sepsis Intravenous canula12/12/2011 Pneumonia 27
  • 27. Causative organisms Common organisms Gram negative bacteria- 0 Escherichia coli 0 Klebsiella sp. 0 Pseudomonas aeruginosa Gram positive bacteria- 0 Streptococcus pneumoniae 0 Staphylococcus aureus12/12/2011 Pneumonia 28
  • 28. Less common organisms 1. Gram negative bacilli other coliforms:Enterobacter sp. 0 Proteus sp. 0 Seratia marcescens 0 Citrobacter sp. 0 Acinobacter sp. 0 Legionella pneumophillia 2. Anaerobic bacteria 3. Fungi- Candida albicans Aspergillus fumigatus 4. Viruses- Cytomegalovirus (CMV), Herpes simplex12/12/2011 Pneumonia 29
  • 29. Treatment Goals of therapy- 0 Eradication of the offending organism. 0 Selection of an appropriate antibiotic. 0 To minimize associated morbidity.12/12/2011 Pneumonia 30
  • 30. General approach to treatment 0 Adequacy of respiratory function 0 Humidified oxygen for hypoxemia 0 Bronchodilators (albuterol) 0 Chest physiotherapy with postural drainage 0 Adequate hydration if necessary 0 Expectorants such as guaifenesin 0 Chest pain- analgesics12/12/2011 Pneumonia 31
  • 31. Selection of an antimicrobial agent 0 Empirical use of relatively broad spectrum antibiotic 0 Narrow spectrum antibiotics to cover specific pathogen 0 Potential pathogens involved 0 Age 0 Previous &current medication history 0 Underlying disease 0 Present clinical status12/12/2011 Pneumonia 32
  • 32. Antibiotic doses for treating pneumonia12/12/2011 Pneumonia 33
  • 33. Treatment for special cases 1. Patient less than 60 years & without comorbidities:- Azithromycine ( 500mg OD) *1day ( 250mg OD) *4days Norfloxacin/Levofloxacin (400mg OD) *7days 2. Outpatient greater than 65 years:- Norfloxacin (400mg OD) *7days or Ceftriaxon (1-2 g/day) / Cifixim (2-4 g/day) 3rd gen cefalosporins +12/12/2011 Pneumonia 34
  • 34. Macrolides like Azithromycin ( 500mg OD) *1day ( 250mg OD) *4days3. Patient is hospitalised but not severely ill:- Combination of 3rd gen cefalosporins + Macrolides Ceftriaxone + Azithromycin OR Norfloxacin/Levofloxacin (400mg OD)4. If the patient is hospitalised but not severely ill:- Combination of 3rd gen cefalosporins + Macrolides Ceftriaxone + Azithromycin and newer fluroquinolones (Gatifloxacin)12/12/2011 Pneumonia 35
  • 35. 5. Patient hospitalised & severely ill:- Combination of 3rd gen cefalosporins + Macrolides Ceftriaxone + Azithromycin and newer fluroquinolones (Gatifloxacin) We can add Vancomycin. 6. Patient with icu admission:- 3rd gen cefalosporins + Fluroquinolones (Gatifloxacin) + Nutritional supplements + Saline Vancomycin/Meropenam12/12/2011 Pneumonia 36
  • 36. 7. For HAP:- Cephalosporins + Aminoglycocides 8. For antipseudomons cephalosporins:- Ceftazidime + Cefexime12/12/2011 Pneumonia 37
  • 37. Drugs with usual doses12/12/2011 Pneumonia 38
  • 38. 12/12/2011 Pneumonia 39
  • 39. 12/12/2011 Pneumonia 40
  • 40. 12/12/2011 Pneumonia 41