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Pneumonitis
Pneumonia
Pneumonitis: broad term for inflammation of the lung.
Pneumonia: used more specifically to indicate ...
Pneumonia
Community Acquired Pneumonia
(CAP)
Hospital Acquired Pneumonia
(HAP)
Pneumonia acquired outside the
hospital or ...
Community Acquired Pneumonia (CAP)Community Acquired Pneumonia (CAP)
Typical Pneumonia [85 %]
(Typical Organisms)
Atypical...
Routes of InfectionRoutes of Infection
Inhalation Haematogenous
Direct
Extension
Predisposing FactorsPredisposing Factors
...
COPD, Smoking, Bronchiectasis, Cystic Fibrosis Pseudomonas
Influenza Staph. aureus
Aspiration - Gm –ve enteric bacteria
- ...
Diagnosis of CAPDiagnosis of CAP
Clinical Radiologic Microbiologic
Required for
Diagnosis
• Onset: Acute (more common) or ...
Investigations in CAP
Oxymetry should complement clinical exam. It may give a clue for presence
of pneumonia and/or hypoxa...
Lobar Pneumonia, middle lobe of Rt LungLobar Pneumonia, middle lobe of Rt Lung
Criteria of Severe CAP
Minor MajorClinical
• Tachypnoea > 30 breath/min
• Hypotension requiring aggressive IV fluid
resusc...
Criteria of Clinical Stability
These criteria are required for the decision to:
• Switch from IV to oral treatment.
• Disc...
Non-Responding Pneumonia
These criteria of clinical stability are achieved within 3 – 6 days in most
patients. Absence of ...
This means persistence of pulmonary infiltrates > 30 days after initial
presentation.
• Causes:
• Resistant organism.
• Mi...
Empiric Antibiotic Treatment
• Mild cases can be treated as out-patient with oral monotherapy.
Once cases on IV therpy sta...
Macrolide Monotherapy
• Azithromycin 500 mg PO/IV OD.
• Clarithromycin 500 mg PO BID or Extended Release tablet 1000 mg PO...
Macrolide + β-Lactam
• Ampicillin / Sulbactam 1 gm PO/IV q8h
• Amoxacillin / Clavulinic Acid 2 gm PO/IV q12h
• Cefotaxime ...
Respiratory Fluoroquinolones
• Levofloxacin 750 mg PO/IV q24h
• Moxifloxacin 400 mg PO/IV q24h
• Respiratory fluoroquinolo...
Pseudomonas aeroginosa
Anti-Pseudomonal β-Lactam + Respiratory Fluoroquinolone
• Piperacillin / Tazobactam 4.5 gm IV q6h
•...
Aspiration Pneumonia / Lung Abscess
(Polymicrobial including Anaerobes)
β-Lactam + Antibiotic targeting anaerobes
β-Lactam...
MSSA (Methicillin Sensitive Staph. Aureus)
Add anti-Staphylococcal β-Lactam:
• Cefazolin 0.5 – 1 gm IV q6-8h
• Oxacillin 1...
Klebsiella & Acinetobacter
Carbapenem (Imipenem or Meropenem)
If resistant: Colistin (Polymixin E) 2.5 – 5 mg/kg/day IV in...
Antibiotics for Specific Pathogens
Mycoplasma
pneumonia &
Chlamydia
pneumonia
Doxycyclin 100 PO BID
Or Macrolide (Azithrom...
Viral Pneumonia
Influenza
Types
Hosts
Type A Humans,
birds, pigs
and
horses
Type B Humans
only
Type C Humans
only
H:
Haema...
Influenza: Pandemics
•Unpredictably and at irregular intervals,
pandemics associated with increased
mortality occur
•Attac...
Guidelines for Management of Epidemic Flu
Group
Criteria Action
1 •Mild fever (< 38 O
C).
•Other symptoms: cough, sore thr...
Oseltamivir (Tamiflu(
• Effective against both influenza A, B
• One tab 75 mg PO BID for 5 days.
• Early treatment shorten...
Zanamivir (Relenza(
• Powder for oral inhalation.
• Limited efficiency in treatment and
prevention of influenza.
• CI in B...
An N95 respirator is a
respiratory protective
device designed to achieve
a very close facial fit and
very efficient filtra...
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Community acquired pneumonia

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Diagnosis and Management of community acquired pneumonia

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Transcript of "Community acquired pneumonia"

  1. 1. Pneumonitis Pneumonia Pneumonitis: broad term for inflammation of the lung. Pneumonia: used more specifically to indicate lung inflammation which is: • Caused by an infectious agent. • Leads to formation of an inflammatory exudate inside the alveoli. • Leads to loss of aireation of lung tissue. This is referred to as hepatization (pathology) or consolidation (clinical). (Patchy) (Confluent)
  2. 2. Pneumonia Community Acquired Pneumonia (CAP) Hospital Acquired Pneumonia (HAP) Pneumonia acquired outside the hospital or extended care facility without recent exposure to the health care system. Pneumonia that occurs > 48h after hospital admission. Ventilator Associated Pneumonia (VAP) arises > 48h after endotracheal intubation. Health Care Associated Pneumonia (HCAP) arises in patients who were hospitalized in the last 3 months or attended out-patient clinic or HDU in the last month.
  3. 3. Community Acquired Pneumonia (CAP)Community Acquired Pneumonia (CAP) Typical Pneumonia [85 %] (Typical Organisms) Atypical Pneumonia [15 %] (Atypical Organisms) • Strept pnemoniae (Penicillin sensitive and resistant strains) • Haemophilus influenzae (Ampicillin sensitive and resistant strains) • Moraxella catarrhalis (All strains penicillin resistant) • Mycoplasma pneumoniae • Chlamydia pneumoniae • Chlamydia psittaci • Legionella pneumonia (Legionnaires' disease) • Fungal pneumonia • Viral pneumonia CAP is usually caused by a single organism, except aspiration pneumonia, which is commonly polymicrobial. Atypical organisms are not revealed on ordinary Gram stain and culture media.
  4. 4. Routes of InfectionRoutes of Infection Inhalation Haematogenous Direct Extension Predisposing FactorsPredisposing Factors Age > 65 Y Chronic Comorbidities Immune- Compromised Commonest route. From pleura or subdiaphragmatic space Constitute 30% of cases of CAP, and 60% of pneumonia hospitalization heart, liver, kidney disease, DM Aspiration Use of PPI, H2B The decreased gastric acidity ↑ risk of bacterial colonization in the stomach. This may be aspirated to the lungs. Sucralfate does not ↑ CAP risk. Risk ↑ in presence of stroke, seizures, neuromuscular disease
  5. 5. COPD, Smoking, Bronchiectasis, Cystic Fibrosis Pseudomonas Influenza Staph. aureus Aspiration - Gm –ve enteric bacteria - Oral anaerobes Lung Abscess - Oral anaerobes - Fungi Exposure to Birds Chlamydia psittaci (psittacosis) HIV - Pneumocystis jiroveci pneumonia - Fungi Risk Factors for Specific PathogensRisk Factors for Specific Pathogens
  6. 6. Diagnosis of CAPDiagnosis of CAP Clinical Radiologic Microbiologic Required for Diagnosis • Onset: Acute (more common) or Subacute (suggestive of atypical pneumonia) • General (Systemic) Manifestations: fever, myalgia • Local (Pulmonary) Manifestations: • Productive cough, dyspnoea, pleuritic chest pain. • Bronchial breathing, ↑ Vocal resonance • Extra- Pulmonary Manifestations in Atypical Pneumonia: • Erythema nodosum: in Psittacosis • Erythema Multiforme: in Mycoplasma pnemonia • Headache / mental confusion. • Abdminal pain / diarrhoea. • Relative bradycardia
  7. 7. Investigations in CAP Oxymetry should complement clinical exam. It may give a clue for presence of pneumonia and/or hypoxaemia. ABG PaO2/FiO2 < 250 mmHg is a criterion of severe CAP Culture guides therapy if +ve, but not exclusive if –ve, which is usual. Blood and respiratory cultures should be obtained. Respiratory samples include: Sputum (spontaneous or induced), endotracheal aspiration, bronchoalveolar lavage (BAL). Cultures obtained lower down the respiratory tract are more representative for bacteria actually invading the lungs and have higher predictive values. S. pneumoniae and H. influenzae are frequently associated with positive blood cultures. Laboratory - ↑ ESR, ↑ CRP, ↑ WBCs - Serologic markers in atypical pneumonia X-Ray
  8. 8. Lobar Pneumonia, middle lobe of Rt LungLobar Pneumonia, middle lobe of Rt Lung
  9. 9. Criteria of Severe CAP Minor MajorClinical • Tachypnoea > 30 breath/min • Hypotension requiring aggressive IV fluid resuscitation • Hypothermia < 36 O C • Confusion / disorientation Hypoxaemia • PaO2 / FiO2 < 250 mmHg • Need for non-invasive ventilation Investigations • BUN > 20 mg/dL • WBCs < 4000 cells/mm3 • Platelets < 100,000 celss/mm3 • Pulmonary infiltrates (X-Ray) • Invasive mechanical ventialtion • Septic shock with need for vasopressors •The 2 major criteria are absolute indications for admission to ICU. • Other factors associated with increased mortality in CAP: • Hypo- or hyper-glycaemia • Metabolic acidosis, particularly lactic acidosis. • Hyponatraemia
  10. 10. Criteria of Clinical Stability These criteria are required for the decision to: • Switch from IV to oral treatment. • Discharge from hospital. • Temp: < 37.8 O C (totally afebrile for 48h is the clinical criterion usually adopted) • Pulse: < 100 b/min • BP: systolic > 90 mmHg • Resp: < 24 breath/min • ABG: On room air: PaO2 > 60 mmHg O2 Sat > 90 % • A criterion for IV to oral switch: The patient can reliably take oral medicines: • Normally functioning GIT. • Normal mental status
  11. 11. Non-Responding Pneumonia These criteria of clinical stability are achieved within 3 – 6 days in most patients. Absence of clinical response or occurrence of deterioration after 3 – 6 days thus defines non-responding pneumonia. When guideline recommended therapy is adopted, it is the inadequate host response, rather than inappropriate therapy or unexpected micro-organisms, that is responsible for most cases of apparent antibiotic failure. • Causes of Non-Responding Pneumonia: • Resistant organism. • Missed organism (TB / fungus). • Nosocomial superinfection: another pneumonia, empyema, endocarditis • Misdiagnosis (PE, CHF, vasculitis) • Non- infectious complications: eg, Bronchiolitis Obliterans Organizing Pneumonia. • Drug fever Management of Non-Responding Pneumonia: • Transfer to a higher level of care (eg, from ordinary ward to ICU) • Further diagnostic testing. • Escalation or change of treatment • Comorbidities: DM, RF, HF • Immunocompromised states
  12. 12. This means persistence of pulmonary infiltrates > 30 days after initial presentation. • Causes: • Resistant organism. • Missed organism (TB / fungus). • Nosocomial superinfection: another pneumonia, empyema, endocarditis Non-Resolving or Slowly Resolving Pneumonia Bronchiloitis Obliterans Organizing Pneumonia (BOOP) • Comorbidities: DM, RF, HF • Immunocompromised states Resolution of pneumonia requires resorption of the inflammatory exudate in the alveoli. In BOOP, the inflammatory exudate persists in the alveoli and bronchioles and becomes organized into fibrous tissue which further obliterates the air spaces. X-Ray shows bilateral wide spread patches of fibrosis. Diagnosis is confirmed by CT and bronchoscopic biopsy. Most patients recover with steroid tharapy.
  13. 13. Empiric Antibiotic Treatment • Mild cases can be treated as out-patient with oral monotherapy. Once cases on IV therpy stabilize, they should preferably be shifted to oral therpy. • The minimum duration of treatment is 5 days, the usual is 7 – 10 days. • Longer course (2 weeks) is needed in: - In-patients - Pseudomonas - Presence of cavities or signs of lung necrosis. - Atypical pneumonia (2 weeks) - PJP (3 weeks) - Fungal (several months) • The choices for empiric antibiotic therapy of typical CAP (mostly caused by Strept. pneumoniae) are: • Macrolide Monotherapy • Macrolide + β-Lactam. • Respiratory fluoroquinolone.
  14. 14. Macrolide Monotherapy • Azithromycin 500 mg PO/IV OD. • Clarithromycin 500 mg PO BID or Extended Release tablet 1000 mg PO OD. Advantages of Macrolides in treatment of CAP: • Active against the 3 commonest causative typical organisms. • Active against Mycoplasma, Chlamydia, the commonest atypical organisms. Erythromycin is often not used now because of GI intolernce and lack of activity against H. influenzae. Macrolide monotherapy is recommended if the following criteria are fulfilled: • No comorbidities (chronic heart, lung, liver or renal disease). • No immuno-compromised state: (asplenia, use of immunosuppressive drugs). • No use of antibiotics within the last 3 months. • No hospital admission (Patient treated as out-patient).
  15. 15. Macrolide + β-Lactam • Ampicillin / Sulbactam 1 gm PO/IV q8h • Amoxacillin / Clavulinic Acid 2 gm PO/IV q12h • Cefotaxime 1 gm IM/IV q8h • Ceftriaxone 1 gm IM/IV q24h This line is used in presence of: • Comorbidities. • Immunocompromised state. • Use of antibiotics within the last month. • In-patient treatment.
  16. 16. Respiratory Fluoroquinolones • Levofloxacin 750 mg PO/IV q24h • Moxifloxacin 400 mg PO/IV q24h • Respiratory fluoroquinolones are now considered the most cost effective empirical therapy for CAP. • They are ideal for IV to oral shift (same dose). • Increased resistance was not noticed with extensive use.
  17. 17. Pseudomonas aeroginosa Anti-Pseudomonal β-Lactam + Respiratory Fluoroquinolone • Piperacillin / Tazobactam 4.5 gm IV q6h • Ceftazidime 1 gm IM/IV q8h • Cefepime 2 gm IV q12h • Imipenem / Cilastatin 500 mg IV q6h • Meropenem 1 gm IV q8h Antibiotics for Specific Pathogens
  18. 18. Aspiration Pneumonia / Lung Abscess (Polymicrobial including Anaerobes) β-Lactam + Antibiotic targeting anaerobes β-Lactam If Gm +ve • Ampicillin / Sulbactam 1 gm PO/IV q8h • Amoxacillin / Clavulinic Acid 2 gm PO/IV q12h If Gm -ve • Piperacillin / Tazobactam 4.5 gm IV q6h • If either • Ceftriaxone 1 gm IM/IV q24h Antibiotic targeting anaerobes • Clindamycin 600 mg IV q6h • Metronidazole 500 mg IV q6h Antibiotics for Specific Pathogens
  19. 19. MSSA (Methicillin Sensitive Staph. Aureus) Add anti-Staphylococcal β-Lactam: • Cefazolin 0.5 – 1 gm IV q6-8h • Oxacillin 1 gm IV q6h • Fluxacillin 500 mg PO q8h MRSA (Methicillin Resistant Staph. Aureus) Add vancomycin or linezolid • Vancomycin 15 mg/Kg IV q12h • Linezolid 600 mg PO/IV q12h Antibiotics for Specific Pathogens
  20. 20. Klebsiella & Acinetobacter Carbapenem (Imipenem or Meropenem) If resistant: Colistin (Polymixin E) 2.5 – 5 mg/kg/day IV in 3 divided doses 1 mg Colistin Base = 3000 IU There are various forms of colistin used for inhalation therapy (e.g. dry powder for inhalation, solution for nebulization). This minimizes nephrotoxicity from systemic absorption. These inhalation forms are also useful in treatment of cystic fibrosis (mucoviscidosis) complicated with multi-drug resistant gram negative infections Antibiotics for Specific Pathogens
  21. 21. Antibiotics for Specific Pathogens Mycoplasma pneumonia & Chlamydia pneumonia Doxycyclin 100 PO BID Or Macrolide (Azithromycin or Clarithromycin) Treatment for 10 days Chlamydia psittaci Doxycyclin 100 mg PO BID for 14 days Legionella Fluoroquinolones for 14 days, starting IV then shifting to oral. PJP (Pneumcystis Jiroveci Pneumonia) Trimethoprim / Sulphamethoxazole 15 mg TMP/Kg/day IV Div q8h or 2 DS tablets (800 mg sulfamethoxazole and 160 mg trimethoprim) PO q8h for 21 days Fungal Pneumonia (Aspergillosos, Histoplasmosis) Itraconazole 200 mg PO or IV q24h Or Amphotericin B 3 mg/kg q24h if severe Duration of therapy: 1-12 months
  22. 22. Viral Pneumonia Influenza Types Hosts Type A Humans, birds, pigs and horses Type B Humans only Type C Humans only H: Haemagglutinin N: Neuraminidase
  23. 23. Influenza: Pandemics •Unpredictably and at irregular intervals, pandemics associated with increased mortality occur •Attack rates approach 40-50% in some populations •Criteria for a pandemic influenza virus: • novel influenza A strain • little or no immunity in population • person-to-person transmission with disease
  24. 24. Guidelines for Management of Epidemic Flu Group Criteria Action 1 •Mild fever (< 38 O C). •Other symptoms: cough, sore throat, body aches. •NOT high risk group* •Symptomatic treatment. •Reassessment after 24 and 48 hours. 2 •High fever (> 38 O C) with other symptoms as above. •High risk group* (even if presenting with mild fever). •Isolation at home: ­Rest at home till resolution of symptoms. ­Do not mix with public. ­Do not mix with high risk members of the family. •Tamiflu (+ symptomatic treatment). 3 One or more of the following (in addition to fever) •Respiratory distress. •Chest pain. •Drowsiness. •Hypotension. •Haemoptysis. •Hypoxaemia. •Irritability and refusal of feeding in children. •Worsening of underlying chronic disease. •Admission to hospital in an isolation room. •Swab for swine flu (nasal and throat). •Tamiflu (+ symptomatic treatment). *High Risk Group: - Children < 5 Y. - Elderly > 65 Y. - Pregnant women. - Chronic diseases. - Immunocompromized patients
  25. 25. Oseltamivir (Tamiflu( • Effective against both influenza A, B • One tab 75 mg PO BID for 5 days. • Early treatment shortens the course and decreases risk of lower respiratory complications. • Patients should receive also antibiotics covering Strept. Pneumoniae and Staph. aureus which are the most common causes of 2ry bacterial pneumonia in patients with influenza. • Can be used also for post- exposure prophylaxis: One tablet daily for 10 days. Neuraminidase Inhibitors Neuaminidase is an enzyme on surface of influenza virus that enables it to be released from the host cell.
  26. 26. Zanamivir (Relenza( • Powder for oral inhalation. • Limited efficiency in treatment and prevention of influenza. • CI in BA, COPD (induces bronchospasm(
  27. 27. An N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles.
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