Module: Pharmacology and Therapeutics III, (Therapeutics part)
Coordinator: Dr. Arwa M. Amin Mostafa
Academic Level: Undergraduate, B.Pharmacy
School: Dubai Pharmacy College
Year of first presented in Class: 2018
This presentation is for Educational purpose. It has no commercial value associated with it.
2. Arwa M. Amin
What We will Discuss Today?
What is Pneumonia?
What is the pathogenesis of Pneumonia?
What are the risk factors of Pneumonia?
What are the main Types of Pneumonia?
What are the Common pathogens of Typical and Atypical CAP?
What are the Clinical Presentations of Typical and Atypical CAP?
What are the Common pathogens of HAP?
What are the Clinical Presentations of HAP?
How to Diagnose Pneumonia?
How to Manage Pneumonia?
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Pneumonia
Pneumonia has
↑↑ Mortality & ↑↑ Morbidity
globally, particularly in:
Babies
Elderly
Immunocompromised patients.
O2 & CO2 exchange in
Normal Alveoli
Pneumonia is an inflammation of the Alveoli (air sacs) in
the lungs due to infection.
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Pneumonia
Infections causing Pneumonia can be
Bacteria, Virus or Fungi.
Bacteria is the common cause of
Pneumonia in Adults
Virus is the common cause of
Pneumonia in Children
Bacterial Pneumonia has ↑↑ Mortality
& ↑↑ Morbidity than viral pneumonia.
Influenza
virus
E. coli
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Pathogenesis of Pneumonia
A microbial infection which infected the alveoli may have
accessed the LRT* through any of the following routes:
Inhaled particles
Hematogenous spread: infection entered the lung via Blood
stream from an extrapulmonary site of infection
Aspiration of Oropharyngeal content
*LRT: Lower respiratory tract infection
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Pathogenesis of Pneumonia
• Pathogenic Infection of the alveoli (air-sac) cause an
inflammation, irritation and swelling of the alveoli.
• The alveoli may be filled with fluid or pus (purulent material).
Healthy Alveoli Pneumonia
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Pathogenesis of Pneumonia
An inflamed, infected and swelled
alveoli may cause:
Difficulty to Breath
Dyspnea
Lung infiltrates
Cough
It can be productive and non-
productive.
Empyema
Purulent sputum
↓↓ Oxygentaion
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Risk factors of Pneumonia
Age
Elderly (> 65 years) & Children < 2 years
Recent viral respiratory virus (e.g. cold,
influenza)
Cigarette smoking.
Alcohol abuse
Patients with other coexisting illnesses
e.g. Heart disease, Diabetes, Liver
Cirrhosis, COPD.
Impaired consciousness
(Hospitalized patients)
Living in Nursing facility
Chronic Lung disease
Immunocompromised
patients
Mechanical Ventilation
(Hospital acquired
pneumonia HAP)
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Classification of Pneumonia
Pneumonia is classified into two main types based on the mode of
developing pneumonia:
Community Acquired Pneumonia (CAP)
Pneumonia developed in the community/outside the Medical facility
Hospital Acquired Pneumonia (HAP) or (Nosocomial pneumonia)
Pneumonia developed inside the Medical facility/hospital
Hospitalized patient for IV therapy or Hemodialysis within the preceding
30 days
Hospitalized patient in acute-care facility (e.g. ICU) within the
preceding 90 days.
Residence in a long-term care facility
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Types of CAP Pneumonia
Pneumonia is caused by
less common infections:
Bacterial & Viral
CAP
Typical CAP
Pneumonia is caused
by common infections:
Bacterial pneumonia
Atypical CAP
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Common Pathogens of Typical CAP
Streptococcus pneumonia (pneumococcus) G (+)
75% of all Cases
Major cause of Bacterial pneumonia
↑↑ Mortality
Haemophilus Influenzae G (-)
Moraxella catarrhalis G (-)
Gram stain of Streptococcus
pneumonia
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Clinical Presentations of Typical CAP
Signs & Symptoms:
Acute Fever, sweating, Shaking Chills
Productive Cough
Pleuritic Chest pain/discomfort
It could be due to pleural effusion
Pleural Empyema
accumulation of pus within the lung
pleura
Dyspnea: Shortness of breath
Rust-colored sputum
Fatigue
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Clinical Presentations of Typical CAP
Physical Examination:
Tachypnea
Rales in the involved lobe
Tachycardia
Bronchial Breath sound
Diminished breath sounds over the affected area
Chest wall retractions and grunting respirations
↑↑ Tactile fremitus
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Common Pathogens of Atypical CAP
Bacterial Pathogens:
Mycoplasma pneumoniae. G (-)
Chlamydia pneumoniae. G (-)
Legionella species G (-)
Viral Pathogens:
Human rhinovirus
Influenza Viruses
Respiratory Syncytial virus (RSV)
Adenovirus
Parainfluenza virus
Influenza virus
RSV
Chlamydia pneumoniae*
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Clinical Presentations of Atypical CAP
Signs & Symptoms:
URTIs symptoms
Nasal congestion with
coryza
Sore-throat
Gradual onset of Fever
Chills (may be less common
than typical CAP)
Dry Cough
Shortness of Breath
Ear pain
Skin Rash
Headache
Fatigue & generalized pain
Myalgias (muscle pain)
Consciousness disturbance
Relative Bradycardia
Other Symptoms but less
common:
Abdominal pain
GI disturbance
Diarrhea
URTIs: Upper respiratory tract infections, GI: Gastrointestinal
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Clinical Presentation of Atypical CAP
Physical Examination:
Patient physically appears normal compared to typical CAP
Lungs Findings: limited to Rales and Rhonchi
Oropharyngeal inflammation
Otitis Media
Sinusitis
Conjunctivitis
Figure Source; otitis media: https://www.health.harvard.edu/diseases-and-conditions/middle-ear-infection-otitis-media
Figure source; conjunctivitis: https://www.optisyen.info/konjonktivit-goz-nezlesi/
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Pseudomonas aeruginosa
Common Pathogens of HAP
Bacterial Pathogens (More common pathogen):
Gram-negative aerobic bacilli G (-)
Pseudomonas aeruginosa G (-)
Staphylococcus aureus G (+)
Methicillin-susceptible Staphylococcus aureus (MSSA)
Methicillin-resistant Staphylococcus aureus (MSRA)
Escherichia coli (G -)
Staphylococcus aureus
E. coli
Viral Pathogens (Less common pathogens):
• Influenza A Virus
• Respiratory Syncytial virus (RSV)
• Human Parainfluenza virus
• Human metapneumovirus
RSV
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Clinical Presentations of HAP
Signs & Symptoms:
Fever & Chills
Worsening in respiratory
parameters
Hypoxemia
Purulent secretions
↑↑ RR
↑↑ HR
Shortness of Breath
General Discomfort
RR: Respiratory Rate, HR: Heart Rate
Sharp chest pain which
increases with deep
breathing or coughing
Cough with greenish phlegm.
Appearance of thick,
Neutrophil-laden respiratory
secretions.
Loss of appetite
Nausea and Vomiting
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Clinical Presentations of HAP
Physical Examination
Rales in the location of the pneumonic process
Tachycardia
Bronchial Breath sound
Chest wall retractions
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Diagnosis of Pneumonia
Chest Radiography
Chest radiograph reveals a new
dense lobar or segmental
infiltrate.
Laboratory Examination:
Leukocytosis with
predominance of
polymorphonuclear cell
Sputum Gram stain (+, -)
Sputum Culture
Two pre-treatment blood
cultures
Source of figure: https://www.pinterest.com/pin/490118371923667992/
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Management of Pneumonia
Goal of Treatment:
To relief symptoms and provide supportive care
To eradicate the offending organisms
To provide complete Clinical Cure
Supportive Treatment:
Bed Rest
Oral Fluid intake
IV fluids if oral fluid is not possible
Using Humidified Oxygen.
Nutritional Support
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Management of Pneumonia
Supportive Treatment:
Chest Physiotherapy with postural drainage if there is evidence of
retained secretions.
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Management of Pneumonia
Symptomatic Treatment:
If fever present, provide Antipyretic Therapy
Bronchodilators when Bronchospasm is present
Short acting β2 agonist (e.g. Albuterol)
Antimicrobial Therapy:
Treatment of Bacterial pneumonia initially involves the empiric Therapy
Broad-spectrum antibiotic (or antibiotics) effective against probable
pathogens
Therapy should be Narrowed to cover specific pathogens once the
results of cultures are known.
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Management of Pneumonia
Empiric Antimicrobial Therapy for CAP
Antimicrobial TreatmentType of Pneumonia
Macrolides: (Clarithromycin (500 mg PO, bid) Or
Azithromycin (500 mg PO OD, then 250 mg OD) Or
Tetracycline: Doxycycline (100 mg PO bid)
Typical CAP in
Previously Healthy
patient
Fluoroquinolones: Moxifloxacin (400 mg PO, OD),
levofloxacin (750 mg PO, OD) Or
β-lactam + Macrolide: Amoxicillin (1 g tid) Or
Amoxicillin/clavulanate (2 g bid); Alternatives: Ceftriaxone (1–
2 g IV OD), Cefpodoxime (200 mg PO, bid), cefuroxime (500
mg PO bid) + Macrolide
Typical CAP in patient
with comorbidities
(DM, Heart, Lung,
Liver, Renal,
Alcoholism)
Fluoroquinolones: Moxifloxacin (400 mg PO, OD), levofloxacin
(750 mg PO, OD) Or
Tetracycline: Doxycycline (100 mg PO bid), Or
Macrolides: Azithromycin (500 mg PO OD, then 250 mg OD)
Atypical CAP
DM: Diabetes Mellites
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Management of Pneumonia
Empiric Antimicrobial Therapy for CAP
Antimicrobial TreatmentType of Pneumonia
Oseltamivir (Tamiflu®) oral capsules Or
Zanamivir Inhalation (Relenza) Diskhaler
Viral Pneumonia
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Management of Pneumonia
Empiric Antimicrobial Therapy for HAP
Antimicrobial TreatmentType of Pneumonia
Ceftriaxone (2 g IV, q24h) Or
Fluoroquinolones: Moxifloxacin (400 mg IV q24h),
Ciprofloxacin (400 mg IV q8h), Or Levofloxacin (750 mg IV
q24h) Or
Ampicillin/sulbactam (3 g IV, q6h) Or
Carbapenems: Ertapenem (1 g IV, q24h), Doripenem (1 g IV, q8h)
HAP without Multi
drug resistance
(MDR) pathogens risk
Antipseudomonal cephalosporine: Cefepime (2 g IV q8-12h) or
Ceftazidime (2 g IV q8h) Or
Antipseudomonal carbapenem: Imipenem (1 g IV q8h) and
Meropenem (1 g IV q8h). Or
β-lactam/β-lactamase + antipseudomonal fluoroquinolones:
Moxifloxacin (400 mg IV OD), Ciprofloxacin (400 mg IV q8h), Or
Levofloxacin (750 mg IV OD) Or
Aminoglycosides: Amikacin (20mg/kg IV q24h), Gentamicin
(7.5mg/kg IV q24h), and Tobramycin (7.5mg/kg IV q24h)
HAP with MDR
pathogens risk