internal medicine

1. PneumoniaPneumonia

2.  Definition: pulmonary inflammatory D ofDefinition: pulmonary inflammatory D of
terminal bronchioles, alveoli and interstitia.terminal bronchioles, alveoli and interstitia.
 PathogensPathogens
 Microbial, physiochemical, immunological,Microbial, physiochemical, immunological,
allergic or drugsallergic or drugs
 Bacterial pneumonia is most commonBacterial pneumonia is most common

3. Prevalence and etiologyPrevalence and etiology
 Almost most commonAlmost most common
 Risk factorsRisk factors
1.1. Genetic variance and antigen driftGenetic variance and antigen drift
2.2. Increased poor population, and agingIncreased poor population, and aging
populationpopulation
3.3. SmokingSmoking
4.4. Increased nosocomial pneumoniaIncreased nosocomial pneumonia
5.5. Unsuitable use of antibioticsUnsuitable use of antibiotics →bacterial→bacterial
multiple-drug resistancemultiple-drug resistance
6.6. Complicated with severe systemic DComplicated with severe systemic D
7.7. Dysfunction of immune system: administrationDysfunction of immune system: administration
of immunosuppressive agents, tumor, DM,of immunosuppressive agents, tumor, DM,
Uremia, AIDS, etcUremia, AIDS, etc

4. ClassificationClassification
 In light of anatomy, etiology, orIn light of anatomy, etiology, or
environmentsenvironments

5. In terms of etiology or pathogenIn terms of etiology or pathogen
 Bacterial: typical bacterial includeBacterial: typical bacterial include
pneumococcus, streptococcus, staphylococcus,pneumococcus, streptococcus, staphylococcus,
haemophilus, type A hemolytic streptococcus,haemophilus, type A hemolytic streptococcus,
Klebsiella, pseudomonas aeruginosa, etcKlebsiella, pseudomonas aeruginosa, etc
 Atypical pathogen: including mycoplasma,Atypical pathogen: including mycoplasma,
Chlamydia, legionella, etcChlamydia, legionella, etc
 Viral: cytomegalovirus, respiratory syncytialViral: cytomegalovirus, respiratory syncytial
virus, measles virus, varicella-zoster virus, &virus, measles virus, varicella-zoster virus, &
havtairus, etchavtairus, etc

6.  Fungal: histoplasma, coccidioides & BlastomycesFungal: histoplasma, coccidioides & Blastomyces
spp., etcspp., etc (( 白色念珠菌 、曲菌 、 放线菌等白色念珠菌 、曲菌 、 放线菌等 ))
 Other pathogenic microbesOther pathogenic microbes:: carinii, etccarinii, etc
 Physiochemical or allergen inducedPhysiochemical or allergen induced
pneumoniae: radiation related, inhalationpneumoniae: radiation related, inhalation
related, etcrelated, etc

7. In terms of environmentsIn terms of environments
 Community acquired pneumoniaCommunity acquired pneumonia
(CAP)(CAP)
 Infected out of the hospital, including thoseInfected out of the hospital, including those
onset in hospital, but infected out ofonset in hospital, but infected out of
hospital in terms of latent periodhospital in terms of latent period
 Common pathogens: streptococcusCommon pathogens: streptococcus
pneumoniae, haemophilus influenza, etcpneumoniae, haemophilus influenza, etc

8.  EvidenceEvidence
1.1. Recent occurrence of cough, sputum orRecent occurrence of cough, sputum or
aggravated on the basis of previousaggravated on the basis of previous
presentationspresentations
2.2. Fever, purulent sputum, chest painFever, purulent sputum, chest pain
3.3. Dullness and/or moist rales,Dullness and/or moist rales,
4.4. WBC>10X109/L or <4X109/L,WBC>10X109/L or <4X109/L,
hyposegmentationhyposegmentation
5.5. X-ray examine show laminar infiltrated shadowX-ray examine show laminar infiltrated shadow
or interstitial changes, with or without pleuralor interstitial changes, with or without pleural
effusioneffusion
 Diagnosed by any one of items 1-4 + item 5Diagnosed by any one of items 1-4 + item 5

9.  Hospital-acquired pneumoniaHospital-acquired pneumonia
(HAP)(HAP)
 Not infected out of hospital or not in the latentNot infected out of hospital or not in the latent
period, but infected within 48 Hrs after admissionperiod, but infected within 48 Hrs after admission
to hospitalto hospital
 Nosocomial infectionNosocomial infection
 EvidenceEvidence
 Similar with CAPSimilar with CAP
 Common pathogens:Common pathogens: streptococcusstreptococcus
pneumoniae, haemophilus influenza, S. aureus,pneumoniae, haemophilus influenza, S. aureus,
enteric aerobic G- bacilli, klebsiella, etcenteric aerobic G- bacilli, klebsiella, etc

10. 1.1. Lobar pneumonia –Lobar pneumonia –termed as alveolar pneumoniatermed as alveolar pneumonia
2.2. Foliolar pneumonia –Foliolar pneumonia – termed as bronchialtermed as bronchial
pneumoniapneumonia
3.3. Interstitial pneumoniaInterstitial pneumonia
According to anatomyAccording to anatomy

11.  Lobar pneumonia–Lobar pneumonia– termed as alveolartermed as alveolar
pneumoniapneumonia
1.1. Alveolar inflammation of one lobe orAlveolar inflammation of one lobe or
segment, parenchymal inflammation,segment, parenchymal inflammation,
bronchi is not involvedbronchi is not involved
2.2. Pathogens:Pathogens: streptococcus pneumoniae,streptococcus pneumoniae,
infiltrated via blood circulationinfiltrated via blood circulation
3.3. X-ray: dullness shadow in a lobe orX-ray: dullness shadow in a lobe or
segmentsegment

12.  Foliolar pneumonia—bronchialFoliolar pneumonia—bronchial
pneumoniapneumonia
1.1. Inflammation ofInflammation of bronchiole, terminal bronchiole,bronchiole, terminal bronchiole,
respiratory bronchiole & alveolarrespiratory bronchiole & alveolar
2.2. Pathogens:Pathogens: streptococcus pneumoniae, S. aureus,streptococcus pneumoniae, S. aureus,
virus, mycoplasma, legionella, etc. infiltrated viavirus, mycoplasma, legionella, etc. infiltrated via
bronchibronchi
3.3. Often secondaryOften secondary to other D such as bronchitis,to other D such as bronchitis,
bronchiectasis, viral infection of upper R tractbronchiectasis, viral infection of upper R tract
4.4. Moist ralesMoist rales is audible, but no dullness signsis audible, but no dullness signs
5.5. X-ray: irregular lamellar shadowX-ray: irregular lamellar shadow distributed alongdistributed along
bronchi with foggy margin, no dullnessbronchi with foggy margin, no dullness

13. Foliate pneumonia on R inferior lung

14.  Interstitial pneumoniaInterstitial pneumonia
1.1. Interstitial inflammation: involve bronchial wallInterstitial inflammation: involve bronchial wall
& their peripheral tissue, hyperplasia of alveolar& their peripheral tissue, hyperplasia of alveolar
wall, edematous changes in interstitiawall, edematous changes in interstitia
2.2. Pathogens: bacteria, mycoplasma, viruses orPathogens: bacteria, mycoplasma, viruses or
cariniicarinii
3.3. Mild symptom, few abnormal signsMild symptom, few abnormal signs
4.4. X-ray: unilateral or bilateral irregular stripe orX-ray: unilateral or bilateral irregular stripe or
net-like shadow on inferior field, stretched fromnet-like shadow on inferior field, stretched from
hilus, accompanied with small piece ofhilus, accompanied with small piece of
atelectasisatelectasis

15. Clinical manifestationsClinical manifestations
 Various with different pathogensVarious with different pathogens
 Determined by the status both of host &Determined by the status both of host &
pathogenspathogens
 Pay much attention to signs of dullnessPay much attention to signs of dullness
and signs of pleural effusionand signs of pleural effusion

16. Diagnosis & DifferentiationDiagnosis & Differentiation
DiagnosisDiagnosis
 ProcedureProcedure
1.1. Make sure of diagnosis of pneumoniaMake sure of diagnosis of pneumonia
2.2. Esp. distinguish from upper R. infectionEsp. distinguish from upper R. infection
3.3. Distinguish from other D such as TB, LC,Distinguish from other D such as TB, LC,
acute lung abscess, lung thromboembolicacute lung abscess, lung thromboembolic
disease, or non-infectious lung infiltrationdisease, or non-infectious lung infiltration
X-ray film
CT, MRI
Scintigraphic Imaging

17. Severity evaluationSeverity evaluation
 Which is determined by 3 factorsWhich is determined by 3 factors
1.1. local inflammationlocal inflammation
2.2. Generalized or notGeneralized or not
3.3. Inflammatory reaction as wholeInflammatory reaction as whole

18. Risk factorsRisk factors
 Factors indicate:Factors indicate: ↑↑severity andseverity and
mortalitymortality
1.1. History:History: >age of 65, with severe diseases such>age of 65, with severe diseases such
as COPD, DM, chronic heart or kidney failureas COPD, DM, chronic heart or kidney failure
2.2. PE:PE: R>30 tpm, P>120tpm, T>40R>30 tpm, P>120tpm, T>40ººC, or <35C, or <35ººC,C,
BP<90/60mmHg, abnormal consciousness,BP<90/60mmHg, abnormal consciousness,
accompanied with infection in other organ oraccompanied with infection in other organ or
system such as meningitis, sepsis, etcsystem such as meningitis, sepsis, etc
3.3. Lab test & imaging:Lab test & imaging: WBC>20WBC>20×10×1099
/L/L<4<4×10×1099
/L,/L,
NN<1<1×10×1099
/L;/L;
PaO2<60mmHgPaO2<60mmHg ，， PaCO2>50mmHg;PaCO2>50mmHg;
Cr>106mol/LCr>106mol/L ，， BUN>7.1mmol/L; toxicBUN>7.1mmol/L; toxic
symptoms or evidence of DIC; X-ray: over 1symptoms or evidence of DIC; X-ray: over 1
lobe involved, cavity, dispersed quickly, orlobe involved, cavity, dispersed quickly, or
pleural effusionpleural effusion

19. Standard for severeStandard for severe
pneumoniapneumonia
 In China, severe pneumonia is determined byIn China, severe pneumonia is determined by
series of indicatorsseries of indicators
1.1. Abnormal consciousnessAbnormal consciousness
2.2. R>30tpmR>30tpm
3.3. PaO2<60mmHg, PaOPaO2<60mmHg, PaO22/FiO/FiO22<300, mechanical<300, mechanical
ventilation requiredventilation required
4.4. BP<90/60mmHgBP<90/60mmHg
5.5. X-ray: bilateral or multiple lobes involved, orX-ray: bilateral or multiple lobes involved, or
pathological region dispersed rapidly>50% 48pathological region dispersed rapidly>50% 48
Hrs after admissionHrs after admission
6.6. Oligouria <20ml/h or <80ml/4hOligouria <20ml/h or <80ml/4h→ acute kidney→ acute kidney
failure when dialysis requiredfailure when dialysis required

20. Detection of pathogenDetection of pathogen
 MethodsMethods
 SamplingSampling
1.1. SputumSputum
2.2. Bronchoscopy-based techniques: airwayBronchoscopy-based techniques: airway
aspiration, brushing sample, alveolar lavageaspiration, brushing sample, alveolar lavage
3.3. Subcutaneous needle aspirationSubcutaneous needle aspiration
 ExaminationExamination
1.1. Directly examinationDirectly examination
2.2. Culture + drug sensitivity test of sputum,Culture + drug sensitivity test of sputum,
Effusion or bloodEffusion or blood

21. TreatmentTreatment
 AntibioticsAntibiotics —most important—most important
 Experience is important—on the basis ofExperience is important—on the basis of
epidemiologic dataepidemiologic data
 More reliable if selection is based resultsMore reliable if selection is based results
from culture + sensitivity testfrom culture + sensitivity test

22.  Antibiotics selection on patients statusAntibiotics selection on patients status
1.1. The youth or patients without basicThe youth or patients without basic
diseases: macrolides, penicillin,diseases: macrolides, penicillin,
quinolones or 1quinolones or 1stst
generationgeneration
cephalosporin is selectablecephalosporin is selectable
2.2. The elder, or those with basic diseases:The elder, or those with basic diseases:
2nd or 3rd cephalosporins and/or2nd or 3rd cephalosporins and/or ββ--
lactamase inhibitors, quinolones, and/orlactamase inhibitors, quinolones, and/or
macrolidesmacrolides

23.  Principles for severe pneumoniaPrinciples for severe pneumonia
1.1. Broad-spectrum, sufficiency &Broad-spectrum, sufficiency &
combination with 2 or morecombination with 2 or more
2.2. CAP: 3rd generation cephalosporin +CAP: 3rd generation cephalosporin +
macrolide +macrolide + ββ-lactamase inhibitors-lactamase inhibitors
3.3. If hypersensitive to penicillin: quinolone +If hypersensitive to penicillin: quinolone +
aminoglycosideaminoglycoside
4.4. Combining with norvancomycin ifCombining with norvancomycin if
necessarynecessary

24.  Situations for changing antibioticsSituations for changing antibiotics
 No improvement 72Hrs after useNo improvement 72Hrs after use
 Possible reasonsPossible reasons
1.1. Pathogen is resistant or not overlappedPathogen is resistant or not overlapped
2.2. Special pathogen: TB, fungus, or virusSpecial pathogen: TB, fungus, or virus
3.3. Influenced by complication orInfluenced by complication or
immunosuppressive statusimmunosuppressive status
4.4. Diagnosis is wrong, e.g.Diagnosis is wrong, e.g. non-infected D, ornon-infected D, or
drug-induced feverdrug-induced fever

25. Family careFamily care
 Enhance basic status by appropriateEnhance basic status by appropriate
exerciseexercise
 Reduce risk factors such as smoking andReduce risk factors such as smoking and
alcohol abusealcohol abuse
 Administration of vaccines to preventAdministration of vaccines to prevent
influenza and pneumonia, esp. for theinfluenza and pneumonia, esp. for the
elder, those with basic D or administrationelder, those with basic D or administration
of suppressive agentsof suppressive agents

26. Streptococcus pneumoniaStreptococcus pneumonia
(( 肺炎链球菌肺炎肺炎链球菌肺炎 ))

27. Natural historyNatural history
 Half of patients with CAPHalf of patients with CAP
 Pathogen: S. pneumoniae—G+Pathogen: S. pneumoniae—G+
 Capsular polysaccharide: main pathogenicCapsular polysaccharide: main pathogenic
factorfactor
 Natural course:1—2 WeeksNatural course:1—2 Weeks 。。
 TT  5—10 days later spontaneously5—10 days later spontaneously
 T normalized by administration of effectiveT normalized by administration of effective
antibiotics within 1-3 daysantibiotics within 1-3 days

28.  TriggersTriggers: coldness, drunkenness,: coldness, drunkenness,
fatigue, viral infectionfatigue, viral infection
 Abrupt onset, characterized of highAbrupt onset, characterized of high
fever, rigor, cough with ferruginousfever, rigor, cough with ferruginous
sputum and chest painsputum and chest pain
 Pleural involvement is commonPleural involvement is common
Clinical manifestationsClinical manifestations

29.  StagingStaging
1.1. Congestion stage:Congestion stage: vascular engorgementvascular engorgement
and serous exudationand serous exudation
2.2. Red hepatization stage:Red hepatization stage: reflecting liverlikereflecting liverlike
appearance of consolidated lung—RBCappearance of consolidated lung—RBC
extravasationextravasation
3.3. Gray hepatization stage:Gray hepatization stage: accumulation ofaccumulation of
fibrins mixed with WBC and RBCfibrins mixed with WBC and RBC
4.4. Resolution stage:Resolution stage: absorption of exudationabsorption of exudation

30.  PEPE
 Acute feverish face, red cheeks, rapidAcute feverish face, red cheeks, rapid
respiration, dry skin, thirsty, herpes onrespiration, dry skin, thirsty, herpes on
mouth corner or around nosemouth corner or around nose
 Cyanosis in some severe patientsCyanosis in some severe patients
 Bleeding in skin & sclerotic jaundice inBleeding in skin & sclerotic jaundice in
those with toxic pneumoniathose with toxic pneumonia
 Stiff neck + in those with meningitisStiff neck + in those with meningitis

31.  Tachycardia or arrhythmiaTachycardia or arrhythmia
 Abdominal tenderness & distentionAbdominal tenderness & distention
 Shock, ARDS or abnormal consciousnessShock, ARDS or abnormal consciousness

32.  Signs of LungSigns of Lung
 No significant signs in early stageNo significant signs in early stage
 Consolidation is the typical signs in redConsolidation is the typical signs in red
and grey hepatization stage: increasedand grey hepatization stage: increased
fremitus, dullness, bronchophony, pleuralfremitus, dullness, bronchophony, pleural
friction sound may be audiblefriction sound may be audible
 Moist rales in resolution stageMoist rales in resolution stage

33.  Complications: rarelyComplications: rarely
 Infectious shockInfectious shock
 Pleurisy and empyema (Pleurisy and empyema ( 脓胸脓胸 ))
 MeningitisMeningitis
 PericarditisPericarditis
 ArthritisArthritis

34. Laboratory testingLaboratory testing
 WBC10--20x10WBC10--20x1099
/L, N>80%, hyposegmentation,/L, N>80%, hyposegmentation,
toxic granulestoxic granules
 WBC may be lower than 4 x10WBC may be lower than 4 x1099
/L in the elder,/L in the elder,
drunk or those with immune deficiency, but ratiodrunk or those with immune deficiency, but ratio
of N/WBC is higherof N/WBC is higher
 Pathogen examinationPathogen examination
 Gram staining or capsule staining with sputumGram staining or capsule staining with sputum
precipitantprecipitant
 CultureCulture
 ELISA or PCR for detection of antigen or geneticELISA or PCR for detection of antigen or genetic
markersmarkers

35. X-rayX-ray
 Typical changes: segmental or lobarTypical changes: segmental or lobar
consolidation shadowconsolidation shadow

36. S. Pneumonia in R superior
lobe (AP view)

37. S. Pneumonia in R superior
lobe (lateral view)

38. S. Pneumonia in R superior
lobe (lateral view)

39. S. Pneumonia resolution
stage in R superior lobe (AP)

40. S. Pneumonia in R meddle
lobe (AP view)

41. S. Pneumonia in R meddle
lobe (lateral view)

42. Diagnosis EssentialsDiagnosis Essentials
 Natural history, triggers and symptomsNatural history, triggers and symptoms
 SignsSigns
 X-rayX-ray
 Pathogen examination, most reliablePathogen examination, most reliable

43. Differentiation DiagnosisDifferentiation Diagnosis
1.1. TB—liquefied pneumoniaTB—liquefied pneumonia
2.2. Lung cancer– obstructive pneumoniaLung cancer– obstructive pneumonia
3.3. Acute lung abscessAcute lung abscess
4.4. Lung thrombemboliaLung thrombembolia
5.5. Non-infectious lung infiltration such asNon-infectious lung infiltration such as
interstitial pulmonary fibrosis, pulmonaryinterstitial pulmonary fibrosis, pulmonary
edema , atelectasis, pulmonaryedema , atelectasis, pulmonary
infiltration of eosinophilic granulocyteinfiltration of eosinophilic granulocyte
and pulmonary vasculitisand pulmonary vasculitis

44. TreatmentTreatment
 AntibioticsAntibiotics
 Primary: penicillin GPrimary: penicillin G
 AdministrationAdministration
1.1. Adult mild: 2,400,000u/d, q8h im;Adult mild: 2,400,000u/d, q8h im;
2.2. Moderate: 2.4Moderate: 2.4~4.8 million~4.8 million u/d, ivgtt, q6h oru/d, ivgtt, q6h or
q8hq8h 。。
3.3. Severe or with meningitis: 10Severe or with meningitis: 10~~30million30million
u/du/d ，， ivgttivgtt ，， q6hq6h

45.  Hypersensitive to penicillin, or infected by MDRHypersensitive to penicillin, or infected by MDR
strainsstrains
 Selectable drugs: quinolones, cephalosporins, orSelectable drugs: quinolones, cephalosporins, or
even norvancomycineven norvancomycin
 Standard course: 14d, or 3 days later after TStandard course: 14d, or 3 days later after T
normalizednormalized
 In some cases, oral administration may persistIn some cases, oral administration may persist
for another 2 weeksfor another 2 weeks

46.  Supportive treatmentSupportive treatment
 Sufficient rest, balanced dietSufficient rest, balanced diet
 In-time monitoring, prevention againstIn-time monitoring, prevention against
shockshock
 Painkillers used for severe chest painPainkillers used for severe chest pain

47. Mycoplasma pneumoniaMycoplasma pneumonia
(( 肺炎支原体肺炎肺炎支原体肺炎 ))

48. General principlesGeneral principles
 Pathogen: mycoplasma pneumoniae, whichPathogen: mycoplasma pneumoniae, which
exists among ciliary epithelial cellsexists among ciliary epithelial cells
 Disseminated via respiratory tractDisseminated via respiratory tract
 More common in childhood or youthMore common in childhood or youth
 Pathology: inflammation of bronchi, bronchioles,Pathology: inflammation of bronchi, bronchioles,
alveolar or interstitiaalveolar or interstitia
 Natural course is 4 weeks, self-limitedNatural course is 4 weeks, self-limited

49. Diagnostic EssentialsDiagnostic Essentials
 2-3 weeks latency2-3 weeks latency
 Stimulant cough, some with fatigue, sore throat,Stimulant cough, some with fatigue, sore throat,
headache, fever, dyspepsia, diarrhea, myalgiaheadache, fever, dyspepsia, diarrhea, myalgia
 Extrapulmonary: dermatitisExtrapulmonary: dermatitis
 Few signsFew signs
 X-ray: segmental distributed polymorphicX-ray: segmental distributed polymorphic
infiltration shadow, mainly in inferior field,infiltration shadow, mainly in inferior field,
disappears spontaneously 3-4 weeks laterdisappears spontaneously 3-4 weeks later

50.  Laboratory testing: WBC countingLaboratory testing: WBC counting
increase slightly, Nincrease slightly, N↑↑
 2/3 patients with positive result of cold2/3 patients with positive result of cold
aggregation test (1:32), more meaningful ifaggregation test (1:32), more meaningful if
titertiter ↑↑ graduallygradually
 Detection of Mycoplasma-specific IgMDetection of Mycoplasma-specific IgM

51. TreatmentTreatment
 Administration of antibioticsAdministration of antibiotics
 Course: 2 weeksCourse: 2 weeks
 Primary: macrolides such as erythromycinPrimary: macrolides such as erythromycin
2g/D, roxithromycin 150mg po bid,2g/D, roxithromycin 150mg po bid,
azithromycin 0.5g, qdazithromycin 0.5g, qd
 Selectable: quinolones or tetracyclinesSelectable: quinolones or tetracyclines
 Ineffective: penicillin and cephalosporinsIneffective: penicillin and cephalosporins

52. Appendices 1 –antibioticsAppendices 1 –antibiotics
 CephalosporinCephalosporin
 44thth
generationgeneration
1.1. Wider spectrum, more effective on GWider spectrum, more effective on G ＋＋
coccus, especially for penicillin-coccus, especially for penicillin-
resistant S. pneumoniaeresistant S. pneumoniae
2.2. Stronger activity on GStronger activity on G--
bacillibacilli
3.3. More stable to β- lactamaseMore stable to β- lactamase

53. CephalosporinCephalosporin GG ＋＋ coccuscoccus G- bacilliG- bacilli
11stst
generationgeneration CephazolinCephazolin
(( 头孢唑啉头孢唑啉 ))
SensitiveSensitive
22ndnd
generationgeneration CefuroximeCefuroxime
(( 头孢呋辛头孢呋辛 ))
SensitiveSensitive SensitiveSensitive
33rdrd
generationgeneration CeftriaxoneCeftriaxone
(( 头孢曲松头孢曲松 ))
WeakWeak StrongStrong
44thth
generationgeneration CefepimeCefepime
（头孢吡肟（头孢吡肟 ))
StrongStrong StrongStrong

54.  CarbopenemCarbopenem
 Representatives: tienam composed ofRepresentatives: tienam composed of
Imipenem and cilastatin sodiumImipenem and cilastatin sodium
 Most effective in the worldMost effective in the world
 Quite stable to β- lactamase because ofQuite stable to β- lactamase because of
trans structure formed by hydroxyl lateraltrans structure formed by hydroxyl lateral
chain and β-lactate loopchain and β-lactate loop
 Cilastatin inhibit enzymes (degradeCilastatin inhibit enzymes (degrade
imipenem) in kidneyimipenem) in kidney

55.  TienamTienam
1.1. Wide spectrum—aerobic or anaerobic GWide spectrum—aerobic or anaerobic G
＋＋ coccus and G- bacilli, including thosecoccus and G- bacilli, including those
with super β-lactamase (ESBL), andwith super β-lactamase (ESBL), and
resistant against 3resistant against 3rdrd
-generation-generation
cephalosporincephalosporin
2.2. Imipenem combine with PBP-2 and PBP-Imipenem combine with PBP-2 and PBP-
2Ib2Ib →induce rapid resolution,→induce rapid resolution, 
production of endotoxinproduction of endotoxin

56.  QuinolonesQuinolones
 Representative: levoflaxacin (Representative: levoflaxacin ( 左旋氧氟沙星来立左旋氧氟沙星来立
信信 ))
 AdvantagesAdvantages
1.1. No need for cutaneous sensitivity testNo need for cutaneous sensitivity test
2.2. Oral administrationOral administration
3.3. Wide-spectrumWide-spectrum
4.4. Less side-effect on liver & kidneyLess side-effect on liver & kidney
5.5. Effective on intracellular pathogens such as legionellaEffective on intracellular pathogens such as legionella
and mycobacterium, mycoplasma, Chlamydia, etc.and mycobacterium, mycoplasma, Chlamydia, etc.
 DisadvantagesDisadvantages
1.1. Weaker effective on GWeaker effective on G++
coccuscoccus
2.2. Toxic to long bones and article, not recommended toToxic to long bones and article, not recommended to
be used in youth (be used in youth (<< ageage of 16)of 16)

57.  MacrolidesMacrolides
 Representative: erythromycin, roxithromycin,Representative: erythromycin, roxithromycin,
clarithromycin, azithromycinclarithromycin, azithromycin
 very effective on Gvery effective on G ＋＋ coccuscoccus
 Effective on atypical infectionsEffective on atypical infections

58.  AminoglycosidesAminoglycosides
 Representations: kanamycin, amikacin,Representations: kanamycin, amikacin,
netimicin, etimicin (netimicin, etimicin ( 爱大爱大 ))
 G- bacilliG- bacilli
 Toxin injury to Ear, auditory Nerve, kidneyToxin injury to Ear, auditory Nerve, kidney
 Etimicin more effective than gentamicinEtimicin more effective than gentamicin
 Netimicin, etimicin less side-effectNetimicin, etimicin less side-effect

59.  Anti fungus drugsAnti fungus drugs
 Representatives: Amphotericin B, ketoconazole,Representatives: Amphotericin B, ketoconazole,
fluconazolefluconazole
 Candida, cryptococcus, aspergillusCandida, cryptococcus, aspergillus
 Anti anaerobic bacteriaAnti anaerobic bacteria
 Penicillin, metronidazole, tinidazole,Penicillin, metronidazole, tinidazole,
chloromycetin, clindamycin. Erythromycin ischloromycetin, clindamycin. Erythromycin is
only against anaerobic coccus, metronidazoleonly against anaerobic coccus, metronidazole
against all anaerobic bacteriaagainst all anaerobic bacteria

60. Appendices 2Appendices 2
organisms & antibioticsorganisms & antibiotics

61. OrganismOrganism TypicalTypical
symptomssymptoms
RadiographicRadiographic
appearanceappearance
TherapyTherapy
S. pneumoniaeS. pneumoniae Sudden onset,Sudden onset,
fever, rigor,fever, rigor,
chest painchest pain
LobarLobar
pneumonia,pneumonia,
pleural effusionpleural effusion
PenicillinPenicillin
vancomycinvancomycin
S. AureusS. Aureus Gradual, fever,Gradual, fever,
purulent phlegm,purulent phlegm,
dyspneadyspnea
Multiple lobar,Multiple lobar,
empyema,empyema,
abscessabscess
Methicillin,Methicillin,
vancomycinvancomycin
K. PneumoniaeK. Pneumoniae Sudden, chestSudden, chest
pain, dyspnea,pain, dyspnea,
blood phlegmblood phlegm
Multiple lobular,Multiple lobular,
empyema,empyema,
abscessabscess
AzithromycinAzithromycin
broad -spectrumbroad -spectrum
cephalosporincephalosporin
H. InfluenzaeH. Influenzae Gradual,Gradual,
bronchitis, chestbronchitis, chest
pain, dyspneapain, dyspnea
Consolidative orConsolidative or
patchy lobularpatchy lobular
patternpattern
Azithromycin, orAzithromycin, or
amoxicillinamoxicillin
P. aeruginosaP. aeruginosa nosocomial,nosocomial,
blood phlegmblood phlegm
Patchy localizedPatchy localized
infiltrateinfiltrate
Cefepime, imipenem,Cefepime, imipenem,

62. OrganismOrganism Typical symptomsTypical symptoms RadiographicRadiographic
appearanceappearance
Basic TherapyBasic Therapy
L. pneumophilaL. pneumophila Gradual, rigor,Gradual, rigor,
chest pain, GIchest pain, GI
disturbancedisturbance
PatchyPatchy
localizedlocalized
infiltrateinfiltrate
AzithromycinAzithromycin
AnaerobicAnaerobic
organismsorganisms
Gradual onset,Gradual onset,
putrid phlegmputrid phlegm
Upper Seg. ofUpper Seg. of
lower lobes,lower lobes,
lower Seg. oflower Seg. of
Upper lobesUpper lobes
Penicillin,Penicillin,
metronidazolemetronidazole
MycoplasmaMycoplasma Gradual onset,Gradual onset,
malaise, fever,malaise, fever,
headacheheadache
PatchyPatchy
localizedlocalized
infiltrateinfiltrate
AzithromycinAzithromycin
ChlamydiaChlamydia Erythromycin,Erythromycin,
roxithromycinroxithromycin
FungalFungal
infectionsinfections
Gradual onset,Gradual onset,
bronchitis,bronchitis,
BilateralBilateral
diffuse, infiltratediffuse, infiltrate
AmophotericinAmophotericin
B, fuconazole,B, fuconazole,

63. Extracurricular taskExtracurricular task
 List the diagnostic essentials forList the diagnostic essentials for
1.1. Viral pneumoniaViral pneumonia
2.2. Fungal pneumoniaFungal pneumonia
3.3. Staphylococcual pneumoniaStaphylococcual pneumonia
4.4. Klebsiella pneumoniaKlebsiella pneumonia
5.5. Pneumonia caused by gramPneumonia caused by gram--
bacillibacilli
6.6. And pneumonia of legionnaires’ diseaseAnd pneumonia of legionnaires’ disease

64.  Look for the primary antibiotics andLook for the primary antibiotics and
selectable ones against pneumonia listedselectable ones against pneumonia listed
above?above?
 Try to make out the essentials forTry to make out the essentials for
diagnosis of pneumonia?diagnosis of pneumonia?