2. Infection of lung parenchyma…
…distal to terminal bronchi
Associated with clinical
& radiological evidence
of consolidation
3. Epidemiology
• High economic burden
• 4.7-11.6/1000 increasing with age
• 22% -51% hospital admission rate
• 7% mortality in those admitted to the hospital
• 21% mortality in severe pneumonia
4. Pathogenesis
• Overwhelmed respiratory defence
mechanisms
• Increased virulence of infecting agent
• Large size of inoculum
• Impaired host defence mechanisms eg
immunosuppression, diabetes, HIV etc
• Risk of infection vs risk of severity
5. Risk factors 1
• Age; 22-45 per 1000 vs 4.7-11.6 in those over 65
years.
– Increases mortality due to increased co-morbidities 9
vs 219/100,000
• Institutionalization
– Organisms somewhat different from CAP
• Malnutrition
• Aspiration, increases to 70% when unconscious
or intubated, anaerobes implicated in gross
aspiration
• Associated conditions or comorbidities
6. Risk factors 2
• Alcoholism
• Cigarette smoking
• Miscellaneous factors
– Soldiers
– South African gold miners
– Previous hospitalization within one year
25. Hospitalise ?
No Yes
Treatment
High dose amoxycillin
+/- Macrolide
(Alt: Co-amoxiclav or 2nd Gen Cephalosporin)
E.g. Erythromycin
Or Newer Fluoroquinolones:
E.g.: Moxiflofloxacin or Gatifloxacin
Pneumococci: High
prevalence of
resistance to
Macrolides
Exception:
Telitromycin
26. Hospitalise ?
No Yes
Severe ?
Yes No
Treatment
Co-amoxiclav
+ Macrolide (Or Fluoroquinolones)
Aminoglycoside
(Alt: 2nd /3rd Gen Cephalosporin)
Combination
lowers mortality
(Bacteraemic
Pnemocococcal)
27. Hospitalise ?
No Yes
Severe ?
Yes No
Age > 60 or
Comorbidity?
Support
Analgesics
Hydration (IV)
Physiotherapy
Rest
28. Hospitalise ?
No Yes
Severe ?
Yes No
Age > 60 or
Comorbidity?
Treat Complications
Supplementary O2
Chest drain (empyema)
ICU admission
Mechanical ventilation
29. Hospitalise ?
No Yes
Severe ?
Yes No
Age > 60 or
Comorbidity?
Duration of Antibiotics
5 – 10 days
14 days for atypical
2-3 weeks if severely ill ?
Little evidence
30. CXR 4 - 6 weeks after discharge
50% should resolve within 2 weeks
66% should resolve within 4 weeks
75% should resolve within 6 weeks
Indications for further investigations:
CXR at 4 weeks ~ no improvement
CXR at 12 weeks ~ not completely resolved
36. Serology
Antibody titre
Organisms not amenable to culture
Baseline serum taken on admission
Follow-up specimen 2 weeks later
Need 4x increase in antibody-titre
or high single titre
37. Lab findings may point towards aetiology
Cold haemagglutinins ~ Mycoplasma
Hyponatraemia, abn LFTs ~ Leigonella
Raised LDH ~ Pneumocystis
39. Infection of lung parenchyma
> 48 hours after admission
Not incubating at time of admission
Synonym: “Hospital acquired”
40. Different aetiology (than CAP)
Often gram negative organisms
Requires broad spectrum empiric antibiotics
41. Advanced age, smoking, alcohol abuse
Immunosuppressive state
Prior care facility
Intubation and mechanical ventilation
Head trauma, coma
Aspiration
Emergency surgery
Severe underlying disease
43. New / progressive pulmonary infiltrate
At least two of the following:
Fever
Leucocytosis
Purulent sputum
New pulmonary infiltrate
Mortality: 20 – 40 %
