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MANAGEMENT OF PNEUMONIA

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MANAGEMENT OF PNEUMONIA

  1. 1. PRIYATMA KHINCHA
  2. 2. INVESTIGATIONS
  3. 3. SPUTUM MICROSCOPY  COLLECTION  >25 NEUTROPHILS / LPF  <10 SQUAMOUS EPITHELIAL CELLS / LPF  DISCARD SALIVA BACTERIA – GRAM STAINING
  4. 4. Streptococcus pneumoniae
  5. 5. Staphylococcus aureus
  6. 6. Klebsiella pneumoniae
  7. 7. Mycobacterium tuberculosis
  8. 8. FUNGI – WET MOUNT PREPARATION
  9. 9. Pneumocystis carinii GROCOTT – GOMORI METHENAMINE SILVER
  10. 10. OTHER TESTS ON SPUTUM -  PNEUMOCOCCAL ANTIGEN DETECTION  LEGIONELLA PNEUMOPHILIA – DFA TEST  PNEUMOCYSTIS – SPECIFIC FLUORESCEIN LABELLED MONOCLONAL ANTIBODIES NOT AFFECTED BY PRIOR ANTIBIOTIC USE RAPID VIRAL DIAGNOSIS BY DFA
  11. 11. SPUTUM CULTURE  DELAY IN GIVING RESULT  CONTAMINATION - NORMAL FLORA  PRIOR ANTIBIOTIC USE  INHIBITS GROWTH
  12. 12. Legionella pneumophilia  BUFFERED CHARCOAL YEAST EXTRACT (BCYE) AGAR – 5 OR MORE DAYS
  13. 13. FUNGAL CULTURE  IN IMMUNOCOMPROMISED  OPPORTUNISTIC FUNGI ( CRYPTOCOCCUS, ASPERGILLUS ) VIRAL ISOLATION  INDICATIONS  NOT RESPONDING TO ANTIBACTERIAL RX  IDENTIFY OUTBREAK OF INFLUENZA  ESTABLISH RSV IN YOUNG CHILDREN  IMMUNOCOMPROMISED
  14. 14.  HIGHEST SENSITIVITY IN PNEUMOCOCCAL PNEUMONIA  POSITIVE CULTURE  HIGH SPECIFICITY  MORE PROGNOSTIC : BACTERIMIA  SEVERE INFECTION BLOOD CULTURE
  15. 15. BACTERIAL ANTIGEN DETECTION  Streptococcus pneumoniae  QUELLUNG REACTION  LATEX AGGLUTINATION  ELISA  MOST SENSITIVE  COUNTER IMMUNOELECTROPHORESIS  SENSITIVITY : 80% 40% 25% SPUTUM URINE BLOOD
  16. 16. Legionella pneumophilia  RADIO-IMMUNO ASSAY  89 – 95% SENSITIVE  99% SPECIFIC  ENZYME LINKED IMMUNOASSAY
  17. 17. VIRAL ANTIGEN DETECTION  DFA – INFLUENZA A & B, RSV, CMV, HSV  EIA  PCR  ASSOCIATED CLINICAL AND LAB FINDINGS TO BE TAKEN INTO ACCOUNT FOR DIAGNOSIS
  18. 18. SEROLOGICAL TESTS  WHEN CAUSATIVE ORGANISM IS HARD TO ISOLATE  RAPID DIAGNOSIS  HELP IN INITIATION OF TREATMENT  INCREASE IN TITRES 4 FOLD  LEGIONELLA, MYCOPLASMA, Q FEVER PNEUMONIA, MYCOTIC PATHOGENS, VIRAL (RETROSPECTIVE DIAGNOSIS)
  19. 19. MOLECULAR DIAGNOSTIC TESTING  PCR  Mycobacterium  Chlamydia  Mycoplasma  HSV  ADENOVIRUS  CMV  EBV  Pneumocystis  Legionella  H1N1 – MOST RECENT  REVERSE TRANSCRIPTASE PCR
  20. 20. SKIN TESTS  FOR DELAYED HYPERSENSITIVITY  TUBERCULIN SKIN TEST  FUNGAL SKIN TEST (COCCOIDIODIN) ?? CURRENT OR PAST INFECTION ??
  21. 21. CHEST RADIOGRAPHY  PATTERN OF INFILTRATION –  LOBAR  PATCHY  INTERSTITIAL  CAVITARY  LARGE EFFUSION  RESPONSE TO TREATMENT LAGS WELL BEHIND CLINICAL IMPROVEMENT
  22. 22. CAVITY
  23. 23. STAGES OF LEGIONELLA PNEUMONIA
  24. 24. PLEURAL EFFUSION
  25. 25. CT SCAN  IN NON-RESPONDING PATIENTS
  26. 26. INVASIVE DIAGNOSTIC PROCEDURES  FIBRE-OPTIC BRONCHOSCOPY WITH TRANSBRONCHIAL LUNG BIOPSY  BRONCHO-ALVEOLAR LAVAGE  IN VAP – PROTECTED SPECIMEN BRUSHING  PERCUTANEOUS TRANSTHORACIC NEEDLE LUNG BIOPSY  OPEN LUNG BIOPSY / VATS
  27. 27. OTHERS  ARTERIAL O2 SATURATION AND BLOOD GAS ANALYSIS  WBC COUNT  HIGH BLOOD UREA  HIGH BILIRUBIN  HIGH ALKALINE PHOSPHATASE  HYPONATREMIA  LEGIONELLA  PROTEIN, RBC AND WBC IN URINE
  28. 28. MARKERS FOR SEVERE ILLNESS  ALTERED MENTAL STATE / CONFUSION  TACHYPNOEA >/= 30 BREATHS/MIN  HYPOTENSION <90/60 mm Hg  ARTERIAL HYPOXEMIA  CXR -- > 1 LOBE INVOLVED / RAPID PROGRESSION  RENAL INSUFFICIENCY
  29. 29. NO MARKERS OF SEVERE ILLNESS SPUTUM FOR GRAM STAIN AND CULTURE BLOOD CULTURE MARKERS OF SEVERE ILLNESS SPUTUM FOR GRAM STAIN AND CULTURE BLOOD CULTURE URINALYSIS SEROLOGY ? INVASIVE LUNG SAMPLING COMMUNITY ACQUIRED PNEUMONIA
  30. 30. TREATMENT HOSPITALISATION??  PNEUMONIA SEVERITY INDEX (PSI)  CURB - 65
  31. 31. PSI  CALCULATES THE PROBABILITY OF MORBIDITY AND MORTALITY AMONG THE COMMUNITY ACQUIRED PNEUMONIA PATIENTS.  USES DEMOGRAPHICS, ASSOCIATED CO-MORBIDITIES, PHYSICAL EXAMINATION, VITAL SIGNS AND LAB FINDINGS  RISK GROUP I – RX AT HOME  RISK GROUP II AND III – HOME RX WITH IV ANTIBIOTICS OR 1 DAY HOSPITAL STAY  RISK GROUP IV AND V – INPATIENT RX
  32. 32. C – CONFUSION U – UREMIA > 7 mmol/L R – RESPIRATORY RATE > 30/min B – BP < 90/60 mm Hg 65 – years old / more
  33. 33. IDSA / ATS GUIDELINES FOR EMPIRICAL ANTIBIOTIC THERAPY
  34. 34. PSI / CURB 65 OUT-PATIENT Healthy No antibiotics in past 3 months Macrolide OR Doxycycline Comorbidities Antibiotics in past 3 months Fluoroquinolone OR (B-lactam + Macrolide) IN-PATIENT Non-ICU ICU
  35. 35. NON-ICU Moxifloxacin 400mg PO/IV OD B-Lactam + Macrolide / IV Azithromycin ICU B-Lactam + Azithromycin / Fluoroquinolone
  36. 36. ONCE ETIOLOGIC AGENT CONFIRMED Rx ALTERED FOR TARGET PATHOGEN FAILURE OF TREATMENT IS IT NON-INFECTIOUS? WRONG PATHOGEN TREATED? SUPERINFECTION?
  37. 37. SPECIAL CONCERNS Pseudomonas aeruginosa  B – LACTAM + AMINOGLYCOSIDE + ANTIPNEUMOCOCCAL FLUOROQUINOLONE Legionella pneumophilia  MACROLIDE /CIPROFLOXACIN + IV RIFAMPICIN  CA – MRSA  ADD LINEZOLID (600mg IV 12 hrly) OR VANCOMYCIN ( 1 g IV 12 hrly)
  38. 38. HEALTH-CARE ASSOCIATED PNEUMONIA Without risk factors for MDR Ceftriaxone/ Moxifloxacine/ Ampicillin/ Ertapenem With risk factors for MDR Ceftazidine/Piperacillin +Gentamicin/Tobramycin +Linezolid/Vancomycin
  39. 39. ETIOLOGIC AGENT CONFIRMED Rx ALTERED FOR TARGET PATHOGEN FAILURE OF TREATMENT CONSIDER – 1. DRUG TOXICITY 2. SUPERINFECTION
  40. 40. SUPPORTIVE TREATMENT  RESPIRATORY SUPPORT  FLUID AND ELECTROLYTE REPLACEMENT  TOTAL PARENTERAL NUTRITION  OTHERS  ANALGESICS  CORTICOSTEROIDS  INOTROPICS
  41. 41. PREVENTION  PNEUMOCOCCAL CAPSULAR POLYSACCHARIDE VACCINE  INFLUENZA VACCINE  FOR NOSOCOMIAL INFECTION –  SURVEILLANCE  EDUCATION & AWARENESS  HANDWASHING  GOOD DISINFECTION  CONTROLLED USE OF ANTIBIOTICS
  42. 42. WORLD PNEUMONIA DAY NOVEMBER 2TH
  43. 43. THANK YOU!

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