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.

1. LOWER RESPIRATORY TRACT INFECTIONs
PNEUMONIA
ARWA M. AMIN MOSTAFA
PHD, M.PHARM CLINICAL PHARM, DIP MANGT, B.PHARM.

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?

3. Arwa M. Amin
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.

4. Arwa M. Amin
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

5. Arwa M. Amin
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

6. Arwa M. Amin
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

7. Arwa M. Amin
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

8. Arwa M. Amin
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)

9. Arwa M. Amin
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

10. Arwa M. Amin
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

11. Arwa M. Amin
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

12. Arwa M. Amin
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

13. Arwa M. Amin
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

14. Arwa M. Amin
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*

15. Arwa M. Amin
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

16. Arwa M. Amin
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/

17. Arwa M. Amin
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

18. Arwa M. Amin
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

19. Arwa M. Amin
Clinical Presentations of HAP
Physical Examination
 Rales in the location of the pneumonic process
Tachycardia
Bronchial Breath sound
Chest wall retractions

20. Arwa M. Amin
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/

21. Arwa M. Amin
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

22. Arwa M. Amin
Management of Pneumonia
Supportive Treatment:
 Chest Physiotherapy with postural drainage if there is evidence of
retained secretions.

23. Arwa M. Amin
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.

24. Arwa M. Amin
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

25. Arwa M. Amin
Management of Pneumonia
Empiric Antimicrobial Therapy for CAP
Antimicrobial TreatmentType of Pneumonia
Oseltamivir (Tamiflu®) oral capsules Or
Zanamivir Inhalation (Relenza) Diskhaler
Viral Pneumonia

26. Arwa M. Amin
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

27. Arwa M. Amin