Pneumonia is characterized by the emergence of new lung infiltrates, accompanied by clinical signs such as fever, purulent sputum, leukocytosis, and decreased oxygenation and Nosocomial Pneumonia is a non-incubating lower respiratory infection that presents clinically two or more days after hospitalization. In this presentation "Nosocomial Pneumonias" has been described including their causes, therapy, Principles, diagnosis, symptoms, management, etc. For more information, please contact us: 9779030507.

1. Nosocomial
Pneumonias

2. NOSOCOMIAL PNEUMONIAS
 Hospital-acquired pneumonia - pneumonia 48 hours or more after admission, and was
not incubating at the time of admission
 Ventilator-associated pneumonia - pneumonia that arises more than 48-72 hours after
endotracheal intubation
 Health Care Associated Pneumonia (HCAP)
i. hospitalized in an acute care hospital ≥ 2days in
preceding 90 days;
ii. nursing home or long-term care facility resident;
iii. recent iv chemotherapy, or wound care within
past 30 days
iv. attended a hospital or hemodialysis clinic

3. ENVIRONMENT
Infected air,water,
fomites,instruments
Cross-contamination
HOST
Impaired immune function
Comorbid illness
Prior surgery/antibiotics
PATHOGEN
- Inoculum
- Virulent strain (MDR)
PATHOGENESIS
NOSOCOMIAL
PNEUMONIA

4. DIAGNOSIS OF HAP
Clinical + Microbiology
• New onset fever
• Purulent expectoration
• Tachycardia
• Tachypnoea
• Leukocytosis /
Leukopenia
• Need of higher FiO2
+
Chest X ray
• Clinical diagnosis,
• high sensitivity,
• low specificity
• empiric treatment
Microbiology
- To identify
etiology
- De-escalate
therapy
- Decide duration of
therapy

5. DRUG RESISTANCE: FACTORS
 Sicker inpatient population
 Immuno-compromised patients
 New procedures & instrumentation
 Emerging pathogens
 Complacency regarding antibiotics
 Ineffective infection control and compliance
 Increased antibiotic use

6. PRINCIPLES OF THERAPY
 Start empiric therapy pending reports of culture and drug-sensitivity test
 Choose antibiotics based on probable organisms as cause of infection
 Combination therapy is preferred
 Parenteral route should be chosen
 Adequate dosages must be used
 Change the drug/s after culture and sensitivity reports
 Monitor for effects & side efffects of drugs

7. SUMMARY
 Nosocomial Pneumonias are frequent & associated with excess mortality
initiate prompt appropriate & adequate therapy
 Pathogens distinct from one hospital to another, specific sites within the
hospital, and from one time period to another
 Avoid overuse of antibiotics, focus on accurate diagnosis, tailor therapy to
recognized pathogen and shorten duration of therapy to the minimum
effective period
 Apply prevention strategies aimed at modifiable risk factors

8. SUPPURATIVE LUNG DISEASE
 Lung Abscess
 Bronchiectasis
 Empyema

9. LUNG ABSCESS
 Localized collection of pus in the lung parenchyma surrounded by a
fibrous tissue wall.
 Single or Multiple
 Necrotizing pneumonia may simulate an abscess; it lacks a wall
May precede lung abscess development

10. CLASSIFICATION
Primary Lung Abscess (Usually single)
Occurs in healthy individuals, e.g. following aspiration, pneumonia
(cavitation)
Secondary Abscess (May be multiple)
Pre-existing lung disease, e.g. Bronchogenic cancer, COPD, lung cysts etc
Systemic: Immunosuppression
Metastatic (eg. Infective endocarditis)

11. FACTORS CONTRIBUTING TO THE
DEVELOPMENT OF LUNG ABSCESS
1. Oral cavity disease
 Periodontal disease
 Gingivitis
2. Altered consciousness
 Alcoholism Coma
 Drug abuse Anesthesia
 Seizures
3. Immunocompromise
 Steroid therapy
 Chemotherapy
 Malnutrition
 Multiple trauma
4. Esophageal disease
 Achalasia
 Reflux disease
 Esophageal obstruction
5. Bronchial obstruction
 Tumor
 Foreign body
 Stricture
6. Generalized sepsis

12. PATHOGENESIS
Aspiration of infectious material
i. Poor oro-dental hygiene (infected gums, tonsils, etc)
ii. Predisposition to aspiration: Dysphagia, Alcoholism, seizure, stroke,
trauma, unconsciousness
 Colonization of organisms in the lung.
 Cellular infiltration and exudation
 Local liquefaction necrosis, destruction
 Bronchial communication, air in the abscess cavity.
 May extend to pleural cavity - pyopneumothorax
 Repair mechanisms and fibrosis - containment

13. MICROORGANISMS RESPONSIBLE FOR
LUNG ABSCESS
1. Aerobic Klebsiella, Pseudomonas
Staphylococci, others
2. Anaerobic Bacteroides, Clostridia
3. Fungal Aspergillus
4. Mycobacterial
5. Parasitic Entamoeba
Echinococcus (Hydatid Cyst)

14. CLINICAL FEATURES
Symptoms:
- Acute or insidious onset
- Fever with rigors, night sweats, Chest pain/ dullness, Cough, Sputum production
(Sputum is large volume, thick, muco-purulent or purulent; blood stained, foul smelling)
Signs:
- Presence of per/sidontal disease, other risk-factor
- Febrile, toxic patient, Finger clubbing
Chest exam:
- May be normal.
- Localized impairment of percussion note
- Breath sounds diminished; bronchial breathing, egophony, Crackles

15. DIFFERENTIAL DIAGNOSIS
(CAVITARY LUNG LESION)
1. Cavitating lung cancer
2. Localized empyema
3. Infected bulla containing a fluid level
4. Infected bronchogenic cyst or
sequestration
5. Pulmonary hematoma
6. Cavitating
pneumoconiosis
7. Hiatus hernia
8. Lung parasites (e.g. hydatid cyst,
Paragonimus infection)
9. Actinomycosis
10. Wegener’s granulomatosis and other
vasculitides
11. Cavitating lung infarcts
12. Cavitating sarcoidosis

16. INVESTIGATIONS
 Polymorphonuclear leukocytosis
 Sputum examination: Smear and culture for different etiological agents
 Chest radiography: CXR, CT scans
 Bronchoscopy for bronchial assessment (Obstruction, ulceration etc); br
secretions for microbiology

17. RADIOGRAPHIC FINDINGS
CXR:
- Smooth or irregularly walled cavity, fluid level; dependent part commonly.
- Klebsiella abscess mostly in upper lobe, bulging fissure sign.
- Staph abscesses: Multiple, sometimes thin walled
CT scans:
Clear demonstration of wall, localization of site within the lung, pleural
communication –
- presence of empyema; other underlying lung problem.
- CT is also helpful for guidance for per-cutaneous aspiration

22. PULMONARY SAMPLES FOR MICROBIOLOGICAL
DEMONSTRATION (UNCONTAMINATED)
• Transtracheal aspirate
• Transthoracic pulmonary aspirate
• Fiberoptic bronchoscopy with protected specimen brush
• Bronchoalveolar lavage fluid for quantitative culture
• Surgical specimens
• Pleural fluid (if empyema present)

23. LEMIERRE’S SYNDROME
 Rare cause of lung abscesses
 Infection with anaerobe
(F. necrophorum)
 Cl Features:
- Sore throat, fever, rigors, neck-swelling, hemoptysis, dyspnea
- Thrombophlebitis & thrombosis of neck veins,
- Metastatic spread to other organs.

24. COMPLICATIONS
 Erosion/ rupture – Broncho-pleural fistula and empyema formation
 Spread into surroundings –
 Metastatic spread – Brain, Liver, Spleen
 Sepsis
Long-term sequelae: Bronchiectasis, Fibrosis
Systemic amyloidosis

25. MANAGEMENT
 General measures
 Antibiotic therapy: parenteral
Aspiration pn. Co-amoxiclav
Metronidazole
Staphylococcal:
CA-MSSA Oral co-amoxilav
CA-MRSA Clindamycin, Linezolid, Vancomycin etc
 Surgical management

26. BRONCHIECTASIS
Definition
Permanent destructive dilatation of the bronchi (following infection,
destruction and fibrosis)
Types
 Cystic
 Cylindrical
 Localized or diffuse

28. ETIOLOGY OF BRONCHIECTASIS
 Post-infectious, e.g. tuberculosis, pneumonia; childhood infection such as
measles, mumps, whooping cough
 Connective tissue diseases, e.g. SLE, rheum arthritis, Sjögren’s syndrome,
relapsing polychondritis
Secondary to inhalation or aspiration, e.g. a foreign body
 Inflammatory bowel disease, e.g. ulcerative colitis
 Allergic bronchopulmonary aspergillosis
 Immune deficiency e.g. Secondary to ch lymphatic leukemia

29. CONGENITAL CAUSES OF BRONCHIECTASIS
 Cystic fibrosis
 Ciliary defects, e.g. primary ciliary dyskinesia, Young’s syndrome
 Kartagener’s syndrome
 Immune deficiency, e.g. IgA deficiency,
X-linked agammaglobulinemia,
Common variable immunodeficiency
 Congenital defects e.g. tracheobronchomegaly (Mounier-Kuhn
syndrome), pulmonary sequestration

30. CLINICAL FEATURES
 Chronic cough and expectoration
 Sputum: Purulent/ muco-purulent, foul-smelling, large volume, thick and tenacious
 Haemoptysis, sometimes massive
 Recurrent exacerbations
SIGNS: - General malnutrition, pallor, edema
- Digital clubbing, osteoarthropathy
Chest:
- Depends on site and extent of involvement
- If large, signs of lung volume reduction
- May be areas of bronchial breathing
- Coarse crepitations, Occasional rhonchi

31. INVESTIGATIONS
 General: Anemia, Hypoglobulinemia
 Chest radiography: CXR, CT scan (HRCT)
 Bronchography
 Sputum examination – For exacerbations.
- AFB to exclude TB, if suspected
-Smear for culture
-- ECG, ECHO for cardiac evaluation in suspected chronic cor-pulmonale

32. DIFFERENTIAL DIAGNOSIS
 Pulmonary tuberculosis
 Cystic fibrosis
 COPD
 Allergic broncho-pulmonary aspergillosis
 Interstitial lung diseases
 Eosinophilic lung diseases
 Hypersensitivity pneumonias

33. RADIOLOGICAL FEATURES
CXR:
 May appear normal in early, limited disease, left lower lobe hidden behind the heart in
PA film.
 Thickened bronchial lines- tram lines
 Cystic shadows/ cavities with fluid levels
HRCT:
 Almost diagnostic.
 Clear demonstration of site of involvement,
 Type of lesions, surrounding lung parenchyma, focal pneumonitis, areas of atelectasis.
 Clue to the underlying etiology (eg ABPA)

38. COMPLICATIONS
 Recurrent pneumonias
 Recurrent hemoptysis, sometimes massive
 Local lung destruction and cavitation
 Aspergilloma formation (fungal ball) in a cavity
 Metastatic spread
 Pulmonary hypertension and chronic cor pulmonale
 Chronic malnutrition
 Amyloidosis
 Chronic respiratory failure if extensive lung destruction and fibrosi

39. MANAGEMENT
Bronchial hygiene: Postural drainage, Chest physiotherapy
Antibiotics for infections
Expectorant and mucolytics
Management of complications, e.g hemoptyis, pulmonary hypertension (Chronic or
pulmonale), respiratory failure
Nutritional supplementation
Surgical management: - Resection, if localized
- Management of hemoptysis
- Lung transplantation

40. RECOMMENDATION FOR ANTIBIOTICS USE
Bacterial infection First choice Second line
Haemophilus influenzae Doxycycline,
or Moraxella catarrhalis Co-amoxiclav ciprofloxacin
Streptococcus pneumoniae Amoxicillin Clarithromycin
MRSA Rifampicin and Rifampicin and
trimethoprim doxycycline or
or IV vancomycin linezolid
or teicoplanin
Ps aeruginosa Ciprofloxacin Ceftazidime
and tobramycin
or colistin

41. PREVENTION OF INFECTIONS
 Preventive vaccinations
 Bronchial hygiene measures
- Chest physiotherapy
- Nebulization/steam inhalation
- Respiratory muscle exercises
 Long term antibiotic use - Oral
Nebulized

42. KARTAGENER’S SYNDROME
 Ciliary dyskinesia i.e. abnormal ciliary movements
 Genetic abnormality
 Clinical features:
- Bronchiectasis
- Situs inversus, dextrocardia
- Chronic sinusitis
- Infertility

43. ALLERGIC BRONCHO PULMONARY
ASPERGILLOSIS
Hypersensitivity to aspergillus in the tracheo-bronchial tree in patients with chronic
asthma.
Clinical Features: Severe attacks, sputum production; hard brown plugs; hemoptysis
Radiology: CXR and HRCT: Fleeting opacities, typical patterns; bronchiectasis –
proximal bronchi
Diagnosis: Skin test: Immediate & delayed +ve
Sputum for aspergillus +ve
Serology +ve; Total & Asperg specific IgE levels
Treatment: Anti-inflammatory drugs (steroids),
Anti-biotics, anti-fungals

45. CYSTIC FIBROSIS
 A common condition in Caucasians – 1 in 2500 live births
 Genetic anomaly: Autosomal recessive mutation on chromosome 7; leads to protein Cystic
Fibrosis Transmembrane Regulator, CFTR) abnormality
 Clinical Features: Multi-organ problem
 Bronchiectasis – thick viscid sputum
 Pancreatic insufficiency - diarrhoea
 Liver disease – biliary cirrhosis
 Sweat glands function abnormality
 Infertility
 Low bone mass

46. CYSTIC FIBROSIS- DIAGNOSIS
Clinical features – Failure to thrive
Intestinal obstruction
Adults: Respiratory infections
Radiological investigations, CXR, HRCT
scans etc
Positive sweat Test – High sweat chloride &
Na
levels on pilocarpine stimulation
Gene analysis – demonstration of CFTR
mutations

47. CYSTIC FIBROSIS- TREATMENT
 Treatment of respiratory infection with
antibiotics: Anti-pseudomonas cover
 Reduce sputum viscosity- mucolytics
 Improve airway clearance
 Management of pancreatic insufficiency
 Correction of malnutrition – high calorie,
high fat diet; supplemental vitamins
 Gene therapy
 Lung transplantation

48. THANK YOU