All About Pneumonia and How to Treat It Effectively. ( Classification,Types and causes,Diagnosis,Treatment Recovery and complications Prevention )

2. Pneumonias – ClassificationPneumonias – Classification
Nosocomial Pneumonias

3. Community Acquired Pneumonia (CAP)Community Acquired Pneumonia (CAP)
 DefinitionDefinition
an acute infection of the pulmonary parenchyma that isan acute infection of the pulmonary parenchyma that is
associated with some symptoms of acute infection,associated with some symptoms of acute infection,
accompanied by the presence of an acute infiltrate on aaccompanied by the presence of an acute infiltrate on a
chest radiograph, or auscultatory findings consistent withchest radiograph, or auscultatory findings consistent with
pneumonia, in a patient not hospitalized forpneumonia, in a patient not hospitalized for >> 14 days14 days
before onset of symptoms.before onset of symptoms.

4. The Two Types of PresentationsThe Two Types of Presentations
ClassicalClassical
• Sudden onset of CAP
• High fever, shaking chills
• Pleuritic chest pain, SOB
• Productive cough
• Rusty sputum, blood tinge
• Poor general condition
• High mortality up to 20% in
patients with bacteremia
• S.pneumoniae causative
• Gradual & insidious onset
• Low grade fever
• Dry cough, No blood tinge
• Good GC
• Low mortality 1-2%; except
in cases of Legionellosis
• Mycoplasma, Chlamydiae,
Legionella, Ricketessiae,
Viruses are causative
AtypicalAtypical

5. PathogenesisPathogenesis

6.  AgeAge
 ObesityObesity
 SmokingSmoking
 Asthma, COPDAsthma, COPD
 Immuno-suppression, HIVImmuno-suppression, HIV
Risk Factors for PneumoniaRisk Factors for Pneumonia

7. Community Acquired Pneumonia (CAP)Community Acquired Pneumonia (CAP)
EpidemiologyEpidemiology
 4-5 million cases annually4-5 million cases annually
 Probably highest incidence in <5 and >65 yrsProbably highest incidence in <5 and >65 yrs
 Over all mortality is 2-30%Over all mortality is 2-30%

8. The Pathogens InvolvedThe Pathogens Involved

9. Streptococcus pneumoniaStreptococcus pneumonia (Pneumococcus)Pneumococcus)
 Most common cause of CAPMost common cause of CAP
 About 2/3 of CAP are due to S.pneumoniaeAbout 2/3 of CAP are due to S.pneumoniae
 These are gram positive diplococciThese are gram positive diplococci
 Typical symptoms (e.g. malaise, shaking chills, fever,Typical symptoms (e.g. malaise, shaking chills, fever,
rusty sputum, pleuritic chest pain, cough)rusty sputum, pleuritic chest pain, cough)
 Lobar infiltrate on CXRLobar infiltrate on CXR
 25% will have bacteremia , serious effects25% will have bacteremia , serious effects

10.  AgeAge
 Asthma, COPD, Steroid or bronchodilator useAsthma, COPD, Steroid or bronchodilator use
 Chronic diseases, Diabetes, CHF, NeoplasiaChronic diseases, Diabetes, CHF, Neoplasia
 Alcohol is NOT related to increased risk forAlcohol is NOT related to increased risk for
hospitalizationhospitalization
CAP – Risk Factors for HospitalizationCAP – Risk Factors for Hospitalization

11.  Age > 65Age > 65
 BacteremiaBacteremia
 Extent of radiographic changesExtent of radiographic changes
 Degree of immuno-suppressionDegree of immuno-suppression
Risk Factors for MortalityRisk Factors for Mortality

12. Evaluation of a PatientEvaluation of a Patient

13. CURB 65CURB 65

14. Laboratory TestsLaboratory Tests
• CXR – PA & lateral
• CBC with Differential
• BUN and Creatinine
• Liver enzymes • Serum electrolytes
• Gram stain of sputum
• Culture of sputum
• Oxygen saturation

15. Value of Chest RadiographValue of Chest Radiograph
• Usually needed to establish diagnosis
• It is a prognostic indicator
• To rule out other disorders
• May help in etiological diagnosis

16. Normal CXR & Pneumonic ConsolidationNormal CXR & Pneumonic Consolidation

17. Lobar PneumoniaLobar Pneumonia

18. CXR – PA and Lateral ViewsCXR – PA and Lateral Views

19. Lobar versus Segmental - Right SideLobar versus Segmental - Right Side

20. Lobar PneumoniaLobar Pneumonia

21. Round Pneumonic ConsolidationRound Pneumonic Consolidation

22. Empiric Treatment For OutpatientEmpiric Treatment For Outpatient
Healthy and noHealthy and no exposure to antibiotics within the previous 3exposure to antibiotics within the previous 3
monthsmonths
1. Macrolide or Doxycycline1. Macrolide or Doxycycline
Presence of co-morbidities, use of antimicrobialsPresence of co-morbidities, use of antimicrobials
within the previous 3 months, and regions with awithin the previous 3 months, and regions with a
high rate (>25%) of infection with Macrolidehigh rate (>25%) of infection with Macrolide
resistantresistant S. pneumoniaeS. pneumoniae
1. Respiratory FQ ( Levoflox or Moxiflox)1. Respiratory FQ ( Levoflox or Moxiflox)
2. Beta-lactam (High dose Amoxicillin,2. Beta-lactam (High dose Amoxicillin, Amoxicillin- Clavulanate isAmoxicillin- Clavulanate is
preferred; Ceftriaxone, Cefpodoxime,preferred; Ceftriaxone, Cefpodoxime,
Cefuroxime)Cefuroxime) plusplus a Macrolidea Macrolide or Doxycyclineor Doxycycline

23. Empiric Treatment For Inpatient Non ICUEmpiric Treatment For Inpatient Non ICU
1.1. A Respiratory Fluoroquinolone (FQ) LevoA Respiratory Fluoroquinolone (FQ) Levo
2.2. A Beta-lactamA Beta-lactam plusplus a Macrolide (or Doxycycline)a Macrolide (or Doxycycline)
(Here Beta-lactam agents are 3 Generation(Here Beta-lactam agents are 3 Generation
Cefotaxime, Ceftriaxone, Amoxiclav)Cefotaxime, Ceftriaxone, Amoxiclav)
3.3. If Penicillin-allergic ( Respiratory FQ)If Penicillin-allergic ( Respiratory FQ)

24. Empiric Treatment For Inpatient in ICUEmpiric Treatment For Inpatient in ICU
1.1. A Beta-lactam (Cefotaxime, Ceftriaxone,A Beta-lactam (Cefotaxime, Ceftriaxone,
or Ampicillin-Sulbactam)or Ampicillin-Sulbactam) plusplus
eithereither AzithromycinAzithromycin oror FluoroquinoloneFluoroquinolone
2.2. For penicillin-allergic patients, a respiratoryFor penicillin-allergic patients, a respiratory
Fluoroquinolone and AztreonamFluoroquinolone and Aztreonam

25. Duration of TherapyDuration of Therapy
• Minimum of 5 daysMinimum of 5 days
• Afebrile for at least 48 to 72 hAfebrile for at least 48 to 72 h
• Longer duration of therapyLonger duration of therapy
If initial therapy was not active against the identified pathogenIf initial therapy was not active against the identified pathogen
or complicated by extra pulmonary infectionor complicated by extra pulmonary infection

26. Switch to Oral TherapySwitch to Oral Therapy
 Four criteriaFour criteria
 Improvement in cough, dyspnea & clinical signsImprovement in cough, dyspnea & clinical signs
 Afebrile on two occasions 8 h apartAfebrile on two occasions 8 h apart
 WBC decreasing towards normalWBC decreasing towards normal
 Functioning GI tract with adequate oral intakeFunctioning GI tract with adequate oral intake

27. ComplicationsComplications
 Hypotension and septic shockHypotension and septic shock
 3-5% Pleural effusion; Clear fluid3-5% Pleural effusion; Clear fluid
 1% Empyema ( pus in the pleural space )1% Empyema ( pus in the pleural space )
 Lung abscess , destruction of lungLung abscess , destruction of lung
 Septicemia , Brain abscess, Liver AbscessSepticemia , Brain abscess, Liver Abscess
 Multiple Pyemic AbscessesMultiple Pyemic Abscesses

28. Complications of PneumoniaComplications of Pneumonia

29. EmpyemaEmpyema

30. Nosocomial PneumoniaNosocomial Pneumonia
Definition
HAP is defined as pneumonia that occurs 48 hours or more
after hospital admission and that was not present at the time of
admission
VAP refers to pneumonia that occurs 48 hours or
more after endotracheal intubation.

31. Nosocomial PneumoniaNosocomial Pneumonia
EpidemiologyEpidemiology
– Common hospital-acquired infectionCommon hospital-acquired infection
– Occurs at a rate of approximately 5-10 cases per 1000Occurs at a rate of approximately 5-10 cases per 1000
hospital admissionshospital admissions
– Incidence increases by 6-20 fold in patients being ventilatedIncidence increases by 6-20 fold in patients being ventilated
– The risk for developing VAP increase in the first 5 daysThe risk for developing VAP increase in the first 5 days
after intubationafter intubation

32. Nosocomial PneumoniaNosocomial Pneumonia
EpidemiologyEpidemiology
– Nosocomial pneumonia is the leading cause of death dueNosocomial pneumonia is the leading cause of death due
to hospital acquired infectionsto hospital acquired infections
– Has an associated crude mortality of 30-50%Has an associated crude mortality of 30-50%
– Hospital stay increases by 7-9 days per patientHospital stay increases by 7-9 days per patient
– Estimated cost > 1 billion dollars/yearEstimated cost > 1 billion dollars/year

33. Nosocomial PneumoniaNosocomial Pneumonia
• PathogenesisPathogenesis
– Invasion of the lower respiratory tract by:Invasion of the lower respiratory tract by:
• Aspiration of oropharyngeal/GI organismsAspiration of oropharyngeal/GI organisms
• Inhalation of aerosols containing bacteriaInhalation of aerosols containing bacteria
• Hematogenous spreadHematogenous spread

34. Colonization Aspiration
HAP
MRSA*

35. Nosocomial PneumoniaNosocomial Pneumonia
RiskRisk FactorsFactors
Host Factors:Host Factors: Extremes of age, severe acute or chronicExtremes of age, severe acute or chronic
illnesses, immunosupression, coma, alcoholism, malnutrition,illnesses, immunosupression, coma, alcoholism, malnutrition,
COPD, DMCOPD, DM
Factors that enhance colonization of the oropharynx andFactors that enhance colonization of the oropharynx and
stomach by pathogenic microorganismsstomach by pathogenic microorganisms
• admission to an ICU, administration of antibiotics, chronicadmission to an ICU, administration of antibiotics, chronic
lung disease, endotracheal intubation, etc.lung disease, endotracheal intubation, etc.

36. Nosocomial PneumoniaNosocomial Pneumonia
• Risk FactorsRisk Factors
Conditions favoring aspiration or refluxConditions favoring aspiration or reflux
Supine position, depressed consciousness, endotracheal intubation,Supine position, depressed consciousness, endotracheal intubation,
insertion of nasogastric tubeinsertion of nasogastric tube
Mechanical ventilationMechanical ventilation
Impaired mucociliary function, injury of mucosa favoring bacterial binding,Impaired mucociliary function, injury of mucosa favoring bacterial binding,
pooling of secretions in the subglottic areapooling of secretions in the subglottic area
Factors that affect adequate pulmonary toiletFactors that affect adequate pulmonary toilet

37. Nosocomial PneumoniaNosocomial Pneumonia
• Etiologic AgentsEtiologic Agents
– S.aureusS.aureus
– EnterobacteriaceaeEnterobacteriaceae
– Pseudomonas aeruginosaPseudomonas aeruginosa
– Acinetobacter sp.Acinetobacter sp.
– Anaerobic bacteriaAnaerobic bacteria
– Aspergillus sp.Aspergillus sp.

38. Nosocomial PneumoniaNosocomial Pneumonia
• DiagnosisDiagnosis
– Not necessarily easy to accurately diagnose HAPNot necessarily easy to accurately diagnose HAP
– Criteria frequently include:Criteria frequently include:
Clinical :Clinical :
fever ; cough with purulent sputum,fever ; cough with purulent sputum,
Radiographic:Radiographic:
new or progressive infiltrates on CXR,new or progressive infiltrates on CXR,

39. Laboratorial:
leukocytosis or leukopenia
Microbiologic:
Suggestive gram stain and positive cultures of
sputum, tracheal aspirate, BAL, bronchial brushing,
pleural fluid or blood
Quantitative cultures

40. Nosocomial PneumoniaNosocomial Pneumonia
• Differential diagnosisDifferential diagnosis
– ARDSARDS
– Pulmonary edemaPulmonary edema
– Pulmonary embolismPulmonary embolism
– AtelectasisAtelectasis
– Alveolar hemorrhageAlveolar hemorrhage
– Lung contusionLung contusion

41. Nosocomial PneumoniaNosocomial Pneumonia
• Antimicrobial TreatmentAntimicrobial Treatment
– Broad spectrum penicillinsBroad spectrum penicillins
– 33rdrd
and 4and 4thth
generation cephalosporinsgeneration cephalosporins
– CarbapenemsCarbapenems
– QuinolonesQuinolones
– AminoglycosidesAminoglycosides
– VancomycinVancomycin
–

42. Supportive Measures
Supportive measures include the following:
1-Analgesia and antipyretics
2-Chest physiotherapy
3-Intravenous fluids (and, conversely, diuretics) if indicated
4-Monitoring Pulse oximetry with or without cardiac
monitoring, as indicated
5-Oxygen supplementation
6-Positioning of the patient to minimize aspiration risk
Respiratory therapy, including treatment with bronchodilators
and, perhaps, N -acetylcysteine in selected patients .

43. 7-Suctioning and bronchial hygiene – Pulmonary toilet
may include active suction of secretions, chest
physiotherapy, positioning to promote dependent
drainage, and incentive spirometry to enhance
elimination of purulent sputum and to avoid atelectasis.
8-Mechanical ventilatory support with low tidal volumes
(6 mL/kg of ideal body weight) in patients with
respiratory failure secondary to bilateral pneumonia or
acute respiratory distress syndrome (ARDS)
9-Systemic support may include proper hydration,
nutrition, and early mobilization to create a positive
host milieu to fight infection and speed recovery. Early
mobilization of patients, with encouragement to sit,
stand, and walk when tolerated, speeds recovery.

44. THANK YOUTHANK YOU