Pneumonia is an inflammatory lung condition caused by infection, usually bacterial or viral. It is characterized by consolidation of the lungs due to inflammatory exudate, bacteria, and white blood cells filling the alveoli. Pneumonia can be classified as lobar or bronchopneumonia based on location in the lungs and as community-acquired or hospital-acquired based on where infection was contracted. Treatment involves use of antibiotics to eradicate the infecting organism as well as supportive care like oxygen supplementation. Antibiotic selection is based on suspected pathogen, patient age and health status, and severity of illness.

2. Introduction
0 Pneumonia is an inflammation of the lung parenchyma
(i.e. alveoli rather than the bronchi) of infective origin.
12/12/2011 Pneumonia 2

3. 0 It is the most common infectious cause of death.
0 It is usually characterized by consolidation.
0 Consolidation is a pathological process in which the
alveoli are filled with a mixture of inflammatory exudate,
bacteria & WBC
12/12/2011 Pneumonia 3

4. EPIDEMIOLOGY
0Occurs throughout the year
0Results from different etiological agents
varying with the seasons
0Occurs in persons of all ages
0Clinical manifestations severe in very
young, elderly & in chronically ill patients
12/12/2011 Pneumonia 4

5. CLASSIFICATION
Classified based on two types
1. Type 1
0 Lobar pneumonia
0 Bronchopneumonia
2. Type 2
0 Community- acquired pneumonia (CAP)
0 Hospital-acquired pneumonia (HAP)
12/12/2011 Pneumonia 5

6. Lobar pneumonia
0 Lobar pneumonia is acute bacterial infection of a part of
lobe the entire lobe, or even two lobes of one or both
the lungs.
12/12/2011 Pneumonia 6

7. Bronchopneumonia
0 Bronchopneumonia is infection of the terminal
bronchioles that extends into the surrounding alveoli
resulting in patchy consolidation of the lung.
12/12/2011 Pneumonia 7

8. Community Acquired
Pneumonia (CAP)
Pneumonia which develops in an otherwise healthy
person outside of hospital or have been in hospital for
less than 48hrs
12/12/2011 Pneumonia 8

9. Nosocomial pneumonia
(HAP)
Pneumonia that was not incubating upon admission
developing in a patient hospitalized for greater than
48 hrs.
12/12/2011 Pneumonia 9

10. PATHOPHYSIOLOGY
Microbial invasion of the normally sterile lower respiratory
tract
Three routes-
0 Inhaled as aerosolized particles
0 Haematogenous spread from an extrapulmonary site of
infection
0 Aspiration of oropharyngeal contents
12/12/2011 Pneumonia 10

11. Various defence mechanisms
that protects lung from
infection
0 Anatomic barriers –epiglottis, larynx
0 Cough reflexes
0 Tracheobronchial secretions
0 Mucocilliary lining
0 Cell & humoral mediated immunity
0 Dual phagocytic system-alveolar macrophages &
neutrophils
12/12/2011 Pneumonia 11

12. Invasion occurs as a result of
0 Defect in host defence mechanism
0 Overwhelming inocculum
0 Lung infection with viruses suppress the
antibacterial activity of the lung by impairing
alveolar macrophage function & mucocilliary
clearance thus setting the stage for secondary
bacterial pneumonia.
12/12/2011 Pneumonia 12

13. Clinical Manifestations
0 Indolent to fulminant in presentation
0 Mild to fatal in severity
0 Typical symptoms –
• Fever
• Chills
• Cough
• Rust coloured sputum
• Mucopurulent sputum
• Dyspnea ( shortness of breath)
• Pleuritic chest pain
0 Elevated WBC
0 Bacteraemic
12/12/2011 Pneumonia 13

14. Chest X-ray
For Lobar Pneumonia
Consolidation
confined to
one or more
lobes (or
segments of
lobes) of
lungs.
Lobarpneumonia
12/12/2011 Pneumonia 14

15. Chest X-ray
For Bronchopneumonia
•Patchy
consolidation
usually in the
bases of both
lungs.
Bronchopneumonia
12/12/2011 Pneumonia 15

16. Diagnosis
Clinical diagnosis
0 History
0 Signs & symptoms
0 Chest x-ray
0 CT
12/12/2011 Pneumonia 16

17. Diagnosis
Etiological diagnosis
0 Gram's Stain and Culture of Sputum
0 Blood Cultures
0 Antigen Tests
0 Polymerase Chain Reaction
0 Serology
0 Bronchoalveolar lavage
0 Bronchoscopy
12/12/2011 Pneumonia 17

18. Complications
Possible complications include:
0 Acute respiratory distress syndrome (ARDS)
0 Fluid around the lung (pleural effusion)
0 Lung abscesses
0 Respiratory failure (which requires a breathing
machine or ventilator)
0 Sepsis, which may lead to organ failure
12/12/2011 Pneumonia 18

19. COMMUNITY ACQUIRED
PNEUMONIA
Pneumonia is most common in winter because of seasonal
increase in viral infections
Mortality
1%- Non hospitalized patients
13.7%-Hospiatalized patients
19.6%-Bacteremic patients
<36.5%- Intensive care unit
12/12/2011 Pneumonia 19

20. Risk factors
1. Comorbidity- Neoplastic disease, neurological
problem
2. Alcoholism
3. Advanced age
4. Asthma
5. Immunosuppression
12/12/2011 Pneumonia 20

21. Etiology
Potential etiologic agents in CAP - Bacteria
Viruses
Fungi
Protozoa
Potential bacteriologic causes can be divided into two
types
0 Typical bacterial pathogens
0 Atypical bacterial pathogens
12/12/2011 Pneumonia 21

22. Typical bacterial pathogens
0 Streptococcus pneumoniae – 30% to 60% ,Severe
illness, death
0 Haemophilus influenzae - 10%
0 S. aureus (in selected patients)
0 gram-negative bacilli –
Klebsiella pneumoniae
Pseudomonas aeruginosa
12/12/2011 Pneumonia 22

23. Atypical bacterial pathogens
0 Mycoplasma pneumoniae
0 Chlamydophila pneumoniae
0 Legionella pneumophillia
0 These organisms are intrinsically resistant to all - B
lactam agents macrolide, a fluoroquinolone, or a
tetracycline.
0 Poor dental hygiene-anaerobes
0 HIV- p.carnii
0 Birds- Chlamydia psittaci
0 Cattle or parturient cat-Coxiella burnetti
12/12/2011 Pneumonia 23

24. HOSPITAL ACQUIRED
PNEUMONIA
0 Pneumonia that was not incubating upon admission
developing in a patient hospitalized for greater than 48
hrs
0 10-15% of all hospital acquired pneumonia, usually
presenting with sepsis or&/or respiratory failure
0 50% acquired on ICU
12/12/2011 Pneumonia 24

25. Predisposing features
Reduced host defence against bacteria
0 Reduced immune defences (Corticosteroid treatment,
diabetes, malignancy)
0 Reduced cough reflux (Post operative)
0 Disordered mucocilliary clearance (Anaesthetic agents)
Aspiration of nasopharyngeal or gastric secretions
0 Immobility or reduced conscious level
0 Vomiting, Dysphagia,
0 Nasogastric intubation
12/12/2011 Pneumonia 25

26. 0 Most bacterial nosocomial infection occur by
microaspiration of bacteria colonizing the patients
oropharynx or upper GI tract
0 Most common pathogen – Aerobic gram negative bacilli
0 Most commonly exposed to multiresistant hospital
pathogen
0 86% nosocomial infection-mechanical ventilation
0 Mortality-0 to 50%
12/12/2011 Pneumonia 26

27. Bacterial introduction into LRT
Endotracheal intubation
Infected ventillatiors / nebuliser /bronchoscopy
Dental or sinus infection
Bacteraemia
Abdominal sepsis
Intravenous canula
12/12/2011 Pneumonia 27

28. Causative organisms
Common organisms
Gram negative bacteria-
0 Escherichia coli
0 Klebsiella sp.
0 Pseudomonas aeruginosa
Gram positive bacteria-
0 Streptococcus pneumoniae
0 Staphylococcus aureus
12/12/2011 Pneumonia 28

29. Less common organisms
1. Gram negative bacilli
other coliforms:Enterobacter sp.
0 Proteus sp.
0 Seratia marcescens
0 Citrobacter sp.
0 Acinobacter sp.
0 Legionella pneumophillia
2. Anaerobic bacteria
3. Fungi- Candida albicans Aspergillus fumigatus
4. Viruses- Cytomegalovirus (CMV), Herpes simplex
12/12/2011 Pneumonia 29

30. Treatment
Goals of therapy-
0 Eradication of the offending organism.
0 Selection of an appropriate antibiotic.
0 To minimize associated morbidity.
12/12/2011 Pneumonia 30

31. General approach to treatment
0 Adequacy of respiratory function
0 Humidified oxygen for hypoxemia
0 Bronchodilators (albuterol)
0 Chest physiotherapy with postural drainage
0 Adequate hydration if necessary
0 Expectorants such as guaifenesin
0 Chest pain- analgesics
12/12/2011 Pneumonia 31

32. Selection of an antimicrobial
agent
0 Empirical use of relatively broad spectrum antibiotic
0 Narrow spectrum antibiotics to cover specific
pathogen
0 Potential pathogens involved
0 Age
0 Previous &current medication history
0 Underlying disease
0 Present clinical status
12/12/2011 Pneumonia 32

33. Antibiotic doses for treating pneumonia
12/12/2011 Pneumonia 33

34. Treatment for special cases
1. Patient less than 60 years & without comorbidities:-
Azithromycine ( 500mg OD) *1day
( 250mg OD) *4days
Norfloxacin/Levofloxacin (400mg OD) *7days
2. Outpatient greater than 65 years:-
Norfloxacin (400mg OD) *7days or
Ceftriaxon (1-2 g/day) / Cifixim (2-4 g/day) 3rd gen
cefalosporins +
12/12/2011 Pneumonia 34

35. Macrolides like Azithromycin ( 500mg OD) *1day
( 250mg OD) *4days
3. Patient is hospitalised but not severely ill:-
Combination of 3rd gen cefalosporins + Macrolides
Ceftriaxone + Azithromycin
OR
Norfloxacin/Levofloxacin (400mg OD)
4. If the patient is hospitalised but not severely ill:-
Combination of 3rd gen cefalosporins + Macrolides
Ceftriaxone + Azithromycin
and newer fluroquinolones (Gatifloxacin)
12/12/2011 Pneumonia 35

36. 5. Patient hospitalised & severely ill:-
Combination of 3rd gen cefalosporins + Macrolides
Ceftriaxone + Azithromycin
and newer fluroquinolones (Gatifloxacin)
We can add Vancomycin.
6. Patient with icu admission:-
3rd gen cefalosporins + Fluroquinolones
(Gatifloxacin)
+
Nutritional supplements + Saline
Vancomycin/Meropenam
12/12/2011 Pneumonia 36

37. 7. For HAP:-
Cephalosporins + Aminoglycocides
8. For antipseudomons cephalosporins:-
Ceftazidime + Cefexime
12/12/2011 Pneumonia 37

38. Drugs with usual doses
12/12/2011 Pneumonia 38

39. 12/12/2011 Pneumonia 39

40. 12/12/2011 Pneumonia 40

41. 12/12/2011 Pneumonia 41