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  1. 1. PneumoniaSriloy MohantyB.N.Y.S
  2. 2. Pneumonia – DefinitionAn acute infection of the pulmonaryparenchyma that is associated with at leastsome symptoms of acute infection,accompanied by some auscultatory findingsconsistent with pneumonia and radiologicalpulmonary shadowing
  3. 3. What happens ???• Inflammatory condition where alveoli arefilled with fluid and blood cells• Begins with infection of alveoli followed byinflamed pulmonary membrane and becomeshighly porous• Whole lobe or sometimes whole lungs isconsolidated
  4. 4. PneumoniaI. Reduction in the total available surface areaof the respiratory membraneII. Decreased ventilation-perfusion ratioThese two causes Hypoxemia hypercapnia
  5. 5. Pneumonia• The major cause of death in the world• The 6thmost common cause of death in theU.S.• Annually in U.S.: 2-3 million cases, ~10million physician visits, 500,000hospitalizations, 45,000 deaths, with averagemortality ~14% inpatient and <1%outpatient
  6. 6. Risk factors• Old age• Recent influenza infection• Pre-existing lung disease• Lowered immune system due to corticosteroidtherapy,• Alcohol,smoking
  7. 7. Pneumonia - Symptoms• Cough (productive ornon-productive)• Dyspnea• Pleuritic chest pain• Fever or hypothermia• Myalgias• Chills/Sweats• Fatigue• Headache• Diarrhea (Legionella)• Sinusitis• Loss of appitite
  8. 8. Findings on Exam• Physical: Vitals: Fever or hypothermia Pyrexia,techicardia,hypoxamia Lung Exam: Crackles, rhonchi, dullness to percussion• Labs: Elevated WBC Hyponatremia – Legionella pneumonia Positive Cold-Agglutinin – Mycoplasma pneumonia
  9. 9. Investigations• Chest X-ray▫ Pulmonary shadow• Microbiological investigation▫ Strep. pneumo urinary antigen▫ Legionella urinary antigen▫ < 10 Squamous Epithelial Cells• Arterial blood gas measurements▫ PO2• General blood test▫ High neutrophil leucocytes
  10. 10. Investigation objectives• To obtain a radiological conformation of thediagnosis• To exclude other condition that may mimicpneumonia• To obtain microbiological diagnosis• To assess the severity of the pneumonia
  12. 12. Chest X-ray – Pneumonia
  13. 13. Chest X-ray - Pneumonia
  14. 14. Chest X-ray -- Pneumonia
  15. 15. Types of Pneumonia• Community-Acquired (CAP)• Hospital-Acquired Pneumonia (HAP)▫ Pneumonia that develops after 5 days of hospitalization▫ Includes: Ventilator-Associated Pneumonia (VAP) Aspiration Pneumonia
  16. 16. Common Bugs for PneumoniaCommunity-Acquired• Streptococcus pneumoniae• Mycoplasma pneumoniae• Chlamydophila psittaci orpneumoniae• Legionella pneumophila• Haemophilus influenzae• Moraxella catarrhalis• Staphylococcus aureus• Nocardia• Mycobacterium tuberculosis• Influenza• RSV• CMV• Histoplasma, Coccidioides,BlastomycosisHCAP or HAP• Pseudomonas aeruginosa• Staphylococcus aureus(Including MRSA)• Klebsiella pneumoniae• Serratia marcescens• Acinetobacter baumanii
  17. 17. Special Clues on Chest X-ray• Lobar pneumonia – Strep. Pneumonia• Diffuse interstitial infiltrates – Pneumocystis• RUL infiltrate – Tuberculosis• Diffuse interstitial infiltrates – Tuberculosisin HIV
  18. 18. PORT Score
  19. 19. PORT Score
  20. 20. Antibiotics treatment• Amoxillin 500mg 8-hourly orally• If patient allargic to penicilin▫ Clarithromycin 500mg 12 hourly orally▫ Erythromycin 500mg 6 hourly orally• If staphylococcus is cultured▫ Flucoxamin 1-2g 6 hourly orally▫ Clarithromycin 500mg 12 hourly orally
  21. 21. Severe CAP▫ Clarithromycin 500mg 12 hourly orally▫ Erythromycin 500mg 6 hourly orally▫ Amoxillin 500mg 8-hourly orally▫ Co-amoxiclav 1.2mg 8 hourly i.v
  22. 22. Treatment of HCAP, HAP, VAP• Antipseudomonal cephalosporin (Cefepime,Ceftazidime) + Vancomycin• Anti-pseudomonal Carbapenem (Imipenem,Meropenem) + Vancomycin• Beta-Lactamase/Beta-Lactamase Inhibitor (Pip-Tazo –Zosyn) + Pseudomonal Fluoroquinolone (Cipro) +Vancomycin• Aminoglycoside (Gentamycin, Amikacin) + Vancomycin
  23. 23. HAP – Failure of Therapy Incorrect diagnosis – it is not pneumonia– Atelectasis, CHF, PE with infarction, lung contusion,chemical pneumonitis, ARDS, pulmonary hemorrhage Pathogen resistance Host factors that increase mortality– Age > 60, prior pneumonia, chronic lung disease– immunosuppression Antibiotic resistance
  24. 24. HAP - Prevention Hand washing Vaccination– Influenza– Pneumococcus Isolation of patients with resistant respiratorytract infections Enteral nutrition Choice of GI prophylaxis Subglottoc secretion removal?
  25. 25. Special Cases!• HIV Pneumocystis jirovecii Mycobacterium tuberculosis Cryptococcus Histoplasmosis• Transplant Patients Fungi (Aspergillosis, Cryptococcus, Histoplasmosis) Nocardia CMV• Neutropenic Patients Fungi ( Aspergillosis) Gram-negatives
  26. 26. More Special Cases• Smokers: S. pneumo, H.influenzae, M. catarrhalis• Alcoholics: S. pneumo,Klebsiella, anaerobes• IV Drug User: S. aureus,Pneumocystis, anaerobes• Splenectomy: encapsulatedorganisms (S. pneumo, H.influenzae)• Cystic fibrosis: Pseudomonas,S. aureus• Deer mouse exposure:Hantavirus• Bat exposure: Histoplasmacapsulatum• Rat exposure: Yersinia pestis• Rabbit exposure: Francisellatularensis• Bird Exposure: C. psitacci,Cryptococcus neoformans• Bioterrorism: Bacillusanthracis, F. tularensis, Y.pestis
  27. 27. Pneumococcal Vaccine• What does it cover? Protects against 23 serotypes of Strep. Pneumoniae (90% of invasive pneumoniainfections)• Who should get it? Anyone over age 65 Anyone with chronic medical problem such as cancer, diabetes, heart disease, lungdisease, alcoholism, cirrhosis, sickle cell disease, kidney failure, HIV, damaged spleenor no spleen, CSF leaks Anyone receiving cancer therapy, radiation, steroids Alaskan natives and certain Native American populations• How often to get it? Give second dose if >5 years from first dose if > 65, cancer, damaged spleen, kidneydisease, HIV or any other condition lowering immune system function
  28. 28. Thank You