Pneumonia Vhara

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PneumoniaPneumoniaVihara Dewi MahendraVihara Dewi Mahendra


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What is pneumonia?What is pneumonia? Pneumonia is an inflammatory illness ofPneumonia is an inflammatory illness of

the lung. Frequently, it is described asthe lung. Frequently, it is described aslung parenchyma/alveolar (microscopiclung parenchyma/alveolar (microscopicairair--filled sacs of the lung responsible forfilled sacs of the lung responsible forabsorbing oxygen from theabsorbing oxygen from the

atmosphere) inflammation andatmosphere) inflammation and(abnormal) alveolar filling with fluid.(abnormal) alveolar filling with fluid.


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PneumoniaPneumonia The major cause of death in the worldThe major cause of death in the world

The 6The 6

thth

most common cause of death inmost common cause of death inthe U.S.the U.S.

Annually in U.S.: 2Annually in U.S.: 2--3 million cases, ~103 million cases, ~10million physician visits, 500,000million physician visits, 500,000

hospitalizations, 45,000 deaths, withhospitalizations, 45,000 deaths, withaverage mortality ~14% inpatient andaverage mortality ~14% inpatient and


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Types of PneumoniaTypes of Pneumonia CommunityCommunity--Acquired (CAP)Acquired (CAP) HealthHealth--Care Associated Pneumonia (HCAP)Care Associated Pneumonia (HCAP)

Hospitalization for > 2 days in the last 90 daysHospitalization for > 2 days in the last 90 days

Residence in nursing home or longResidence in nursing home or long--term care facilityterm care facility Home Infusion TherapyHome Infusion Therapy LongLong--term dialysis within 30 daysterm dialysis within 30 days Home Wound CareHome Wound Care Exposure to family members infected with MDR bacteriaExposure to family members infected with MDR bacteria

HospitalHospital--Acquired Pneumonia (HAP)Acquired Pneumonia (HAP)

Pneumonia that develops after 5 days of hospitalizationPneumonia that develops after 5 days of hospitalization Includes:Includes:

VentilatorVentilator--Associated Pneumonia (VAP)Associated Pneumonia (VAP) Aspiration PneumoniaAspiration Pneumonia


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Community AcquiredCommunity Acquired

PneumoniaPneumonia Infection of the lung parenchyma in aInfection of the lung parenchyma in a

person who isperson who is not hospitalized ornot hospitalized or

living in a longliving in a long--term care facilityterm care facilityfor 2 weeksfor 2 weeks

5.6 million cases annually in the U.S.5.6 million cases annually in the U.S.

Estimated total annual cost of healthEstimated total annual cost of healthcare = $8.4 billioncare = $8.4 billion

Most common pathogen =Most common pathogen = S. pneumoS. pneumo(60(60--70% of CAP cases)70% of CAP cases)


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Nosocomial PneumoniaNosocomial Pneumonia HospitalHospital--acquired pneumonia (HAP)acquired pneumonia (HAP)

Occurs 48 hours or more after admission,Occurs 48 hours or more after admission,which was not incubating at the time ofwhich was not incubating at the time ofadmissionadmission

VentilatorVentilator--associated pneumonia (VAP)associated pneumonia (VAP)

Arises more than 48Arises more than 48--72 hours after72 hours afterendotracheal intubationendotracheal intubation


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Nosocomial PneumoniaNosocomial Pneumonia HealthcareHealthcare--associated pneumonia (HCAP)associated pneumonia (HCAP)

Patients who were hospitalized in an acute carePatients who were hospitalized in an acute care

hospital for two or more days within 90 days ofhospital for two or more days within 90 days ofthe infection; resided in a nursing home or LTCthe infection; resided in a nursing home or LTCfacility; received recent IV abx, chemotherapy, orfacility; received recent IV abx, chemotherapy, orwound care within the past 30 days of the currentwound care within the past 30 days of the currentinfection; or attended a hospital or hemodialysisinfection; or attended a hospital or hemodialysisclinicclinic

Guidelines for the Management of Adults withGuidelines for the Management of Adults withHAP, VAP, and HCAP. American ThoracicHAP, VAP, and HCAP. American ThoracicSociety, 2005Society, 2005


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Etiology of Pediatric PneumoniaEtiology of Pediatric Pneumonia

Birth to 3 WeeksBirth to 3 Weeks

Organisms Clinical Features

Group B streptococci Part of early-onset sepsis picture.Usually very severe

Gram-negative enterics Often nosocomial, therefore oftennot until after 1 week of age.

Cytomegalovirus (CMV) Part of systemic CMV infection.

Listeria monocytogenes Part of early-onset sepsis picture.

Herpes simplex virus (HSV) Part of systemic HSV infection.


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3 Weeks to 3 Months3 Weeks to 3 Months

Chlamydia trachomatis From maternal genital infection. Afebrile,subacute interstitial pneumonia

Respiratory syncytial virus (RSV) Peak incidence at 2-7 months of age; usuallywheezing illness (bronchiolitis/pneumonia)

Parainfluenza virus (PIV) type 3 Very similar to RSV, but slightly older infantsand not epidemic in the winter.

Streptococcus pneumoniae Probably the most common cause of bacterial

pneumonia, even in this young age group.

Bordetella pertussis Causes primarily bronchitis, but secondarybacterial pneumonia

Staphylococcus aureus Less common now unless nursery epidemic.


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5 to 15 Years5 to 15 Years

Organisms Clinical Features

Mycoplasma pneumoniae The major cause of pneumonia in this agegroup.

Chlamydia pneumoniae Still controversial, but probably an important cause in older children in this age group.

Streptococcus pneumoniae Most likely cause of lobar pneumonia, but

probably etiologic in other forms as well.

Mycobacterium tuberculosis Particularly in areas of high prevalence; mayexacerbate at onset of puberty and withpregnancy.


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AgeAge--Specific PathogensSpecific PathogensCommunity acquired pneumoniaCommunity acquired pneumonia

Age Pathogen

irth to days roup StreptococciListeria monocytogenes

ram negative enteric acteria

ks to mths Streptococcus pneumoniae

espiratory syncytial virus ( S )

Chlamydia trachomatis

mths to years SStreptococcus pneumoniae

ycoplasma pneumoniaeaemophilus influenzae

to years ycoplasma pneumoniaeStreptococcus pneumoniaeChylamydia pneumoniae

NEngl J ed 6: 9- 7


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PneumoniaPneumonia

The alveoli are tiny air sacs within theThe alveoli are tiny air sacs within thelungs where the exchange of oxygenlungs where the exchange of oxygenand carbon dioxide takes place.and carbon dioxide takes place.


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BronchioleBronchiole

Bronchiole: A tiny tube in the air conduitBronchiole: A tiny tube in the air conduitsystem within the lungs that is asystem within the lungs that is acontinuation of the bronchi and connectscontinuation of the bronchi and connectsto the alveoli (the air sacs) where oxygento the alveoli (the air sacs) where oxygenexchange occurs. Bronchiole is theexchange occurs. Bronchiole is thediminutive of bronchus, from the worddiminutive of bronchus, from the word

bronchos by which the Greeks referred tobronchos by which the Greeks referred tothe conduits to the lungs.the conduits to the lungs.


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Morphological classification

- Bronchopneumonia

- Lobar pneumonia


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Complications of lobar pneumonia

1. Abscess formation2. Empyema

3. Failure of resolution intra-alveolar scarring

('carnification')

permanent loss of ventilatoryfunction of affected parts of lung.

4. Bacteraemia:

- Infective endocarditis- Cerebral abscess / meningitis

- Septic arthritis


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Red hepatization

Firm, 'meaty' and airless appearance of lung.

Alveolar capillary dilatation.

Strands of fibrin extending from one alveolusto

another via inter-alveolar pores of Kohn.

Also neutrophils in alveoli. Pleura: Fibrinous exudate.


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Grey hepatization

Less hyperaemia.

Macrophages, neutrophils + fibrin


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Resolution- Lysis and removal of fibrin via sputum +

lymphatics.

- Begins after 8-9 days (without antibiotics).

- Sudden improvement of patient's condition.


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Klebsiella pneumoniae

Common inhabitant of oral cavity (poor

oral hygiene).

Lobar pneumonia in the elderly, diabetics,

alcoholics (aspiration of saliva).


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Community acquired vs. nosocomial infection

Nosocomial infection:

- Often patients in ICU

- Local resistance to infection in lungs

- Intubation of respiratory tract

- Altered normal flora due to antibiotics

- E.coli, Klebsiella, Proteus, Pseudomonas,

Staph. aureus.


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Immune status

Infection by usually non-pathogenic

organisms('opportunistic infection')

- Pneumocystis carinii

- Other fungi- Cytomegalovirus (CMV)


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Defense MechanismsDefense Mechanisms 80% of cells lining central airways are80% of cells lining central airways are

ciliated, pseudostratified,ciliated, pseudostratified,

columnar epithelial cellscolumnar epithelial cells Each ciliated cell containsEach ciliated cell contains

about 200 cilia that beat inabout 200 cilia that beat in

coordinated waves aboutcoordinated waves about

1000x/minute1000x/minute So the lower respiratory tractSo the lower respiratory tract

is normally sterileis normally sterile


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Pneumonia PathophysiologyPneumonia Pathophysiology Microbial pathogens enter the lung by:Microbial pathogens enter the lung by: AspirationAspiration of organisms fromof organisms from oropharynxoropharynx

More common in patients with impaired level of consciousness:More common in patients with impaired level of consciousness:alcoholics, IVDA, seizures, stroke, anesthesia, swallowing disorders, NGalcoholics, IVDA, seizures, stroke, anesthesia, swallowing disorders, NGtubes, ETTtubes, ETT

Gram positive and anaerobes: StrepGram positive and anaerobes: Strep pneumopneumo, H flu,, H flu, MycoplasmaMycoplasma,,

MoraxellaMoraxella,, ActinomycesActinomyces Gram negatives:Gram negatives:

more likely with hospitalization, debility, alcoholism, DM, and advanced agemore likely with hospitalization, debility, alcoholism, DM, and advanced age Source may be stomach which can become colonized with these organismsSource may be stomach which can become colonized with these organisms

with use of H2blockerswith use of H2blockers

InhalationInhalation of Infectious Aerosolsof Infectious Aerosols Influenza,Influenza, LegionellaLegionella, Psittacosis,, Psittacosis, HistoplasmosisHistoplasmosis, TB, TB

HematogenousHematogenous DisseminationDissemination StaphStaph aureusaureus FusobacteriumFusobacterium infections of the retropharyngeal tissues:infections of the retropharyngeal tissues: LemierresLemierres

syndromesyndrome

Direct inoculation and Contiguous SpreadDirect inoculation and Contiguous Spread Tracheal intubation, stab woundsTracheal intubation, stab wounds


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Hostfactors

Medications

Respiratory therapyequipment

Surgery Invassivedevices

Gastriccolonization

Aspiration

Numbers of bacteriavirulence

BacteremiaLung Defenses

Mechanicalcellular/humoral

Pneumonia

Oropharyngealcolonization

Translocation

?


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PathogenesisPathogenesis Inhalation, aspiration andInhalation, aspiration and

hematogenous spread are the 3 mainhematogenous spread are the 3 main

mechanisms by which bacteria reachesmechanisms by which bacteria reachesthe lungsthe lungs

Primary inhalationPrimary inhalation: when organisms: when organismsbypass normal respiratory defensebypass normal respiratory defensemechanisms or when the Pt inhalesmechanisms or when the Pt inhalesaerobic GN organisms that colonize theaerobic GN organisms that colonize theupper respiratory tract or respiratoryupper respiratory tract or respiratorysupport equipmentsupport equipment


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PathogenesisPathogenesisAspirationAspiration: occurs when the Pt: occurs when the Pt

aspirates colonized upper respiratoryaspirates colonized upper respiratory

tract secretionstract secretions Stomach: reservoir ofGNR that canStomach: reservoir ofGNR that can

ascend, colonizing the respiratory tract.ascend, colonizing the respiratory tract.

HematogenousHematogenous: originate from a: originate from adistant source and reach the lungs viadistant source and reach the lungs viathe blood stream.the blood stream.


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At the left the alveoli are filled with a neutrophilic exudate thatcorresponds to the areas of consolidation seen grossly with thebronchopneumonia. This contrasts with the aerated lung on the rightof this photomicrograph.


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PneumoniaPneumonia-- SymptomsSymptoms Cough (productive orCough (productive or

nonnon--productive)productive)

DyspneaDyspnea Pleuritic chest painPleuritic chest pain

Fever or hypothermiaFever or hypothermia

MyalgiasMyalgias

Chills/SweatsChills/Sweats

FatigueFatigue

HeadacheHeadache Diarrhea (Diarrhea (LegionellaLegionella))

URI, sinusitisURI, sinusitis((MycoplasmaMycoplasma))


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Pneumonia SymptomsPneumonia Symptoms Typical pneumonia: sudden onset ofTypical pneumonia: sudden onset of

fever, cough productive of purulentfever, cough productive of purulent

sputum, pleuritic chest painsputum, pleuritic chest pain Atypical: gradual onset, dry cough,Atypical: gradual onset, dry cough,

prominence of extrapulmonaryprominence of extrapulmonarysymptoms: headache, myalgias,symptoms: headache, myalgias,fatigue, sore throat, nausea, vomitingfatigue, sore throat, nausea, vomiting

Includes diverse entities and has limitedIncludes diverse entities and has limitedclinical valueclinical value


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Pneumonia in Children: DxPneumonia in Children: Dx SymptomsSymptoms

Infants: nonInfants: non--specific manifestationsspecific manifestations Fever, poor feeding, irritability, vomiting, diarrhea, URIFever, poor feeding, irritability, vomiting, diarrhea, URI

Sx, cough, respiratory distressSx, cough, respiratory distress

Older children: more specificOlder children: more specific Fever, cough, chest pain, tachypnea, tachycardia,Fever, cough, chest pain, tachypnea, tachycardia,

grunting, nasal flaring, retracting. Cyanosis usually verygrunting, nasal flaring, retracting. Cyanosis usually verylate.late.

Signs/Physical examSigns/Physical exam RR > 60 for all agesRR > 60 for all ages

HypoxiaHypoxia

Rales, wheezes, crackles, coarse breath soundsRales, wheezes, crackles, coarse breath sounds


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Findings on ExamFindings on Exam Physical:Physical:

Vitals: Fever or hypothermiaVitals: Fever or hypothermia

Lung Exam: Crackles, rhonchi, dullness toLung Exam: Crackles, rhonchi, dullness topercussion or egophany.percussion or egophany.

Labs:Labs: Elevated WBCElevated WBC

HyponatremiaHyponatremia LegionellaLegionella pneumoniapneumonia

Positive ColdPositive Cold--AgglutininAgglutinin MycoplasmaMycoplasmapneumoniapneumonia


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Chest XChest X--rayray

RUL

RML

RLL

LUL

Lingula

LLL

RUL

RML

RLL

LUL

Lingula

LLL


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Chest XChest X--rayray PneumoniaPneumonia


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Chest XChest X--rayray -- PneumoniaPneumonia


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Chest XChest X--rayray ---- PneumoniaPneumonia


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Diagnosis of pathogenDiagnosis of pathogen Sputum CultureSputum Culture

< 10 Squamous Epithelial Cells< 10 Squamous Epithelial Cells

> 25 PMNs> 25 PMNs

Blood CulturesBlood Cultures

Strep. pneumoStrep. pneumo urinary antigenurinary antigen

LegionellaLegionella urinary antigenurinary antigen HIV test?HIV test?


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Special Clues on Chest XSpecial Clues on Chest X--rayray Lobar pneumoniaLobar pneumonia Strep. PneumoniaStrep. Pneumonia

Diffuse interstitial infiltratesDiffuse interstitial infiltrates PneumocystisPneumocystis

RUL infiltrateRUL infiltrate TuberculosisTuberculosis

Diffuse interstitial infiltratesDiffuse interstitial infiltrates

Tuberculosis in HIVTuberculosis in HIV


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Infiltrate PatternsInfiltrate PatternsPatternPattern Possible DiagnosisPossible Diagnosis

LobarLobar S. pneumo, Kleb, H. flu,S. pneumo, Kleb, H. flu,

GNGNPatchyPatchy Atypicals, viral,Atypicals, viral,

LegionellaLegionella

InterstitialInterstitial Viral, PCP, LegionellaViral, PCP, Legionella

CavitaryCavitary Anaerobes, Kleb, TB, S.Anaerobes, Kleb, TB, S.

aureus, fungiaureus, fungi

Large effusionLarge effusion Staph, anaerobes, KlebStaph, anaerobes, Kleb


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Inpatient or Outpatient Treatment of CAPInpatient or Outpatient Treatment of CAP

Patients safety at homePatients safety at home

PORT scorePORT score

Clinical JudgementClinical Judgement


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PORT ScorePORT Score


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PORT ScorePORT Score


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CAPCAP Patient StratificationPatient Stratification

Am J Respir Crit Care Med 163:1730-54, 2001


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CAPCAP TestingTesting CXRCXR

Sputum Gram Stain and cultureSputum Gram Stain and culture

Pulse oximetryPulse oximetry

Routine lab testingRoutine lab testing CBC, BMP, LFTsCBC, BMP, LFTs

ABGABG

Thoracentesis if pleural effusion presentThoracentesis if pleural effusion present



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CAPCAP Modifying FactorsModifying Factors



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CAPCAP Modifying FactorsModifying Factors


MODIFYING FACTORS THAT INCREASE THE RISK OF

INFECTIO

N WITH

SPECIFIC PATHO

GENSPenicillin-resistant and drug-resistant pneumococciAge > 65 yrB-Lactam therapy within the past 3 moAlcoholismImmune-suppressive illness (including therapy w/ corticosteroids)Multiple medical comorbidities

Exposure to a child in a day care centerEnteric gram-negativesResidence in a nursing homeUnderlying cardiopulmonary diseaseMultiple medical comorbiditiesRecent antibiotic therapy

Pseudomonas aeruginosa

Structural lung disease (bronchiectasis)Corticosteroid therapy (10 mg of prednisone per day)Broad-spectrum antibiotic therapy for > 7 d in the past monthMalnutrition


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CAPCAP AlgorithmsAlgorithms



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Duration of TherapyDuration of Therapy ? ? ? ? ? ?? ? ? ? ? ?

55 --7 days7 days -- outpatientsoutpatients

77--10 days10 days inpatients,inpatients, S. pneumoniaeS. pneumoniae

1010--14 days14 days Mycoplasma, Chlamydia,Mycoplasma, Chlamydia,LegionellaLegionella

14+ days14+ days -- chronic steroid userschronic steroid users



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CAPCAP --The Switch to OralThe Switch to Oral

AntibioticsAntibiotics Switch if patient meets the following:Switch if patient meets the following:

Inproved cough and dyspneaInproved cough and dyspnea

Afebrile on 2 occasions 8 hours apartAfebrile on 2 occasions 8 hours apart If otherwise improving way waive this criteriaIf otherwise improving way waive this criteria

Decreasing WBC countDecreasing WBC count

FunctionalG

I tract with adequate PO intakeFunctionalG

I tract with adequate PO intake



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CAPCAP -- PreventionPrevention Influenza VaccineInfluenza Vaccine

Pneumococcal VaccinePneumococcal Vaccine


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HAPHAP StratificationStratification



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HAPHAP Failure of TherapyFailure of Therapy Incorrect diagnosisIncorrect diagnosis it is not pneumoniait is not pneumonia

Atelectasis, CHF, PE with infarction, lungAtelectasis, CHF, PE with infarction, lung

contusion, chemical pneumonitis, ARDS,contusion, chemical pneumonitis, ARDS,pulmonary hemorrhagepulmonary hemorrhage

Pathogen resistancePathogen resistance

Host factors that increase mortalityHost factors that increase mortality

Age > 60, prior pneumonia, chronic lung diseaseAge > 60, prior pneumonia, chronic lung disease immunosuppressionimmunosuppression

Antibiotic resistanceAntibiotic resistanceAm J Respir Crit Care Med 153:1711-25, 1995


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HAPHAP -- PreventionPrevention Hand washingHand washing

VaccinationVaccination

InfluenzaInfluenza PneumococcusPneumococcus

Isolation of patients with resistant respiratoryIsolation of patients with resistant respiratorytract infectionstract infections

Enteral nutritionEnteral nutrition Choice ofGI prophylaxisChoice ofGI prophylaxis

Subglottoc secretion removal?Subglottoc secretion removal?Am J Respir Crit Care Med 153:1711-25, 1995


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RESUME THERAPYRESUME THERAPY


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Treatment of CAPTreatment of CAP Outpatient:Outpatient:

Macrolide (Macrolide (AzithromycinAzithromycin))

Fluoroquinolone (Fluoroquinolone (Levaquin,Levaquin,MoxifloxacinMoxifloxacin))

DoxycyclineDoxycycline

Inpatient:Inpatient: BetaBeta--Lactam + MacrolideLactam + Macrolide

CeftriaxoneCeftriaxone ++ AzithromycinAzithromycin

Fluoroquinolone (Fluoroquinolone (Levaquin,Levaquin,MoxifloxacinMoxifloxacin)) For sus icion of hi hl resistantFor sus icion of hi hl resistant Stre .Stre .


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Treatment of HCAP, HAP, VAPTreatment of HCAP, HAP, VAP Antipseudomonal cephalosporin (Antipseudomonal cephalosporin (Cefepime,Cefepime,

CeftazidimeCeftazidime) +) +VancomycinVancomycin

AntiAnti--pseudomonal Carbapenem (pseudomonal Carbapenem (Imipenem,Imipenem,MeropenemMeropenem) +) +VancomycinVancomycin

BetaBeta--Lactamase/BetaLactamase/Beta--Lactamase Inhibitor (PipLactamase Inhibitor (Pip--TazoTazo ZosynZosyn) + Pseudomonal Fluoroquinolone () + Pseudomonal Fluoroquinolone (CiproCipro) +) +VancomycinVancomycin

Aminoglycoside (Aminoglycoside (Gentamycin, AmikacinGentamycin, Amikacin) +) +VancomycinVancomycin


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Special Cases!Special Cases! HIVHIV

Pneumocystis jiroveciiPneumocystis jirovecii Mycobacterium tuberculosisMycobacterium tuberculosis CryptococcusCryptococcus HistoplasmosisHistoplasmosis

Transplant PatientsTransplant Patients Fungi (Aspergillosis, Cryptococcus, Histoplasmosis)Fungi (Aspergillosis, Cryptococcus, Histoplasmosis) NocardiaNocardia CMVCMV

Neutropenic PatientsNeutropenic Patients Fungi ( Aspergillosis)Fungi ( Aspergillosis) GramGram--negativesnegatives


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More Special CasesMore Special Cases Smokers:Smokers: S. pneumo, H.S. pneumo, H.

influenzae, M. catarrhalisinfluenzae, M. catarrhalis Alcoholics:Alcoholics: S. pneumo,S. pneumo,

KlebsiellaKlebsiella, anaerobes, anaerobes

IV Drug User:IV Drug User: S. aureus,S. aureus,PneumocystisPneumocystis, anaerobes, anaerobes

Splenectomy: encapsulatedSplenectomy: encapsulatedorganisms (organisms (S. pneumo, H.S. pneumo, H.influenzaeinfluenzae))

Cystic fibrosis:Cystic fibrosis:

Pseudomonas, S. aureusPseudomonas, S. aureus

Deer mouse exposure:Deer mouse exposure:HantavirusHantavirus

Bat exposure:Bat exposure: HistoplasmaHistoplasmacapsulatumcapsulatum

Rat exposure:Rat exposure: Yersinia pestisYersinia pestis Rabbit exposure:Rabbit exposure: FrancisellaFrancisella

tularensistularensis Bird Exposure:Bird Exposure: C. psitacci,C. psitacci,

Cryptococcus neoformansCryptococcus neoformans Bioterrorism:Bioterrorism: BacillusBacillus

anthracis, F. tularensis, Y.anthracis, F. tularensis, Y.pestispestis

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