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Transcript
Pneumonia
Disease Definition


Pathological
Clinical





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infiltrate(s) on CXR is need
CAP
HAP
VAP
HCAP
Typical and Atypical
Pathogenesis


HOST DEFENSES
Routes of Infection
Gross aspiration
 Microaspiration
 Aerosolization
 Hematogenous spread from a distant infected site
 Direct spread from a contiguous infected site

PATHOLOGY

Lobar Pneumonia

Bronchopneumonia

Interstitial Pneumonia

Miliary Pneumonia
Risk Factors


Impaired Host defense
Anatomical defects


such as obstructed bronchus, bronchiectasis, or
sequestration
Alcoholism , asthma , immunosuppression , age
of >70 , dementia, seizures, CHF, CVD,
alcoholism, COPD , chronic illness, smoking,
and passive smoking
Epidemiology

Extremes of age

During the winter months

Rates of pneumonia are higher for men than for
women and for black than for white persons
ETIOLOGY

Common respiratory pathogens
S. pneumoniae, H. influenzae, S.aureus, Moraxella
catarrhalis
 C. pneumoniae, M. pneumoniae Legionella spp.
 Influenza viruses, adenoviruses, and respiratory
syncytial virus

S. pneumoniae

meta-analysis of CAP 1966 – 1995

S. pneumoniae

66% of 7000 cases

66% of fatalities
Fine JAMA 1996:275;134
Atypical Pathogens

M. pneumoniae, C. pneumoniae and
Legionella sp. ranked 2nd 3rd and 4th
of over 2700 hospitalized CAP patients
with a definite etiologic diagnosis.

Marston et al Arch Intern Med 157:1709,1997
CLINICAL MANIFESTATIONS

Symptoms

Signs

Examination

Auscultatory findings
Severity

CURB

CURB 65

PORT
Mortality

P. aeruginosa >50%

Klebsiella spp., E. coli, S. aureus, and
Acinetobacter spp. 30 to 35%

Serotype 3 pneumococcus is associated with a
much higher mortality rate than serotype 1

M serotypes 1 and 3 of group A Streptococcus
Mortality


The in-hospital mortality rate from pneumonia
is ~8%.
The most common causes:
respiratory failure
 heart disease
 Infections


Half of deaths are related to pneumonia, and
the other half are due to comorbid illnesses.
DIAGNOSIS








CXR
CT scan
Sputum smear
Sputum culture
Serology
Ag study
PCR
Blood Culture
Outpatient or Inpatient

CURB-65 criteria:(confusion, uremia, respiratory
rate, low blood pressure,age 65 years or greater)

For patients with CURB-65 scores 2,
hospitalization is usually warranted.
ICU admission decision



2 major criteria (need for mechanical ventilation and
septic shock),
Minor criteria (respiratory rate, 130 breaths/min;
arterial oxygen pressure/fraction of inspired oxygen
(PaO2/FiO2) ratio <250; multilobar infiltrates;
confusion; blood urea nitrogen Level>20 mg/dL;
leukopenia resulting from infection;
thrombocytopenia;hypothermia; or hypotension
requiring aggressive fluid resuscitation.
The presence of at least 3 of these criteria suggests the
need for ICU care
CXR resolve

Age
Co morbidity
Lung disease
Pathogen

4-8 weeks



Resistant pneumococci

To Penicillin

To Macrolides
To Tetracyclines
To FQ


MIC<0.06
0.12<MIC<1
MIC >2 mg/mL
Duration
Patients with CAP should be treated for



a minimum of 5 days
should be afebrile for 48–72 h
should have no more than 1 CAP-associated sign of clinical
instability before discontinuation of therapy
A longer duration of therapy may be needed if initial
therapy was not active against the identified pathogen
or if it was complicated by extrapulmonary infection,
such as meningitis or endocarditis.
PO Therapy & Discharge
Switched from intravenous to oral therapy when




they are hemodynamically stable
Improving clinically
are able to ingest medications
have a normally functioning gastrointestinal tract.
Patients should be discharged as soon as



they are clinically stable
have no other active medical problems
have a safe environment for continued care
Inpatient observation while receiving oral therapy is not
necessary.
Complications

Pleural effusion

Empyema

Lung abscess

Recurrent pneumonia

No response
Aspiration Pneumonia


The usual causes of aspiration pneumonia in the
elderly are Enterobacteriaceae, S. aureus, S.
pneumoniae, and H. influenzae.
In the setting of aspiration of oropharyngeal
contents and poor dental hygiene, anaerobic
bacteria may be present, and lung abscess is not
an uncommon complication. Particulate matter
may be aspirated, with consequent mechanical
obstruction of the airway.
NOSOCOMIAL
PNEUMONIA
Acquired by a patient in the following
settings:
 in
a hospital or long-term-care facility after
being admitted for >48 hours or
 <7 days after a patient is discharged from
hospital ( patient’s initial hospitalization should
be 3 days duration )
Risk Factors
 Host
factors ( e.g. extremes of age, severe
underlying disease )
 Colonization by gram-negative
microorganisms
 Aspiration or reflux
 Prolonged mechanical ventilation
 Factors that impede adequate pulmonary
toilet
Nosocomial Bacterial
Pneumonia - Etiology
Gram-negative enteric bacilli (predominant)
 Gram-positive cocci, including:
Staphylococcus aureus ( e.g., MRSA ),

Streptococcus pneumoniae


Anaerobes
Others
Prevention

Inactivated influenza vaccine

Pneumococcal polysaccharide vaccine

Respiratory hygiene measures, including the use
of hand hygiene and masks or tissues for patients
with cough, should be used in outpatient settings
and EDs as a means to reduce the spread of
respiratory infections.