Download 15. Pneumonia

Andriy Lepyavko, MD, PhD
Department of Internal Medicine № 2
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Definition
Classification
Diagnostic criteria
CAP – clinical signs, treatment
Nasocomial pneumonia
Aspiration pneumonia
Pneumonia in the immunocompromised host
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“The most wide spread and fatal of all acute
diseases, pneumonia, is now Captain of the
Men of Death”
Sir William Osler
The Principles and Practice of Medicine, 1901
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Sixth most common cause of death
The most common cause of infection-related
mortality
Incidence 170-280/10 000
Costs of treatment exceed $12 billion
Inpatient treatment costs 25 times more than
outpatient treatment
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Pneumonia – this is an inflammation in the
lung parenchyma caused by bacteria, viruses or
fungi which is characterized by intraalveolar
exudation
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Etiology (if it is known)
Variants:
Community-acquired pneumonia
Nosocomial pneumonia – when patient was
hospitalized with any another diagnosis, and
after 48 hours in the hospital (not earlier!)
pneumonia was diagnosed, or pneumonia after
artificial lung ventilation
Pneumonia due to aspiration. It results from the
aspiration of gastric contents in addition to
aspiration of upper respiratory flora in
secretions.
Pneumonia in immunocompromised host –
patients with AIDS or immunodeficit of other
origin. Causes of pneumonia – viruses, fungi of
saprofites (E.coli etc.)
III. Localization (side, lobe, segment)
IV. Stages of severity:
 Mild stage –conciousness is clear, t less than 38, heart
rate less than 90, BP normal, dyspnea mild in case of
physical activity, CXR – small infiltration
 Moderate – conciousness is clear, sweating, general
weakness, t 38-39, heart rate 90-100, moderate
dccreased BP, dyspnea, large size of infiltration
 Severe – t 39-40, conciousness is not clear, heart rate
more than 100, low BP, severe dyspnea, cyanosis, large
size of infiltration and presence of complications
V. Complications.
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I – patients in the age 2-65 without concomitant
diseases, are outpatients
II – patients <2 or >60, with concomitant
diseases, are outpatients, but near 25 % of them
treatment will not be effective, and they will
need hospitalization
II – patients <2 or >60, with concomitant
diseases, are inpatient
II – patients <2 or >60, with concomitant
diseases, have to be treated in the Emergency
department
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I – patients without risk factors, with mild or
moderate severity pneumonia which was
diagnosed at any day of hospitalization or
severe early pneumonia (at first 5 days of
hospitalization)
II – patients with risk factors + I
III – patients with risk factors and severe
pneumonia or late pneumonia
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Route of entry
- Inhalation
- Aspiration
- Bloodborne
Host/ organism dynamics tipped by
- Defect in host defences
- Virulent organism
- Overwhelming inoculum
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Nasal hair
Dynamics of airflow
Cough
Mucous
Mucociliary apparatus
Bacterial interference
Immunoglobulin
Surfactant
Fibronectin
Complement
Cytokines
Alveolar macrophages
Polymorphonuclear leucocytes
Cell-mediated immunity
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Predisposition – CHF, diabetes, alcoholism, COPD
Classic symptoms – cough, fever, sputum production,
dyspnea
Clinical syndrome – fever, pleuritic chest pain,
productive cough with mucopurulent sputum
Focal pulmonary findings (rales, crapitation or signs of
consolidation) – less sensitive than CXR
General blood analysis – increased ESR, leucocytosis,
shift to the left
Sputum analysis – causative microorganism and its
sencitivity to antibiotics may be found
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CXR with infiltrates – diagnosis
“pneumonia” is invalid without it
Most common pathogens:
 Streptococcus pneumoniae (9% to 75%; mean,
33%),
 Haemophilus influenzae (0 to 50%; mean, 10%),
 Legionella species (0 to 50%; mean, 7%),
 Chlamydia pneumoniae (0 to 20%; mean, 5%).
 Mycoplasma pneumoniae
Macrolide
Claritromycin (Clacid) 0,5 g 2-3 t/day,
Azitromycin (Sumamed) 0,5 g 1t/d
Roxitromycin (Rulid) 0, 15 g 2t/d
Midekamycin (Macropen) 0,4 g 3 t/d
 Amoxicillin + clavulonic acid
0, 625 g 2-3-4 t/d
“+” – there is i/v form as well
 Doxycyclin
0,1 g 2 t/d
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Cephalosporin
Cefuroxim 0,75-1,7 g i/m 3 times per day
Cefatoxini 1-2 g i/m, i/v 2 t/d
Ceftazidini 1 g i/m, i/v 2-3 t/d
Respiratory fluoroquinolone
Cyprofloxacini (Cyprobai) 0,2 g 2 t/d or 0,5 g 2 t/d
i/v
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I – Macrolide, doxacyclin (?)
II – Cefalosporine, Amoxiclav, Macrolide
III - Cefalosporine, Amoxiclav, Macrolide
IV - Cefalosporine, Amoxiclav, Macrolide,
Fluoroquinolone
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At least 5 days
Until afebrile for 48-72 hours
Stable vital signs
Longer course needed if
Initial antibiotic choice did not cover the
pathogen
Extrapulmonary infection (meningitis)
Lung abscess, cavitation or empyema
Gram negative pathogen or S.aureus
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Staphylococcus aureus
Gram-negative microorganisms Pseudomonas, Klebsiella, Proteus,
enterobacteria, E.coli
Fungi - Candida, Aspergillus, Rizopus.
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Clindamicini i/m, i/v every 6 hours, total - 1 g/day
Aztreonam (Azactam) – i/v, i/m every 8 hours, average – 3-6
g/day
Vancomycini – i/v every 8-12 hrs, average – 30 mg/kg/d, max
– 3 g/d
Rifampicini – orally 0,15 g 2 t/d, i/m 1,5-3 g every 8-12 hrs
Useful combinations:
 Clindamycini+Aztreonam
 Clindamycin+Vancomycin
 B-lactam+Vancomycin
 Floroquinolon+Rifampicin
Most effective are:
 Aminoglycozyde (tobramycin, sizomycin)+
Metronidazol
 Cephalosporini III-IV generation+Metronidazol
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Cephalosporine III-IV generation
Aminoglycozyde (tobramycin, sizomycin)
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Annual Influenza immunization
Thanks for your
attention!