Download Pneumonia Decisions

PNEUMONIA
Dr.M.Shahparianpour
Mr. P
• 92 yo male w/ h/o fall 3 days prior to admission,
came to ER with c/o mental status changes (per
NH staff), and 1 day h/o vomiting and dyspnea.
• Pmhx of alzheimers, emphysema, glaucoma.
• Meds included 5 different eye drops and
donepezil. No drug allergies.
• Shx: nursing home resident, no recent etoh or
tobacco. Daughter involved.
• Pneumovax 2001, flu vaccine 2002.
• PE: T 97.9, rr 22, bp 109/65, p 77, 70% RA oxygen
saturation.
• Confused, non-rebreather in place. Heent wnl.
Lungs: coarse crackles bilaterally. CV: reg, s1s2, no
mrg. Abd: wnl. Ext: +2 ankle edema. Neuro: nonfocal, not oriented, following some commands.
• Labs remarkable for wbc 12.6 w/ 90% n, chem 7
wnl, po2 on ABG of 38 mm Hg (ph 7.44)
• CXR w/ ? small RLL infiltrate, but portable film,
final read by radiology negative.
Does this patient have
pneumonia?
In other words, how do you
define pneumonia?
Why is diagnosing pneumonia important?
And if he has pneumonia, what kind, and how do you
investigate possible causes further?
How do you triage the patient?
How do you treat him?
When do you send him home?
Could it have been prevented?
• Pneumonia is defined as inflammation and
consolidation of the lung tissue due to an
infectious agent.
•
•
Pneumonia that develops outside the hospital setting
is considered community-acquired pneumonia
Pneumonia developing48 hours or more after
admission to the hospital is termed nosocomial or
hospital-acquired pneumonia.
• Community-acquired pneumonia is caused most
commonly by bacteria that traditionally have been
divided into 2 groups, typical and atypical.
• Typical organisms include S pneumoniae
(pneumococcus) and Haemophilus and
Staphylococcus species.
• Atypical refers to pneumonia caused by Legionella,
Mycoplasma, and Chlamydia species.
Definition
(perof IDSA)
Acute infection
the pulmonary
parenchyma accompanied by:
• Acute infiltrate on CXR or auscultatory findings
consistent with pneumonia
• And usually two of the following: fever or hypothermia,
rigors, sweats, new cough with or without sputum (or
change in color), chest discomfort, dyspnea.
• In the elderly, more common to be
afebrile/hypothermic, and altered mental status
sometimes is the ONLY complaint.
Pneumonia
• Community
• Nosocomial
• Eldery house
• Immunocompromised host
• Community-acquired pneumonia
remains a common illness.
• pneumonia is reported to be 170 cases
per 100,000 persons.
• Estimates of incidence of nosocomial
pneumonia range from 4-7 episodes per
1000 hospitalizations.
• Approximately 25% of patients in
intensive care units (ICUs) develop
pneumonia.
• 20% result in hospitalization
• With advancing age, the incidence
increases 3 folds in patients( aged 44
years to 65 years)
• Pneumonia as a cause of
hospitalization increased from 36 to
48 cases per 100,000 persons between
1984 and 1995.
• Pneumonia is the sixth leading cause of death
• the most common infectious causes of
death.
• The mortality rate is reported to be 1% in the
outpatient setting but may increase to up to
25% in those requiring hospital admission.
• In a patient with preexisting respiratory
disease, onset of bacterial pneumonia may
result in deterioration of respiratory status,
leading to respiratory failure and death.
• Nosocomial pneumonia is the leading
cause of death among hospital-acquired
infections.
• Recent studies have shown that
nosocomial pneumonia causes excessive
risk of death, and the mortality rates
range from 20-50%.
• Although less common in the antibiotic
era, bacterial pneumonia may lead to
bronchiectasis.
• However, lower respiratory infection
with pneumococci, staphylococci, and
Klebsiella species may result in
bronchiectasis, especially if treatment is
delayed.
• Incidence is greater in males than in
females.
• Advanced age increases the incidence
of pneumonia and the mortality from
pneumonia.
• Elderly persons have
• weaker immune responses,
• higher risk of aspiration,
• comorbidities.
• Resistant bacteria are becoming an
increasing problem, which affects
treatment.
• We have an increasing population with
immunosuppression or chronic diseases
(which impacts cause and mortality)
Pathogenesis of typical
pneumonia
• S pneumoniae generally resides in the
nasopharynx and is carried asymptomatically
in approximately 50% of healthy individuals.
• Invasive disease may occur upon acquisition
of a new epithelium serotype.
• A strong association exists with viral
illnesses, such as influenza.
• Viral infections increase pneumococcal
attachment to the receptors on activated
respiratory epithelium.
• Once aspirated from the nasopharynx to the
alveolus, pneumococci infect type II
alveolar cells.
• The pneumonic lesion progresses as
pneumococci multiply in the alveolus and
invade alveolar epithelium.
• Pneumococci spread from alveolus to alveolus
through the pores of Kohn, thereby
producing inflammation and consolidation
along lobar compartments.
Pathogenesis of atypical
infection
• After inhalation, the atypical organisms
attach to the respiratory epithelial cells
by a variety of mechanisms.
• The presence of pili on the surface of
Legionella species facilitates
attachment.
• Once adhered, the organisms cause
injury to the epithelial cells and their
associated cilia.
• Many of the pathogenetic mechanisms
may be immune-mediated rather than
due to direct injury by the bacteria.
• A host defense is mounted via cellmediated and humoral immunity.
• Infection caused by atypical organisms
often spreads beyond the lobar
boundaries and frequently is
bilateral.
Pathogenesis of nosocomial
pneumonia
• Aspiration plays a central role in the pathogenesis of
nosocomial pneumonia
.
• Approximately 45% of healthy subjects aspirate
during sleep, and an even higher proportion of
severely ill patients aspirate routinely.
• Depending on the number and virulence of the
pathogenic organisms reaching the lower respiratory
tract and on the host defense factors, pneumonia
may develop.
• The oropharynx of hospitalized patients may
become colonized with aerobic gramnegative bacteria within a few days of
admission.
• Therefore, nosocomial pneumonia is caused
predominantly by the gram-negative
bacilli.
• However, the incidence of Staphylococcus
aureus lower respiratory tract infection is
increasingly common in the hospitalized and
institutionalized patient and must now be
considered a possible pathogen for
nosocomial pneumonia.
Pneumonia
Decisions
• PORT
• Microbiology
• Empiric Therapy
Pneumonia
Routes of
Transmission
• Inhalation
• Aspiration
• Blood-borne
Community Acquired Pneumonia
etiology
S.pneumoniae
H.influenzae
Other
Anaerobes
L.pneumophilia
M.pneumoniae
C.pneumoniae
Community - Acquired
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Bacteria
Streptococcus pneumoniae
Hemophilus influenzae
Staphylococcus aureus
“Atypical”
Mycoplasma pneumoniae
Chlamydia pneumoniae
Virus
Influenzae
Adenovirus
% Cases
50-70
10-15
5
10-30
10-20
Epidemic
Community Pneumonia
Microbiology
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Unusual / Don’Miss
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Very Unusual
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PCP
Tb
Moraxella
Legionella
Hantavirus
Fungi (cocchisto)
Anthrax, SARS
Different categories of
pneumonia and common
pathogens
• Patients w/ minimal co-morbidities (cause
identified only 50% of the time):
• S. pneumoniae (most common overall)
• M. pneumoniae/C. pneumoniae
• Viruses
• Chronic pulmonary/cardiovascular disease:
•
•
•
•
Drug resistant S. pneumoniae
H. influenza
M. catarrhalis
Legionella
• Nosocomial (hospitalized or nursing home
patients):
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•
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•
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Resistant GNR’s
Pseudomonas aeruginosa
S. aureus (MRSA)
Aspergillosis
Anaerobes (aspiration)
• In alcoholics:
• Klebsiella pneumoniae, anaerobes, TB
• IVDU:
• S. aureus, PCP, anaerobes
• Post-splenectomy:
• S. pneumoniae, H. influenza
• HIV/AIDs:
• PCP, S. pneumonia, TB, fungal
• Leukemic patients/bone marrow transplant:
• Aspergillosis, legionella, CMV, other fungal.
• Post influenza:
• S. pneumoniae, S. aureus
• Cystic fibrosis:
• Pseudomonas aeruginosa, S. aureus
• In patients who have received solid
organ transplants, pneumonia from S
pneumoniae may occur more than 3
months after the transplant.
• Other organisms include Legionella
species, Pneumocystis carinii, and
cytomegalovirus.
• Sickle cell disease may indicate S
pneumoniae or H influenzae infection.
• Diabetic ketoacidosis may lead to S
pneumoniae or S aureus infection
• Animal exposure:
• C. psittaci, Cryptococcus neoformans,
Histoplasmosis capsulatum (birds)
• Tularemia (rabbit), plague (rat), hantavirus (deer
mouse), H. capsulatum (bat).
• Q fever (C. burnetii) – farm animals
• Travel:
• SARS (Asia), coccidiomycoses, (SW USA), Legionella
(endemic/epidemic areas).
This sputum smear shows staphylococcus bacteria using
Gram stain technique in a patient with staphylococcal pneumonia.
A photomicrograph of Streptococcus spp. bacteria
using Gram stain technique.
Scanning electron micrograph of S.
pneumoniae
Photomicrograph of Streptococcus pneumoniae bacteria
revealing capsular swelling using the Neufeld-Quellung test.
Pneumocystis carinii, now called P. jiroveci,
is present in this lung impression smear, using Giemsa stain.
A photomicrograph of Pseudomonas aeruginosa bacteria.
Photomicrograph of Haemophilus influenzae
as seen using a Gram stain technique.
MYCOPLASMA
History
•
Clinical presentation in patients with pneumonia varies from a
mildly ill ambulatory patient to a critically ill patient with
respiratory failure or septic shock.
• The character of sputum produced may suggest a
particular pathogen.
• Patients with pneumococcal pneumonia may produce bloody or rustcolored sputum.
• Infections with Pseudomonas, Haemophilus, and pneumococcal
species are known to expectorate green sputum.
• Anaerobic infections characteristically produce foul-smelling and badtasting sputum.
• Currant-jelly sputum suggests pneumonia from Klebsiella or
pneumococcal species.
• Patients may report rigors or shaking chills.
• Patients may complain of other nonspecific
symptoms, which include headaches, malaise,
nausea, vomiting, and diarrhea.
• These symptoms may suggest infection with
Legionella, Chlamydia, or Mycoplasma
species.
• Malaise, myalgias, and exertional dyspnea may
be observed.
• Pleuritic chest pain or abdominal pain
secondary to pleuritis is a common feature of
pneumococcal infection, but these may occur
in other bacterial pneumonias.
Physical examination
• Physical examination findings vary
depending on the type of organisms,
severity of pneumonia, coexisting host
factors, and presence of complications.
• The common findings of consolidation are as follows:
•
•
•
•
•
•
•
•
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•
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Fever or hypothermia (temperature >38.5°C or <36°C)
Tachypnea (respiratory rate >18 breaths per min)
Tachycardia or bradycardia
Central cyanosis
Dullness to percussion over pneumonic consolidation
Decreased intensity of breath sounds
Rales or crackles
Egophony upon auscultation
Whispering pectoriloquy
Pleural friction rub
Altered mental status
• Physical examination findings that
may indicate the etiology of
pneumonia are as follows:
• Periodontal disease with foul-smelling sputum - Anaerobes,
possible mixed aerobic-anaerobic infection
• Bullous myringitis - Mycoplasma pneumoniae
• Absent gag reflex, altered level of consciousness, recent seizure
- Polymicrobial (aerobic and anaerobic), possible
macroaspiration or microaspiration
• Encephalitis - M pneumoniae, C burnetii, L pneumophila
• Cerebellar ataxia, erythema multiforme, erythema nodosum Chlamydia pneumoniae, M tuberculosis
• Erythema gangrenosum - Pseudomonas aeruginosa, Serratia
marcescens
• Cutaneous nodules (abscesses and CNS findings) - Nocardia
species
Lab Studies
• Leukocytosis with a left shift, although
commonly observed in any bacterial
infection, may be absent in patients who
are elderly or debilitated.
• Leukopenia (defined as a WBC count of
<5000) is an ominous sign of impending
sepsis and portends a poor outcome.
• Sputum examination provides an accurate
diagnosis in approximately 50% of
patients.
• An adequate specimen must have less than 10 squamous epithelial
cells and more than 25 WBCs per low-power field.
• However, the number of WBCs in the sputum of a neutropenic patient
may be fewer than 25 WBCs per low-power field, despite origination
from the lower respiratory tree.
• A single pathogen present on the Gram stain is indicative of
pneumonia;
• mixed flora may indicate oral contamination or anaerobic infections.
• An adequate specimen uncontaminated by oral flora is required for a
proper workup.
• Sputum cultures are submitted only from specimens that are deemed
satisfactory after Gram stain.
• Other tests may include the following:
• Urinary antigen testing for Legionella serogroup 1 has a high yield.
• A urinary antigen test for pneumococcus is available and may be performed
at the bedside.
• A Legionella serum antibody titer rising by 1:128 confirms the diagnosis
retrospectively. Mycoplasma and Chlamydia immunoglobulin M antibodies
contribute to the diagnosis.
• Serology is essential in the diagnosis of unusual causes of pneumonia such
as Q fever and brucellosis.
• Culture and Gram stain of pleural effusions or empyema fluid has a high
yield.
• Pleural fluid pH determination should be made to classify the effusion as
simple versus complicated.
• The Legionella-specific direct fluorescent antibody
test is performed when indicated, even though this
technique is associated with a high rate of falsenegative results
• Performing blood cultures is important, but the
results have a limited value.
• When positive, the results confirm a causative
agent.
• Blood cultures are positive only in approximately 40%
of cases,
Imaging Studies
Chest radiograph findings
may indicate the following:
• In a patient with a clinical picture of pneumonia,
pathogenic organisms may be suggested based on
the chest radiographic pattern.
• The common patterns are described as follows:
• Focal opacity (segment or lobar pneumonia) - S pneumoniae,
M pneumoniae, L pneumophila, S aureus, C pneumoniae, M
tuberculosis, B dermatitidis
• Interstitial pattern (diffuse process identified as
reticulonodular or reticular process) - M pneumoniae, P carinii,
C psittaci
• Interstitial pattern with hilar and/or mediastinal
lymphadenopathy - Epstein-Barr virus, Francisella tularensis,
C psittaci, M pneumoniae, fungi
• Cavitation or necrotizing pneumonia - Mixed aerobicanaerobic infection (lung abscess), aerobic gram-negative
bacilli, M tuberculosis, L pneumophila, C neoformans,
Nocardia asteroides, Actinomyces israelii, C immitis
• Bulging oblique or horizontal fissure - K pneumoniae,
L pneumophila
• Multifocal bilateral segment or lobar opacities - S
aureus, C burnetii, L pneumophila, S pneumoniae
• Miliary (diffuse micronodular) pattern - M
tuberculosis, H capsulatum, C immitis, B dermatitidis,
varicella zoster
• Pneumatoceles (thin-walled cavities) - S aureus,
Streptococcus pyogenes, P carinii
• "Round" pneumonia (often presents as solitary
pulmonary nodule) - C burnetii, S pneumoniae, L
pneumophila, S aureus
• Bronchoscopy: Bronchial washing specimens
can be obtained.
• Protected brush and bronchoalveolar
lavage can be performed for quantitative
cultures.
• Transtracheal aspiration for culture:
• This procedure is mentioned primarily for
historical significance. This method of
obtaining lower respiratory secretions has
been replaced by fiberoptic bronchoscopy.
• Thoracentesis: This is an essential procedure
in patients with a parapneumonic pleural
effusion.
Triage (home, admit, step
down, ICU)
• Decision based on patient’s clinical condition,
risk of death and complications, presence of
other medical problems, social support.
• Age more than 65 yo alone is not an indication
for admission.
• All patients with
new hypoxemia (sat <90% or Po2 <60mm Hg),
hemodynamic instability** should be
hospitalized.
Pneumonia Severity Index
(PSI)
• Based on data available at presentation
(age, coexisting illnesses, findings on PE,
lab and radiographic findings).
• Stratifies patients into five risk classes.
• 30 day mortality estimated for each risk
class (.1%-27%).
• Patients in risk class I-III at low risk of
death – most can be safely treated as
outpatient.
Risk class IV and V should
definitely be hospitalized (for
both consider step-down bed,
or ICU for class V).
Diagnosis of CAP
Can CAP be reliably differentiated from
other respiratory conditions by clinical
features alone?
NO
The diagnosis of CAP on the basis of
history and physical findings is
inaccurate without a chest
radiograph.
Nosocomial Pneumonia
Major Factors:
• Alteration oropharyngeal flora
• Aspiration
• Contaminated aerosol nebulizers
• Attendant’s hands
• Injudicious use antibiotics
Pneumonia Microbiology
• Organisms
•
•
•
•
•
•
Acquired %
Strep pneumonia
Staph aureus
Pseudomonas aerug
Klebsiella
Enterobacter
• Hemophilus
• Anaerobes
• Atypical
hospital
5
15
31
12
15
community
50
5
2
1
1
1
2
2
10
5
30
Pneumonia
Physiologic Impairment
• Hypoxemia (low V/Q)
• shunt
• Hyperventilation (low
PCO2, high pH)
• Restriction
Elderly Patients with
CAP
• Classic symptoms and signs of
pneumonia less likely
• Non-specific symptoms especially
confusion, more likely
• Comorbid illness more common
• Higher mortality rate
• Fever less likely
• Aspiration is a risk factor
Algorithm
Patient with community-acquired pneumonia
Is the patient > 50 years of age
Yes
No
Does the patient have a history of any of the
following comorbid conditions ?
Neoplastic disease
Congestive heart failure
Cerebrovascualr disease
Renal disease
Liver disease
Yes
No
Does the patient have a history of any of the
following abnormalities on physical examination
Altered mental status
Pulse ≥ 125 / minute
Respiratory rate ≥ 30 / minute
Systolic blood pressure < 90 mmHg
Temp < 35° C or ≥ 40° C
No
Assign patient to risk class I
Yes
Assign patient to
risk class II-V
based on
prediction mosel
scoring system
Prediction model for C A P
Patient
Points
characteristics assigned
Demographic factors
Age: males
age (in yrs)
females age (in yrs) -10
Nursing home resident
+10
Comorbid illnesses
Neoplastic disease
+30
Liver disease
+ 20
Congestive heart failure +10
Cerebrovascular disease
+10
Renal disease
+10
Physical examination findings
Altered mental status
+20
Respiratory rate ≥ 30/mi
+20
Systolic blood pressure
< 90 mmHg
+20
Temp. < 35° C or ≥ 40° C
+15
Pulse >125 / min
+10
Laboratory findings
pH < 7.35
BUN > 10.7 mmol/L
Sodium < 130 mEq/L
Glucose > 13.9 mmol/L
Hematocrit < 30%
PO < 60 mmHg2
Pleural effusion
+30
+20
+20
+10
+10
+10
+10
Stratification of Risk
Score
Risk
Risk class
I
Low
II
Moderate
lll
IV
High
V
Based on
Algorithm
< 70 total points
71-90 total points
91-130 total points
> 130 total points
Flow Chart Approach to Treating
Outpatients and Inpatients with C.A.P.
Patient with suspected pneumonia
Chest radiograph
Decision to hospitalize
Managed as
outpatient
Hospitalized patient
Expectorated sputum
No sputum
Sputum for stain (optional)
Empirical antibiotic
treatemnt
Gram stain
or other rapid
test identifies
likely pathogen
Antibiotic treatment
selected for
pathogen
No rapid
diagnostic
test positive
Empirical
treatment
Subsequent data (blood
culture, sputum
culture, etc.) yields
likely pathogen
Empirical
treatment
Risk-Class Mortality
Rates for Patients with
Pneumonia
Risk
class
No. of points
Mortality
(%)
Recommendations
for site of care
I
No predictors
0.1
Outpatient
II
< 70
0.6
Outpatient
III
(briefly)
71- 90
2.8
Inpatient
IV
91 - 130
8.2
Inpatient
V
> 130
29.2
Inpatient
CORE ADVERSE PROGNOSTIC
FEATURES (CURB SCORE)
 Confusion : Abbreviated Mental Test score of 8 or
less
 Urea : raised >7mmol/l (for patients being seen in
hospital)
 Respiratory rate: raised ≥30/min
 Blood pressure: low (systolic <90 mmHg and/or
diastolic ≤60 mmHg)
These features (except Urea) should be assessed
for ALL patients.
The Abbreviated Mental Test
Each question scores 1 mark, total 10marks
• Age
• Date of birth
• Time (to nearest
hour)
• Year
• Hospital name
• Recognition of two
persons
• Recall address
• Date of major event
• Name of monarch
(president)
• Count backwards 20
→1
“Pre-existing” Adverse
Prognostic Features
• Age 50 years and over
• Presence of coexisting disease
Congestive cardiac failure
Coronary artery disease
Stroke
Diabetes mellitus
Chronic lung disease
Cancer
“Additional” Adverse
Prognostic Feature
If available to some GPs who have
oximeters.
• Hypoxaemia (Sao2 <92% or Pao2 <8kPa)
Consider “core” adverse prognostic features
None present
Consider “pre-existing”
adverse
prognostic features
NO
Home management*
1 feature present
YES
2 or more features
present
Consider “additional “
adverse prognostic
feature if available
Clinical judgement
Refer to hospital
Associated Mortality
by Age and Treatment
Age
Mortality
18-64 yr
10% - 15%
65-74 yr
20%
75-84 yr
30%
> 85 yr
40%
Untreated
50% - 90%
Patient Preference:
Inpatient vs. Outpatient
Therapy
80%
80%
74%
60%
40%
20%
0%
9%
Patients Favoring
Outpatient Therapy
Patients willing to
pay
24% of Monthly
Income to Ensure
Outpatient Therapy
Patients Favoring
Inpatient Therapy
Antibiotic Decision
Making
• Severity of disease
• Microbiology environment
• Patient
• Host status
• Individual considerations
• Practice Guidelines
Antibiotic Use
• Empiric oral vs.. parenteral
• Loading dose
• Dosing
• Speed of delivery
• Switch to oral from IV
• Duration of therapy
Bacteriology of HospitalAcquired Pneumonia
Early-Onset
Pneumonia
Late-Onset
Pneumonia
Other
S pneumoniae
P aeruginosa
Anaerobic bacteria
H influenzae
Enterobacter sp
Legionella pneumophilia
Moraxella cattarrhalis Acinetobacter SP Influenza A and B
S aureus
K pneumoniae
Aerobic gram-negative bacilli
Respiratory syncitial virus
S marcenscens
Fungi
E coli
Other gram-negative bacilli
S aureus
PREVENTION
Vaccination strategies
Influenza vaccine
Pneumococcal vaccine
Pneumococcal vaccine
• Pneumococcal vaccine: contains purified
capsular polysaccharide from the 23
serotypes that cause 85-90% of the
invasive pneumococcal infections in adults
and children in the United States.
• Cost-effective among individuals over the
age of 65 for prevention of bacteremia.
• Benefit has been shown in some studies
for patients with diabetes, CHF, chronic
pulmonary disease, asplenia.
• Effectiveness has not been proven in
immunosuppressed, but still
recommended.
• Antibody response declines over 5-10
years.
• Revaccination after 5 years given to
patients who received initial
vaccination when less that 65 yo age,
asplenic patients, and
immunocompromised.
Influenza vaccine
• Influenza vaccine: modified annually
to reflect the anticipated strains in
the upcoming season.
• The vaccine virus is grown in eggs,
purified, and inactivated (does not
contain live virus).
• Efficacy can range from 70-90%.
Shown to reduce all-cause mortality
during influenza season by 27-54%.
• Groups that benefit: age>65, residents
of nursing homes, patients with
chronic lung or cardiovascular disease,
people frequently hospitalized,
pregnant women in 2nd/3rd trimester,
health care providers, HIV patients,
travelers to foreign countries during
influenza epidemics.
• Need vaccination yearly (Sept – Feb).
• New, live attenuated virus vaccine only
for children and healthy adults <age
50.
.
The end
INFLUENZA VACCINE
• Primary influenza pneumonia is
rare and carries a high mortality
rate
• Secondary bacterial pneumonia
is more common notably due to
S aureus
• Bronchitis is also a common
complication
• The greatest mortality is in
those patients with underlying
disease
INFLUENZA VACCINE
Evidence on Efficacy
 Based on several large well
designed case-control field
studes from North America
 Other studies from UK and
Netherlands
INFLUENZA VACCINE
Results of Studies:Reduces hospital deaths from
pneumonia and influenza by
about 65% and from all
respiratory causes by 45%
Decreases hospital admissions
and outpatient visits
PNEUMOCOCCAL VACCINE
Recommendations in U.K.
Asplenia
Severe spleen dysfunction
Chronic renal disease
Chronic heart disease
Chronic lung disease
Chronic liver disease
Diabetes mellitus
Immunosuppression/Immunodefi
ciency
PNEUMOCOCCAL VACCINE
EFFICACY STUDIES
• Protection offered of around
66% against definitive
pneumococcal pneumonia with
bacteraemia for “normal” or “low
risk” adults .
• NO evidence that vaccine is
effective in “high risk” groups
and in those aged 60 to 70
years.
NOSOCOMIAL
PNEUMONIA
Disease Definition
new cough
auscultatory findings
new infiltrate or progressive infiltrate(s)
on
chest radiograph, accompanied by:
fever or hypothermia, leukocytosis,
sputum
production
Etiology: polymicrobial
Disease Definition - cont’d
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
Problems in Diagnosis of NP
Clinical criteria lack specificity
No “gold standards” for diagnostic
procedures (e.g. invasive procedures)
High potential for more than one ongoing
infectious process
Use of antimicrobials in ICU empirically or
use for infections of other sites or organs.