Pneumonia Undergrad.mansfans.com

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Pneumonias for undergradute

By Prof. Mohammad Khairy ElBadrawy Professor Of Chest Medicine April 2009 www.MansFans.com 2

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)Pneumonia )definition • Inflammation of the respiratory zone of the lung )consolidation) • The cause may be infectious or non infectious. • It may be acquired in the community or hospital. • It may occur in the immunocompetent or in the immunocompromized. 3

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Bacterial causes of pneumonia • • • • • • •

Streptococcus pneumoniae: the most common cause )35% of causes). Gram negative organisms Staph aureus. Atypical pneumonia. Anaerobic organisms )aspiration pneumonia). TB. Rare causes: Strept pyogenes, rickettsia, Yersinia pestis )plague).

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Viral causes of pneumonia: • Influenza. - Parainfluenza. • Measles. - Coxsackie virus. • Adenoviruses. Rhinoviruses. • Varicella. - EpsteinBarr virus. • Cytomegalovirus. - Herpes simplex. www.MansFans.com • Respiratory syncytial - Corona 5 pneumonia mk 2009 underg viruses.

:Fungal pneumonia – Pneumocystis carinii. – Aspergillus. – Coccidiomycosis. – Histoplasmosis. – Candidiasis. www.MansFans.com 6

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Non infectious causes of pneumonia • Chemical pneumonia: Air pollution with gases and fumes. • Physical pneumonia: – Radiation pneumonitis: following radiotherapy of the chest. – Burns.

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Predisposing factors 1. Decreased resistance: General/immune 2. Virulent organisms. 3. Defective Clearing mechanism:

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Cough/gag Reflex: Coma, paralysis, addiction

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Mucosal Injury: smoking, toxin, aspiration

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Pulmonary edema: Cardiac, ARDS.

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Obstructions: foreign body, tumors

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Bronchial dilatation: as bronchiectasis. pneumonia mk 2009 underg

Sources of infection Person to Person • S. pneumoniae, • M. tuberulosis, • Chlamydia • Group A strep • Influenza, • SARS CoV, • Varicella 9

Environment

•Psittacosis )pet birds) •Legionella )water) •Aspergillosis )air, water) •Histoplasmosis )bird droppings & bat caves) •Anthrax )soil) www.MansFans.com pneumonia mk 2009 underg

Oganism entery into the lungs • • • • •

Aspiration. Inhalation. Inoculation. Colonization. Hematogenous spread. • Direct spread. 10

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Normal Lung

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:Pathogenesis

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Grey Hepatization Resolution

Pathogenesis of Pneumonia

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Congestion Redpneumonia Hepatisation mk 2009 underg

:Pneumonia Types 1. Etiologic Types: • Infective – – – –

Bacterial Tuberculosis Viral Fungal

• Non Infective – Toxins – chemical – Aspiration

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3. Clinical Types: • Community acquired pneumonia: – Acquired in the community.

• Hospital acquired – In the hospital.

• Pneumonia in the ICH.

2. Morphologic types: • Lobar • Bronchopneumonia pneumonia mk 2009 underg • Interstitial

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Lobar Bronchopn Pneumoni eumonia a

Interstiti al

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Pathological description of pneumonia

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:Clinical types This classification is a useful guide for the empiric therapy of pneumonia • (1) Community acquired pneumonia (CAP). Pneumonia occurring in the community. Causative organisms: • In younger healthy patient: – Strept pneumoniae – Atypical organisms.

• In elder patients )> 60y), or unhealthy young patients – Gram negative bacilli – Staph aureus – atypical organisms.

• In aspiration pneumonia: 18

– Mixed organisms – Anaerobic bacteria.

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:Clinical types (2) Hospital acquired pneumonia (HAP): Pneumonia occurring after 48-72h of hospital admission. Causative organisms: – Early onset HAP (first 5 days): • Strept. Pneumoniae • Hemophilus influenzae. • Moraxella catarrhalis.

– Late onset HAP (>5 days): • Gram negative organisms )Klebsiella pneumonia, Pseudomonas aerogenosa).

www.MansFans.com – Aspiration pneumonia in HAP: 19

pneumonia mk 2009 underg • Mixed organisms • Anaerobes.

:Clinical types 3) Pneumonia in immunocompromised host: Any organism can cause pneumonia in this group of patients with atypical clinical and radiological pictures.

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Legionella pneumonia (L. Pneumonia): • Caused by inhalation of droplets of contaminated water by the aquatic organism L. pneumophila. • The source of infection include domestic hot and cold water systems, humidifires etc. • It is more common in summer, majority of cases are sporadic and community acquired. • Attack rate is higher in: – – – – –

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Elderly, Tobacco smokers, Chronic lung disease, Alcoholism diabetics, Immune-compromised patients. pneumonia mk 2009 underg

Diagnosis of Pneumonia • • • •

History Examination Lab tests Chest X-Ray Enough for Therapy ?

Diagnostic“ • Microbiolog ”y 22

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Symptoms of pneumonia

1. 2. – –

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Fever. Cough: at first it will be dry then it become productive of sputum. Sputum may be yellowish, brownish, rusty, green or mucopurulent sputum according to the causative organism(s). Sputum may be of offensive odor as in anaerobic pneumonia.

Dyspnea in: Severe cases (more than one lobe or bilateral pneumonia) Or if there is pleural effusion of empyema.

Chest pain: pleuritic pain due to inflammation of the parietal pleura. 23

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• • • • • • • •

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General signs of pneumonia

Tachypnea and tachycardia. Temp: 38.5 - 39.5oC. Myalgia with or without rigors. Flushed face. Cyanosis in severe cases. Herpes labialis )in Strept pneumonia). Respiratory distress with working alae nasi. In Mycoplasma pneumina: –

Bulbous myringitis )painful haemorrhagic blisters on the external auditory canal and ear drum).

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Generalized lymphadenopathy and splenomegaly. pneumonia mk 2009 underg

Local signs of pneumonia

Inspection: diminished respiratory movement and limited chest expansion of the affected side. Palpation: central trachea and increased TVF over the affected lobe. Percussion: impaired note or dullness over the affected lobe. Auscultation: – – –

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Bronchial breath sounds and increased vocal resonance over the affected lobe. Crepitations: The type of crepitations are at first fine late inspiratory crepitation in the stage of lung congestion, then become coarse inspiratory crepitations in the stage of gray hepatization and www.MansFans.com stage of resolution. pneumonia mk 2009 underg

:CP of Staph aureus pneumonia • High fever • Clinical picture of severe pneumonia • Purulent sputum • Hemoptysis. • C/P of multiple lung abscesses )pneumatoceles) • Pleural involvement )effusion, empyema, pleurisy, 26 pneumonia mk 2009 underg pyopneumothorax)

Clinical picture of atypical :pneumonia • It differs from that of classical pneumonia in the following points: – Non-respiratory symptoms are dominating, e.g. headache, confusion, loss of mental clarity, abdominal pain, diarrhoea. – The usual auscultatory findings of consolidation may be absent or difficult to detect making a chest xray is essential for diagnosis 27

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Clinical picture of viral :pneumonia It occurs mainly in ICH, characterized by: – Severe illness with prostration general malaise. – Minimal local chest signs. – CXR is essential for diagnosis. www.MansFans.com 28

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Laboratory investigations: • Leucocytosis or leucopenia. • Lymphocytosis. • Thrombocytopenia. • Hypoxemia hypocapnea and in late stages may be hypercapnea. • Hypokalemia • Elevated liver enzymes and /or bilirubin. 29 pneumonia mk 2009 underg

Microbiological diagmosis Less Commonly available Commonly available • Urine antigen detection • Sputum and pleural (legionella, fluid gram and pneumococcus) culture. • Serum ag detection (Aspergillus, • Sputum acid fast Histoplasma, stains Cryptococcus) • Blood Cultures (>1) • PCR for virus, chlamydia, • Nasal cultures for Mycobacterium virus • Serology for Psittacosis • Ag detection for viruses (RSV, Influenza) 30 pneumonia mk 2009 underg • Special stains for PCP

Radiological diagnosis

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Broncho Pneumonia

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www.MansFans.com pneumoniaLUNG mk 2009 underg ABSCESS

Air-fluid level

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Criteria for severe pneumonia: Minor criteria 1. Respiratory rate> 30 breaths/min 2. PaO2/FiO2 ratio< 250 3. Multilobar infiltrates 4. Confusion/disorientation 5. Uremia )BUN level 20 mg/dL) 6. Leukopenia: )WBC count <4000 cells/mm3) 7. Thrombocytopenia )platelet count <100,000 cells/mm3) 8. Hypothermia )core temperature <36C) 9. Hypotension requiring aggressive fluid resuscitation

Major criteria 1. Invasive mechanical ventilation www.MansFans.com 2. Septic shock with the need for vasopressors 41

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Atypical bacterial pneumonia • Mycoplasma, • Legionella, • Chlamydia

– Unusual presentation – Extrapulmonary features – CXR often normal early in infection – WCC normal – Diagnosis:

• serology,

– Treatmentmacrolides, newer 42 quinolones pneumonia mk 2009 underg

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Complications of Pneumonia

Local complications: • Pleural effusion and empyema. • Lung abscess. • Delayed resolution. • Incomplete resolution • Bronchiectasis later on specially in viral pneumonia )e.g., post measles). • ARDS • Resp failure in severe cases.

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Complications of Pneumonia 1. Bacteraemia and metastatic abscess, widely disseminated infection includes purulent pericarditis, meningitis, peritonitis, endocarditis, septic arthritis, brain abscess, septic shock and toxic capillaritis. 2. Shock and prerenal faluire. 3. Disseminated intravascular coagulopathy )DIC). 4. Multiorgan dysfunction syndrome. www.MansFans.com 45

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Causes of delayed resolution: 1. Inadequate treatment in type or dose of antibiotics. 2. Specific etiology e.g., Tuberculosis. 3. Underlying tumor, foreign body or bronchiectasis. 4. Local complications as empyema. 5. Immunosuppression. If pneumonia did not respond to treatment in the expected time. 46

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Recurrent pneumonia Definition: Two or more separate attacks of pneumonia with complete resolution for at least 1 month between the attacks during one year.

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Causes of recurrent pneumonia a- Recurrent at the same site: - Endobronchial tumor. - Endobronchial foreign body. - Bronchiectasis. b- Recurrent at different sites: - Bilateral bronchiectasis. - Cystic fibrosis. - Immunosuppression. 48

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Management Issues for CAP • Hospitalize or Not • Isolation – when appropriate • What antibiotics to use )IV or oral) • Supportive treatment as MV, O2 therapy, nutrition.. • When to Discharge www.MansFans.com

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Treatment of pneumonia Till the results of Gram stain and/ or cultures, the antibiotics are used on empirical base according to the international guidelines. The drug choice were adopted according to the following: – – – – – 50

Whether infection is severe or not. Presence of co morbid disease. Age of the patient. Previous intake of antimicrobials. Severe pneumonia always necessitates hospitalization and intensive care management. pneumonia mk 2009 underg

Treatment of pneumonia A- Community acquired pneumonia: Outpatient treatment: 1- Mild to moderate CAP in young patients without co-morbidity: IV benzylpencillin 1.2g/kg/6h and macrolide antibiotic as azithromycin, or clarithromycin. If inadequate response add one of the following: Fluroquinolone e.g., ciprofloxacin. 2nd generation cephalosporin. Amoxicillin-clavulanic acid. 51

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Treatment of pneumonia 2- Mild or moderate CAP in young patients with comorbidity or in elderly: Macrolid antibiotic with any of the following: Second generation cephalosporin or third generation cephalosporin or amoxicillin-clavulanic acid. www.MansFans.com 52

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Treatment of pneumonia Inpatient treatment of CAP: 1- Not severely ill: - I.V 2nd generation cephalosporin )cefuroxime) or I.V 3rd generation cephalosporin as cefotaxime or ceftriaxone and macrolide if there is suspected atypical organism. 53

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Treatment of pneumonia 2- Severe ill-hospitalized patient with CAP: Therapy must be intravenous and combined antibiotic therapy are used including a macrolid and one or two anti-pseudomonal agents e.g: - Aminoglycosides. - 3rd generation cephalosporin: ceftazidime. - Fluroquinolone )ciprofloxacin). - Antipseudomonas pencillin )Pipracillin). - β-lactame β-lactamase inhibitor combination clavulanate or pipracillin-tazobactam. 54

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Treatment of pneumonia

B- Hospital acquired pneumonia: 1- Non severe HAP: Fluoroquinolone )ofloxacin or ciprofloxacin) and one of the following: 2nd generation cephalosporin: cefuroxine or 3rd generation cephalosporin )ceftriaxone or cefotaxime). β-lactam β-lactamase inhibitor combination )ampicillin- sulbactam, or pipracillin tazobactam). 55

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2- Severe or late onset HAP: The I.V antibiotic therapy must cover pseudomonas aeuroginosa. Any line of the following may be used: Gentamycine )or ciprofloxacin) and antipseudomonal pencillin )pipracillin) or, Gentamycine )or ciprofloxacin) and antipseudomonal 3rd generation cephalosporin )ceftazidim) or, Gentamycine )or ciprofloxacin) and B-lactam carbapenen )impenem or meropenem) or, Gentamycine )or ciprofloxacin) and antipseudomonal pencillin B-lactamase inhibitor combination )pipracillin / tazobactam) or, Or combination of ciprofloxacin with aminoglycoside if there is pencillin allergy. Vancomycin is used if resistant staph aureus is suspected. 56 pneumonia mk 2009 underg

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The antibiotic used in treatment of pneumonia must be changed to that resulted in culture and sensitivity for samples taken from www.MansFans.com the patient on pneumonia mk 2009 underg

As the atypical organisms can not be detected by culture or gram stains the following drugs can be used: Macrolid group of antibiotics e.g. erythromycin, azithromycin, clarithromycin. Quinolone group )e.g. ciproflxacin).

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Treatment of Staph aureus pneumonia must include: antistaph antibiotics such as: • fusidic acid, • vancomycin, • fluoroquinolones such as ciprofloxacin, • antistaph penicillin such as flucloxacillin, oxacillin or nafcillin. 59

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Supportive treatment Fluid and electrolyte replacement. Corticosteroids and inotropic agents as dopamine and dobutamine in shocked patients. Total parenteral nutrition in severe pneumonias in whom mechanical ventilation is likely to be prolonged. Respiratory support: a- Oxygen inhalation. b- Mechanical ventilation if: - PaO2 < 60 mmHg. - Rising PaCO2 or PaCO2 > 50mmHg. - Respiratory acidosis. (3) Other problems www.MansFans.com - Pleuritic pain: simple analgesics. 60

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