Pneumonia

Pneumonia
ts an infection of lung parenchyma
Classification
1.Community acquired
2. Hospital acquired
3. Ventilator associated
Revised classification
Community acquired
Health care associated
Host factors
mpaired host defense
Hypogammaglobulinemia
Defects in phagocytosis or ciliary function
Neutropenia
Asplenia
Reduction in CD4 counts
Anatomical defects
Obstructed bronchus
Bronchiectasis
Sequestration of pulmonary segment
How does microorganisms reach lower respiratory tract???
1.Aspiration from oropharynx
- elderly during sleep
- decreased consciousness
2. nhalation of contaminated droplets
3. hematogenous spread
4.Contiguous spread from adjacent pleura
CIinicaI syndrome of pneumonia
Contributed more by host response
ncrease in L 1 and TNF d fever
L 8 and GM CSF ^ peripheral leucocytosis and purulent
secretions
nflammatory mediators - cause alveolar capillary leak
Hemoptysis
Radiological infiltrate
Rales on auscultation
Hypoxemia
TYPES OF PNEUMONA
1. Lobar pneumonia
2. Bronchopneumonia
3. nterstitial pneumonia
4. Miliary pneumonia
Pathological stages
1.Stage of congestion ( edema)
2.Stage of red hepatization
3.Stage of grey hepatization
4.Stage of resolution
COMMUNITY ACQUIRED PNEUMONIA
ETOLOGY
Etiological agents can be classified
as bacterial, fungi, viruses and
protozoa
Newly identified pathogens
Hantavirus
Metapneumoviruses
SARS
Methicillin resistant sthylococcus
aureas
Microbial causes of community acquired
pneumonia, by site of care
OUTPATENTS
HOSPTALZED PATENTS HOSPTALZED PATENTS
NON NON CU CU CU
- Strep. Pneumoniae
- Mycobacterial
pneumoniae
- H. influenzae
- C. pneumoniae
- Respiratory viruses
- - Strep. Strep.
pneumoniae pneumoniae - - - -
Mycobacterial Mycobacterial
pneumoniae pneumoniae
- - Chlamydophila Chlamydophila
pneumoniae pneumoniae
- - H. influenza H. influenza
- - Legionella Legionella
species species
- - Respiratory Respiratory
viruses viruses
- Strep. Strep.
Pneumoniae Pneumoniae
- - Stap Stap. . Aureas Aureas
- - Legionella Legionella
spp. spp.
- - Gram Gram ve ve
bacilli bacilli
- - H. influenza H. influenza
Typical pneumonia
Streptococcus pneumoniae
Hemophilus pneumoniae
Staphylococcus pneumoniae
Gram ve bacilli
Anaerobes
They are often complicated by abscess formation, significant
empyema or parapneumonic effusion
Risk factors for community acquired pneumonia
Alcoholism, asthma, immunosuppression, institutionalization, age
>70yrs
Risk factors for pneumococcal pneumonia
Dementia, seizure disorders, heart failure, CVA, alcohol, smoking,
COPD, and HV infection
Enterobacteriaceae
h/o recent hospitalization or antibiotic usage, alcoholics, heart
failure, and renal failure
Risk factors for pseudomonas
infection
Structural lung disease
Risk factors for legionella
DM, hematological malignancy, cancer,
renal failure, HV, and smoking
Clinical manifestations
Fever with chills and sweats
Cough is either nonproductive or productive of
mucoid, purulent or blood tinged sputum
Shortness of breath
Pleuritic chest pain
G symptoms like nausea, vomoiting, and/or
diarrhea
Fatigue, myalgia, headache and arthralgia
Physical examination
^ respiratory rate
Tactile fremitus
Dull note
Bronchial breathing
^ vocal fremitus and vocal resonance
Whispering pectoriluqy
Bronchophony
Aegophony
Elderly
confusion
Chest x-ray
t serves as a baseline
t identifies cavitation or multilobar involvement
t may suggests an etiological diagnosis
Pneumatoceles in staph. aureas
Upper lobe cavitation in tuberculosis
CT chest
For patients with suspected post obstructive pneumonia caused
by a tumor or foreign body
Wedge shaped consolidation
CXR showing right lower lobe pneumonia
CT of the chest demonstrating right sided
pneumonia
Pneumatocele
nvestigation
Grams stain
Spuutum AFB
Culture sensitivity
sputum
Blood
PCR
mmunodiagnosis
Treatment
Appropriate Antibiotics
Oxygen Support
Bronchodilator
Humidity With Mist Tent
Percussion & Postural Drainage
Hydration/Fever Control/Nutritional support
CURB 65 criteria
C- confusion
U- urea >7mmol/L
Respiratory rate <30/mins
Blood pressure systolic >90 mmHg
diastolic > 60 mmHg
Age <65
EmpiricaI antibiotic treatment of CAP
Outpatients
Previously healthy and no antibiotic in past 3 months
A macrolide (clarithromycin 500mg bd or azithromycin 500mg
od) or
Doxycycline 100mg bd
Comorbidities or antibiotics in past 3 months
A respiratory fluroquinolone (levofloxacin 750mg od,
moxifloxacin 400mg od or gemifloxacin 320mg od) or
A -lactum (high dose amoxacillin 1gm tds or amox/clavulanate
2gm bd, ceftriaxone 1-2 gm iv od, cefpodoxime 200mg bd) pIus
a macrolide
npatients (non-icu)
A respiratory fluroquinolone or
A -lactum (cefotaxime 1-2gm iv tds,
ceftriaxone 1-2gm iv bd, ampicillin 1-2gm iv
qid, ertapenam 1gm iv od) pIus a macrolide
ntensive care unit no risk factors for P.
aeruginosa
- azithromycin 1 g V pIus
- ceftriaxone 1 g 12
th
hrly or
- cefotaxime 2 g V 6
th
hrly or
- quinolones
ntensive care unit risk factors for P. aeruginosa
- imipenam (or meropenam) 500mg 6
th
hrly or
- piperacillin/tazobactum 3.375 g 6
th
hrly pIus
- ciprofloxacin 750 mg 8
th
hrly
Aspiration pneumonia
- metronidazole 500 mg 12
th
hrly or
- piperacillin/tazobactum 3.375 g 6
th
hrly or
- imipenam 500 mg 6
th
hrly pIus
- respiratory quinolones
Concomitant meningitis
- vancomycin 1 g V 12
th
hrly pIus
- ceftriaxone 2 g V 12
th
hrly
Switching from intravenous to oral
antibiotic therapy
When WBC is returning towards
normal
There are two normal temperature
readings (<37.5C) 16 hrs apart
There is improvement in cough and
shortness of breath
Duration of antibiotic therapy for most
patients with CAP is 10 to 14 days
Discharge from the hospital
- once physiological stability is achieved
COMPLCATONS
PULMONARY
Necrotizing pneumonia
Lung abscess
Vascular invasion with infarction
Cavitation
Bronchopleural fistula
Pleural effusion
Empyema
Recurrent pneumonia
Respiratory and circulatory failure
Metastatic infection
Recurrent pneumonia
Same site anatomical obstruction
Different site
COPD and repeated micro-aspiration
Evaluation for immunodeficiency states
PREVENTON
Cessation of smoking
nfluenza and pneumococcal vaccination
if, appropriate
EMPYEMA
Empyema is a collection of pus in the space
between the lung and the inner surface of
the chest wall (pleural space).
Causes, incidence, and risk factors
Empyema is usually caused by an infection
that spreads from the lung. t leads to a
buildup of pus in the pleural space.
There can be a pint or more of infected fluid.
This fluid puts pressure on the lungs.
Risk factors include:
Bacterial pneumonia
Chest surgery
Lung abscess
Trauma or injury to the chest
n rare cases, empyema can occur after a
needle is inserted through the chest wall to
draw off fluid in the pleural space for
medical diagnosis or treatment
(thoracentesis).
$ymptoms
Chest pain, which worsens when you breathe
in deeply (pleurisy)
Dry cough
Excessive sweating especially night sweats
Fever and chills
General discomfort, uneasiness, or ill feeling
(malaise)
Shortness of breath
Weight loss (unintentional)
The health care provider may note
decreased breath sounds or an abnormal
sound (friction rub) when listening to the
chest with a stethoscope (auscultation).
Tests may include the following:
Chest x-ray
CT scan of chest
Pleural fluid Gram stain and culture
Thoracentesis
The goal of treatment is to cure the infection and remove
the collection of pus from the space between the lung
and the inner surface of the chest wall. Antibiotics are
prescribed to control the infection.
The health care provider will place a chest tube to
completely drain the pus. A surgeon may need to
perform a procedure to peel away the lining of the lung
(decortication) if the lung does not expand properly.

Radiological Features
Common site is Right
Lung
Posterior segment of
upper lobe
Superior segment of
lower lobe
n sitting posture
basilar segments of
lower lobe
n lying
posture
CT Picture
Cavity with
air fluid level

Management
Antibiotics & Physical Drainage
Antibiotics
nitially high dose Pencillins
Clindamycin 600 mg Q 6hrly for initial 4 days followed by oral
300 mg Q 6
th
hourly for 2-3 weeks
Other drugs
Amox + Clavulanic Acid
Piperacillin + Clavulanic acid
Amox + Metronidazole
No role for Metronidazole as single agent

Management
Postural Drainage
Surgery
Mortality in recent times 5 10 %