PNEUMONIAPNEUMONIA
Definition: Infection of Lung ParenchymaDefinition: Infection of Lung Parenchyma 1/6 of All Deaths in USA 1/6 of All Deaths in USA
Most Common Infectious Cause of DeathMost Common Infectious Cause of Death
Pneumonia Defense Mechanisms
Defense Mechanism Things that Impair the Defense Mechanism
Cough Reflex AnesthesiaNeuromuscular DisorderComa
Mucociliary Apparatus Cigarette SmokeCorrosive Gases
Phagocytic Action of Alveolar Macrophages
AlcoholTobacco
Secretion Clearance Cystic Fibrosis
Innate, Humoral, Cell-Mediated Immunity
Classification of Pneumonia
Community-Acquired, AcuteS. pneumoniaeH. influnzaeM. catarrhalisStaph aureusEnterobacteriacea
Community-Acquired, AtypicalMycoplasmaChlamydiaLegionellaCoxiella burnettiViruses
NosocomialEnterobacteriacea
PseudomonasS. Aureus (MRSA)
AspirationAnaerobic oral floraAerobic bacteria
ChronicNocardiaActinomycesGranulomatous
Necrotizing and Abscess AnaerobicStaph aureusKlebsiellaStrep pyogenes
Immunocompromised HostCMVPCPMACAspergillosisCandidiasis
CAP - ACUTECAP - ACUTE
Clinical Presentation: High Fever, Shaking ChillsHigh Fever, Shaking Chills Cough Productive of Mucopurulent SputumCough Productive of Mucopurulent Sputum Pleuritic Chest Pain, Pleural Friction RubPleuritic Chest Pain, Pleural Friction Rub
Clinical Course: Marked Improvement
in Symptoms after 48-72
Hours of Antibiotics <10% Mortality
Pathogenesis of Acute CAP
Invasion of Lung Parenchyma
Inflammatory Exudate Fills Alveoli
Consolidation
Normal Alveoli
Pneumonia
Morphology of Acute CAP
Bronchopneumonia Patchy Consolidation
Lobar Pneumonia Fibrinosuppurative
Consolidation of Entire Lobe or Large Portion of Lobe
Pathogens of Acute CAP
S. pneumoniae H. influnzae M. catarrhalis Staph aureus Enterobacteriacea <10 epi’s/lpf
Streptococcus Pneumoniae
= Pneumococcus Most Common Cause of CAP Colored Sputum False Positive Sputum Cultures
Normal Flora of Nasopharynx Blood Cultures More Specific
30% Mortality if Bacteremic Treatment:
Fluoroquinolones, Amoxil, PCN, Macrolides Some Resistant Strains
Immunization
Up to 50%Up to 50%
Staphylococcus Aureus
Follows Influenza or ABX Colored Sputum Treatment:
1st Generation Cephalosporin or PCN Vanco (if MRSA suspected)
High Incidence of Complications Lung Abscess Empyema Glomerulonephritis Pericarditis
Enteric Gram-Negatives
Most Frequent Cause of GN Pneumonia Debilitated and Malnourished
Chronic Alcoholics ECF
Sputum Treatment:
Fluoroquinolones Pip+Tazo
Klebsiella, E. Coli, Proteus
Haemophilus Influenzae
Gram-Negative Coccobacilli Encapsulated Form > Unencapsulated Form
Infections from Unencapsulated Forms Elderly, COPD Bronchopneumonia Treatment:
Ampicillin, Augmentin, Doxycycline,
3rd Generation Cephalosporins, Fluoroquinolones, TMP/SMX
Immunization for b Serotype
Moraxella Catarrhalis
Gram Negative Cocci COPD, DM, CA Treatment:
Doxycycline Macrolide Cephalosporin Augmentin
CAP - ATYPICALCAP - ATYPICAL
Clinical Presentation: Symptoms out of Proportion to PE Findings
Less Sputum No Consolidation
Moderate WBCs Clinical Course:
Sporadic Form < 1% Mortality Interstitial Form has been Epidemic Secondary Bacterial Infections
Pathogenesis of Atypical CAP
Organism Attaches to Upper Respiratory Tract Epithelium
Cell Necrosis and Inflammatory Response
Interstitial Inflammation
Predispose to
Secondary
Bacterial
Infections
Pathogens of Atypical CAP
Mycoplasma Chlamydia Pneumoniae Legionella Coxiella Burnetti (Q Fever) Viruses:
Influenza Respiratory Syncytial Virus Adenovirus Rhinovirus Rubeola Varicella
Mycoplasma Pneumoniae Most Common Cause of Atypical CAP Children and Young Adults Sporadic or Epidemic 2-3 Week Incubation Period Extrapulmonary Manifestations:
Hemolytic Anemia Splenomegaly Erythema Multiforme Arthritis Myringitis Bullosa Pharyngitis Tonsillitis Mental Status Change
Diagnosis: Complement Fixation to Measure IgM Antibody Treatment: Macrolide, Doxycycline Up to 6 Months Recovery
Legionella Pneumophila
Artificial Aquatic Environments Transmitted by Inhalation or Aspiration Associated Diarrhea, Neuro Sx Na and Phos Fatality Rate 50% in Immunosuppressed Diagnosis:
Antigen in Urine +Fluorescent Antibody Test on Sputum Culture is Gold Standard
Treatment: Macrolides or Quinolones
Chlamydophilia Pneumoniae
Young Adults Laryngitis precedes Pneumonia by 2-3 Wks Diagnosis:
IgM titer > 1:16 Positive Culture PCR 4x Increase in IgG
Treatment: x 3 Wks Doxycycline Macrolides
Influenza Virus
8 Helices of Single-Stranded RNA Encodes Nucleoprotein Determines Type (A, B, C)
Lipid Bilayer = Envelope Containing Hemagglutinin and Neuraminidase Determines Subtype (H1-3, N1-2)
Type A is Major Cause of Human Infections Epidemics
Antigenic Drift (Mutations of Hemagglutinin and Neuraminidase)
Pandemics Antigenic Shift (Hemagglutinin and Neuraminidase
Replaced with Animal Virus RNA Segments) Type B, C Infect Children Treatment: Oseltamir (Tamiflu) and Zanamivir (Relenza)
Severe Acute Respiratory Syndrome
Pandemic of 2002 started in China > 8,000 Cases 774 Deaths
Coronavirus from Animals Diffuse Alveolar Damage, Multinucleated Giant Cells Clinical Presentation:
Incubation Period 2-10 Days Dry Cough, Malaise, Myalgias, Fever, Chills
Clinical Course: 1/3 Resolve 2/3 Progress to SOB, Tachypnea, Pleurisy 10% Mortality
NOSOCOMIAL PNEUMONIANOSOCOMIAL PNEUMONIA
Types: Hospital Acquired (HAP)
>48 hours after Admission Ventilator Associated (VAP)
>48 hours after Intubation Healthcare Associated (HCAP)
Hospitalized >2 Days within 90 Days Resident of ECF IV ABX, Chemo, Wound Care within 30 Days Hemodialysis
Pathogens: GNR (Enterobacteriaceae and Pseudomonas) Staph Aureus (MRSA)
Life-Threatening
Pseudomonas Aeruginosa
Risk Factors: ICU Steroids ABX > 7 Days in Past Month CHF Malnutrition Cystic Fibrosis
Extrapulmonary Spread Hematogenously Treat with 2 Antipseudomonals
Aminoglycoside + Antipseudomonal Beta-Lactam
ASPIRATION PNEUMONIAASPIRATION PNEUMONIA
Abnormal Gag and/or Swallowing Reflex
Pneumonia from Oral Flora Aerobes > Anaerobes
Chemical Pneumonitits from Gastric Acid
Necrotizing, Fulminant Course
Lung Abscess or Empyema are Common Complications
Treatment: Augmentin or Clindamycin
CHRONIC PNEUMONIACHRONIC PNEUMONIA
Localized Lesion with/without Nodes Immunocompetent Granulomatous Inflammation Fungal
Histoplasma Capsulatum Blastomyces Dermatitidis Coccidioides Immitis
Histoplasmosis Ohio and Mississippi Rivers and
Caribbean Inhalation of Bird and Bat
Droppings Contaminated with Spores
Primary Stage: Self-Limited or Latent Coin Lesion on Chest X-Ray
Secondary Stage: Chronic, Progressive Cough, Fever, Night Sweats Lung Apices
Extrapulmonary Manifestations: Adrenals Liver Meninges
No Treatment Indicated unless Disseminated
Blastomycosis
Central and SE U.S., Canada, Mexico, Africa, India, and the Middle East
Male : Female 10:1 Clinical Presentation:
Abrupt Onset Productive Cough Headache Chest Pain, Abdominal Pain Weight Loss, Anorexia Fever, Chills, Night Sweats
May Resolve, Persist, or Progress to Chronic Treatment: Itraconazole
Coccidioidomycosis
SW and Far West U.S. and Mexico Deserts
>80% of Population in Endemic Areas are Infected
Only 10% are Symptomatic Lung Lesions Fever Cough Pleuritic Pain Erythema Nodosum or
Multiforme Treat if Hemoptysis or Abnormal
CXR with Fluconazole or Amphotericin B
Pneumonia Severity Index – Step 2Risk Factors Points
Age (M) Years
Age (F) Years-10
ECF 10
Active Neoplasm 30
Chronic Liver Dz 20
CHF 10
Cerebrovascular Dz 10
CKD 10
Altered Mental Status 20
Resp > 30 20
SBP < 90 20
Temp < 35 or > 40 15
Pulse > 125 10
pH < 7.35 30
BUN > 30 20
Na < 130 20
Glucose > 250 10
Hematocrit < 30 10
PaO2 < 60 10
Pleural Effusion 10
De
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ics
La
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x-r
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PE
PM
Hx
Pneumonia Severity Index – Step 3
Class Points Mortality Treatment
I 0.1 Outpatient
II < 70 0.6 Outpatient
III 71-90 2.8 Observation
IV 91-130 8.2 Inpatient
V > 130 29.2 Inpatient
CURB-65
Confusion (disorientation to person, place, or time) Urea (blood urea nitrogen) >7 mmol/L (20 mg/dL) Respiratory rate >30 breaths/minute Blood pressure (systolic <90 or diastolic <60) Age >65 years
Score Mortality Treatment
0-1 0.7-2.1 Outpatient
2 9.2 Inpatient
>3 >14.5 ICU
Empiric Outpatient Treatment
Healthy and No ABX within 3 months: MacrolideOr Doxycycline
Comorbidities (chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs) or ABX within 3 months FluoroquinoloneOr B-Lactam Plus Macrolide
For Macrolide-Resistant Streptococcus pneumoniae FluoroquinoloneOr B-Lactam Plus Macrolide
Empiric Inpatient Treatment
Non-ICU: Fluoroquinolone
Or B-Lactam
Plus
Macrolide
ICU: B-Lactam (cefotaxime,
ceftriaxone, or ampicillin-sulbactam)
Plus
Azithromycin
Or
Fluoroquinolone
For Penicillin-Allergy: Fluoroquinolone and
Aztreonam
Special Circumstances
For Pseudomonas: Piperacillin-tazobactam, cefepime, imipenem, or
meropenemPlus Ciprofloxacin or LevofloxacinOr Aminoglycoside and AzithromycinOr Aminoglycoside and Fluoroquinolone
For Penicillin-Allergy, Substitute Aztreonam for B-Lactam
For CA-MRSA: Vancomycin or Linezolid
Extras
First Dose of ABX in ER IV to PO when:
Hemodynamically Stable Clinically Improving Able to Ingest RX Functioning GI Tract
Length of Treatment: Minimum of 5 days Afebrile for 48–72 hours Clinically Stable
Immunizations: Influenza Pneumococcal
Smoking Cessation