PNEUMONIA

Bag / SMF Penyakit Dalam FK UNDIP / RS

Dr.Kariadi
1
 Pneumonias – Classification

CAP • Community Acquired

HCAP • Health Care Associated

HAP • Hospital Acquired

ICUAP • ICU Acquired

VAP • Ventilator Acquired

Nosocomial Pneumonias
2
 PNEUMONIA
• Pneumonia adalah inflamasi dan / atau infeksi jaringan parenkim paru, yang
disebabkan oleh beberapa penyebab : virus, bakteri, jamur, parasit, dan bahan-bahan
toksik yang menimbulkan inflamasi.

Macam klasifikasi pneumonia

• Klasifikasi berdasarkan jaringan paru mana yang terkena pneumonia : pneumonia
lobaris, pneumonia lobularis, bronkopneumonia, dan pneumonia interstitialis.

• Klasifikasi berdasarkan tempat asal ditemukannya patogen penyebab pneumonia,

dikenal
1) CAP,
2) HAP termasuk diantaranya HCAP dan VAP

• Klasifikasi didasarkan agen atau patogen penyebabnya :

bakterial (patogen tipikal), patogen atipikal, virus, jamur, dan parasit.

• Klasifikasi pneumonia berdasarkan risiko timbulnya kematian (prognosis) pada

penderita pneumonia.
1) menurut ATS : PSI
3 2) menurut BTS : CURB-65, CURB, CRB-65.
 Community Acquired Pneumonia (CAP)

 Definition
… an acute infection of the pulmonary parenchyma
that is associated with some symptoms of acute
infection, accompanied by the presence of an acute
infiltrate on a chest radiograph, or auscultatory
findings consistent with pneumonia, in a patient not
hospitalized or residing in a long term care facility
for > 14 days before onset of symptoms.

4 Bartlett. Clin Infect Dis 2000;31:347-82.

 HAP - VAP

• HAP  pneumonia yang terjadi 48 jam atau lebih

setelah perawatan rumah sakit, dimana belum
terjadi inkubasi kuman saat masuk rumah sakit.

• VAP  pneumonia yang muncul lebih dari 48 –

72 jam setelah intubasi endotrakheal. Tidak
termasuk pasien yang mendapatkan intubasi
setelah terjadi HAP berat.

5
 HOSPITAL-ACQUIRED PNEUMONIA,
HEALTHCARE-ASSOCIATED PNEUMONIA,

• Antimicrobial therapy in preceding 90 d

• Current hospitalization of 5 d or more
• High frequency of antibiotic resistance in the community or
in the specific hospital unit
• Presence of risk factors for HCAP:
Hospitalization for 2 d or more in the preceding 90 d
Residence in a nursing home or extended care facility
Home infusion therapy (including antibiotics)
Chronic dialysis within 30 d
Home wound care
Family member with multidrug-resistant pathogen
• Immunosuppressive disease and/or therapy
 Guidelines for CAP-HAP

 American Thoracic Society (ATS)

 Guidelines - Management of Adults with CAP (2001)
 Infectious Diseases Society of America (IDSA)
 Update of Practice Guidelines Management of CAP
in Immuno-competent adults (2003)
 ATS and IDSA joint effort (we will follow this)
 IDSA/ATS Consensus Guidelines on the
Management of CAP in Adults (March 2007)

7
CAP – The Two Types of Presentations

Classical Atypical

• Sudden onset of CAP • Gradual & insidious onset

• High fever, shaking chills • Low grade fever
• Pleuritic chest pain, SOB • Dry cough, No blood tinge
• Productive cough • Good GC – Walking CAP
• Rusty sputum, blood tinge • Low mortality 1-2%; except
• Poor general condition in cases of Legionellosis
• High mortality up to 20% in • Mycoplasma, Chlamydiae,
patients with bacteremia Legionella, Ricketessiae,
• S.pneumoniae causative Viruses are causative
8
 CAP – Pathogenesis

Inhalation

Aspiration

Hematogenous

9
 CAP – Risk Factors for Pneumonia

 Age
 Obesity; Exercise is protective
 Smoking, PVD
 Asthma, COPD
 Immuno-suppression, HIV
 Institutionalization, Old age homes etc
 Dementia

10 ID Clinics 1998;12:723. Am J Med 1994;96:313

 Community Acquired Pneumonia (CAP)
Epidemiology
 4-5 million cases annually
 ~500,000 hospitalizations – 20% require admission
 ~45,000 deaths
 Fewest cases in 18-24 yr group
 Probably highest incidence in <5 and >65 yrs
 Mortality disproportionately high in >65 yrs
 Over all mortality is 2-30%; Hospitalized Pt  mort
 <1% for those not requiring hospitalization
11 Bartlett. CID 1998;26:811-38.
 Nosocomial Pneumonia-HAP

Epidemiology
– Common hospital-acquired infection
– Occurs at a rate of approximately 5-10 cases per 1000 hospital
admissions
– Incidence increases by 6-20 fold in patients being ventilated
mechanically.
– One study suggested that the risk for developing VAP increases
1% per day
– Another study suggested, highest risk occur in the first 5 days after
intubation

12
 CAP – The Pathogens Involved
40-60% - No causative agent identified
2-5% - Two are more agents identified

9%
4% S.pneumoniae
4% H.influenza
5% Chlamydia
Legionella spp
6%
S.aureus
56%
6% Mycoplasma
Gram Neg bacilli
10% Viruses

13
 Streptococcus pneumonia
(Pneumococcus)

 Most common cause of CAP

 About 2/3 of CAP are due to S.pneumoniae
 These are gram positive diplococci
 Typical symptoms (e.g. malaise, shaking chills
fever, rusty sputum, pleuritic chest pain, cough)
 Lobar infiltrate on CXR
 May be Immuno suppressed host
 25% will have bacteremia – serious effects
14
 S. aereus CAP – Dangerous

 This CAP is not common; Multi lobar Involvement

 Post Influenza complication, Class IV or V
 Compromised host, Co-morbidities, Elderly
 CA MRSA – A Problem; CA MSSA also occurs
 Empyema and Necrosis of lung with cavitations
 Multiple Pyemic abscesses, Septic Arthritis
 Hypoxemia, Hypoventilation, Hypotension common
 Vancomycin, Linezolid are the drugs for MRSA
15
 CAP – Risk Factors for Hospitalization

 Older, Unemployed, Unmarried

 Recurrent common cold
 Asthma, COPD; Steroid or bronchodilator use
 Chronic diseases, Diabetes, CHF, Neoplasia
 Amount of smoking
 Alcohol is NOT related to increased risk for
hospitalization

16 ID Clinics 1998;12:723. Am J Med 1994;96:313

 CAP – Risk Factors for Mortality

 Age > 65
 Bacteremia (for S. pneumoniae)
 S. aureus, MRSA , Pseudomonas
 Extent of radiographic changes
 Degree of immuno-suppression
 Amount of alcohol consumption

17 ID Clinics 1998;12:723. Am J Med 1994;96:313

 Nosocomial Pneumonia

• Risk Factors
– Host Factors
• Extremes of age, severe acute or chronic illnesses,
immunosupression, coma, alcoholism, malnutrition,
COPD, DM
– Factors that enhance colonization of the oropharynx and
stomach by pathogenic microorganisms
• admission to an ICU, administration of antibiotics,
chronic lung disease, endotracheal intubation, etc.

18
 Nosocomial Pneumonia

• Risk Factors
– Conditions favoring aspiration or reflux
• Supine position, depressed consciousness, endotracheal
intubation, insertion of nasogastric tube
– Mechanical ventilation
• Impaired mucociliary function, injury of mucosa favoring
bacterial binding, pooling of secretions in the subglottic
area, potential exposure to contaminated respiratory
equipment and contact with contaminated or colonized
hands of HCWs
– Factors that impede adequate pulmonary toilet
• Surgical procedures that involve the head and neck, being
immobilized as a result of trauma or illness, sedation etc.
19
 Nosocomial Pneumonia

• Pathogenesis
– Invasion of the lower respiratory tract by:
• Aspiration of oropharyngeal/GI organisms
• Inhalation of aerosols containing bacteria
• Hematogenous spread

20
21
Colonization Aspiration

MRSA*

HAP
22
 Pathogens Associated With HAP
P = .003 Early-onset NP
40
Late-onset NP
Nosocomial Pneumonia (%)

35
PA = P aeruginosa
OSSA = Oxacillin-sensitive
30 S aureus
ORSA = Oxacillin-resistant
P = .408 S aureus
25 ES = Enterobacter
P = .043 species
20 SM = S marcescens

15 P = .985 P = .144

10

0
PA OSSA ORSA ES SM

23 Pathogen
Ibrahim, et al. Chest. 2000;117:1434-1442.
 CAP – Evaluation of a Patient

Hx. PE, CXR

Infiltrate or Clinical
No Infiltrate
evidence of CAP

Evaluate need PORT &

Alternate Dx.
for Admission CURB 65

Out Medical
ICU Adm.
Patient Ward

24
 CAP – Management Guidelines

 Rational use of microbiology laboratory

 Pathogen directed antimicrobial therapy
whenever possible
 Prompt initiation of Antibiotic therapy
 Decision to hospitalize based on
prognostic criteria - PORT or CURB 65

25
 Nosocomial Pneumonia
• Diagnosis
– Not necessarily easy to accurately diagnose HAP
– Criteria frequently include:
• Clinical
– fever ; cough with purulent sputum,
• Radiographic
– new or progressive infiltrates on CXR,
• Laboratorial
– leukocytosis or leukopenia
• Microbiologic
– Suggestive gram stain and positive cultures of sputum, tracheal
aspirate, BAL, bronchial brushing, pleural fluid or blood
26 – Quantitative cultures
Clinical Parameter Scoring Clinical Parameter Scoring
Age in years Example Clinical Findings
For Men (Age in yrs) 50 Altered Sensorium 20 points
For Women (Age -10) (50-10) Respiratory Rate > 30 20 points
NH Resident 10 points SBP < 90 mm 20 points

Co-morbid Illnesses Temp < 350 C or > 400 C 15 points

Neoplasia 30 points Pulse > 125 per min 10 points

Investigation Findings
Liver Disease 20 points
Arterial pH < 7.35 30 points
CHF 10 points
BUN > 30 20 points
CVD 10 points
Serum Na < 130 20 points
Renal Disease (CKD) 10 points
Hematocrit < 30% 10 points
PORT Scoring – PSI Blood Glucose > 250 10 points

Pneumonia Patient Outcomes Pa O2 10 points

Research Team (PORT) X Ray e/o Pleural Effusion 10 points
27
 Classification of Severity - PORT

Class Class Class

I Predictors II III
Absent  70 71 – 90

Class Class
IV V
91 - 130 > 130

28
 CAP – Management based on PSI Score

PORT Class PSI Score Mortality % Treatment Strategy

Class I No RF 0.1 – 0.4 Out patient

Class II  70 0.6 – 0.7 Out patient

Class III 71 - 90 0.9 – 2.8 Brief hospitalization

Class IV 91 - 130 8.5 – 9.3 Inpatient

Class V > 130 27 – 31.1 IP - ICU

29
 CURB 65 Rule – Management of CAP

CURB 0 or 1 Home Rx
CURB 65
Confusion
BUN > 30 CURB 2 Short Hosp
RR > 30
BP SBP <90 CURB 3 Medical Ward
DBP <60
Age > 65
CURB 4 or 5 ICU care

30
 Algorithmic Approach
Step 4
Step 3
Step 2
Step 1 Class I
No CURB
No
< 50 Years
Co-morbidity Only OP

CAP Patient Co-morbidity CURB +

Present

 50 Years OP / IP/
ICU
PORT
Class II-V

31
 Who Should be Hospitalized?

Class I and II Usually do not require hospitalization

Class III May require brief hospitalization
Class IV and V Usually do require hospitalization

Severity of CAP with poor prognosis

RR > 30; PaO2/FiO2 < 250, or PO2 < 60 on room air
Need for mechanical ventilation; Multi lobar involvement
Hypotension; Need for vasopressors
Oliguria; Altered mental status
32
 CAP – Criteria for ICU Admission
Major criteria
 Invasive mechanical ventilation required
 Septic shock with the need of vasopressors
Minor criteria (least 3)
 Confusion/disorientation
 Blood urea nitrogen ≥ 20 mg%
 Respiratory rate ≥ 30 / min; Core temperature < 36ºC
 Severe hypotension; PaO2/FiO2 ratio ≤ 250
 Multi-lobar infiltrates
 WBC < 4000 cells; Platelets <100,000
33
 CAP – Value of Chest Radiograph

• Usually needed to establish diagnosis

• It is a prognostic indicator
• To rule out other disorders
• May help in etiological diagnosis

J Chr Dis 1984;37:215-25

34
 Infiltrate Patterns and Pathogens

CXR Pattern Possible Pathogens

Lobar S.pneumo, Kleb, H. influ, Gram Neg

Patchy Atypicals, Viral, Legionella

Interstitial Viral, PCP, Legionella

Cavitatory Anerobes, Kleb, TB, S.aureus, Fungi

Large effusion Staph, Anaerobes, Klebsiella

35
 CAP – Gram’s Stain of Sputum
Good sputum samples is obtained only from 39%
83% show only one predominant organism

Efficiency of test S. pneumoniae H. influenza

Sensitivity 57 % 82 %

Specificity 97 % 99 %

Positive Predictive Value 95 % 93 %

Negative Predictive Value 71 % 96 %

36
 Pathogens Retrieved from Blood Culture

5%
11%
S.pneumoniae
16% Enterobacteria
Staph.aureus
68% Others

37
 COMMUNITY ACQUIRED
PNEUMONIA
Difrensial Diagnosis : Infiltrat
• Penyakit Jantung Kongestif
• Tumor paru
• Infark paru
• Atelektasis
• Pneumonitis radiasi
• ARDS
• Penyakit Paru Interstitial / Penyakit Sistemik
Wagener granulomatosis ,Goodpasteur Syndrome
38 Kolagenosis
 Nosocomial Pneumonia

• Differential diagnosis
– ARDS
– Pulmonary edema
– Pulmonary embolism
– Atelectasis
– Alveolar hemorrhage
– Lung contusion

39
 Diagnosis Pneumonia

• Adanya infiltrat pada parenkhim paru berdasarkan

pemeriksaan Ro foto dada dengan :
– 1.Demam
– 2.Lekositosis atau lekopenia
– 3.Batuk dengan sputum purulent dengan PMN >
20 lp
– 4.Pemeriksaan Fisik : asimetris, redup
,bronkhial dan ronkhi basah-crackles

40
VAP ditegakkan berdasarkan adanya perubahan atau ditemukan
infiltrat baru pada pemeriksaan x-foto thorax disertai sekurang-
kurangnya 2 dari:
1. Temperatur > 38,5 C atau <36 C
2. Trakea sekresi purulen
3. Leukopenia (leukosit < 4.000/mm3) atau leukositosis (leukosit >
12.000/mm3)
4. PaO2/FiO2 < 300
5. Ditemukan kolonisasi kuman dengan kriteria sebagai berikut :
• >103 CFU sekresi trakea / bronkus diambil dengan sikat
berproteksi
• >104 CFU sekresi trakea / bronkus dengan bronchoalveolar
lavage (BAL)
• >105 CFU sekresi trakea / bronkus dengan non
bronchoalveolar lavage.5
41
 Mortality of CAP – Based on Pathogen

 P. aeruginosa - 61.0 %
 K. pneumoniae - 35.7 %
 S. aureus - 31.8 %
 Legionella - 14.7 %
 S. pneumoniae - 12.0 %
 C. pneumoniae - 9.8 %
 H. influenza - 7.4 %

42
 Traditional Treatment Paradigm

Conservative start with ‘workhorse’ antibiotics

Reserve more potent drugs for non-responders

43
 New Treatment Paradigm

Hit hard and early with appropriate antibiotic(s)

Short Rx. Duration; De-escalate where possible

44
 The Therapy Conundrum
Avoid emergence
of
multidrug
resistant Immediate
microorganisms Rx.
of patients
with serious
sepsis

Objective 1
Objective 2

45
 CAP Treatment Consensus

 Risk assessment approach

 Early Antibiotic selection
 Change treatment driven by local
surveillance
 Hit hard and hit early
 As short a duration as possible
 De-escalate when and where possible

46
 OPAT – OP Parenteral Antimicrobial Therapy

47
 Antibiotics of choice for CAP

Macrolide -M
Fluroquinolone-FQ Betalactum - B
• Azithromycin • Ceftriaoxone
• Levofloxacin
• Clarithromycin • Cefotaxime
• Moxifloxacin • B Inhibitor - BI
• Erythromycin
• Sulbactam
• Gatifloxacin
• Telithromycin • Tazobactam
• Trovafloxacin • Piperacillin
• Doxycycline

48
Antibiotic Dosage, Route, Frequency and Duration

Doxyclycline 100-200 mg PO/IV BID for 7 to 10 days

Azithromycin 500 mg OD IV –3 days + 500 mg OD PO for 7-10 days

Clarithromycin 250 – 500 mg BID PO for 7 – 14 days

Telithromycin 800 mg PO OD for 7 – 10 days

Levofloxacin 750 mg PO/IV OD for 5 days

Gatifloxacin 400 mg PO or IV OD for 5 to 7 days

Moxifloxacin 400 mg PO or IV OD for 5 to 7 days

Gemifloxacin 320 mg PO OD for 5 – 7 days

Amoxyclav 2 g of Amoxi +125 mg of Clauv PO BID for 7 to 10 days

Ceftriaxone 2 g IV BID for 3 to 5 days + PO 3G CS

49
Ertapenum 1 g OD IV or IM for 7 to 14 days
 Empiric Treatment – Outpatient
Healthy and no risk factors for DR S.pneumoniae
1. Macrolide or Doxycycline
Presence of co-morbidities, use of antimicrobials
within the previous 3 months, and regions with a
high rate (>25%) of infection with Macrolide
resistant S. pneumoniae
1. Respiratory FQ – Levoflox, Gemiflox or Moxiflox
2. Beta-lactam (High dose Amoxicillin, Amoxicillin-
Clavulanate is preferred; Ceftriaxone, Cefpodoxime,
Cefuroxime) plus a Macrolide or Doxycycline
50
 Empiric Treatment – Inpatient – Non ICU

1. A Respiratory Fluoroquinolone (FQ) Levo or

2. A Beta-lactam plus a Macrolide (or Doxycycline)
(Here Beta-lactam agents are 3 Generation
Cefotaxime, Ceftriaxone, Amoxiclav)
3. If Penicillin-allergic Respiratory FQ or
Ertapenem is another option

51
 Duration of Therapy

• Minimum of 5 days
• Afebrile for at least 48 to 72 h
• No > 1 CAP-associated sign of clinical instability
• Longer duration of therapy
If initial therapy was not active against the identified
pathogen or complicated by extra pulmonary infection

52
 CAP – Summary of Empiric Treatment
Outpatient Rx – any one of the three
• Macrolide or Doxycycline or Fluoroquinolone
Patients in General Medical Ward
• 3rd Generation Cephalosporin + Macrolide
• Betalactum / B-I + Macrolide or B / B-I + FQ
• Fluroquinolone alone
Patients in ICU
• 3GC + Macrolide or 3GC + FQ
• B/B-I + Macrolide or B/B-I + FQ
53 IDSA guidelines: Clin Infect Dis 2000;31:347-82
 CAP – Treatment Summary

CAP Class Site of Care Treatment 1 Treatment 2 Treatment 3

Class I OP AZ CLR ER / Doxy

Class II OP FQ B+M B + Doxy

Class III OP + IP FQ IV I V - B + AZ Aztreo + FQ

Class IV Med Ward FQ + AZ B 3G + AZ Etrap + M

Carbepenum
Class ICU B 3G + AZ B 3G + FQ
54 V Sulbac ,Tazob
 Strategies for Prevention of CAP
• Cessation smoking
• Influenza Vaccine (Flu shot – Oct through Feb)
It offers 90% protection and reduces mortality by 80%
• Pneumococcal Vaccine (Pneumonia shot)
It protects against 23 types of Pneumococci
70% of us have Pneumococci in our RT
It is not 100% protective but reduces mortality
Age 19-64 with co morbidity of high for pneumonia
Above 65 all must get it even without high risk
55 • Starting first dose of antibiotic with in 4 h & O2 status
 Switch to Oral Therapy

 Four criteria
 Improvement in cough, dyspnea & clinical signs
 Afebrile on two occasions 8 h apart
 WBC decreasing towards normal
 Functioning GI tract with adequate oral intake
 If overall clinical picture is otherwise favorable,
hemodynamically stable; can switch to oral
therapy while still febrile.

56
57 Dikutip dari PERDICI (2009)4
 Management of Poor Responders

 Consider non-infectious illnesses

 Consider less common pathogens
 Consider serologic testing
 Broaden antibiotic therapy
 Consider bronchoscopy

58
 CAP – Complications

 Hypotension and septic shock

 3-5% Pleural effusion; Clear fluid + pus cells
 1% Empyema thoracis pus in the pleural space
 Lung abscess – destruction of lung - CSLD
 Single (aspiration) anaerobes, Pseudomonas
 Multiple (metastatic) Staphylococcus aureus
 Septicemia – Brain abscess, Liver Abscess
 Multiple Pyemic Abscesses

59
 Viruses and Pneumonia
Pneumonia in the normal host
• Adults or Children
• Influenza A and B, RSV, Adenovirus Para Influenza
Pneumonia in the immuno-compromised
• Measles, HSV, CMV, HHV-6, Influenza viruses
• Can cause a primary viral pneumonia. Cause partial
paralysis of “mucociliary escalator” - increased risk of
secondary bacterial LRTI. S.aureus pneumonia is a
known complication following influenza infection.

60
 CAP – So How Best to Win the War?
 Early antibiotic administration within 4-6 hours
 Empiric antibiotic Rx. as per guidelines (IDSA / ATS)
 PORT – PSI scoring and Classification of cases
 Early hospitalization in Class IV and V
 Change Abx. as per pathogen & sensitivity pattern
 Decrease smoking cessation - advice / counseling
 Arterial oxygenation assessment in the first 24 h
 Blood culture collection in the first 24 h prior to Abx.
 Pneumococcal & Influenza vaccination; Smoking X
61
 Normal CXR & Pneumonic Consolidation

62
 Lobar Pneumonia – S.pneumoniae

63
 CXR – PA and Lateral Views

64
 Lobar versus Segmental - Right Side

65
 Lobar Pneumonia

66
 Special forms of Consolidation

67
 Round Pneumonic Consolidation

68
 Special Forms of Pneumonia

69
 Special Forms of Pneumonia

70
 Complications of Pneumonia

71
 Empyema

72
 Mycoplasma Pneumonia

73
 Mycoplasma Pneumonia

74
 Chlamydia Trachomatis

75
 Rare Types of Pneumonia

76
 A CASE STUDY
Day 1

• A 76-year-old white male is sent to the local

hospital from a long-term care (LTC) facility for
evaluation of a pneumonic process

• Past medical history reveals multiple

admissions, with a history of diabetes,
hypertension, and foot ulcer

• The patient was discharged 10 days ago

following a cholecystectomy.

• The patient is admitted for pneumonia.

Necessary blood work, cultures, and labs are Michael Zgoda, MD
performed. Ceftriaxone and azithromycin IV are
77started. 77
 Chest X-Ray

78 78
Day 3

• The patient is still febrile and has developed a cough (mucoid). He

is uncomfortable and very restless. Staff notes that he is
somewhat disoriented to time and place. The patient has no
history of dementia

• Follow-up information sent from the LTC facility shows that the
patient has been on oral dicloxacillin, for previous infections, with
poor results

• Current laboratory test values denote increased white blood cell

count and Gram-positive cocci

79 79
• Days 5 to 7

• The patient’s therapy was reviewed by the attending

physician:
– Therapy was changed on day 3 by adding levofloxacin
– At present the patient is worsening and requires intubation and
mechanical ventilation
– Several hours later he continues to spike temperatures at 39
degrees C and becomes hypotensive despite 6 liters of lactated
ringers IVF.
– Pressors are started and the patient is then transferred to a
tertiary care hospital

80 80
• Day 7

• Culture results from referring hospital reveal:

– Species of bacteria; S aureus
– Strain of bacteria; MRSA

• The patient is treated with appropriate antibiotics upon

arrival to tertiary care hospital and the pneumonia
resolves. He has a prolonged ICU stay of 28 days at
which point the family decides to withdraw care
because profound malnutrition and subsequent ICU
associated complications from his underlying diabetes
including a NSTEMI, pseudomonas sinusitis, and a
stage 3 sacral ulcer requiring debridement.
81 81
82