Pneumonia

Outline
• Definition
• Classification
• Pathophysiology
• Etiology
• Clinical features & Diagnosis
• Treatment
 Definition
• Pneumonia: is an inflammation of the substance of
the lungs & usually caused by bacteria.

• Clinically presents as an acute illness with cough,

purulent sputum and fever together with physical
signs or radiological changes compatible with
consolidation of the lung

• One of top 10 cases of outpatient and inpatient

diagnosis
Anatomic Classification of
Respiratory Infections
 Anatomic Classification
1. Lobar pnemonia
– -S. pneumoniae, Klebsiella
Multilobar pneumonia
2. Bronchial pneumonia- affects the lungs in patches
around bronchi or bronchioles
– -Staph, gram negatives, some fungi
3. Interstitial pneumonia-involves areas between
alveoli, "interstitial pneumonitis."
– More likely to be caused by viruses or by atypical
bacteria.
Lobar Pneumonia

Tarver et al. Radiol Clin N Am 43 (2005) 497 – 512

Bronchopneumonia

Image Consult
Interstitial Pneumonia

Image Consult
 Other Classifications
• Microbiologic • Time Course • Acquisition
– Bacterial – Acute – Community
• Typical – More likely acquired
• Atypical typical
– Hospital
– Viral – Chronic
acquired
– More likely
– Fungal atypical – Nursing home
acquired(HCAP)

Primary benefit of classification schemes is to provide framework

to guide appropriate management and empiric treatment
 Class…
• Community acquired Pneumonia(CAP) ─ infection of the lung
parenchyma in a patient who is in the community i.e not
hospitalized.

• Nosocomial Pneumonia
– Hospital acquired Pneumonia(HAP): Occurs 48 hours or more
after admission
– Ventilator associated pneumonia(VAP): more than 48 to 72
hours after endotracheal intubation
 CONT..
• Health care associated Pneumonia(HCAP) ─occurs in
a non-hospitalized pts with one or more :
─ Chronic dialysis……..Home infusion therapy
─ Family member with MDR infection…..Home wound care

─ Antibiotic therapy in preceding 3 month

─ Nursing home or extended-care facility residence
─ Hospitalization for 2 days in prior 3months
 CONT..
• Routes of infection:
─ Aspiration from the oropharynx
•Gross aspiration(Post op,CNS abn)
•Microaspiration(inhaled droplet -commonest )
─Hematogenous spread (endocarditis,UTI)
─Direct (from pleura,mediastinum)
 Precipitating factors
• Viral influenza or parainfluenza – S.pneumoniae
• Hospitalized ‘ill’ patients – Gram negatives
• Cigarette smoking – strongest independent risk factor for
invasive pneumococcal disease
• Alcohol
• Bronchiectasis /COPDMorexella, S.pneumonia ,CONS,Pseudomonas spp.
• Bronchial obstruction(lung ca)
• Immunosuppression (e.g. AIDS or cytotoxic Rx ) – organisms
include PCP, MAC, CMV
• IV drug users – S.aureus
• Esophageal obstruction – anaerobes
 Pathogenesis
• Proliferation of microbial pathogens at the
alveolar level and the host's response to
those pathogens
Pathogenesis

NEJM 2008
 Etiology…CAP

• Typical organisms
─ Streptococcal Pneumonia
─ H.Influenza
─ S. aureus and Gram Neegative bacilli (Klebsiella pneumoniae
& Pseudomonas aeruginosa) in special patient pop
• Atypical organisms
─ Mycoplasma pneumoniae
─ Chlamydia pneumoniae (in outpatients)
─Legionella spp. (in inpatients)
─Respiratory viruses (influenza viruses adenoviruses, and
RSV)
• 10–15% of CAP are polymicrobial
 Etiology…CAP
• Anaerobes ( aspiration in patients with unprotected
airway (e.g., in pts with alcohol or drug overdose or a
seizure d/o & significant gingivitis
• 50% of cases specific etiology is not found
CAP – The Pathogens
40-60% - No causative agent identified
Involved
2-5% - Two are more agents identified
9%
4%
4% S.pneumoniae
H.influenza
5%
Chlamydia
Legionella spp
6%
56%
S.aureus
Mycoplasma
6% Gram Neg bacilli
Viruses
10%
 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
 Clinical Presentation

• Fever,tachycardia , chills +/- sweats

• Cough-nonproductive or productive of mucoid,
purulent, or blood-tinged sputum
• Pleuritic chest pain,Dyspnea
• 20% of pts GI sxs - nausea, vomiting +/- diarrhea
• Fatigue, headache, myalgias & arthralgias
• Signs of Consolidation +/- pleural effusion
 C/f…
• ↑RR & use of accessory muscles of respiration
• Palpation -↑or↓ tactile fremitus & Percussion
note -dull to flat, reflecting underlying
consolidated lung and pleural fluid, respectively
• Auscultation - Crackles, BBS, pleural friction rub
• Severely ill patients may have septic shock and
evidence of organ failure
Physical Examination of the Lungs and Pleura
Lobar Pneumonia – Consolidation.
0 Tracheal deviation

Fremitus

dull or flat Percussion

bronchial Breath sounds

Voice sounds

crepitant rales Rales

 DIAGNOSIS
• Differentiate from other similar presentations
-is this Pneumonia? Ddx,(clinical,CXR)
• Identify severity Rx implication
• Etiologic dx…needs lab
 Ddx
• Acute bronchitis
• Acute exacerbations of chronic bronchitis
• Heart failure
• Pulmonary Embolism
• Radiation pneumonitis
 Sensitivity & specificity of the findings on P/E
are less than ideal, ~ 58% & 67%, respectively
 Investigation

• CXR – PA & lateral • Serum electrolytes

• CBC with Differential • Gram stain of
• BUN and Creatinine sputum
• FBG, PPBG • Culture of sputum
• Liver enzymes • Pre Rx. blood
cultures
 Investigation
• CBC: High WBC or low WBC
• Increased ESR
• CXR may show areas of consolidation, x-ray
usually lags behind clinical response,may stay
upto SIX WEEKs
• CXR suggest an etiologic dx(Eg.
Pneumatoceles S. aureus, & upper-lobe
cavitating lesion TB )
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

 Infiltrate Patterns and Pathogens
exam
CXR Pattern Possible Pathogens
S.pneumo, Kleb, H. influ, Gram
Lobar
Neg
Patchy Atypicals, Viral, Legionella

Interstitial Viral, PCP, Legionella

Anerobes, Kleb, TB, S.aureus,
Cavitatory
Fungi
Large effusion Staph, Anaerobes, Klebsiella
CXR
 Bronchial Pneumonia
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pneumonia.jpg
 Bronchitis vs. Pneumonia

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 Etiologic DX
• No strong evidence exist that show RX directed
at a specific pathogen is statistically superior to
empirical therapy
• Gram's stain & culture of sputum
─Sensitivity of Sputum culture is low (proven bacteremic
pneumococcal pneumonia ~ 50%)
─ deep-suction aspirate or BAL has yield
• Blood culture yield is very low (~5–14% )
• PCR
• Thoracentesis and pleural fluid analysis
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
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 - (50-10) Respiratory Rate > 30 20 points
10) SBP < 90 mm 20 points
NH Resident 10 points Temp < 350 C or > 400 C 15 points
Co-morbid Illnesses Pulse > 125 per min 10 points
Neoplasia 30 points Investigation Findings
Liver Disease 20 points Arterial pH < 7.35 30 points
CHF 10 points BUN > 30 20 points
Serum Na < 130 20 points
CVD 10 points
Hematocrit < 30% 10 points
Renal Disease (CKD) 10 points
Blood Glucose > 250 10 points
PORT Scoring – PSI
Pa O2 10 points
Pneumonia Patient X Ray e/o Pleural 10 points
Outcomes Research Team Effusion
(PORT)
Classification of Severity - PORT
Predictors Absent  70 71 – 90

Clas Clas Clas

sI s II s III

Class Class
IV V
91 - 130 > 130
CAP – Management based on PSI Score

Mortality
PORT Class PSI Score Treatment Strategy
%

Class I No RF 0.1 – 0.4 Out patient

Class II  70 0.6 – 0.7 Out patient

Brief
Class III 71 - 90 0.9 – 2.8
hospitalization

Class IV 91 - 130 8.5 – 9.3 Inpatient

27 –
Class V > 130 IP - ICU
31.1
CURB 65 Rule – Management of CAP

CURB 0 or 1 Outpatient
CURB 65
Confusion
BUN > 30 CURB 2 Short Hosp
RR > 30
BP SBP <90 Medical
CURB 3
Ward
DBP <60
Age > 65
CURB 4 or 5 ICU care
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/dl
 Respiratory rate ≥ 30 / min;
 Core temperature < 36ºC
 Severe hypotension;
 PaO2/FiO2 ratio ≤ 250
 Multi-lobar infiltrates
 WBC < 4000 cells;
 Platelets <100,000
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
CAP categories 1st line 2nd line
CAP :outpatient No Amoxicillin X 5- 7 days Doxycycline OR
comorbidities AND No risk Clarithromycin/Azithromyc
factors* in
CAP: out patient With Amoxicillin-clavulanate Cefuroxime or
comorbiditie s AND Cefpodoxime AND
Clarithromycin/Azithromyc Clarithromycin/Azithromyc
in X 5-7 days in
CAP for hospitalized Ceftriaxone OR cefotaxime Amoxicillin-clavulanate +
patients IV + Clarithromycin or azithromycin or
Azithromycin for 5 to 7 Clarithromycin
days
• If the patient has Recent Hospitalization and
parenteral antibiotics use ( in the last 90 days)
- Take culture and and Add coverage for
MRSA and P. aeruginosa*
Empiric Rx. – Suspected Pseudomonas
1. Piperacillin-Tazobactam, Cefepime, Carbapenums
(Imipenem, or Meropenem) plus either Cipro or Levo
2. Above Beta-lactam + Aminoglycoside + Azithromycin
3. Above Beta-lactam + Aminoglycoside + an
antipseudomonal and antipneumococcal FQ
4. If Penicillin allergic - Aztreonam for the Beta-lactam
 Empiric Rx. – CA MRSA
For Community Acquired Methicillin-Resistant
Staphylococcus aureus (CA-MRSA)
 Vancomycin or Linezolid
Neither is an optimal drug for MSSA
 For Methicillin Sensitive S. aureus (MSSA)
B-lactam and sometimes a respiratory
Fluoroquinolone, (until susceptibility
results).
 Specific therapy with a penicillinase-resistant
semisynthetic penicillin or Cephalosporin
 Duration of Therapy

• Minimum of 5 days
• Afebrile for at least 48 to 72 h
• Longer duration of therapy
If initial therapy was not active against the
identified pathogen or complicated by extra
pulmonary infection
 Main Reasons for Failure or Lack of
Improvement
• Inadequate /wrong antimicrobial selection
– Consider less common pathogens
– Broaden antibiotic therapy
• Unusual pathogens
– Consider serologic testing /other tests
• Complications of pneumonia
– Up to 10% pneumococcal pneumonia
• Meningitis,Arthritis,Endocarditis
• Pericarditis,Peritonitis,Empyema
• Consider non-infectious illnesses
•
 CAP – Complications
 Hypotension and septic shock
 3-5% Pleural effusion; Clear fluid + pus cells
 1% Empyema thoracis pus in the pleural space
 Lung abscess
- Single (aspiration) anaerobes, Pseudomonas
- Multiple (metastatic) Staphylococcus aureus
 Septicemia – Brain abscess, Liver Abscess
 Multiple Pyemic Abscesses
 Prognosis

– Early treatment better outcome

– Poor outcome-severe/HAP/etiology
– Risk factor for mortality-
• age
• alcohol
• extent on CXR
• bactermia, (for S. pneumoniae)
• immunosuppression
 Preventions
• Stop smoking
• Polyvalent Pneumococcal vaccine
• Influenza vaccine
• Prevent aspiration
• prophylaxis
 Reading assignment
• HCAP
• HAP & VAP
Thank You