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  1. 1. PNEUMONIA Dr. Nooruddin Jaffer Professor of Medicine.
  2. 2. Definition <ul><li>Syndrome caused by acute infection caused by a wide variety of microorganisms, characterized by clinical and/or radiological signs of consolidation of a part or parts of one or both lungs . </li></ul>
  3. 3. Definition <ul><li>“ Pneumonitis” is used as synonym for pneumonia when inflammation of lung has resulted from a non-infectious cause e.g chemical or radiation injury. </li></ul>
  4. 4. Clinical Definition <ul><li>Symptoms of acute LRT infection </li></ul><ul><li>a) Cough, sputum,chest pain </li></ul><ul><li>b) Fever,sweating,shiver, aches and pains </li></ul><ul><li>New focal chest signs on examination </li></ul><ul><li>OR </li></ul><ul><li>New radiographic pulmonary infiltrates </li></ul>
  5. 5. Epidemiology <ul><li>Common and serious illness despite antibiotics and vaccines </li></ul><ul><li>Sixth leading cause of death and number one infectious death in USA </li></ul><ul><li>Overall incidence rate is 170 (per 10,000) and increases with age, with an incidence of 280 for those 65 years of age or older </li></ul><ul><li>Outpatient mortality 1- 5 % , inpatient mortality approaches 25 %, greater if an ICU admission is required </li></ul>
  6. 6. Epidemiology <ul><li>Risk Factors </li></ul><ul><li>Advanced age </li></ul><ul><li>chronic illnesses </li></ul><ul><li>Cigarette smoking </li></ul><ul><li>Dementia </li></ul><ul><li>Malnutrition </li></ul><ul><li>Previous episode of pneumonia </li></ul><ul><li>Splenectomy </li></ul>
  7. 7. Etiology of Community Acquired Pneumonia <ul><li>Pathogen not defined in as many as 50 % patients even with extensive diagnostic testing </li></ul><ul><li>S. pneumoniae is the leading cause of CAP </li></ul><ul><li>H. influenzae ( type B), S. aureus, and gram (-) bacteria each account for 3 to 10 % </li></ul><ul><li>Staph aureus CAP is usually seen in the elderly and as post-influenza pneumonia </li></ul>
  8. 8. Etiology of Community Acquired Pneumonia <ul><li>P. aeruginosa causes CAP in neutropenia, cystic fibrosis, HIV infection & bronchiectasis </li></ul><ul><li>N. meningitidis, M. catarrhalis & S. pyogenes can occasionally cause CAP </li></ul><ul><li>Anaerobic organisms are implicated in aspiration pneumonia and lung abscess </li></ul><ul><li>MRSA, M. tuberculosis, and certain viral agents are common in nursing-home patients </li></ul>
  9. 9. Causes of community acquired pneumonia in North America <ul><li>Streptococcus pneumoniae 20 - 60 </li></ul><ul><li>Hemophilus influenzae 3 - 10 </li></ul><ul><li>Staphyloccus aureus 3 - 5 </li></ul><ul><li>Gram-negative bacilli 3 - 10 </li></ul><ul><li>Aspiration 6 - 10 </li></ul><ul><li>Miscellaneous 3 - 5 </li></ul><ul><li>Legionella sp. 2 - 8 </li></ul><ul><li>Mycoplasma pneumoniae 1 - 6 </li></ul><ul><li>Chlamydia pneumoniae 4 - 6 </li></ul><ul><li>Viruses 2 - 15 </li></ul>
  10. 10. Four patient categories have been defined on the basis of information collected at the time of initial evaluation
  11. 11. Outpatient Pneumonia without Comorbidity and 60 years or Younger <ul><li>ORGANISMS </li></ul><ul><li>S. pneumoniae </li></ul><ul><li>M. pneumoniae </li></ul><ul><li>Respiratory viruses </li></ul><ul><li>C. pneumoniae </li></ul><ul><li>H. influenzae </li></ul><ul><li>MISCELLANEOUS </li></ul><ul><li>Legionella </li></ul><ul><li>S. aureus </li></ul><ul><li>M.. Tuberculosis </li></ul><ul><li>endemic fungi </li></ul><ul><li>anaerobic Gram-negative bacilli </li></ul>
  12. 12. Outpatient Pneumonia with Comorbidity and/or 60 years or Older <ul><li>ORGANISMS </li></ul><ul><li>S. pneumoniae </li></ul><ul><li>Respiratory viruses </li></ul><ul><li>H. influenzae </li></ul><ul><li>Anaerobic Gram-negative bacilli </li></ul><ul><li>S. aureus </li></ul><ul><li>MISCELLANEOUS </li></ul><ul><li>M. catarrhalis </li></ul><ul><li>Legionella </li></ul><ul><li>M. tuberculosis </li></ul><ul><li>Endemic fungi </li></ul>
  13. 13. Hospitalized Patients with Community Acquired Pneumonia <ul><li>ORGANISMS </li></ul><ul><li>S. pneumoniae </li></ul><ul><li>H. influenzae </li></ul><ul><li>Polymicrobial (including anaerobic bacteria) </li></ul><ul><li>Anaerobic gram-negative bacilli </li></ul><ul><li>Legionella </li></ul><ul><li>S. aureus </li></ul><ul><li>C. pneumonia </li></ul><ul><li>Respiratory viruses </li></ul><ul><li>MISCELLANEOUS </li></ul><ul><li>M. pneumoniae </li></ul><ul><li>M. catarrhalis </li></ul><ul><li>M. tuberculosis </li></ul><ul><li>Endemic fungi </li></ul>
  14. 14. Severe Hospitalized Community Acquired Pneumonia <ul><li>ORGANISMS </li></ul><ul><li>S. pneumonia </li></ul><ul><li>Legionella </li></ul><ul><li>Anaerobic gram-negative bacilli </li></ul><ul><li>M. pneumoniae </li></ul><ul><li>Respiratory viruses </li></ul><ul><li>MISCELLANEOUS </li></ul><ul><li>H. influenzae </li></ul><ul><li>M. tuberculosis </li></ul><ul><li>Endemic fungi </li></ul>
  15. 15. PATHOGENESIS <ul><ul><ul><li>Predisposing conditions </li></ul></ul></ul><ul><ul><ul><li>1-Suppressed cough reflex </li></ul></ul></ul><ul><ul><ul><li>2-Impaired mucociliary activity </li></ul></ul></ul><ul><ul><ul><li>3-Reduced phagocytic activity of alveolar macrophages and neutrophils </li></ul></ul></ul><ul><ul><ul><li>4-Impaired immunoglobulins </li></ul></ul></ul>
  16. 16. Routes of Entry <ul><li>Aspiration </li></ul><ul><li>Inhalation </li></ul><ul><li>Colonization </li></ul><ul><li>Hematogenous spread </li></ul>
  17. 17. Classification <ul><li>Community acquired pneumonia </li></ul><ul><li>Hospital acquired (nosocomial) pneumonia </li></ul><ul><li>Aspiration pneumonia </li></ul><ul><li>Immunocompromised host pneumonia </li></ul>
  18. 18. Typical or Atypical CAP ? <ul><li>Difficult to differentiate on clinical grounds alone </li></ul><ul><li>The term ‘atypical ’ is used to refer to a group of organisms rather than a clinical picture </li></ul>
  19. 19. Clinical Features <ul><li>Symptoms </li></ul><ul><li>Respiratory </li></ul><ul><li>Cough 90% </li></ul><ul><li>Sputum 70% </li></ul><ul><li>Dyspnoea 70% </li></ul><ul><li>Chest pain 65% </li></ul><ul><li>URT symptoms 33% </li></ul><ul><li>Haemoptysis 15% </li></ul>
  20. 20. Clinical Features <ul><li>Symptoms </li></ul><ul><li>Non-Respiratory </li></ul><ul><li>Fever 90% </li></ul><ul><li>Vomiting 20% </li></ul><ul><li>Confusion 15% </li></ul><ul><li>Diarrhoea 15% </li></ul><ul><li>Rash 5% </li></ul><ul><li>Abdominal pain 5% </li></ul>
  21. 21. Clinical Features <ul><li>Signs </li></ul><ul><li>Fever 90% </li></ul><ul><li>Tachypnoea 80-90% </li></ul><ul><li>Tachycardia 80-90% </li></ul><ul><li>Crackles & 80-90% </li></ul><ul><li>Bronchial breathing 80-90% </li></ul><ul><li>Hypotension 20% </li></ul><ul><li>Confusion 15% </li></ul><ul><li>Herpes labialis 10% </li></ul>
  22. 22. Investigations <ul><li>In community </li></ul><ul><li>clinical diagnosis is enough if patient is stable. Patients who do not respond to empiric therapy, consider i-Chest X-ray ii-Sputum gram stain & culture </li></ul>
  23. 23. Test(s) in those who require hospital admission <ul><li>Chest X-Ray </li></ul><ul><li>Full blood count </li></ul><ul><li>Urea / Creatinine, Electrolytes, Sugar, LFT’s </li></ul><ul><li>CRP- if available? (BTS) </li></ul><ul><li>Arterial Blood Gases / Pulse oximetry </li></ul><ul><li>Blood culture, Sputum Gram stain & Culture, AFB smear & culture (in selected patients) </li></ul><ul><li>Routine serologic testing is not recommended </li></ul>
  24. 25. Adequate Sputum Sample <ul><li>Less than10 buccal squamous epithelial cells per low power field </li></ul><ul><li>More than 25 neutrophils per low power field </li></ul><ul><li>Leucocyte to squamous epithelial cell ratio greater than 5 </li></ul>
  25. 26. DIAGNOSIS
  26. 27. DIAGNOSIS Sputum Gram Stain
  27. 28. Invasive diagnostic techniques <ul><li>Transtracheal aspiration </li></ul><ul><li>Bronchoscopy with a protected brush catheter </li></ul><ul><li>Bronchoalveolar lavage with or without balloon protection </li></ul><ul><li>Direct needle aspiration of the lung </li></ul>
  28. 29. Features of Severe Pneumonia <ul><li>‘ Core’ clinical adverse prognostic features </li></ul><ul><li>(CURB) </li></ul><ul><li>C onfusion </li></ul><ul><li>U rea > 7 mM (>19.1 mg/dL) </li></ul><ul><li>R esp.rate >30 /min </li></ul><ul><li>B lood Pressure: Systolic BP < 90 mm Hg and/or diastolic BP ≤ 60 mmHg </li></ul><ul><li>NOTE : Patients with 2 or more CURB are at high risk of death </li></ul>
  29. 30. Severity assessment in CAP in the community (CRB-65 score) UPDATED 2004 <ul><li>C onfusion • R espiratory rate = 30/min • B lood pressure (SBP < 90mmHg or DBP = </li></ul><ul><li>60mmHg) • A ge = 65 years </li></ul><ul><li>Score 1 point for each feature present </li></ul>
  30. 31. Severity assessment in CAP in the community (CRB-65 score) UPDATED 2004 <ul><li>1-2 suitable for home treatment </li></ul><ul><li>3-4 Needs hospital referral </li></ul>
  31. 32. Additional Clinical Adverse Prognostic Features <ul><li>PO 2 <60 mm or O 2 saturation < 90 % </li></ul><ul><li>Bilateral or multilobar (>2 lobes) infiltrates on chest radiograph </li></ul>
  32. 33. SEVERE CAP <ul><li>There is no universally accepted definition of severe CAP: </li></ul><ul><li>1. Respiratory frequency >30 breaths min at admission </li></ul><ul><li>2. Severe respiratory failure defined by a Pao2/Flo2 ratio <250 </li></ul><ul><li>3. Requirement for mechanical ventilation </li></ul><ul><li>4. Chest radiograph showing a) bilateral involvement b) involvement of multiple lobes c) an  in the size of the opacity by  50 % within 48 h of admission </li></ul><ul><li>5. Shock ( SBP < 90 mmHg or DBP < 60 mmHg) </li></ul><ul><li>6. Requirement for vasopressors for more than 4 h </li></ul><ul><li>7. Urine output < 20 ml/h or acute renal failure requiring dialysis </li></ul>
  33. 34. Management (subset of patients) <ul><li>Group I : Outpatients with no h/o cardiopulmonary disease and no modifying factors. </li></ul><ul><li>Group II : Outpatients with cardiopulmonary disease (eg. CCF or COPD) and/or other modifying factors. </li></ul>
  34. 35. Management (subset of patients) <ul><li>Group III : Inpatients not admitted to the ICU, who have the following: </li></ul><ul><li>a) Cardiopulmonary disease, and/or other modifying factors including being from a nursing home) </li></ul><ul><li>b) No cardiopulmonary disease, and/or other modifying factors. </li></ul>
  35. 36. Management (subset of patients) <ul><li>Group IV : ICU-admitted patients who have the following: </li></ul><ul><li>No risk for Pseudomonas aeroginosa </li></ul><ul><li>Risks for Pseudomonas aeroginosa </li></ul>
  36. 37. General Management of CAP In the community <ul><li>Not to smoke , to rest and drink plenty of fluids </li></ul><ul><li>Pleuritic chest pain should be relieved using simple analgesics like Paracetamol </li></ul><ul><li>Review of patients in the community is recommended after 48 hours, those who fail to improve should be considered for hospital admission </li></ul>
  37. 38. Decision to Hospitalize <ul><li>1. Age over 65 yr </li></ul><ul><li>2. Presence of coexisting illnesses or other findings </li></ul><ul><li>a. COPD, bronchiectasis, cystic fibrosis </li></ul><ul><li>b. Diabetes mellitus </li></ul><ul><li>c. Chronic renal failure </li></ul><ul><li>d. Congestive heart failure </li></ul><ul><li>e. Chronic liver disease of any etiology </li></ul><ul><li>f. Previous hospitalization within 1 yr </li></ul><ul><li>g. Suspicion of aspiration </li></ul><ul><li>h. Altered mental status </li></ul><ul><li>i. Postsplenectomy state </li></ul><ul><li>j. Chronic alcohol abuse or malnutrition </li></ul>
  38. 39. Decision to Hospitalize <ul><li>3. Physical findings </li></ul><ul><li>a. Respiratory rate > 30 breaths/min </li></ul><ul><li>b. DBP 60 mmHg or a SBP 90 mmHg </li></ul><ul><li>c. Temperature >38.3º C (101º F) </li></ul><ul><li>d. Extrapulmonary sites of disease e.g, presence of </li></ul><ul><li>septic arthritis, meningitis, etc. </li></ul><ul><li>e. Confusion and/or decreased level of </li></ul><ul><li>consciousness </li></ul>
  39. 40. Decision to Hospitalize <ul><li>4. Laboratory findings </li></ul><ul><li>a. WBC <4,000/mcL or >30,000/mcL </li></ul><ul><li>b. Pao2 <60 mmHg or Paco2 of >50 mmHg on room air. </li></ul><ul><li>c. Need for mechanical ventilation. </li></ul><ul><li>d. Serum creatinine >1.2 mg/dl or BUN >20 mg/dl (>7 mmol/L) </li></ul><ul><li>e. Unfavorable chest radiographic findings: - more than one lobe involvement - presence of a cavity - rapid radiographic spread - pleural effusion </li></ul><ul><li>f. Hct of <30 % or hemoglobin <9 g/dl </li></ul><ul><li>g. Evidence of sepsis or organ dysfunction as manifested by a metabolic acidosis, an increased PT, an increased PTT, decreased platelets, fibrin split products > 1:40 </li></ul>
  40. 41. General Management of CAP In hospital <ul><li>All patients should receive supplemental oxygen </li></ul><ul><li>Assess for volume depletion </li></ul><ul><li>CXR should be repeated in patients not showing clinical response </li></ul><ul><li>Role of Bronchoscopy ? (Retained secretions, Samples for culture, Exclude endobronchial abnormality) </li></ul>
  41. 42. Therapy Principles <ul><li>All admitted patients should receive first antibiotic dose within 8 hours of arrival to the hospital </li></ul><ul><li>All populations should be treated for the possibility of atypical pathogens </li></ul><ul><li>Upto 10% of all CAP patients will not respond to initial therapy. A diagnostic evaluation is mandatory </li></ul>
  42. 43. What antibiotics to use ? <ul><li>Group 1: Outpatients, age < 60, no cardiopulmonary disease </li></ul><ul><li>Erythromycin or other Macrolides </li></ul><ul><li>(Erythromycin is not active against H.influenzae and newer macrolides are better tolerated) </li></ul><ul><li>Amoxicillin (high dose) </li></ul><ul><li>Amoxicillin/Clavulanate </li></ul><ul><li>Doxycycline (many isolates of S.pneumo are resistant to tetracycline) </li></ul>
  43. 44. What antibiotics to use? <ul><li>Group 2: Outpatients, age >60, with co-existing diseases and/or modifying factors </li></ul><ul><li>Amoxicillin + Macrolide </li></ul><ul><li>Amox/Clav + Macrolide </li></ul><ul><li>Cefuroxime + Macrolide </li></ul><ul><li>Antipneumococcal fluoroquinolone (used alone) </li></ul>
  44. 45. What antibiotics to use? <ul><li>Group 3: Inpatients, not in ICU </li></ul><ul><li>Intravenous Beta-lactam (Cefotaxime, Ceftriaxone) + Intravenous/Oral Macrolide </li></ul><ul><li>Intravenous antipneumococcal FQ </li></ul><ul><li>used alone (Levofloxacin, Sparfloxacin, Grepafloxacin) </li></ul>
  45. 46. What antibiotics to use? <ul><li>Group 4: ICU-admitted patients </li></ul><ul><li>No risk for Pseudomonas aeruginosa </li></ul><ul><li>Intravenous Beta Lactam (Cefotaxime, Ceftriaxone, Penicillin/Beta lactamase inhibitor) </li></ul><ul><li>+ </li></ul><ul><li>IV Macrolide or IV Fluoroquinolone </li></ul>
  46. 47. What antibiotics to use? <ul><li>Group 4: ICU-admitted patients </li></ul><ul><li>Risks for Pseudomonas aeruginosa </li></ul><ul><li>Selected intravenous antipseudomonal Beta-lactam (Cefepime, Imipenem/Meropenem, Piperacillin/Tazobactam) + Intravenous antipseudomonal quinolone (Ciprofloxacin) or Intravenous aminoglycoside </li></ul>
  47. 48. ORAL OR PARENTERAL ANTIBIOTICS ? <ul><li>Parenteral </li></ul><ul><li>Severe Pneumonia </li></ul><ul><li>Impaired consciousness </li></ul><ul><li>Loss of swallowing reflex </li></ul><ul><li>Malabsorption, functional or anatomical </li></ul><ul><li>Oral </li></ul><ul><li>Community managed </li></ul><ul><li>Hospital managed, non-severe with no other contraindications </li></ul>
  48. 49. Clinical Response <ul><li>Most patients with CAP will have an adequate response within 3 days </li></ul>
  49. 50. Switch to oral therapy <ul><li>Resolution of fever for >24 hrs. </li></ul><ul><li>Resolution of tachypnoea </li></ul><ul><li>Pulse < 100 beats /min </li></ul><ul><li>Resolution of hypotension </li></ul><ul><li>Hydrated and taking oral fluids </li></ul><ul><li>Absence of hypoxia </li></ul><ul><li>Improving white cell count </li></ul><ul><li>Non-bacteremic infection </li></ul><ul><li>No concern over GI absorption </li></ul>
  50. 51. Duration of therapy <ul><li>Patients managed in community and admitted non-severe uncomplicated pneumonia: </li></ul><ul><li>07 DAYS THERAPY IS ENOUGH </li></ul>
  51. 52. Duration of therapy <ul><li>Patients with severe microbiologically undefined pneumonia: </li></ul><ul><li>10 DAYS THERAPY IS PROPOSED </li></ul><ul><li>Patients suffering from legionella, staphylococcal, or Gram negative enteric bacilli pneumonia: </li></ul><ul><li>14-21 DAYS THERAPY IS RECOMMENDED </li></ul>
  52. 53. Complications of Pneumonia
  54. 57. Non Resolving Pneumonia <ul><li>Consider other diagnosis </li></ul><ul><li>TB </li></ul><ul><li>Lung Cancer </li></ul><ul><li>Fungal pneumonia </li></ul><ul><li>Foreign body inhalation </li></ul><ul><li>BOOP, Eosinophilic pneumonias, Sarcoidosis </li></ul><ul><li>Pulmonary embolism </li></ul><ul><li>Pulmonary hemorrhage </li></ul><ul><li>Heart failure </li></ul>
  55. 58. Correct Diagnosis but Fail to Respond <ul><li>Host : Obstruction, Foreign body, Superinfection, Empyema </li></ul><ul><li>Drug : Error in drug selection, dose or route, Compliance, Drug interaction </li></ul><ul><li>Pathogen : Nonbacterial, Resistant </li></ul>
  56. 59. SOME FACTS ABOUT CAP <ul><li>The etiologic agent causing CAP cannot be accurately predicted from clinical or radiological features </li></ul><ul><li>The term ‘ atypical pneumonia ’ should be abandoned </li></ul><ul><li>Elderly patients with CAP more frequently present with non specific symptoms and are less likely to have fever </li></ul><ul><li>Radiological resolution lags behind clinical improvement </li></ul><ul><li>Radiological resolution is slow in the elderly and cases of multilobar involvement. </li></ul>
  57. 60. Prevention <ul><li>23-valent polysaccharide pneumococcal vaccine </li></ul><ul><li>90 percent of the serotypes are included in the 23 valent vaccine </li></ul><ul><li>70 % response in the general population </li></ul><ul><li>Lower in immunocompromised patients and those on maintenance dialysis </li></ul>
  58. 61. Prevention <ul><li>Target hosts at greatest risk for pneumococcal disease </li></ul><ul><li>- > 65 yrs </li></ul><ul><li>- Chronic cardiovascular and pulmonary disease </li></ul><ul><li>- Metabolic diseases, alcoholism, cirrhosis, nephrotic syndrome </li></ul><ul><li>- Immunosuppression, asplenia </li></ul><ul><li>- Lymphoma, multiple myeloma </li></ul>
  59. 62. Prevention <ul><li>Influenza vaccine </li></ul><ul><li>Younger patients at risk </li></ul><ul><li>- Chronic cardiovascular and pulmonary diseases </li></ul><ul><li>- Renal and metabolic disease </li></ul><ul><li>- Immune deficiency </li></ul><ul><li>- Nursing home residents and health care workers </li></ul>
  60. 63. Thank You!