Gabriella Gálffy

Pulmonology Hospital

Törökbálint

Hungary

Pneumonia

Pneumonia

• Very common (1-10/1000), significant mortality

• Severity assessment, aided by score, is a key

management step

• Caused by a variety of different pathogens

• Antibiotic treatment initially nearly always empirical, local

guidelines and microbial resistance rates may support it

Definition

Acute, infectious inflammation of the

lower respiratory tract parenchyma

(distal to bronchiolus terminalis).

Pathogens

• Bacteria /aerobic,anaerobic, atypical/

• Virus /influenza ,parainfluenza,

adenovirus,

herpesvirus,cytomegalovirus, RSV/

• Fungi /Aspergillus,Candida/

• Parasites /Pneumocystis jiroveci,

Toxoplasma gondii,Ascaris

lumbricoides/

Clinical classification

• Community-acquired, CAP

• Nosocomial, hospital-acquired, HAP, VAP

• Aspiration and anaerobic

• Pneumonia in the immuncompromised host

• AIDS-related

• Reccurent

• Pneumonias peculiar to specific geographical

areas

Epidemiology of CAP

Mycoplaspa pn.

Chlamydia pn.

Pathogenesis

• Inhalation of infected droplets

• Aspiration /residents from nasopharynx/

• Spread through bloodstream

• Direkt spread (concomittant)

Risk factors

• Prolonged supine position

• Antibiotics, antacids

• Patient contact

• Decreased defense mechanisms

• Infected health care materials

Etiology

• 1. Streptococcus pneumoniae 40-60%

• 2. Mycoplasma pneumoniae 10-20%

• 3. Haemophilus influenzae 6-10%

• 4. Influenza A 5-8%

Clinical features I.

• General symptoms

– malaise, anorexia

– sweating, rigors

– myalgia, arthralgia

– headache

– fast (bacteremia) vs. slow (Mycoplasma) progression

– marked confusion (Legionella, psittacosis)

– acute abdominal or urinary problem (lower lobe, age!)

• Respiratory symptoms

- cough, dsypnea, pleural pain

- purulent sputum, hemoptysis

• Physical signs

- high fever and rigor (Pneumococus)

- little or no fever (elderly, seriously ill)

- herpes labialis (Pneumococcus)

- dullness, inspiratory crackles, bronchial breathing

- upper abd. tenderness (lower lobe)

- rash (antibiotic, mycoplasma, psittacosis)

Clinical features II.

Differential diagnosis

• Pulmonary infarction

• Atypical pulmonary oedema

• Less common: pulmonary eosinophilia,

acute allergic alveolitis, lung tumours

• Diseases below the diaphragm: hepatic

abscess, appendicitis, pancreatitis,

perforated ulcer

Investigations

• Chest x-ray (lateral!, neoplasm) – compulsory

• WBC , >30 or < 4 G/L: poor prognosis

• Sputum Gram stain and culture

• Blood culture (20-25% positive)

• Pleural fluid (25%, exclude empyema: pH!)

• Serology (atipical, viral), antigen detection (Legionella, Pneumococcus)

• Invasive tests: uncontaminated LRT secretions (BAL,PBS) or lung biopsies

Radiological features

• Lobar or segmental opacification

• Patchy shadows

• Small pleural effusions

• Cavitation (infrequent, Staphylococcus, Pneumococcus serotype 3)

• Spread to more than one lobe (Legionella. Mycoplasma)

• Clearance of shadow may last for months

Treatment at home or in hospital ?

CAP PORT (NEJM 1997, 40 000 patients)

• male age

• female age – 10

• elderly’s home +10

• Neoplasia +30

• Liver dis. +20

• CHF +10

• Cerebrovasc. +10

• Renal dis.

+10

• Confusion +20

• Pleurisy +10

• Resp.rate > 30 +20

• RR<90 +20

• Temp.<35 v. >40 +15

• Pulse>125 +10

• pH<7,35 +30

• UN>11 +20

• Na<130 +20

• Se glucose>13,9 +10

• Htk<30% +10

• PaO2<60 Hgmm

+10

PORT categories

• I.-II. <70, mortality < 1%, outpatient

• III. 70-90, mortality 2,8%, short hospital,

sequential ATB

• IV. 91-130, mortality 8,2%, hospital

• V. >130, mortality 29,2%, consider ICU

CURB65 score (1-1point)

C Mental confusion

U UN > 7 mM/L

R Respiratory rate > 30/min

B RR<90/60 mmHg

65 Age > 65 years

Mild: 0-1point, 1.5% mortality

Moderate: 2point, 9% mortalility

Severe: 3-5 point, 22% mortalitty

“Ten commandments” of CAP

treatment

• Only a few pathogens are involved

• Always cover Pneumococcus

• Consider epidemiology, age and health status

• Mycoplasma during epidemics, Staph.aur. in flu

• Do not delay starting antibiotics

• Assess prognostic factors and severity early

• Establish etiology quickly

• Adequate oxygen, hydration and nutrition

• Careful monitoring –transfer early to ICU

• Initial antibiotics must cover all the likely pathogens

All Severe

Treatment of CAP

1) <65 year, no comorbidity, home: macrolide,

doxycyclin,

amoxycillin/clavulanic acid, 2. gen. cephalosporin

2) >65 year, comorbidity, home: amoxycillin/clavulanic

acid, 2-3 gen. cephalosporin +- macrolide, respiratory

fluoroquinolon (levofloxacin, moxifloxacin)

3) hospital: amoxycillin/clavulanic acid, 2-3 gen.

cephalosporin + macrolide, resp.fluoroquinolon

4) ICU: ceftriaxon/cefotaxim, cefepim, carbapenemes

(imipenem, meropenem), piperacillin/tazobactam +

macrolides, resp. fluoroquinolon

Risk factors of nosocomial pneumonia, HAP

Pathogens and treatment of non-severe HAP

‘Core’ pathogens ‘Core’ antibiotics

Gram-neg.

Enterobacteriaceae:

E. coli, Klebsiella spp.,

Proteus spp,

Serratia marcescens,

Enterobacter spp.

‘Usual’ community pa-

thogens:Pneumococcus,

H.influenzae,Staph.aureus

2nd- or 3 rd- gen

cephalosporins,

beta-lactam/lactamase

inhibitor,

fluoroquinolones

Pathogens and treatment of non-severe HAP

with additional risk factors

‘Core’ path. plus Risk factor ‘Core’ ant. plus

Anaerobes Surgery, impaired swal-

loing, aspiration, dental

sepsis

clindamycin,beta-

lactam + inhibitor,

moxifloxacin

Staph.aureus Diabetes,renal failure, coma,

head trauma, neurosurgery

add vancomycin if

MRSA susp.

Legionella spp High dose steroid, endemic

in hospital

macrolides +-fluo-

roquinolones+- rifam.

Pseuodomonas

aeruginosa

prior ant., high dose ster.

ICU, CF,bronchiectasia

ciprofloxacin,amino-

glycoside,3rd gen ceph.

with antipseud. act.

Pathogens and treatment of severe HAP

‘Core’ pathogens plus ‘Core’ antibiotics

Pseudomonas

aeruginosa,

Acinetobacter spp,

MRSA

ciprofloxacin or

aminoglycoside,

plus one of:

antipseudomonal beta-

lactam,

meropenem,

vancomycin

Reccurent pneumonia (GERD)

Streptococcus

pneumoniae

Streptococcus pneumoniae• Most common bacterium in adults

• Significant morbidity and mortality

• Polysaccharide capsule impairs phagocytosis

need of opsonization risk population: lymphoma,

hyposplenia, hypogammaglobulinaemia

• Abrupt onset, cough, rigors, high fever, tachycardia, tachypnoe, sticky pink sputum, focal crackles,

• Sputum Gram stain: diplococcus, blood culture (20% pos.)

• Good sputum sample: LRT: > 25 PMN, < 10 EC (low power field)

• X-ray: homogenouos consolidation

• Complications: pleura, pericardium, meninges, joints, endocardium, Type 3: abscess, lung scarring

Streptococcus pneumoniae II.

• Treatment:

– Penicillin, ampicillin, amoxycillin

– Cephalosporins 2-3 gen.

– Macrolides

– Carbapenems (imipenem, meropenem)

• Prevention

– 23 or 8-valent vaccines, 90% adult types

– Chronic lung, heart, liver, renal disease,

HIV

– Diabetes, after spelenctomy, sickle-cell

disease

Mycoplasma pneumoniae

Mycoplasma pneumoniae

(Atypical pneumonia)

• Atypical pathogen, moderate morbidity, low mortality

• Close communities (schools, barracks, dormitories)

• Intracellular pathogen (Chlamydia, Legionella)

• Patchy, inhomogenous consolidation on X-ray

• Extrapulmonary manifestations: lymphadenopathy,

cardiac, neurological, skin lesions,

gatrointestinal,haematological, musculoskeletal

• Treatment: macrolides, tetracyclin, fluoroquinolones

Legionella pneumophila

Staphylococcus

aureus

Staphylococcus aureus

• High morbidity and mortality (30-70% in

bacterae-mia)

• 30% of adults carry in the anterior nares

• Intravascular tubes (catheters, cannules)

• Usually follows influenza infections

• Toxins tissue necrosis abscess

• Treatment: beta-lactamase resistant penicillins

(oxacillin), cephalosporins, MRSA: vancomycin

Lung abscess

• many other cavitating lesions than abscess

• careful review of chest x-ray to distinguish from empyema

• most are secondary to aspiration of oropharyngeal secretions

• exclude malignancy or other cause, bronchoscopy!

• a single microbe is unusual unless abscesses developed after bacterial pneumonia. More commonly, there is a mixed growth, including anaerobes

Key points

Causes of lung abscess

• Aspiration from the oropharynx

• Bronchial obstruction

• Pneumonia

• Blood-borne infection

• Infected pulmonary infarct

• Trauma

• Transdiagphragmatic spread

Diff. dg of lung abscess

• Cavitated tumour

• Infected bulla or cyst

• Localised saccular bronchiectatsis

• Aspergilloma

• Wegener’s granulomatosis

• Hydatid cyst

• Coal workres’ pneumoconiosis

- progressive massive fibrosis

- Caplan’s sy

• Cavitated rheumatoid nodule

• Gas-fluid level in oesophagus, stomach or bowel

Treatment of lung abscess

• Based on bacteriologic findings

• Penicillin (amoxicillin/clavulanic acid)

• Clindamycin + aminoglycosid (mixed

flora)

• moxifloxacin

Thank You for yout

attention!