PNEUMONIA IN DAILY PRACTICE

PNEUMONIA IN DAILY PRACTICE

Ananda Wibawanta Ginting, MD

THE 7TH JAKARTA INTERNATIONAL CHEST AND CRITICAL CARE INTERNAL MEDICINE (JICCIM)

6-7 APRIL, 2019

HISTORY• Was described 2,500 years ago by

Hippocrates

• William osler: captain of the men of

death

• 1930: the third leading cause of

death in USA

• “The Winter fever”

Figure 1. Pneumonia ranks third... Sources:

States U, Osler W. Whom does it affect?

2006;155–63.

DEFINITION

• Pneumonia is an inflammation of the lung, usually caused by an infection

• The most common cause: bacterial, virus, fungi

• Classification: community-acquired pneumonia (CAP); hospital-acquired

pneumonia (HAP); and ventilator-associated pneumonia (VAP)

• Can be transmitted by the aspiration or by inhalation of a pathogenic

microorganism

EPIDEMIOLOGY

Figure 2. Top 10 global causes of deaths, 2016.

Source: Global health estimates 2016: Deaths

by cause, age, sex, country and by region,

2000-2016. Geneva. WHO; 2018

Figure 3. Top 10 causes of death in 2017 and

percent change, 2007-2017, all ages, number.

Sources: http://www.healthdata.org/indonesia

http://www.healthdata.org/indonesia

• Pneumonia is caused by the invasion and

overgrowth of pathogens in the lung parenchym

• Infection can also spread from the lungs,

causing complications such as bacteraemia,

sepsis, meningitis, empyema and septic

embolism

• Summary pathogenesis of pneumonia are:

• Alteration of normal oropharyngeal flora

• Depressed cough and glottis reflexes

• Altered consciousness

• Impaired mucocilliary apparatus

mechanism

• Alveolar macrophage dysfunction

• Immune dysfunction

PATHOLOGY AND PATHOGENESIS

Table 1. Pathophysiological modes of spread.

Source: Singh Y D, Pathophysiology of community

acquired pneumonia

• Not always necessary

• Recommendations etiologic testing: patients with severe CAP or CAP unresponsive to the initial empiric treatment regimen, and ICU patients (VAP).

• In selected cases: galactomannan and (1-3)-β-D-glucan tests for fungi, the latest antigen or molecular biology tests for viruses and atypical pathogens

• Streptococcus pneumoniae (pneumococcus) is the most common pathogen causing community-acquired pneumonia.

• Hospital: wide range of pathogens (the patients and the hospital environment). Gram negative bacteria are more frequent than Gram-positive bacteria in these cases

MICROBIAL ETIOLOGY OF PNEUMONIA

Figure 5. Pathogen associated with early-onset and late-onset pneumonia.

Sources: Cilloniz C et al. Int. J. Mol. Sci. 2016, 17, 2120

INVESTIGATIONS DIAGNOSTIC

History and Physical

Examination

Imaging Methods

Laboratorium and

biomarkers

Scoring systems

criteria

Source: Kaysin A, Viera AJ, Carolina N, Hill C, Carolina N.

Community-Acquired Pneumonia in Adults: Diagnosis and

Management. 2016;

Table 2. Risk Factors and Pathogens in

Community-Acquired Pneumonia

INVESTIGATIONS DIAGNOSTICHistory and Physical

Examination

Table 3. Factors associated with community-acquired pneumonia Bartolf A, Cosgrove C, Pneumonia, Medicine (2016), Torres A, et al.

Thorax 2013;68:1057–1065.

Figure 6. The impact of age on the incidence of patients hospitalized with community-

acquired pneumonia. Sources: Ramirez et al. Adults With Pneumonia: Incidence and

Mortality. CID 2017:65

Figure 7. The impact of comorbid conditions on the incidence of patients hospitalized

with community-acquired pneumonia. Sources: Ramirez et al. Adults With Pneumonia:

Incidence and Mortality. CID 2017:65

Table 4. Risk factors for drug-resistant pneumonia pathogens. Sources:

Rider AC. Community acquired pneumonia. Emerg Med Clin N Am 2018.

SYMPTOMS

• Productive cough

• Fever

• Chest pain

• Dyspnea

• Haemoptysis

• Decreased exercise tolerance

• Abdominal pain

• Malaise

• Non specific symptoms

SIGNS AND SYMPTOMSSIGNS

• Reduced expansions

• Crackles

• Bronchial breathing

• Reduced breath sound

• Lymphadenopathy

• High or low temperature,

• Tachypnoea

• Use of accessory muscles,

• Tachycardia

• Cyanosis

• Altered mental status


History and Physical

Examination

INVESTIGATIONS DIAGNOSTICImaging Methods

• Chest Radiography: Standard method of diagnosing pneumonia.

differentiate lobar and bronchopneumonia and it can reveal cavitation,

effusion or air bronchograms.

• Further imaging, for example ultrasonography or computed

tomography, can be warranted in certain situations

• Lung ultrasonography has the potential to more accurately and

efficiently diagnose pneumonia, as well as pleural effusions,

pneumothorax, pulmonary embolism, and pulmonary contusions

• Chest CT is the most sensitive method for identifying infectious

involvement of the lung parenchym.


Laboratorium and

biomarkers

• Blood tests: CBC, inflammatory markers, RFT and LFT and oxygen

saturation (blood gasses analysis)

• Sputum and blood cultures

• Urinary antigen tests for pneumococcal and legionella, nasopharyngeal

samples

• Inflammatory markers: CRP, Procalcitonin

• HIV testing, tuberculosis, PCP: high risk sexual exposures or history of

injection drug use

• For people presenting with symptoms of lower respiratory tract infection in

primary care, consider C-reactive protein test if after clinical assessment a

diagnosis of pneumonia has not been made and it is not clear whether

antibiotics should be prescribed

C-reactive protein test to guide antibiotic prescribing in people without a

clinical diagnosis of pneumonia

• CRP < 20 mg/litre: Do not routinely offer antibiotic

• CRP 20-100 mg/litre: Consider a delayed antibiotic prescription (a

prescription for use at a later if symptoms worsen)

• CRP > 100 mg/litre: Offer antibiotic therapy if the C-reactive protein

INVESTIGATIONS DIAGNOSTICLaboratorium and

biomarkers

Figure 8. Serum procalcitonin (PCT) levels in community-acquired pneumonia (CAP). Adapted

from Julián-Jiménez et al.


biomarkers

Table 8. Diagnostic testing in patients with suspected CAP. Sources: , Kaysin A, Vera JA.

Community Acquired Pneumonia in Adults: Diagnosis and Management. American Family

Physician Volume 94, Number 9 November 1 2016


biomarkers

Table 9. Samples and Diagnostic Testing in Pneumonia. Sources: Cilloniz et al, Int. J. Mol.

Sci. 2016, 17, 2120

INVESTIGATIONS DIAGNOSTICScoring systems

• Patients with a diagnosis of CAP should always be assessed for disease

severity, a precaution that has a direct positive impact on mortality

• PSI, CURB 65, SMART-COP, SCAP 2007 IDSA/ATS guidelines

Table 10. Pneumonia Severity Index Scoring and Risk stratification by the Pneumonia

Severity Index. Adapted from Correa et al.


Figure 9. CURB-65 score and suggested site of care for patients with community-acquired pneumonia. CURB-

65: mental Confusion; Urea > 50 mg/dL; Respiratory rate > 30 breaths/min; Blood pressure (systolic < 90 mmHg

or diastolic < 60 mmHg); and age ≥ 65 years; and CAP: community-acquired pneumonia. Adapted from Correa et

al.


Table 11. Criteria for severe acquired CAP. Adapted from Kaysin A, Vera JA.

Community Acquired Pneumonia in Adults: Diagnosis and Management. American

Family Physician Volume 94, Number 9 November 1 2016

Figure 10. Risk stratification in the emergency room. Sources: Kolditz M et al



Figure 12. Does patient have pneumonia, an alternative diagnosis, or

perhaps both?


Figure 13. Profile of disease severity


Table 12. The Clinical Pulmonary Infection score (CPIS). Source: Basyigit S et al.

• Simple tool for the diagnosis of VAP is a scoring system which

included 7 clinical parameters for VAP diagnosis

• Pneumonia can be prevented by the use of pneumococcal and

influenza vaccines in appropriate at risk populations.

• Smoking cessation should be promoted in all patients.

• Patients with severe pneumonia or a sepsis syndrome should have

antibiotic treatment within an hour, fluid resuscitation, oxygen therapy

and close observation with additional supportive treatment

• The initial antibiotic regimen is determined empirically

TREATMENT

Low-severity CAP• 5-day course of a single antibiotic to patients with low-severity CAP

pneumonia.

• Consider extending the course of the antibiotic for longer than 5 days as a

possible management strategy for patients with low-severity CAP whose

symptoms do not improve

• Do not routinely offer patients with low-severity CAP: a fluoroquinolone, dual

antibiotic therapy.

Moderate- and high-severity CAP

• Consider a 7- to 10-day course of antibiotic therapy for patients with moderate or

high-severity CAP.

• Consider dual antibiotic therapy with amoxicillin and a macrolide for patients

with moderate-severity CAP.

• Consider dual antibiotic therapy with a beta-lactam and a macrolide for patients with

high-severity CAP.

TREATMENT

Hospital-acquired pneumonia

Antibiotic therapy

• Offer antibiotic therapy as soon as possible after diagnosis, and certainly within

4 hours, to patients with HAP.

• Choose antibiotic therapy in accordance with local hospital policy (which should

take into account knowledge of local microbial pathogens) and clinical

circumstances for patients with HAP.

• Consider a 5- to 10-day course of antibiotic therapy for patients with HAP.

CAP is present

Outpatient therapy Inpatient therapy

No cardiopulmonary

disease, no modifiers

GROUP 1, TABLE 2

History of cardiopulmonary

disease, +/- modifiers

GROUP II, TABLE 3Mild-moderate illness Severe CAP

Cardiopulmonary disease +/or

modifiers

No Cardiopulmonary disease,

no modifiersNo Risk for P. Aeruginosa Risk for P. Aeruginosa

Group III, TABLE 4A Group III, TABLE 4B Group IV, TABLE 5A Group IV, TABLE 5B

TREATMENT

OUTPATIENT THERAPY

INPATIENT THERAPY

Table 13. Guideline recommendations on duration of antibiotic therapy for community-

acquired pneumonia. Sources: Correa et al. J Bras Pneumol. 2018;44(5):405-423

Table 14. Recommended Initial Empiric Antibiotic Therapy for Hospital-Acquired

Pneumonia (Non-Ventilator-Associated Pneumonia)

HAP TREATMENT

Table 15. Suggested Empiric Treatment Options for Clinically Suspected Ventilator-

Associated Pneumonia

VAP TREATMENT

PREVENTION

• Vaccination: influenza and pneumococcal

• Smoking cessation

• Immunocompromised patient should avoid close contact with person who

have lower respiratory tract infections

• Stop alcohol consumption

Ventilator-associated Pneumonia (VAP) Prevention Bundle. Sources: Miller F.

ATOTW 382- Ventilator associated pneumonia, june 2018

Do not routinely discharge patients with community-acquired pneumonia if in

the past 24 hours they have had 2 or more of the following findings:

• Temperature higher than 37.5°C

• Respiratory rate 24 breaths per minute or more

• Heart rate over 100 beats per minute

• Systolic blood pressure 90 mmHg or less

• Oxygen saturation under 90% on room air

• Abnormal mental status

• inability to eat without assistance.

DISCHARGE ATTENTION

Explain to patients with CAP that after starting treatment, their symptoms should

steadily improve, although the rate of improvement will vary with the severity of the

pneumonia.

1 week: fever should have resolved

4 weeks: chest pain and sputum production should have substantially reduced

6 weeks: cough and breathlessness should have substantially reduced

3 months: most symptoms should have resolved but fatigue may still be present

6 months: most people will feel back to normal.

PATIENT INFORMATION

COMPLICATIONS

Thank you

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PNEUMONIA IN DAILY PRACTICE