4DEFINITIONSPneumonitis is a general term for inflammation of the lungs.Pneumonia is an inflammation of the lungs with consolidation, usually due to an infectious agent.
5Pneumonia: “The Old Man’s Best Friend” Sixth leading cause of death in the USLeading infectious cause of death in the US
6Case Presentation 1 Mr “T” , a 45 year old male Fever, and rigors started 12h earlierCough with purulent sputumLooks unwell, paleTachycardia, tachypnea (20 breaths/min)On chest examination: signs of RLL consolidation
8Case presentation 2 Mr “A” , a 45 year old male Fever - low grade, intermittent, started one week ago.Dry cough with occasional mucoid sputumLooks unwell and pale. No signs of distressOn examination: few crackles over LUL
14Pathogens - Common Streptococcus pneumoniae Haemophilus influenzae Mycoplasma pneumoniaeChlamydia pneumoniaeRespiratory virusesS. pneumoniae is the most common pathogen in CAP!
15Pneumococcal Pneumonia: Right upper-lobe consolidation with air bronchogram. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th edition (2001)
16Pneumococcal pneumonia: Bilateral lower-zone consolidation (arrows). Although pneumococcal pneumonia is typically unifocal, multifocal involvement is not uncommon.Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th edition (2001)
17Typical broncho-pneumonic pattern. H. Influenzae pneumonia:Typical broncho-pneumonic pattern.Such infections are commonly basal.Grainger & Allison's Diagnostic Radiology:A Textbook of Medical Imaging, 4th edition (2001)
18Grainger & Allison's Diagnostic Radiology: Mycoplasma pneumoniae pneumonia:The CXR shows two patterns that are common with this infection: In the lower zone consolidation is homogeneous, whereas in the mid and upper zones it is heterogeneous and nodular.Grainger & Allison's Diagnostic Radiology:A Textbook of Medical Imaging, 4th edition (2001)
20The predominant opacities are 5–10 mm nodules, confluent in parts. Varicella pneumonia:The predominant opacities are 5–10 mm nodules, confluent in parts.Grainger & Allison's Diagnostic Radiology:A Textbook of Medical Imaging, 4th edition (2001)
21Measles pneumonia. An example of a widespread primary viral pneumonia with extensive bilateral confluent consolidation.Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th edition (2001)
25Anaerobic Pneumonia Suspect anaerobic bacteria in the presence of: Predisposing condition for aspirationPeriodontal diseasePutrid sputumFailure to recover likely pulmonary pathogens with cultures of expectorated sputumRadiological evidence of pulmonary necrosis
27Typical vs. Atypical Pneumonia SubacuteAbruptOnsetMild fever, Mucoid sputumHigh fever, RigorsPleurisy, Purulent sputumSymptomsCracklesConsolidationPhysical ExaminationVariable/ NormalHighWBCInterstitialLobar, SegmentalCXRMycoplasma, ChlamydiaS. pneumoniae, H. influenzaePathogens
28Clinical ManagementThe clinical setting in which pneumonia occurs is important in determining the likely pathogen(s).
29Clinical Setting of Pneumonia Community acquired pneumonia (CAP)Nosocomial pneumoniaNursing home residentsRecent antibiotic therapyAge (elderly, neonate)Aspiration pneumoniaGeographical location/recent travelImmunocompromised host
30Clinical Setting: Community Acquired Pneumonia S. pneumoniaeH. influenzaeMycoplasma pneumoniaeChlamydia pneumoniaeRespiratory virusesS. pneumoniae is the most common pathogen in CAP, no matter what the clinical context!
31Clinical Setting: Hospital Acquired Pneumonia Early onset (<5 days) - increased risk of:Gram negativeS. aureusDrug resistant S. pneumoniaeLegionellaSimilar pattern in nursing home residents!
32Clinical Setting: Hospital Acquired Pneumonia Late onset (≥5 days) – pathogens with multidrug resistance likely:Methicillin resistant S. aureus (MRSA)Pseudomonas, AcinetobacterLocal epidemiology very important!
33Clinical Setting: Recent Antibiotic Therapy Definition: course of antibiotics for any infection in the past 3 monthsIncreased risk of:Drug resistant S.pneumoniaeGram negative bacilli
34Clinical Setting: Elderly Patient Increased risk of:drug resistant S. pneumoniaeLegionella
35Clinical Setting: Geographical Location Consider recent travel!Geographical patterns of drug resistance (S. pneumoniae)Locations endemic for:TBFungi (histoplasma)Viruses (SARS, avian flu)
36Diagnostic Testing CXR Pulse oximetry or arterial blood gases In hospitalized patients also:Blood countElectrolytes, renal function, liver functionCultures:Sputum gram stain and culture2 Blood culturesPleural fluid biochem., gram stain & culture
37Diagnostic Testing: Cultures Cultures probably not justified in ambulatory pts.Low sensitivity of cultures: % of patients are not diagnosed despite extensive testing.Incidence of mixed infection unclearIn immunocompromised hosts, invasive techniques often required due to wider range of potential pathogens.
38Sputum Gram Stain: Infectious Diseases Society of America Guideline 2000 Recommend using Gram's stain to narrow initial empiric therapy in patientsSource: ATS guideline 2001
39Clinical Management The severity of a case of pneumonia determines: Placement (ambulatory care, hospitalization, intensive care)Tolerance for potential treatment failureSupportive treatment needsPrognosis
40PORT Clinical Prediction Rule: Criteria for Determining Severity (1) I. DemographicAgeSexNursing home residenceII. ComorbidityCancerChronic liver diseaseHeart failureCerebrovascular diseaseChronic renal disease
41PORT Clinical Prediction Rule: Criteria for Determining Severity (2) III. Physical FindingsAltered mental statusTachypneaHypotensionFever / HypothermiaTachycardiaIV. LaboratoryAcidosisAzotemiaHyponatremiaHyperglycemiaAnemiaHypoxemiaPleural effusion
42PORT Rule: Mortality by Risk Class ScoreClass-I≥70II71-90III91-130IV>130VBased on: Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-riskpatients with community-acquired pneumonia. N Engl J Med 1997; 336: 243–50 (Cited in IDSA guideline, 2000).Fine et al., N Engl J Med (1997) 336: 243–50
43Initial Site of Care Ambulatory Hospital Ward ICU Factors: PORT risk classPsychosocial factorsCo-morbiditiesPrediction rules are meant to contribute to, rather than supersede, physician judgement!
45Macrolides Erythromycin (PO), IV Roxithromycin PO Azithromycin PO, IV Clarithromycin“advanced macrolides” (A-Macs)
46Drug Resistant Pneumococcus Refers to resistance to PenicillinIntermediate level MIC mcg/mlHigh level MIC >2.0 mcg/mlIn vitro co-resistance to other ABIn vitro resistance does not always predict clinical treatment failure.
47Drug Resistant Pneumococcus: Risk Factors Geographic areas with high prevalenceAge > 65Recent -lactam therapy (within 3 mo)Exposure to children in day care centersMultiple co-morbiditiesImmunosuppression
48Empiric Antibiotic Therapy Empiric therapy is chosen to cover the most likely pathogens in the individual patient. Consider:Typical vs. atypical pneumonia syndromeComorbid illnessResistant Streptococci or gram negative bacteriaOld age/ residence in nursing facilitiesRisk of aspiration
49Empiric Antibiotic Therapy In severely ill patients - low failure rate is imperativeCaution in immunocompromised hostsImportant to:Monitor clinical responseRevise according to culture results
50Supportive Treatment Appropriate monitoring Oxygen, ventilatory supportFluids, electrolytes and nutritionBronchodilatorsPhysiotherapy
51Patient Not Responding to Treatment Patient not receiving treatmentnon-compliance, enteral drug not absorbed, staff errorResistant organismSuppurative complicationlung abscess, pleural empyema, obstructed bronchusAlternative diagnosisDrug fever
52Patient Not Responding to Treatment Suppurative Complications : Empyema
53Patient Not Responding to Treatment Suppurative Complications : Lung Abscess