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Pneumonia ד"ר אורי לקסר מכון הראה בית החולים האוניברסיטאי הדסה.

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Presentation on theme: "Pneumonia ד"ר אורי לקסר מכון הראה בית החולים האוניברסיטאי הדסה."— Presentation transcript:

1 Pneumonia ד"ר אורי לקסר מכון הראה בית החולים האוניברסיטאי הדסה

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4 DEFINITIONS Pneumonitis is a general term for inflammation of the lungs. Pneumonia is an inflammation of the lungs with consolidation, usually due to an infectious agent.

5 Pneumonia: “The Old Man’s Best Friend” Sixth leading cause of death in the US Leading infectious cause of death in the US

6 Case Presentation 1 Mr “T”, a 45 year old male Fever, and rigors started 12h earlier Cough with purulent sputum Looks unwell, pale Tachycardia, tachypnea (20 breaths/min) On chest examination: signs of RLL consolidation

7 Case presentation 1

8 Case presentation 2 Mr “A”, a 45 year old male Fever - low grade, intermittent, started one week ago. Dry cough with occasional mucoid sputum Looks unwell and pale. No signs of distress On examination: few crackles over LUL

9 Case presentation 2

10 Clinical Management Assessment – Diagnosis – Severity – Etiology (pathogen) Treatment – Antibiotic Rx Empiric Specific – Supportive treatment

11 Clinical Presentation Fever +/- rigors Cough – dry or productive Chest pain Dyspnea, respiratory distress Crackles +/- signs of consolidation Abnormal X-ray

12 Chest X-Ray Important in order to Distinguish pneumonia from acute bronchitis Identify complications –Abscess / cavitation –Pleural effusion Monitor progress

13 RLL Infiltrate

14 Pathogens - Common Streptococcus pneumoniae Haemophilus influenzae Mycoplasma pneumoniae Chlamydia pneumoniae Respiratory viruses S. pneumoniae is the most common pathogen in CAP!

15 Pneumococcal Pneumonia: Right upper-lobe consolidation with air bronchogram. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4 th edition (2001)

16 Pneumococcal pneumonia: Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4 th edition (2001) Bilateral lower-zone consolidation (arrows). Although pneumococcal pneumonia is typically unifocal, multifocal involvement is not uncommon.

17 Typical broncho- pneumonic pattern. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4 th edition (2001) H. Influenzae pneumonia:

18 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, 4 th edition (2001) Mycoplasma pneumoniae pneumonia:

19 Viral Pneumonia Epidemic - Influenza virus, SARS Sporadic - RSV, adenovirus, parainfluenza, varicella, measles, (hantavirus) CXR - interstitial pattern May be complicated by bacterial superinfection!

20 The predominant opacities are 5–10 mm nodules, confluent in parts. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4 th edition (2001) Varicella pneumonia:

21 Measles pneumonia. An example of a widespread primary viral pneumonia with extensive bilateral confluent consolidation. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4 th edition (2001)

22 Other Pathogens Gram negative –Klebsiella pneumoniae, E. Coli, Pseudomonas Staph. aureus Anaerobes Legionella (Endemic fungi) Tuberculosis

23 Legionella Pneumonia Increased risk in: – elderly – co-morbid illness – immunosuppressed Extra-pulmonary manifestations: – Neurologic – Gastrointestinal – Articular

24 Legionella Pneumonia Recommended treatment: – Macrolides – Fluoroquinolones

25 Suspect anaerobic bacteria in the presence of: – Predisposing condition for aspiration – Periodontal disease – Putrid sputum – Failure to recover likely pulmonary pathogens with cultures of expectorated sputum – Radiological evidence of pulmonary necrosis Anaerobic Pneumonia

26 Increased risk of complications: – lung abscess – pleural empyema Recommended treatment: – Clindamycin – Amoxicillin/Clavulanic Acid

27 Typical vs. Atypical Pneumonia AtypicalTypical SubacuteAbruptOnset Mild fever, Mucoid sputumHigh fever, Rigors Pleurisy, Purulent sputum Symptoms CracklesConsolidationPhysical Examination Variable/ NormalHighWBC InterstitialLobar, SegmentalCXR Mycoplasma, ChlamydiaS. pneumoniae, H. influenzaePathogens

28 Clinical Management The clinical setting in which pneumonia occurs is important in determining the likely pathogen(s).

29 Clinical Setting of Pneumonia Community acquired pneumonia (CAP) Nosocomial pneumonia Nursing home residents Recent antibiotic therapy Age (elderly, neonate) Aspiration pneumonia Geographical location/recent travel Immunocompromised host

30 Clinical Setting: Community Acquired Pneumonia S. pneumoniae H. influenzae Mycoplasma pneumoniae Chlamydia pneumoniae Respiratory viruses S. pneumoniae is the most common pathogen in CAP, no matter what the clinical context!

31 Clinical Setting: Hospital Acquired Pneumonia Early onset (<5 days) - increased risk of: Gram negative S. aureus Drug resistant S. pneumoniae Legionella Similar pattern in nursing home residents!

32 Clinical Setting: Hospital Acquired Pneumonia Late onset (≥5 days) – pathogens with multidrug resistance likely: Methicillin resistant S. aureus (MRSA) Pseudomonas, Acinetobacter Local epidemiology very important!

33 Clinical Setting: Recent Antibiotic Therapy Definition: course of antibiotics for any infection in the past 3 months Increased risk of: –Drug resistant S.pneumoniae –Gram negative bacilli

34 Clinical Setting: Elderly Patient Increased risk of: drug resistant S. pneumoniae Legionella

35 Clinical Setting: Geographical Location Consider recent travel! Geographical patterns of drug resistance (S. pneumoniae) Locations endemic for: – TB – Fungi (histoplasma) – Viruses (SARS, avian flu)

36 Diagnostic Testing CXR Pulse oximetry or arterial blood gases In hospitalized patients also: Blood count Electrolytes, renal function, liver function Cultures: –Sputum gram stain and culture –2 Blood cultures –Pleural fluid biochem., gram stain & culture

37 Diagnostic Testing: Cultures Cultures probably not justified in ambulatory pts. Low sensitivity of cultures: 40-60% of patients are not diagnosed despite extensive testing. Incidence of mixed infection unclear In immunocompromised hosts, invasive techniques often required due to wider range of potential pathogens.

38 Sputum Gram Stain: Infectious Diseases Society of America Guideline 2000 Recommend using Gram's stain to narrow initial empiric therapy in patients

39 Clinical Management The severity of a case of pneumonia determines: Placement (ambulatory care, hospitalization, intensive care) Tolerance for potential treatment failure Supportive treatment needs Prognosis

40 PORT Clinical Prediction Rule: Criteria for Determining Severity (1) I. Demographic Age Sex Nursing home residence II. Comorbidity Cancer Chronic liver disease Heart failure Cerebrovascular disease Chronic renal disease

41 PORT Clinical Prediction Rule: Criteria for Determining Severity (2) III. Physical Findings Altered mental status Tachypnea Hypotension Fever / Hypothermia Tachycardia IV. Laboratory Acidosis Azotemia Hyponatremia Hyperglycemia Anemia Hypoxemia Pleural effusion

42 PORT Rule: Mortality by Risk Class Fine et al., N Engl J Med (1997) 336: 243–50 ScoreClass -I ≥70II 71-90III IV >130V

43 Initial Site of Care Ambulatory Hospital Ward ICU Factors: –PORT risk class –Psychosocial factors –Co-morbidities Prediction rules are meant to contribute to, rather than supersede, physician judgement!

44 Clinical Management Assessment – Diagnosis – Etiology (pathogen) – Severity Treatment – Antibiotic Rx – Supportive treatment

45 Macrolides Erythromycin(PO), IV RoxithromycinPO AzithromycinPO, IV ClarithromycinPO “advanced macrolides” (A-Macs)

46 Drug Resistant Pneumococcus Refers to resistance to Penicillin –Intermediate level MIC mcg/ml –High level MIC >2.0 mcg/ml In vitro co-resistance to other AB In vitro resistance does not always predict clinical treatment failure.

47 Drug Resistant Pneumococcus: Risk Factors Geographic areas with high prevalence Age > 65 Recent  -lactam therapy (within 3 mo) Exposure to children in day care centers Multiple co-morbidities Immunosuppression

48 Empiric Antibiotic Therapy Empiric therapy is chosen to cover the most likely pathogens in the individual patient. Consider: –Typical vs. atypical pneumonia syndrome –Comorbid illness –Resistant Streptococci or gram negative bacteria –Old age/ residence in nursing facilities –Risk of aspiration

49 Empiric Antibiotic Therapy In severely ill patients - low failure rate is imperative Caution in immunocompromised hosts Important to: –Monitor clinical response –Revise according to culture results

50 Supportive Treatment Appropriate monitoring Oxygen, ventilatory support Fluids, electrolytes and nutrition Bronchodilators Physiotherapy

51 Patient Not Responding to Treatment Patient not receiving treatment non-compliance, enteral drug not absorbed, staff error Resistant organism Suppurative complication lung abscess, pleural empyema, obstructed bronchus Alternative diagnosis Drug fever

52 Patient Not Responding to Treatment Suppurative Complications : Empyema

53 Patient Not Responding to Treatment Suppurative Complications : Lung Abscess

54 Prevention Stop smoking! Influenza vaccine Pneumococcal vaccine (Pneumovax) Prevent aspiration

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