2 Pneumonia is defined as inflammation and consolidation of the respiratory part of lung tissue (alveoli) due to an infectious agent.
3 Community-acquired pneumonia remains a common illness Community-acquired pneumonia remains a common illness. Pneumonia is the sixth leading cause of death in the the world and is the most common infectious cause of death.Pneumonia is the leading cause of death among hospital-acquired infections, and the mortality rates range from 20-50%.Advanced age increases the incidence of pneumonia and the mortality from it.
4 Causes of bacterial pneumonia include infection with respiratory pathogens.Exposure to pulmonary irritants or direct pulmonary injury causes noninfectious pneumonitis
5 Intrinsic factors that predispose pneumonia include 1)the host's immune response,2)the presence of comorbidities3) aspiration of oropharyngeal flora into the lung.4) local lung pathologies
6 Aspiration is facilitated by altered mental status from intoxication, deranged metabolic states, neurological causes (eg, stroke), and endotracheal intubation.Local lung pathologies (tumors, chronic obstructive pulmonary disease, bronchiectasis) are predisposing factors for bacterial pneumonia.Smoking impairs the host's defense to infection by a variety of mechanisms.
8 1. Pneumonia that develops outside the hospital setting is considered community-acquired pneumonia. 2. Pneumonia developing 48 hours or more after admission to the hospital is termed nosocomial or hospital-acquired pneumonia.
9 3. Aspiration pneumonia takes the special place due to high risk of lung tissue destruction and bad prognosis.4. Pneumonia in immunocompromised patients (those who receive immunodepressants, such as cytostatics or system steroids, HIV-infected persons on last stage).
10 Community-acquired pneumonia is caused most commonly by bacteria that traditionally have been divided into 2 groups, typical and atypical.
11 A. Typical organisms in community-acquired pneumonia (approximately 85%) includeStreptococcus pneumoniae (pneumococcus),Haemophilus influenzae (is associated with asthma and COPD), andMoraxella catarrhalis (in patients with chronic bronchitis).
12 S pneumoniae remains the most common agent responsible for community-acquired pneumonia.
13 Rare bacterial pathogens in community-acquired pneumonia are Klebsiella pneumoniae (in persons with chronic alcoholism),Staphylococcus aureus (in the setting of postviral influenza),Pseudomonas aeruginosa (in patients with bronchiectasis).
14 B. Atypical pathogens in community-acquired pneumonia (approximately 15%) areLegionella pneumophila,Mycoplasma pneumoniae,Chlamydia psittaci,Coxiella burnetii.
15 Do not mix community-acquired pneumonia due to atypical flora with “atypical pneumonia” due to virus (SARS – severe acute respiratory syndrome)!.
16 Typical (predominantly pneumococcal) pneumonia produces the following: a characteristic clinical pattern, with sudden onset of fever and shaking chills, pleuritic chest pain, and production of rust-colored sputum andradiological evidence of consolidation.examination of sputum in case of pneumococcal pneumonia shows gram-positive diplococci in chains.This clinical picture was recognized as “typical” (classical) pneumonia.
17 ”Atypical" community-acquired pneumonia Most patients present with a gradual onset of the disease without shaking chills.A prodrome of it consists of headache, photophobia, sore throat, and eventually a dry, nonproductive cough.Their sputum does not contain gram-positive diplococci (pneumococci).Although these patients were not feeling well, they were not critically ill.Laboratory evaluations showed white blood cell counts to be normal.
18 Hospital-acquired (nosocomial) pneumonia defines as pneumonia occurring more than 48 hours after admission to the hospital.It is a major cause of morbidity and mortality in hospitalized patients.
19 The most common organisms responsible for nosocomial pneumonia are Staphylococcus aureusKlebsiella pneumoniaeGram-negative pathogens:Enterobacter,Pseudomonas aeruginosa, andEscherichia coli.
20 S. aureus pneumonia generally occurs in those who abuse intravenous drugs: in hospitalized patients and patients with prosthetic devices; it spreads hematogenously to the lungs from contaminated local sites.Infection by Pseudomonas aeruginosa tend to cause pneumonia in the patients, requiring mechanical ventilation.
21 Essentials of diagnosis of community-acquired pneumonia Occurs in healthy personSudden onset of fever and shaking chills, cough, and production of rust-colored sputum sometimes accompanied by pleuritic chest pain due to pleurisyPhysical examination detects signs of consolidationCrackles in auscultationPulmonary infiltrate on chest x-ray.
22 Essentials of diagnosis of hospital-acquired (nosocomial) pneumonia Occurs more than 48 hours after admission to the hospital.One or more clinical findings (fever, cough, leukocytosis, purulent sputum) in most patients.Especially frequent in patients requiring intensive care and mechanical ventilation.Pulmonary infiltrate on chest x-ray.
23 Clinical presentation in patients with pneumonia varies from a mildly ill ambulatory patient to a critically ill patient with respiratory failure or septic shock.Typically, patients with pneumonia present with variable degrees of fever; they may report rigors or shaking chills.Pleuritic chest pain secondary to pleurisy is a common feature of pneumococcal infection, but these may occur in other bacterial pneumonias.
24 Clinical presentation in patients with pneumonia A productive cough is characteristic feature of pneumonia. The character of sputum may suggest a particular pathogen.Patients with pneumococcal pneumonia produce rust-colored sputum.Infections with Pseudomonas and Haemophilus are known to expectorate green sputum.Anaerobic infections produce foul-smelling sputum.Currant-jelly sputum suggests pneumonia from Klebsiella.
25 Clinical presentation in patients with pneumonia Malaise, myalgias, and exertional dyspnea may be observed.Patients may complain of other nonspecific symptoms, which includeheadaches,nausea, andvomiting.These symptoms are accompanied by intoxication.
26 A detaled past medical history and history of environmental and occupational exposures should be obtainedThis history should include whether the patient has recently traveled or had contact with animals that might serve as a source of an infectious agent.Patients may reportexposure to turkeys, chickens, ducks in case of Chlamydia psittaci infectionexposure to contaminated air-conditioning cooling towers in case of Legionella pneumophila infection.
27 Evaluation of host factors often provides a clue to the bacterial diagnosis Diabetic ketoacidosis may lead to S. pneumoniae or S. aureus infection.Alcoholism may indicate Klebsiella pneumoniae infection.Chronic obstructive lung disease may lead to Haemophilus influenzae or Moraxella catarrhalis infection.HIV infection may lead to Cryptococcus neoformans, Mycobacterium avium-intracellulare infection or Pneumocystis pneumonia.
28 Precise clinical diagnosis of nosocomial pneumonia is much more difficult than community-acquired pneumonia.It is because of the absence of a typical clinical picture against the background of the disease, which was the reason for hospitalization.The subclinical course without clear typical picture is widespread.However, one or more clinical findings (fever, leukocytosis, purulent sputum), and a pulmonary infiltrate on chest x-ray are present in most patients.
29 PhysicalA.The common symptoms and signs (due to intoxication and respiratory failure) are as follows:Fever (temperature >38.5°C)TachypneaTachycardiaCentral cyanosisThese symptoms are non-specific and indicate severity of the disease, not etiology. They can’t help to diagnose pneumonia, but they determine therapy and prognosis.
30 PhysicalB. The most important information on physical examination is connected with signs of lung tissue consolidation due to local inflammation:Dullness to percussionIncreased tactile fremitusDecreased intensity of breath soundsCrackles (crepitation) at the beginning and resolving of inflammationLocal ralesPleural friction rub
31 The main doctor’s task on physical examination is revealing of asymmetric pathology.Pneumonia is local respiratory pathology. Therefore, the presence of focal area of lung tissue consolidation has the most diagnostic value.It is direct indication for chest radiograph.
32 Imaging StudiesThe diagnosis of pneumonia is impossible without X-ray investigation.Direct indication for chest X-ray is not only focal acoustic pathology but also any clinical situation accompanied by chronic or prolonged cough.
33 Imaging StudiesIn chest medicine 80% of information is on the developed film.Chest radiograph findings in typical case of pneumonia indicate a segmental or lobar opacity, or infiltration corresponding to the impaired area.
45 Lab StudiesComplete blood countLeukocytosis with a left shift is commonly observed in case of pneumonia.These findings may be absent in elderly or debilitated patients.Leukopenia is an ominous sign of impending sepsis and a poor outcome.
46 Lab Studies Sputum examination provides an accurate diagnosis in approximately 50% of patients. A single pathogen present on the Gram stain is typical for pneumonia.The main value of sputum examination is to exclude the presence of such microorganisms as mycobacteria, fungi, Legionella, and Pneumocystis through special smears and cultures.
47 Bacterial pneumonia. Pneumococci on sputum Gram stain.
48 Bacterial pneumonia. Histopathological micrograph of bacterial pneumonia showing extensive infiltration with inflammatory cells
49 Bacterial pneumonia. Klebsiella pneumoniae on sputum Gram stain
50 Lab StudiesThe diagnosis of pneumonia cannot be based solely on the results of culture of expectorated sputum.100% sputum cultures are impossible in most clinics. No ordinary lab can ensure 100% etiological diagnosis of pneumonia in time.The standard lab limits sputum investigation by Gram-stained smear.That is why diagnosis of pneumonia is clinical-radiological, not etiological.
51 Lab StudiesAdditional lab tests are necessary when diagnosis is unclear and the treatment based on the findings of standard tests has no effect.Other tests may include serology, which is essential in the diagnosis of unusual causes of pneumonia such as Legionella, Mycoplasma, Chlamydia, and other.Blood cultures are of a limited value, as they are positive only in approximately 40% of cases.
52 Other TestsArterial blood gas (ABG) determination: Evaluation of the patient's gas exchange is essential in order to decide if hospital admission, oxygen supplementation, or other efforts are indicated.Pulse oximetry of less than 90% indicates significant hypoxia; an ABG determination should be performed in these patients.
53 Procedures Bronchoscopy Bronchial washing specimens can be obtained. Protected brush and bronchoalveolar lavage can be performed for quantitative cultures.ThoracentesisThis is an essential procedure in patients with a parapneumonic pleural effusion.Obtaining fluid from the pleural space for laboratory analysis allows for the differentiation between simple and complicated effusions. This determination helps guide further therapeutic intervention.
54 Differential diagnosis Any case of pneumonia requires excluding of 2 other pulmonological problems.They arelung cancer andtuberculous.
56 Criteria for hospitalization The decision to hospitalize patients with community-acquired pneumonia is dictated by risk factors that increase either the risk of death or the risk of a complicated course of disease.
57 Some of indications for hospitalization include Advanced age (over 65)comorbidity (alcoholism, diabetes mellitus, COPD, chronic renal or heart failure, chronic liver disease)suspicion of aspirationleukopenia or marked leukocytosisany evidence of respiratory failureseptic appearance andabsence of supportive care at home (social indications).
58 Who can be treated at home? Only young people in case of mild course.If there’s the smallest sign of a moderate course, the patient must be directed to the in-patient department immediately!
59 TreatmentEstablishing a specific etiologic diagnosis of pneumonia is often difficult.In most cases of both community-acquired and hospital-acquired pneumonia no etiology was identified.Therefore, when organisms are not known, therapy should be empiric.
60 The initial approach to treating patients with сommunity-acquired pneumonia involves a determination of 3 factors.Should the patient with pneumonia be treated in the hospital or as an outpatient?Does the patient have a serious coexisting illness or is the patient elderly?How severely ill is the patient at the time of the initial evaluation?
61 Community-acquired pneumonia: treatment Empiric therapy for pneumonia based on recommendations by the WHO (2000).Patients with community-acquired pneumonia are categorized into 4 groups because a different microbiologic spectrum is suggested in each group to choose the initial empiric therapy the most effectively.
62 Community-acquired pneumonia: treatment A. The 1st major category includes outpatients aged 60 years or younger without comorbidity.Antibiotic treatment with one of the newer macrolides (clarithromycin or azithromycin) is advised.
63 Community-acquired pneumonia: treatment B. The 2nd group combines community-acquired pneumonias occurring in outpatients with comorbidity or age 60 years or older.The recommended therapy isa 2nd-generation cephalosporin (cefuroxime), ora beta-lactam + a beta-lactamase inhibitor (amoxicillin-clavulanate), ora newer fluoroquinolone (levofloxacin or moxifloxacin).
64 Community-acquired pneumonia: treatment C.Community-acquired pneumonia requiring hospitalizationThe recommended therapy isa 2nd-generation cephalosporin (cefuroxime), ora 3rd-generation cephalosporin (ceftriaxone), oramoxicillin-clavulanate.Combination therapy is advised with 2nd- or 3rd-generation cephalosporin + macrolide
65 Community-acquired pneumonia: treatment D. Severe community-acquired pneumonia requiring ICU careCombination therapy is advised witha macrolide plus a 3rd-generation cephalosporin (eg, ceftazidime), ortriple therapy with(1) ceftazidime or carbapenem +(2) amikacin +(3) macrolide or fluoroquinolone (ciprofloxacin)
67 Severe nosocomial pneumonia: treatment The possible combinations areone of the following:(1) aminoglycoside or ciprofloxacin ++ (2) amoxicillin-clavulanate, orceftazidime, orimipenem+vancomycin
68 Pneumonia is not treated with gentamycin or penicillin! NB!Pneumonia is not treated with gentamycin or penicillin!
69 Telithromycin (KETEK) is first antibiotic in a new class called ketolides. It keeps active against gram-positive cocci in the presence of resistance. Indicated to treat mild-to-moderate community-acquired pneumonia, including infections caused by multidrug-resistant S. pneumoniae.