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

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.

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

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

Case presentation 1

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

Case presentation 2

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

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

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

RLL Infiltrate

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

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

Pneumococcal 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)

Typical 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)

Grainger & 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)

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

The 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)

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, 4th edition (2001)

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

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

Legionella Pneumonia Recommended treatment: Macrolides Fluoroquinolones

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

Typical vs. Atypical Pneumonia Subacute Abrupt Onset Mild fever, Mucoid sputum High fever, Rigors Pleurisy, Purulent sputum Symptoms Crackles Consolidation Physical Examination Variable/ Normal High WBC Interstitial Lobar, Segmental CXR Mycoplasma, Chlamydia S. pneumoniae, H. influenzae Pathogens

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

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

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!

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!

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!

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

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

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

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

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.

Sputum Gram Stain: Infectious Diseases Society of America Guideline 2000 Recommend using Gram's stain to narrow initial empiric therapy in patients Source: ATS guideline 2001

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

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

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

PORT Rule: Mortality by Risk Class Score Class - I ≥70 II 71-90 III 91-130 IV >130 V Based 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

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!

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

Macrolides Erythromycin (PO), IV Roxithromycin PO Azithromycin PO, IV Clarithromycin “advanced macrolides” (A-Macs)

Drug Resistant Pneumococcus Refers to resistance to Penicillin Intermediate level MIC 0.1-1.0 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.

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

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

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

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

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

Patient Not Responding to Treatment Suppurative Complications : Empyema

Patient Not Responding to Treatment Suppurative Complications : Lung Abscess

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

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