1. Pneumonia Halmat M. Jaafar (MSc. Clinical pharmacy)
Hawler Medical University/ College of Pharmacy
Department of Pharmacology

2. Outline of this lecture:
What is pneumonia?
Epidemiology.
Etiology And Pathophysiology.
Classification .
Sign and symptoms
diagnosis
Complications.
treatment and management of pneumonia

3. PNEUMONIA Pneumonia is an infection in one or both
of the parenchyma lungs.
Characterized
primarily by inflammation
of the alveoli in the lungs
(alveoli are microscopic sacs
in the lungs that absorb
oxygen).

4. DEFINITION
“inflammation and consolidation of lung tissue due to an infectious agent”
CONSOLIDATION = ‘Inflammatory induration of a normally aerated lung due to the presence of cellular exudative in alveoli’
Consolidation is a pathological process in which the alveoli are filled with a mixture of inflammatory exudate, bacteria & WBC

5. EPIDEMIOLOGY Occurs throughout the year
Results from different etiological agents
Occurs in persons of all ages
Clinical manifestations severe in very young, elderly & in chronically ill patients
Most common cause of death in infectious disease
Most common cause of death in children under 5 yeras.

6. How does Pneumonia develop?
Most of the time, the body filters organisms.
This keeps the lungs from becoming infected.
But organisms sometimes enter the lungs and cause infections.
body fails to filter the organisms.

7. Factors that predispose to Pneumonia
Cigarette smoking
Upper respiratory tract infections
Alcohol
Corticosteroid therapy
Old age
Recent influenza infection
Pre-existing lung disease

8. Factors that predispose to Pneumonia
Reduced host defences against bacteria
Reduced immune defences (e.g. corticosteroid treatment, diabetes, malignancy)
Reduced cough reflex (e.g. post-operative)
Disordered mucociliary clearance (e.g. anaesthetic agents)
Bulbar or vocal cord palsy

9. Factors that predispose to Pneumonia
Aspiration of nasopharyngeal or gastric secretions
Immobility or reduced conscious level
Vomiting, dysphagia or severe reflux
Nasogastric intubation
Bacteria introduced into lower respiratory tract
Endotracheal intubation/tracheostomy
Infected ventilators/nebulisers/bronchoscopes
Dental or sinus infection

10. Factors that predispose to Pneumonia
Bacteraemia
Abdominal sepsis
Intravenous cannula infection
Infected emboli

11. PNEUMONIA
PNEUMONIA
Causes of infectious pneumonia. Bacterial. Common. - streptococcus pneumoniae Group B streptococci Group A streptococci . - Mycoplasma pneumoniae - chlamydia pneumoniae  Adolescent.
- chlamydia trachomatis  infant. -Mixed anaerobes  Aspiration pneumonia - Gram-negative enteric.

12. PNEUMONIA Uncommon. Haemphilus influenza  Unimmunized.
Staphylococcus aureus
Moraxella catarrhalis
Neisseria meningitides
Francisella tularensis  animal fly contact
Nocardia species  Immunosuppressed person.
Chlamydia psittaci  Bird contact.
Yersinia pestis  Plague
- Legionella species  Exposure to contamianted water.

13. PNEUMONIA - Viral -Common
Respiratory syncytial virus Parainflueza type 1 – 3 Influeza A . B
Adenovirus Metapneumovirus
- Un Common Rhinovirus Enterovirus Neonates Herpes simplex Neontes Cytomegalovirus Immunosuppressed person. Measles Varicella Hantavirus Sars agent.

14. PNEUMONIA
-Fungal.
Histoplasma capsulatum  Bird bat contact Cryptococcus neoformans  Bird contact. Aspergillus species  Immunosuppressed. Mucomycosis  Immunosuppressed Coccidioides immitis Blastomyces dermatitides
- Rickettsial
Coxiella burnetii  Goat sheep cattle exposure Rickettsia rickettsiae

15. PNEUMONIA
Mycobacterial Nycobacterium Tuberculosis  Developed countries Nycobacterium avium-inteacellulare  Immunosuppressed.
Parasitic Pneumocystis Carini  Immunosuppressed. Steroid. Eosinophilic  Ascaris . Loeffler syndrom
Non infectious causes -Aspiration Of food. -Gastric acid. -foreign body. -Hydrocarbon  Kerosen -Lipoid substances - Aspiration of amniotic fluid.

16. PNEUMONIA Frequent Pathogens Age group
Group B straptococcus – E coli streptococcus Pneumoniae – H influeza.
Neonate <1mo
Rsv . Influenza viruses para fluenza viruses – adenovirus S. pneumoniae . H . influenza
1-3 mo febrile Pneu
Chlamydia trachomatis Mycoplasma hominis cytomegalovirus.
Afebrile Pneu
R.S.V Influenza viruses para fluenza viruses adenovirus S. pneumoniae H . Influenza Chlamydia trachomatis Mycoplasma pneumoniae Group A straptococcus
3 – 12 mo
Influenza viruses para fluenza viruses adenovirus S. pneumoniae H . Influenza Mycoplasma pneumoniae Chlamydia pneumoniae
Group A straptococcus S . Aureus.
2 – 5 yr
Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae H . Influenza Influenza viruses adenovirus
5 – 18 yr
Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae H . Influenza Influenza viruses adenovirus.
> 18 yr

17. Types of Pneumonia

18. ANATOMICAL CLASSIFICATION
Bronchopneumonia affects the lungs in patches around bronchi
Lobar pneumonia is an infection that only involves a single lobe, or section, of a lung.
Interstitial pneumonia involves the areas in between the alveoli

19. CLINICAL CLASSIFICATION
Community Acquired - Typical/Atypical/Aspiration
Pneumonia in Elderly
Nosocomial- HAP,VAP,HCAP
Pneumonia in Immunocompromised host

20. Community Acquired Pneumonia (CAP)
DEFINITION:
An infection of the pulmonary parenchyma
Associated with symptoms of a/c infection
Presence of a/c infiltrates on CXR or auscultatory findings consistent with Pneumonia

21. Hospital Acquired pneumonia - HAP
HAP is defined as pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission.

22. Ventilator Associated Pneumonia- VAP
VAP refers to pneumonia that arises more than 48–72 hours after endotracheal intubation .

23. Health Care Associated Pneumonia HCAP
HCAP includes any patient
Who was hospitalized in an acute care hospital for 2 or more days within 90 days of the infection
Resided in a nursing home or long-term care facility
Received recent i.v antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection
Attended a hospital or hemodialysis clinic

24. ATYPICAL PNEUMONIA - Why ‘Atypical’?
Clinically
Subacute onset
Fever less common or intense
Minimal sputum
Microbiologically
Sputum does not reveal a predominant microbial etiology on routine smears (Gram’s stain, Ziehl-Neelsen) or cultures

25. ATYPICAL PNEUMONIA - Why ‘Atypical’?
Radiologically
Patchy infiltrates or
Interstitial pattern
Haemogram
Peripheral leukocytosis are less common or intense

26. Aspiration pneumonia
Overt episode of aspiration or bronchial obstruction by a foreign body.
Seen in - alcoholism, nocturnal esophageal reflux, a prolonged session in the dental chair, epilepsy
Usually Anaerobes

27. ELDERLY Infection has a more gradual onset, with less fever and cough
often with a decline in mental status or confusion and generalized weakness
often with less readily elicited signs of consolidation

28. Diagnosis Clinical presentation and history (sign and symptoms)
-chest X-ray
CT scan
Other investigation
Invasive procedures and biopsy
Other tests

29. GENERAL SYMPTOMS High grade fever Cough-productive
Pleuritic chest pain
Breathlessness

30. Additional symptoms Sharp or stabbing chest pain Headache
Excessive sweating and clammy skin
Loss of appetite and fatigue
Confusion, especially in older people

31. General Signs Febrile Tachypnoea Tachycardia Cyanosis-central
Hypotension
Altered sensorium
Use of accessory muscles of respiration
Confusion- advanced cases

32. SIGNS OF CONSOLIDATION
Percussion-dull
Bronchial Breath sounds
Crackles
Increased VF & VR
Aegophony & Whispering Pectoriloquy
Pleural Rub

33. INVESTIGATIONS Complete white blood count
Blood Sugar
Electrolytes
Creatinine
Blood culture
Oxygen saturation by pulse oximetry
ABG

34. INVASIVE Bronchoscopy Thoracoscopy Percutaneous aspiration/biopsy
Open lung biopsy
Pleural aspiration

35. OTHER TESTS Bacterial antigen in sputum and urine
Rapid viral antigen detection in respiratory secretion
Serological- mainly for atypical
Molecular study
C-reactive Protein

36. OTHER TESTS Bacterial antigen in sputum and urine
Rapid viral antigen detection in respiratory secretion
Serological- mainly for atypical
Molecular study
C-reactive Protein, serum procalcitonin, and neopterin

37. OTHER TESTS Bacterial antigen in sputum and urine
Rapid viral antigen detection in respiratory secretion
Serological- mainly for atypical
Molecular study
C-reactive Protein, serum procalcitonin, and neopterin

38. Complications Possible complications include:
Acute respiratory distress syndrome (ARDS)
Fluid around the lung (pleural effusion)
Lung abscesses
Respiratory failure (which requires a breathing machine or ventilator)
Sepsis, which may lead to organ failure

39. Complications Possible complications include:
Acute respiratory distress syndrome (ARDS)
Fluid around the lung (pleural effusion)
Lung abscesses
Respiratory failure (which requires a breathing machine or ventilator)
Sepsis, which may lead to organ failure
12/12/2011
Pneumonia

40. TREATMENT

41. Treatment Goals of therapy- Eradication of the offending organism.
Selection of an appropriate antibiotic.
minimize associated morbidity.

42. General approach to treatment
Adequacy of respiratory function
Humidified oxygen for hypoxemia
Bronchodilators (albuterol)
Chest physiotherapy with postural drainage
Adequate hydration if necessary
Expectorants such as guaifenesin
Chest pain- analgesics

43. Selection of an antimicrobial agent
Empirical use of relatively broad spectrum antibiotic
Narrow spectrum antibiotics to cover specific pathogen
Potential pathogens involved
Age
Previous &current medication history
Underlying disease
Present clinical status

44. CURB 65

45. Most people can be treated at home.
If pneumonia becomes so severe that treatment is in the hospital, you may receive fluids and antibiotics in your veins, oxygen therapy, and possibly breathing treatments.
Viral Pneumonia: Anti-virals like Oseltamivir and zanamivir
Bacterial pneumonia: Patients with mild pneumonia who are otherwise healthy are treated with oral macrolide antibiotics (azithromycin, clarithromycin, or erythromycin).
Patients with other serious illnesses, such as heart disease, chronic obstructive pulmonary disease, or emphysema, kidney disease, or diabetes are often given more powerful and/or higher dose antibiotics.

46. ANTIBIOTICS Penicillin: common penicillins used to treat pneumonia-
Amoxicillin (Amoxil)
Amoxicillin-clavulanate (Augmentin)
Ampicillin 
Benzylpenicillin (Crystapen)
Piperacillin-tazobactam (Tazocin)
Ticarcillin-clavulanate (Timentin).
There is a risk of a type of jaundice if you take amoxicillin-clavulanate. (affects liver function)

47. Contd..
2. Macrolides:
Often prescribed. Interference with other medicines.
Stomach cramps and can damage liver if taken for long time.
Common macrolides used are-
Azithromycin (Zithromax)
Clarithromycin (Klaricid)
Erythromycin (Erymax, Erythrocin).
3. Ceftaroline, a cephalosporin, is newly approved for the treatment against methicillin-resistant Staphylococcus (S.) aureus (MRSA) and multidrug-resistant Streptococcus pneumoniae.

48. Fluoroquinolones Ciprofloxacin (Cipro) Levofloxacin (Levaquin)
Gemifloxacin (Factive)
Side effects include-
Nervous system, mental, and heart problems
Sensitivity to light
Pregnant women should not take these medications.

49. Fluoroquinolones Ciprofloxacin (Cipro) Levofloxacin (Levaquin)
Gemifloxacin (Factive)
Side effects include-
Nervous system, mental, and heart problems
Sensitivity to light
Pregnant women should not take these medications.

50. Treatment for special cases
1. Patient less than 60 years & without comorbidities:- Azithromycine ( 500mg OD)/day for 3 days. ( 250mg OD) *4days Norfloxacin/Levofloxacin (400mg OD) *7days 2. Outpatient greater than 65 years:- Norfloxacin (400mg OD) *7days or Ceftriaxon (1-2 g/day) / Cifixim (2-4 g/day) 3rd gen cefalosporins +

51. Macrolides like Azithromycin ( 500mg OD) *1day
( 250mg OD) *4days
Patient is hospitalised but not severely ill:-
Combination of 3rd gen cefalosporins + Macrolides
Ceftriaxone + Azithromycin OR
Norfloxacin/Levofloxacin (400mg OD)
If the patient is hospitalised but not severely ill:-
and newer fluroquinolones (Gatifloxacin)

52. Patient hospitalised & severely ill:-
Combination of 3rd gen cefalosporins + Macrolides
Ceftriaxone + Azithromycin
and newer fluroquinolones (Gatifloxacin)
We can add Vancomycin.
Patient with icu admission:-
3rd gen cefalosporins + Fluroquinolones (Gatifloxacin) +
Nutritional supplements + Saline
Vancomycin/Meropenam

53. For HAP:-
Cephalosporins + Aminoglycocides
For antipseudomons cephalosporins:-
Ceftazidime + Cefexime