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

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, 4th edition (2001)

16. 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)

17. 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)

18. 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)

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.
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)

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, 4th edition (2001)

22. Other Pathogens Gram negative Staph. aureus Anaerobes Legionella
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. 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

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

27. 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

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: % 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
Source: ATS guideline 2001

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
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

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 Roxithromycin PO Azithromycin PO, IV
Clarithromycin
“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

56. Questions?