1. Pneumonia

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 comorbidities
3) 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.

7. Classification 1. Community-acquired pneumonia 2.Nosocomial pneumonia
typical
atypical
2.Nosocomial pneumonia
3. Aspiration pneumonia.
4.Pneumonia in immunocompromised patients.

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%) include
Streptococcus pneumoniae (pneumococcus),
Haemophilus influenzae (is associated with asthma and COPD), and
Moraxella 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%) are
Legionella 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 and
radiological 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 aureus
Klebsiella pneumoniae
Gram-negative pathogens:
Enterobacter,
Pseudomonas aeruginosa, and
Escherichia 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 person
Sudden onset of fever and shaking chills, cough, and production of rust-colored sputum sometimes accompanied by pleuritic chest pain due to pleurisy
Physical examination detects signs of consolidation
Crackles in auscultation
Pulmonary 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 include
headaches,
nausea, and
vomiting.
These symptoms are accompanied by intoxication.

26. A detaled past medical history and history of environmental and occupational exposures should be obtained
This 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 report
exposure to turkeys, chickens, ducks in case of Chlamydia psittaci infection
exposure 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. Physical
A.The common symptoms and signs (due to intoxication and respiratory failure) are as follows:
Fever (temperature >38.5°C)
Tachypnea
Tachycardia
Central cyanosis
These 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. Physical
B. The most important information on physical examination is connected with signs of lung tissue consolidation due to local inflammation:
Dullness to percussion
Increased tactile fremitus
Decreased intensity of breath sounds
Crackles (crepitation) at the beginning and resolving of inflammation
Local rales
Pleural 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 Studies
The 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 Studies
In 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.

34. Left low lobe pneumonia

35. Low lobe pneumonia

36. Right upper lobe lobar pneumonia secondary to Streptococcus pneumoniae infection

37. Bacterial pneumonia. Bilateral airspace infiltration secondary to community-acquired pneumonia, subsequently confirmed to be Legionella pneumonia

38. Bacterial pneumonia. Rarely, severe pneumococcal infection may be associated with necrotizing pneumonia.

39. Chest radiographs showing right middle lobe pneumonia

40. Hospital-acquired right lower lobe pneumonia; sputum culture confirmed this to be secondary to gram-negative organisms

41. Aspergillus pneumonia

42. Pneumonia caused by Chlamydia psittasi

43. Aspiration pneumonia

44. CT in case of pneumonia

45. Lab Studies
Complete blood count
Leukocytosis 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 Studies
The 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 Studies
Additional 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 Tests
Arterial 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.
Thoracentesis
This 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 are
lung cancer and
tuberculous.

55. Complications Pleural effusion Empyema Pulmonary abscess
Respiratory failure
Acute heart failure
Death

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 aspiration
leukopenia or marked leukocytosis
any evidence of respiratory failure
septic appearance and
absence 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. Treatment
Establishing 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 is
a 2nd-generation cephalosporin (cefuroxime), or
a beta-lactam + a beta-lactamase inhibitor (amoxicillin-clavulanate), or
a newer fluoroquinolone (levofloxacin or moxifloxacin).

64. Community-acquired pneumonia: treatment
C.Community-acquired pneumonia requiring hospitalization
The recommended therapy is
a 2nd-generation cephalosporin (cefuroxime), or
a 3rd-generation cephalosporin (ceftriaxone), or
amoxicillin-clavulanate.
Combination therapy is advised with 2nd- or 3rd-generation cephalosporin + macrolide

65. Community-acquired pneumonia: treatment
D. Severe community-acquired pneumonia requiring ICU care
Combination therapy is advised with
a macrolide plus a 3rd-generation cephalosporin (eg, ceftazidime), or
triple therapy with
(1) ceftazidime or carbapenem +
(2) amikacin +
(3) macrolide or fluoroquinolone (ciprofloxacin)

66. Nosocomial pneumonia: treatment
Nosocomial pneumonia remains a prevalent hospital-acquired infection.

67. Severe nosocomial pneumonia: treatment
The possible combinations are
one of the following:
(1) aminoglycoside or ciprofloxacin +
+ (2) amoxicillin-clavulanate, or
ceftazidime, or
imipenem+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.