1. Acute Pneumonia David Hassin, Tel-Aviv Medical Center

2. Community-Acquired Pnumonia Bacterial Pneumonia: Bacterial Pneumonia: ► Streptococcus pneumonia (16% - 60%). ► Haemophilus influenzae (3% - 38%). ► Staphylococcus aureus (2% - 5%). ► Gram-negative rods (7% - 18%): Pseudomonas aeuginosa, Klebsiella pneumonia, E. coli… Atypical Pneumonia: ► Mycoplasma pneumonia. * ► Chlamydophila pneumoniae ► Chlamydophila psittaci. ► Coxiella burnetii. ► Legionella pneumophila. ► Chlamydia trachomatis. ► Viral pneumonia: Influenza A and B, adenovirus (types 3,4 and 7), parainfluenza virus, respiratory syncytial virus. * 50% or 7% to 28% of CAP.

3. Medical History and Physical Examination of CAP Bacterial Pneumonia: Bacterial Pneumonia: ► Chronic underlying diseases: COPD, CHF, DM, alcohol abuse asplenia, myeloma, AIDS…. (58% to 89%). ► Advanced age. ► Sudden onset. ► True rigors. ► Pleuritic chest pain. ► Productive cough, purulent ”rusty” sputum. ► Consolidation. ► Pleural effusion. Atypical Pneumonia: ► Younger patients. ► Environmental history: exposure to young children and sick people. Exposure to birds, sheep, goats, cattle, domestic animals. Exposure to air coolers, wearlpools, hospital water supply… ► Gradual onset. ► Non productive cough. ► Sore throat and hoarseness. ► Minimal findings on physical examination. ► Bullous myringitis, (5%). ► Diarrhea, (Legionella).

4. Vibratory Palpation and Auscultation of the Lungs and Pleura ► Tactile Fremitus, Vocal fremitus, is best felt or heard with low pitched sounds: 99, 44… ► Vocal Fremitus diminished or absent: thickened pleura, pleural effusion, pneumothorax, atelectasis. ► Vocal Fremitus increased: consolidation, lung fibrosis. ► Auscultation for voice sounds is more sensitive then palpation. Whispered Pectoriloquy, Bronchophony in consolidation. Voice sounds helpful in lining pleural effusion fluid level.

5. Percussion of the Lungs and Pleura ► Percussion sounds: tympany, hyperresonance, resonance,impaired resonance, dullnes, flatness. ► Definitive Percussion: outlines the border between lung resonance and dullness of pleural effusion, the upper border of the liver, the heart and the lung bases ( 10 th ribs ). ► Anteriorly liver dullness at the Rt. 6 th rib, the stomach tympany at the Lt. 6 th rib – Traube’s semilunar space. ► Dullness in the upper lung: neoplasm, consolidation, atelectasis, thick pleura. ► Dullness in the lower lung: pleural effusion and the above. ► Flatness results from massive pleural effusion. Traube’s semilunar space dull resonance dull

6. Auscultation of the Lungs and Pleura ► Vesicular Breathing: long inspiratory and short expiratory sound ► Bronchial Breathing: short inspiratory and long expiratory sound ► Asthmatic Breathing: expiration sound prolonged and whizzing ► Amphoric Breathing: like blowing air over the mouth of a bottle ► Bronchovesicular Breathing. Vesicular Vesicular Bronchial Bronchial Asthmatic Asthmatic

7. Physical Examination of the Lungs and Pleura Lobar Pneumonia – Consolidation. 0 Tracheal deviation Fremitus dull or flat dull or flatPercussion bronchial bronchial Breath sounds Voice sounds crepitant rales crepitant ralesRales

8. Laboratory Diagnosis of CAP. Bacterial Pneumonia: Bacterial Pneumonia: ► Leukocytosis. ► Elevated CRP (sen.-100%) ► Purulent sputum, “rusty”. ► Gram stain: > 25 leuk. 25 leuk. < 10 epithelial cells. (x 100) Bacteria. Bacteria. ► Sputum culture. ► Positive blood cultures, (1% - 16%). (1% - 16%). ► Hepatitis. Atypical Pneumonia: ► Serum antibody assays: Mycoplasma pneumoniae. Chlamydophila pneumoniae. Coxiella burnetii. Legionella pneumophila. ► Ag. In the urine, (L. pneu.). ► Cold agglutinins, (M. pneu.) ► Hepatitis, (Q. fever, L. pne.) ► Hyponatremia, elevated Cr. Hypophosphatemia, LDH- (Legionella pneumophilla).

9. Sputum Examination and Gram stain: 30% to 40% fail to produce sputum. >25 Neut. 25 Neut. < 10 epithelial cells (x 100) Streptococcus Pneumonia Staph. Aureus Gram Negative Rods. Klebsiella Pneumpnia Haemophilus Influenza

10. Chest x-ray of Bacterial Pneumonia Streptococcus pneumoniae Haemophilus influenzae Klebbsiella pneumonia Staph. aureus

11. Chest x-ray of Atypical Pneumonia Syndrome Mycoplasma pneumonia Chlamydophila pneumonia Coxiella burnetii Chlamydophila psittaci Viral pneumonia

12. Legionella pneumophila

13. Other Pneumonia Syndromes ► Nosocomial pneumonia. ► Respirator associated pneumonia. ► Aspiration pneumonia. ► Pneumonia in the immunosuppressed host. ► Tuberculosis. ► Viral pneumonia: Adenovirus, Influenza, SARS, Hantavirus, Varicella… ► Fungal pneumonia: Histoplasmosis, Coccediodomycosis, Cryptococcosis. Coccediodomycosis, Cryptococcosis. ► Pulmonary infiltrates with eosinophilia, (PIE).

14. Severity Index of CAP by the PORT Study. The 30-day mortality was lowest (0.1%): The 30-day mortality was lowest (0.1%): ► Younger then 50 years. ► No coexisting condition, (neoplasia, CHF, CVA, renal disease, liver disease). ► Normal physical findings, including mental status. ► Pulse < 125 beats per minute. ► Temperature 40.

15. Empiric Antibacterial Selection for CAP DisadvantagesAdvantagesDrugs 1) 20%-30% in vitro resistance vs. S. pneumon. 2) Breakthrough pneumoco. Bacteria with resistant strains. 3) H. influenza resistant to Er. 4) Mortality> then ceph. With macrolide or fluoroquinolon. 1) Active vs. most common pathogens, also atypical. 2) Good results in clinical trials even with in vitro resistant strains. 3) Reduced mortality combined w. Cephalosporin Macrolides: Clarithromycin. Azithromycin. Erythromycin. 1) Lacks activity against atypical and β-lactamase producing bacteria. 2) Recent clinical trials of efficacy - modest. Active against 90%-95% of S. pneumoniae treated with 3-4 gr. / day. Amoxicillin. Gastrointestinal intolerance Gastrointestinal intolerance 1) Active vs. β-lactamase producing bacteria. 2) Good clinical trials. Amoxicillin- clavulanate.

16. Empiric Antibacterial Selection for CAP DisadvantagesAdvantagesDrugs 1) Amoxicillin more active vs. S. pneumoniae. 2) No activity vs. atypical pathogens. 1) Active vs. 75%-85% of S. pneumoniae and all H. influenzae. 2) Efficacious in outpatients CAP trials. Cefuroxime axetil Very limited recent clinical publications. 1) Active vs. 90%-95% of S. pneumoniae. Also active vs. H.influenzae and atypical pathogens. 2) Good outcome with CAP of hospitalized pt. 3) Well tolerated. 1) Active vs. 90%-95% of S. pneumoniae. Also active vs. H.influenzae and atypical pathogens. 2) Good outcome with CAP of hospitalized pt. 3) Well tolerated. Doxycycline. 1) No activity vs. atypical pathogens and H. influ. 2) Limited published data on CAP. 1) Active vs. 90% of S. pneumoniae. 2) Active vs. anaerobic inf. 3) Preferred vs. strep. g. A. 1) Active vs. 90% of S. pneumoniae. 2) Active vs. anaerobic inf. 3) Preferred vs. strep. g. A. Clindamycin.

17. Empiric Antibacterial Selection for CAP DisadvantagesAdvantagesDrugs 1) Abuse will result in resistance; resistance emerged on therapy. 2) Expensive. 1) Active vs.>98% S. pneu. Also H. influ. Atypical agents and MSSA. 2) Meta-analysis of trials: better then β-lactams and macrolides. 3) Well tolerated. Fluoroquinolones: Levofloxacin, Moxifloxacin, Gatifloxacin, Gemifloxacin. 1) No activity vs. atypical agents. 2) Higher mortality of ceph. Alone then ceph. plus macrolide or fluoroquinolone alone. 1)Active vs. 90%-95% of S. pneumonia also H. influ. And MSSA. 2) Pareteral drugs of choice vs. S. p., extensive clinical trial experience. Cephalosporins: Ceftriaxone, Cefotaxime. Data uncontrolled. 1) Ceph. better vs. S. pneu. Macrolide vs. atypical. 2) Retrospective analysis: reduced mortality in bacteremic S. pneu. Cephalosporin Plus Macrolide

18. Empiric Antibacterial Selection for CAP DisadvantagesAdvantagesDrugs No documented benefit May increase antimicrobial activity vs. S. pneumonia. Fluoroquinolone Plus Cephalosporin Limited activity against other common pulmonary pathogens. 1) Preferred treatment vs. penicillin sensitive S. pneu. Along with ceftriaxon and amoxicillin. 2) Extensive documented clinical efficacy. Penicillin G Clinical trials considered preliminary. 1) Active in-vitro vs. most S. pneu. (Also macrolide resistant) H. influenza and atypical agents. 2) Clinical trials: equivalence to macrolides, amoxicillin, trovafloxacin. Telithromycin

19. Empiric Antibacterial Selection for CAP DisadvantagesAdvantagesDrugs 1) Lacks established activity vs. atypical agents. 2) Expensive. 1) Active vs. most gram positives including resistant S. pneu. and S. aureus. 2) Efficacy comparable to ceftriaxon vs. pneu. pneum. 3) oral plus parenteral. Linezolid. 1) No activity vs. atypical agents. 2) Less active vs. pseudomonas aerug. 1) Clinical efficacy for CAP comparable to ceftriaxon. 2) Once daily. Ertapenem. 1) High rate of rash. 2) Only oral formulation. 1) The most active among the fluoroquinolons vs, S. pneumonia. 2) Clinlcal CAP trials: good results. Gemifloxacin.

20. Percentage of Resistance to Antibiotics of Streptococcus Pneumonia.

21. Guide to Empirical Choice of Antimicrobial Agent for Treating Patients with Community-Acquired Pneumonia Initiation of antibiotic therapy within 4 hours of presentation has been associated with a shorter hospital stay independent of clinical or demographic parameters.

22. Masaccio

23. Masaccio

24. Pulmonary Host Defenses

25. Causative Agents of Acute Pneumonia.

26. Medical and Environmental History of Pneumonia