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    Dibaca

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    This document presents the case of a 55-year-old male patient presenting with symptoms of acute pulmonary infection including dyspnea, fever, cough, and infiltrates in his left lower lung lobe on chest X-ray. It then poses several key clinical questions about diagnosing and treating this type of pneumonia. The most likely diagnoses are community-acquired pneumonia caused by typical bacterial pathogens like Streptococcus pneumoniae given the patient's risk factors of smoking, diabetes, and recent respiratory symptoms. Diagnostic tests may include sputum culture, blood tests, and chest imaging while treatment should involve hospital admission and intravenous antibiotics like a respiratory fluoroquinolone or beta-lactam plus macrolide.

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    Dibaca

    Uploaded by

    Jhelly Hariyati
    66 views37 pages
    This document presents the case of a 55-year-old male patient presenting with symptoms of acute pulmonary infection including dyspnea, fever, cough, and infiltrates in his left lower lung lobe on chest X-ray. It then poses several key clinical questions about diagnosing and treating this type of pneumonia. The most likely diagnoses are community-acquired pneumonia caused by typical bacterial pathogens like Streptococcus pneumoniae given the patient's risk factors of smoking, diabetes, and recent respiratory symptoms. Diagnostic tests may include sputum culture, blood tests, and chest imaging while treatment should involve hospital admission and intravenous antibiotics like a respiratory fluoroquinolone or beta-lactam plus macrolide.

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    This document presents the case of a 55-year-old male patient presenting with symptoms of acute pulmonary infection including dyspnea, fever, cough, and infiltrates in his left lower lung lobe on chest X-ray. It then poses several key clinical questions about diagnosing and treating this type of pneumonia. The most likely diagnoses are community-acquired pneumonia caused by typical bacterial pathogens like Streptococcus pneumoniae given the patient's risk factors of smoking, diabetes, and recent respiratory symptoms. Diagnostic tests may include sputum culture, blood tests, and chest imaging while treatment should involve hospital admission and intravenous antibiotics like a respiratory fluoroquinolone or beta-lactam plus macrolide.

    Copyright:

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    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    66 views37 pages

    Dibaca

    Uploaded by

    Jhelly Hariyati
    This document presents the case of a 55-year-old male patient presenting with symptoms of acute pulmonary infection including dyspnea, fever, cough, and infiltrates in his left lower lung lobe on chest X-ray. It then poses several key clinical questions about diagnosing and treating this type of pneumonia. The most likely diagnoses are community-acquired pneumonia caused by typical bacterial pathogens like Streptococcus pneumoniae given the patient's risk factors of smoking, diabetes, and recent respiratory symptoms. Diagnostic tests may include sputum culture, blood tests, and chest imaging while treatment should involve hospital admission and intravenous antibiotics like a respiratory fluoroquinolone or beta-lactam plus macrolide.

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    of 37

    ACUTE PULMONARY INFECTIONS

    Dr. Sudarto Jemagam, SpPD Medical Faculty, Sriwijaya University

    Case presentation
    A 55-year-old male with a history of type 2 diabetes, presents with dyspnea, high fever, chills, and productive cough with purulent sputum for 2 days duration. He denies hemoptysis. He has smoked 2 packs of cigarettes a day for the past 20 years and drinks six beers a day.

    On physical exam he appears acutely ill. His vital signs show a temperature of 40.2C, pulse is 130 beats/minute, RR is 48x/per minute, BP is 113/60.
    Lungs are dull to percussion and bronchial breath sound heard over the left lower lobe. Chest X-ray showed infiltrates in the left lower lobe.

    Key clinical questions


    1. What are the most likely diagnosis in this patient? 2. What are the most likely causative organisms in this patient? 3. What further diagnostic tests are recommended for diagnosis? 4. What are the risk factors for pneumonia 5. Can this patient be treated as an outpatient or should he be admitted? 6. What antibiotic agent would be recommended for this patient?

    What are the most likely diagnosis in this patient?

    Differential diagnostic
    Pneumonia Tuberculosis Acute bronchitis Acute exacerbation of chronic bronchitis Upper respiratory infection Sinusitis CHF Asthma Lung cancer

    Definition of pneumonia
    An acute infection of the lung parenchyma distal to the terminal bronchiole, associated with clinical or radiologic evidence of consolidation of part or parts of one or both lungs.

    Terminology
    Community Acquired Pneumonia versus Nosocomial pneumonia Typical pneumonia versus atypical pneumonia Mild pneumonia; Moderate pneumonia and Severe pneumonia Lobar pneumonia; Bronchopneumonia and Pleuropneumonia

    Clinical manifestations
    Sudden onset of fever, chills Cough Sputum production Pleuritic chest pain Dyspnea; Tachypnea Tachycardia Extra pulmonary symptoms (nausea, vomiting, malaise, headache, myalgia)

    Physical examinations
    Sign of pulmonary consolidation
    o o o o o

    Restricted movement of the afflicated hemithorax Increased fremitus Dullness Bronchial breath sounds Rales

    Clinical manifestations of pneumonia


    Features
    Onset Age Appearance Fever Rigor Cough Sputum Extra pulmonal Pleuritic chest pain Lung consolidation Gram stain WBC, difrential Chest x-ray

    Typical
    Sudden Younger Toxic High Common Productive Purulent Uncommon Common Common Abundant bacteria Elevated; left shit Consolidation

    Atypical
    Gradual Older Malaise, fatique Low grade Uncommon Nonproductive Mucoid Common Uncommon Uncommon Rare bacteria Normal Patchy, infiltrate

    Patient
    - Acute (2 days) - Dyspnea, High fever, Chills - Productive cough, purulent sputum - T: 39.8C - Pulse: 130 x/minute - RR: 48x/per minute - Percussion: dull - Auscultation: bronchial breath sound over the left lower lobe - CXR: infiltrates in the left lower lobe.

    Pneumonia
    - Sudden onset of fever - Shortness of breath - Productive cough, purulent sputum - Pleuritic chest pain - Tachypnea - Restricted movement of the afflicated hemithorax - Increased fremitus - Dullness - Bronchial breath sounds; Rales - CXR: infiltrates (lobar, multilobar, segmental) or pleural effusions

    What are the most likely causative organisms in this patient?

    Microbial causes of pneumonia


    CAP
    S.pneumoniae H.influenzae Moraxella catarrhalis S.aureus

    Nosocomial Pneumonia
    Gram negative bacilli S.aureus Pseudomonas aeruginosa

    Atypical Pneumonia
    M.pneumoniae C.pneumoniae Legionella pneumophila

    Gram negative bacilli


    Virus

    Woodhead M.Medicine International 1995; 31 (9)

    CAP : Most Common Pathogens


    Mild (Ambulatory Patients) Moderate (hospitalized, non ICU)* Severe (ICU)*

    S. Pneumoniae M. Pneumoniae H. Influenzae C. Pneumoniae Viruses Mixed flora (aspiration)

    S. Pneumoniae M. Pneumoniae C. Pneumoniae H. influenzae Legionella spp Mixed flora (aspiration)

    S. Pneumoniae S. aureus H. influenzae Gram negative bacilli Legionella spp

    excluding Pneumocystis spp. ICU = intensive care unit


    File MJ. Tan JS. Cure open Purn Med 1997. 3(2) 89

    Bacterial Pathogens in CAP


    4,2% 12,5% 33,3% 12,5% No pathogen discover Klebsiella S. aureus S. pneumoniae Acinobacter Pseudomonas S.pyogenes

    12,5% 20,8% 16,7%

    Persahabatan Hosp. 2000

    What further diagnostic tests are recommended for diagnosis?

    Diagnostic
    CXR Sputum examination Blood count Blood cultures Thoracentesis Invasive diagnostic procedures Transtracheal aspiration Bronchoscopy Direct needle aspiration

    CXR
    CXR is the most important diagnostic tool
    New or progressive pulmonary infiltrates Lobus consolidation Segmental consolidation Patchy infiltrate Pulmonary cavitations Lymphadenopathy Pleural effusions

    Lobar pneumonia

    Location of pneumonia

    Sputum examination
    The key factor to identification of the etiology

    Macroscopic; Gram stain and Sputum culture


    Lower sensitivity 3050% pathogen could not identifiable Frequently contaminated by MO in the URI

    What are the risk factors for pneumonia

    Risk factors for pneumonia


    Extreme of age Underlying co-morbid illness Imunocompromise Impaired mucociliary clearance Alcoholism; Drug abusers Smoking Endotracheal intubation Upper respiratory infection Impaired level of consciousness An increase in gastric pH (the use of H2 Blocker, Antacid) Neurologic dysfunction

    Can this patient be treated as an outpatient or should he be admitted?

    Risk Factors used to determine assignment to risk classes I-V

    Risk class for patients with CAP

    Algorithm pneumonia
    Patients with Community Acquired pneumonia
    Is the patients over 50 years of age ?
    No Yes

    Does the patient have a history of any of the following comorbid conditions ? Neoplastic disease Congestive heart failure Cerebrovascular disease Renal disease Liver disease
    No

    Yes

    Assign patient to risk class II-V based on prediction model scoring system

    Does the patient have any of the following on physician examination ? Altered mental statis Pulse 125/minute Respiratory rate 30/minute Sistolic blood presure < 90 mmHg Temperature < 35C or 40 C
    No

    Yes

    Assign patient to risk class I

    What antibiotic agent would be recommended for this patient?

    The ideal antibiotic in pneumonia


    Bactericidal +++ Low resistance Coverage, almost all of respiratory pathogen Single drug Once-daily dose Safe High respiratory penetration Cost effective

    Antibiotics in pneumonia
    Macrolide Tetracycline Cotrimoxazole Co-Amoxyclav Sultamicillin - lactam (include cephalosporin) Fluoroquinolone Aminoglycoside Antipseudomonas

    CAP Management Issues


    Causative pathogen frequently not found Typical and atypical found together Therapy must be started early (<8 hours) Increasing resistant to penicillin and macrolide Atypical: unresponsive against - lactam AB Cost and adverse reaction Oral route more convenient Decision to hospitalize/outpatient
    Bartlett: Clin Infect Dis 26:811, 1998. Whitney et al.New England Journal of Medicine,December 2000

    Outpatient treatment (IDSA/ATS 2007)


    Previously healthy and no use of antimicrobials within the previous 3 months A macrolide Doxycyline Have a comorbid (chronic heart, lung, liver /renal disease; DM; alcoholism; malignancies; asplenia; immunosuppressing conditions ; use of immunosuppressing drugs; use of antimicrobials within the previous 3 months
    A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin) A b-lactam plus a macrolide (strong recommendation; level I evidence)

    In regions with a high rate of infection with high-level (MIC _16 mg/mL) macrolide-resistant S. pneumoniae, consider use of alternative agents listed above in (2) for patients without comorbidities

    Inpatients, non-ICU treatment


    A respiratory fluoroquinolone (strong recommendation; level I evidence) A b-lactam plus a macrolide (strong recommendation; level I evidence)

    Inpatients, ICU treatment


    A b-lactam (cefotaxime, ceftriaxone, or ampicillinsulbactam) plus either azithromycin (level II evidence) or a respiratory fluoroquinolone (level I evidence) (strong recommendation)

    (for penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are recommended)

    Failure of empirical treatment

    Incorrect diagnosis

    Correct diagnosis

    Host issues

    Drug issues

    Pathogen issues
    Bacterial Nonbacterial

    Local factor Error in drug selection Inadequate host response Error in dose/route Complication Compliance Adverse drug reaction

    Prognostic factors
    Extremes of age Inappropriate antibiotic therapy Shock Involvement of 1 lobe Peripheral WBC count 5000/l Presence of associated disorders (eg: cirhosis; heart/renal failure) Development of extrapulmonary complications (eg: meningitis, endocarditis)

    Complications
    Acute respiratory distress syndrome Lung abscess Renal failure Septic shock Pleural effusions/Empyema Bacteriemia (Septic arthritis; Endocarditis; Meningitis; Peritonitis; Endopthalmitis.

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