Pneumonia

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Prognosis
& Treatme
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Introduction
0 Pneumonia is an inflammation of the lung
parenchyma (i.e. alveoli rather than the

bronchi) of infective origin.
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Pneumonia
0 It is the most common infectious cause of
death.
0 It is usually characterized by consolidation.
0 Consolidation is a pathological process in
which the alveoli are filled with a mixture of

inflammatory exudate, bacteria & WBC
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Pneumonia
EPIDEMIOLOGY
0Occurs throughout the year
0Results from different etiological
agents varying with the seasons

0Occurs in persons of all ages
0Clinical manifestations severe in very
young, elderly & in chronically ill
patients
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Pneumonia
CLASSIFICATION
Classified based on two types
1. Type 1
0.
Lobar pneumonia
0.
Bronchopneumonia
2.
Type 2
0. Community- acquired pneumonia (CAP)
0. Hospital-acquired pneumonia (HAP)
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Pneumonia
Lobar pneumonia
0 Lobar pneumonia is acute bacterial infection
of a part of lobe the entire lobe, or even two

lobes of one or both the lungs.
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Pneumonia
Bronchopneumonia
0 Bronchopneumonia is infection of the
terminal bronchioles that extends into the

surrounding alveoli resulting in patchy
consolidation of the lung.
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Pneumonia
Community Acquired
Pneumonia (CAP)
Pneumonia which develops in an otherwise
healthy person outside of hospital or have
been in hospital for less than 48hrs
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Pneumonia
Nosocomial pneumonia
(HAP)
Pneumonia that was not incubating upon
admission developing in a patient
hospitalized for greater than
48 hrs.
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Pneumonia
PATHOPHYSIOLOGY
Microbial invasion of the normally sterile lower
respiratory tract
Three routes0 Inhaled as aerosolized particles
0 Haematogenous spread from an extrapulmonary
site of infection
0 Aspiration of oropharyngeal contents
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Pneumonia
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Various defence
mechanisms that
protects lung from
infection
0 Anatomic barriers epiglottis, larynx
0 Cough reflexes
0 Tracheobronchial secretions
0 Mucocilliary lining
0 Cell & humoral mediated immunity
0 Dual phagocytic system-alveolar
macrophages & neutrophils
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Pneumonia
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Invasion occurs as a result of
Defect in host defence mechanism
Overwhelming inocculum
0 Lung infection with viruses suppress
the antibacterial activity of the lung by

impairing alveolar macrophage
function & mucocilliary clearance thus
setting the stage for secondary
bacterial pneumonia.
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Pneumonia
12
Clinical Manifestations
0 Indolent to fulminant in presentation
0 Mild to fatal in severity
0 Typical symptoms
Fever
Chills
Cough
Rust coloured sputum
Mucopurulent sputum
Dyspnea ( shortness of breath)
Pleuritic chest pain

0 Elevated WBC
0 Bacteraemic
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Pneumonia
13
Chest X-ray
For Lobar Pneumonia
Consolidati
on
confined to
one or
more
lobes (or
segments
of lobes) of
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lungs.
Lobarpneumonia
Pneumonia
14
Chest X-ray
For Bronchopneumonia
Patchy
consolidation
usually in
the bases of
both lungs.
Bronchopneumonia
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Pneumonia
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Diagnosis
Clinical diagnosis
0
History
0
Signs & symptoms
0
Chest x-ray
0
CT
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Pneumonia
16
Diagnosis
Etiological diagnosis
0
Gram's Stain and Culture of
Sputum
0
Blood Cultures
0
Antigen Tests
0
Polymerase Chain Reaction
0
Serology
0
Bronchoalveolar lavage
0
Bronchoscopy
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Pneumonia
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Complications
Possible complications include:
0 Acute respiratory distress syndrome(ARDS)
0 Fluid around the lung (pleural effusion)
0 Lung abscesses
0 Respiratory failure (which requires a
breathing machine or ventilator)
0 Sepsis, which may lead to organ failure
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Pneumonia
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COMMUNITY ACQUIRED
PNEUMONIA
Pneumonia is most common in winter because
of seasonal increase in viral infections
Mortality
1%- Non hospitalized patients
13.7%-Hospiatalized patients
19.6%-Bacteremic patients
<36.5%- Intensive care unit
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Pneumonia
19
Risk factors
1.
2.
3.
4.
5.
Comorbidity- Neoplastic disease,

neurological problem
Alcoholism
Advanced age
Asthma
Immunosuppression
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Pneumonia
20
Etiology
Potential etiologic agents in CAP - Bacteria
Viruses
Fungi
Protozoa
Potential bacteriologic causes can be divided into
two types
0 Typical bacterial pathogens

0 Atypical bacterial pathogens
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Pneumonia
21
Typical bacterial
pathogens
0 Streptococcus pneumoniae 30% to 60%
,Severe illness, death

0 Haemophilus influenzae 10%
0 S. aureus (in selected patients)
0 gram-negative bacilli
Klebsiella pneumoniae
Pseudomonas
aeruginosa
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Pneumonia
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Atypical bacterial
pathogens
0 Mycoplasma pneumoniae
0 Chlamydophila pneumoniae
0 Legionella pneumophillia
0 These organisms are intrinsically resistant to all -
B lactam agents macrolide, a fluoroquinolone, or

a tetracycline.
0 Poor dental hygiene-anaerobes
0 HIV- p.carnii
0 Birds- Chlamydia psittaci
0 Cattle or parturient cat-Coxiella burnetti
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Pneumonia
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HOSPITAL ACQUIRED
PNEUMONIA
0 Pneumonia that was not incubating upon
admission developing in a patient

hospitalized for greater than 48 hrs
0 10-15% of all hospital acquired pneumonia,
usually presenting with sepsis or&/or

respiratory failure
0 50% acquired on ICU
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Pneumonia
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Predisposing features
Reduced host defence against bacteria
0 Reduced immune defences (Corticosteroid
treatment, diabetes, malignancy)
0
Reduced cough reflux (Post operative)
0
Disordered mucocilliary clearance (Anaesthetic
agents)
Aspiration of nasopharyngeal or gastric
secretions
0
Immobility or reduced conscious level

0 Vomiting, Dysphagia,
0 Nasogastric intubation
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Pneumonia
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0 Most bacterial nosocomial infection occur by
microaspiration of bacteria colonizing the

patients oropharynx or upper GI tract
0 Most common pathogen Aerobic gram
negative bacilli
0 Most commonly exposed to multiresistant
hospital pathogen
0 86% nosocomial infection-mechanical
ventilation
0 Mortality-0 to 50%
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Pneumonia
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Bacterial introduction into LRT

Endotracheal intubation
Infected ventillatiors / nebuliser /bronchoscopy
Dental or sinus infection
Bacteraemia
Abdominal sepsis
Intravenous canula
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Pneumonia
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Causative organisms
Common organisms
Gram negative bacteria0
Escherichia coli
0
Klebsiella sp.
0
Pseudomonas aeruginosa
Gram positive bacteria0
Streptococcus pneumoniae
0
Staphylococcus aureus
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Less common organisms

1.
0
0
0
0
0
2.
3.
4.
Gram negative bacilli

other coliforms:Enterobacter sp.
Proteus sp.
Seratia marcescens
Citrobacter sp.
Acinobacter sp.
Legionella pneumophillia
Anaerobic bacteria
Fungi- Candida albicans Aspergillus
fumigatus
Viruses- Cytomegalovirus (CMV), Herpes
simplex
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Pneumonia
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Treatment
Goals of therapy-
Eradication of the offending organism.
Selection of an appropriate antibiotic.
To minimize associated morbidity.
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General approach to
treatment
0 Adequacy of respiratory function
0 Humidified oxygen for hypoxemia
0 Bronchodilators (albuterol)
0 Chest physiotherapy with postural drainage
0 Adequate hydration if necessary
0 Expectorants such as guaifenesin
0 Chest pain- analgesics
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Selection of an
antimicrobial agent
0 Empirical use of relatively broad spectrum
antibiotic
0 Narrow spectrum antibiotics to cover
specific pathogen
0 Potential pathogens involved
0 Age
0 Previous &current medication history
0 Underlying disease
0 Present clinical status
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Pneumonia
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Antibiotic doses for treating

pneumonia
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Pneumonia
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Treatment for special

cases
1. Patient less than 60 years & without
comorbidities:Azithromycine ( 500mg OD) *1day
( 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
+
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Macrolides like Azithromycin ( 500mg OD) *1day

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

Macrolides
and newer fluroquinolones
(Gatifloxacin)
We can add Vancomycin.
6. Patient with icu admission:3rd gen cefalosporins + Fluroquinolones
(Gatifloxacin)
+
Nutritional supplements + Saline
Vancomycin/Meropenam
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Pneumonia
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7. For HAP:-
Cephalosporins + Aminoglycocides
8. For antipseudomons cephalosporins:-
Ceftazidime + Cefexime
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Pneumonia
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Drugs with usual doses
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Pneumonia
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Pneumonia
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Pneumonia
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Pneumonia
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Pneumonia

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What are the different types of pneumonia?

What are the different types of pneumonia?

What are the common causes of pneumonia?

What are the common causes of pneumonia?

ed

parenchyma (i.e. alveoli rather than the

0 It is the most common infectious cause of

which the alveoli are filled with a mixture of

agents varying with the seasons

of a part of lobe the entire lobe, or even two

terminal bronchioles that extends into the

macrophages & neutrophils

Invasion occurs as a result of

Defect in host defence mechanism

0 Lung infection with viruses suppress

the antibacterial activity of the lung by

Rust coloured sputum

Dyspnea ( shortness of breath)

Pleuritic chest pain

Comorbidity- Neoplastic disease,

0 Typical bacterial pathogens

,Severe illness, death

B lactam agents macrolide, a fluoroquinolone, or

admission developing in a patient

usually presenting with sepsis or&/or

Immobility or reduced conscious level

0 Most bacterial nosocomial infection occur by

microaspiration of bacteria colonizing the

Bacterial introduction into LRT

Less common organisms

Gram negative bacilli

Eradication of the offending organism.

Selection of an appropriate antibiotic.

To minimize associated morbidity.

Antibiotic doses for treating

Treatment for special

Macrolides like Azithromycin ( 500mg OD) *1day

5. Patient hospitalised & severely ill:-

Combination of 3rd gen cefalosporins +

Drugs with usual doses

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