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    Pneumonia

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    Azhar Ghori
    Community-acquired pneumonia (CAP) is a common illness caused most often by Streptococcus pneumoniae. It affects millions in the US annually and has significant health care costs. Diagnosis is based on symptoms, chest x-ray findings, and microbiologic testing when needed. Treatment depends on severity and patient risk factors, but generally involves antibiotics targeting the most common pathogens. Ongoing efforts focus on prevention through smoking cessation and vaccination.

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    Pneumonia

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    Azhar Ghori
    51 views38 pages
    Community-acquired pneumonia (CAP) is a common illness caused most often by Streptococcus pneumoniae. It affects millions in the US annually and has significant health care costs. Diagnosis is based on symptoms, chest x-ray findings, and microbiologic testing when needed. Treatment depends on severity and patient risk factors, but generally involves antibiotics targeting the most common pathogens. Ongoing efforts focus on prevention through smoking cessation and vaccination.

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    Community-acquired pneumonia (CAP) is a common illness caused most often by Streptococcus pneumoniae. It affects millions in the US annually and has significant health care costs. Diagnosis is based on symptoms, chest x-ray findings, and microbiologic testing when needed. Treatment depends on severity and patient risk factors, but generally involves antibiotics targeting the most common pathogens. Ongoing efforts focus on prevention through smoking cessation and vaccination.

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    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    51 views38 pages

    Pneumonia

    Uploaded by

    Azhar Ghori
    Community-acquired pneumonia (CAP) is a common illness caused most often by Streptococcus pneumoniae. It affects millions in the US annually and has significant health care costs. Diagnosis is based on symptoms, chest x-ray findings, and microbiologic testing when needed. Treatment depends on severity and patient risk factors, but generally involves antibiotics targeting the most common pathogens. Ongoing efforts focus on prevention through smoking cessation and vaccination.

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    of 38

    Community-Acquired

    Pneumonia
    Joanna M. Delaney, D.O.
    Georgetown University /
    Providence Hospital
    June 8, 2007
    Objectives
     Describe the common pathogenesis and
    pathogens of pneumonia
     Discuss diagnosis and initial management of
    community acquired pneumonia (CAP)
     Understand features of the Pneumonia PORT
    Severity Index
     Discuss the IDSA/ATS guidelines and
    recommendations for final antibiotic choice
     Understand issues in basic management for
    pneumonia in children, nursing home patients,
    and immunocompromised patients.
    Epidemiology
     Unclear! Few population-based statistics on the
    condition alone
     CDC combines PNA with influenza for morbidity
    & mortality data
     PNA & influenza = 7th leading causes of death in the
    US (2001)
     Age-adjusted death rate = 21.8 per 100,000
     Mortality rate: 1-5% out-Pt, 12% In-Pt, 40% ICU
     Death rates increase with comorbidity and age
     Affects race and sex equally
    Community Acquired
    Pneumonia
     Infection of the lung parenchyma in a
    person who is not hospitalized or living
    in a long-term care facility for ≥ 2 weeks
     5.6 million cases annually in the U.S.
     Estimated total annual cost of health care
    = $8.4 billion
     Most common pathogen = S. pneumo (60-
    70% of CAP cases)
    “Nosocomial” Pneumonia
     Hospital-acquired pneumonia (HAP)
     Occurs 48 hours or more after admission,
    which was not incubating at the time of
    admission
     Ventilator-associated pneumonia (VAP)
     Arises more than 48-72 hours after
    endotracheal intubation
    “Nosocomial” Pneumonia
     Healthcare-associated pneumonia (HCAP)
     Patients who were hospitalized in an acute care
    hospital for two or more days within 90 days of the
    infection; resided in a nursing home or LTC facility;
    received recent IV abx, chemotherapy, or wound care
    within the past 30 days of the current infection; or
    attended a hospital or hemodialysis clinic
     Guidelines for the Management of Adults with
    HAP, VAP, and HCAP. American Thoracic
    Society, 2005
    Pathogenesis
     Inhalation, aspiration and hematogenous
    spread are the 3 main mechanisms by
    which bacteria reaches the lungs
     Primary inhalation: when organisms
    bypass normal respiratory defense
    mechanisms or when the Pt inhales
    aerobic GN organisms that colonize the
    upper respiratory tract or respiratory
    support equipment
    Pathogenesis
     Aspiration: occurs when the Pt aspirates
    colonized upper respiratory tract
    secretions
     Stomach: reservoir of GNR that can ascend,
    colonizing the respiratory tract.
     Hematogenous: originate from a distant
    source and reach the lungs via the blood
    stream.
    Pathogens
     CAP usually caused by a single organism
     Even with extensive diagnostic testing,
    most investigators cannot identify a
    specific etiology for CAP in ≥ 50% of
    patients.
     In those identified, S. pneumo is causative
    pathogen 60-70% of the time
    Streptococcus pneumonia
     Most common cause of CAP
     Gram positive diplococci
     “Typical” symptoms (e.g. malaise, shaking
    chills, fever, rusty sputum, pleuritic hest
    pain, cough)
     Lobar infiltrate on CXR
     Suppressed host
     25% bacteremic
    Atypical Pneumonia
     #2 cause (especially in younger population)
     Commonly associated with milder Sx’s:
    subacute onset, non-productive cough, no focal
    infiltrate on CXR
     Mycoplasma: younger Pts, extra-pulm Sx’s
    (anemia, rashes), headache, sore throat
     Chlamydia: year round, URI Sx, sore throat
     Legionella: higher mortality rate, water-borne
    outbreaks, hyponatremia, diarrhea
    Viral Pneumonia
     More common cause in children
     RSV, influenza, parainfluenza
     Influenza most important viral cause in
    adults, especially during winter months
     Post-influenza pneumonia (secondary
    bacterial infection)
     S. pneumo, Staph aureus
    Other bacteria
     Anaerobes
     Aspiration-prone Pt, putrid sputum, dental disease
     Gram negative
     Klebsiella - alcoholics
     Branhamella catarrhalis - sinus disease, otitis, COPD
     H. influenza
     Staphylococcus aureus
     IVDU, skin disease, foreign bodies (catheters,
    prosthetic joints) prior viral pneumonia
    Diagnosis and Management
    Guidelines
     American Thoracic Society
     Guidelines for the Management of Adults with CA
    (2001)
     Infectious Diseases Society of America
     Update of Practice Guidelines for the Management of
    CAP in Immunocompetent adults (2003)
     ATS and IDSA joint effort
     IDSA/ATS Consensus Guidelines on the
    Management of CAP in Adults (March 2007)
    Guidelines
     2001 ATS & 2003 IDSA Guideline Update
     Expert panels
     Evidence-based recommendations
     Recommend patient stratification to
    identify likely pathogens and suggested
    empiric abx
     Site of care
     Presence of cardiopulmonary disease
     Presence of “modifying factors”
    Clinical Diagnosis
     Suggestive signs and symptoms
     CXR or other imaging technique
     Microbiologic testing
    Signs and Symptoms
     Fever or hypothermia
     Cough with or without sputum, hemoptysis
     Pleuritic chest pain
     Myalgia, malaise, fatigue
     GI symptoms
     Dyspnea
     Rales, rhonchi, wheezing
     Egophony, bronchial breath sounds
     Dullness to percussion
     Atypical Sx’s in older patients
    Clinical Diagnosis: CXR
     Demonstrable infiltrate by CXR or other
    imaging technique
     Establish Dx and presence of complications
    (pleural effusion, multilobar disease)
     May not be possible in some outpatient
    settings
     CXR: classically thought of as the gold
    standard
    Infiltrate Patterns
    Pattern Possible Diagnosis

    Lobar S. pneumo, Kleb, H. flu,


    GN
    Patchy Atypicals, viral,
    Legionella
    Interstitial Viral, PCP, Legionella

    Cavitary Anaerobes, Kleb, TB, S.


    aureus, fungi
    Large effusion Staph, anaerobes, Kleb
    Clinical Diagnosis:
    Recommended testing
     Outpatient: CXR, sputum Cx and Gram
    stain not required
     Inpatient: CXR, Pox or ABG, chemistry,
    CBC, two sets of blood Cx’s
     If suspect drug-resistant pathogen or
    organism not covered by usual empiric abx,
    obtain sputum Cx and Gram stain.
     Severe CAP: Legionella urinary antigen,
    consider bronchoscopy to identify pathogen
    Clinical Diagnosis
     Assess overall clinical picture
     PORT Pneumonia Severity Index (PSI)
     Aids in assessment of mortality risk and
    disposition
     Age, gender, NH, co-morbidities, physical
    exam lab/radiographic findings
    IDSA: Outpt Management in
    Previously Healthy Pt
     Organisms: S. pneumo, Mycoplasma, viral,
    Chlamydia pneumo, H. flu
     Recommended abx:
     Advanced generation macrolide (azithro or clarithro)
    or doxycycline
     If abx within past 3 months:
     Respiratory quinolone (moxi-, levo-, gemi-), OR
     Advanced macrolide + amoxicillin, OR
     Advanced macrolide + amoxicillin-clavulanate
    IDSA: Outpt Management in
    Pt with comorbidities
     Comorbidities: cardiopulmonary dz or
    immunocompromised state
     Organisms: S. pneumo, viral, H. flu, aerobic GN
    rods, S. aureus
     Recommended Abx:
     Respiratory quinolone, OR advanced macrolide
     Recent Abx:
     Respiratory quinolone OR
     Advanced macrolide + beta-lactam
    IDSA: Inpt Management-
    Medical Ward
     Organisms: all of the above plus polymicrobial
    infections (+/- anaerobes), Legionella
     Recommended Parenteral Abx:
     Respiratory fluoroquinolone, OR
     Advanced macrolide plus a beta-lactam
     Recent Abx:
     As above. Regimen selected will depend on nature of
    recent antibiotic therapy.
    IDSA: Inpt Management-
    Severe/ICU
     One of two major criteria:
     Mechanical ventilation
     Septic shock, OR
     Two of three minor criteria:
     SBP≤90mmHg,
     Multilobar disease
     PaO2/FIO2 ratio < 250
     Organisms: S. pneumo, Legionella, GN,
    Mycoplasma, viral, ?Pseudomonas
    IDSA: Inpt Management:
    Severe/ICU
     No risk for Pseudomonas
     IV beta-lactam plus either
    • IV macrolide, OR IV fluoroquinolone
     Risk for Pseudomonas
     Double therapy: selected IV antipseudomonal beta-lactam
    (cefepine, imipenem, meropenem, piperacillin/tazobactam),
    plus
    • IV antipseudomonal quinolone
    -OR-
     Triple therapy: selected IV antipseudomonal beta-lactam
    plus
    IV aminoglycoside plus either
    IV macrolide, OR IV antipseudomonal quinolone
    Switch to Oral Therapy
     Four criteria:
     Improvement in cough and dyspnea
     Afebrile on two occasions 8 h apart
     WBC decreasing
     Functioning GI tract with adequate oral intake
     If overall clinical picture is otherwise
    favorable, can can switch to oral therapy
    while still febrile.
    Management of Poor
    Responders
     Consider non-infectious illnesses
     Consider less common pathogens
     Consider serologic testing
     Broaden antibiotic therapy
     Consider bronchoscopy
    Prevention
     Smoking cessation
     Vaccination per ACIP recommendations
     Influenza
    • Inactivated vaccine for people >50 yo, those at risk
    for influenza compolications, household contacts of
    high-risk persons and healthcare workers
    • Intranasal live, attenuated vaccine: 5-49yo without
    chronic underlying dz
     Pneumococcal
    • Immunocompetent ≥ 65 yo, chronic illness and
    immunocompromised ≤ 64 yo
    Pneumonia in Children: Dx
     Symptoms
     Infants: non-specific manifestations
    • Fever, poor feeding, irritability, vomiting, diarrhea, URI Sx,
    cough, respiratory distress
     Older children: more specific
    • Fever, cough, chest pain, tachypnea, tachycardia, grunting,
    nasal flaring, retracting. Cyanosis usually very late.
     Signs/Physical exam
     RR > 60 for all ages
     Hypoxia
     Rales, wheezes, crackles, coarse breath sounds
    Pneumonia in Children:
    Pathogens
     0-4 wks: GBS, GN enterics, Listeria
     4-12 wks: C. trachomatis, GBS, GN
    enterics, Listeria, viral
    (RSV/parainfluenza), B. pertussis
     3 mos-4 yrs: Viral, S. pneumo, H.
    influenza, M. catarrhalis, Grp A Strep,
    Mycoplasma
     > 5yrs: Mycoplasma (5-15yrs), C. pneumo,
    S. pneumo, viral
    Pneumonia in the Elderly
     Prevention important
     Presentation can be subtle
     Antibiotic choice in CAP is same as other adults
     Healthcare associated pneumonia
     Consider S. aureus (skin wounds) and GN bacteria
    (aspiration)

    • Pneumonia in Older Residents of Long-term Care Facilities.


    AFP 2004; 70: 1495-1500.
    Pneumonia in
    Immunocompromised Pts
     Smokers, alcoholics, bedridden, immuno-
    compromised, elderly
     Common still common
     S. pneumo
     Mycoplasma
     Pneumocystis Carinii Pneumonia
     P. jirovecii
     Fever, dyspnea, non-prod cough (triad 50%), insidious
    onset in AIDS, acute in other immunocompromised Pts
     CXR: bilateral interstitial infiltrates
     Steroids for hypoxia
     TMP-SMZ still first line
    New Guideline
    IDSA/ATS 2007 Guideline
     Hospital Admission Decision
     CURB-65 criteria (confusion, uremia, RR, low BP, age
    65 yrs or greater) or PSI can be used to ID candidates
    for outpt management
     Diagnostic Testing
     Acknowledges the low yield and infrequent positive
    impact on clinical care
     Outpt testing for etiologic Dx remain optional
     Inpt testing for etiologic Dx recommended for specific
    indications
     Antimicrobial therapy: essentially unchanged
    Summary
     Use overall clinical presentation to guide
    therapy
     The admission decision is an “art of
    medicine” decision
     Use risk factors and guidelines to assist
    with clinical judgement
    References
    American Thoracic Society. Guidelines for the Management of Adults with
    Community-acquired Pneumonia. Am J Respir Crit Care Med 2001 Vol.
    163:1730-1754.

    Mandell LA, Bartlett JG, Dowell SF, File TM Jr, Musher DM, Whitney C.
    Update of practice guidelines for the management of community-acquired
    pneumonia in immunocompetent adults. Clin Infect Dis 2003 Dec
    1;37(11):1405-33.

    Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean
    NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A,
    Whitney CG. Infectious Diseases Society of America/American Thoracic
    Society consensus guidelines on the management of community-acquired
    pneumonia in adults. Clin Infect Dis 2007 Mar 1;44 Suppl 2:S27-72.

    Arch Ped Adol Med 1995; 149: 283-7.

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