What is pneumonia? Infection of the lung parenchyma Causative agents include bacteria, viruses, fungi, protozoa.

Transcription

1 Pneumonia

2 What is pneumonia? Infection of the lung parenchyma Causative agents include bacteria, viruses, fungi, protozoa

3 Definition acute infectious disease, etiology usually bacterial; characterized by focal lesions of the lung and intra alveolar exudation

4 Categorization of Pneumonia by Clinical Setting Community Acquired Pneumonia (CAP) = pneumonia in person having no or little contact with the healthcare system Nosocomial/Hospital Acquired Pneumonia (HAP) = Pneumonia occurring 48 h post admission, excludes infection incubating at time of admission

5 Categorization of Pneumonia by Clinical Setting HAP CAP Pneumonia in immunocompetent patients Aspiration pneumonia Pneumonia in immunocompromised patients Hospital-associated pneumonia Ventilator-associated pneumonia Health care associated pneumonia (HCAP) Aspiration pneumonia Pneumonia in immunocompromised patients

6 Etiologic agents of CAP Typical pathogens: Streptococcus pneumoniae % + Haemophilus influenzae % Staphylococcus aureus 2-10% + Klebsiella pneumoniae - Atypical (intracellular) pathogens (cannot be cultured on standard media): Mycoplasma pneumoniae % Chlamydophila pneumoniae % Legionella pneumophila - 1-6% Respiratory viruses % Combination of typical and atypical pathogens %

7 Common Organisms in Pneumonia Nosocomial Enteric GNB (e.g. E. coli) Pseudomonas aeruginosa S. aureus (including MRSA) Aspiration Oral anerobes (e.g. Bacteroides) Enteric GNB (e.g. E. coli) S. aureus Gastric contents (chemical pneumonitis)

8 Common Organisms in Pneumonia Immunocompromised Patients Pneumocystis jiroveci Fungi (e.g. Cryptococcus) Nocardia CMV HSV TB Alcoholic Patients Klebsiella Enteric GNB S. aureus Oral anaerobes (aspiration) TB

9 DIAGNOSIS When confronted with possible CAP, the physician must ask two questions: Is this pneumonia, and, if so, what is the likely etiology?

10 DIAGNOSIS clinical history focused physical examination CXR Pulse oximetry Routine lab testing complete blood count (CBC), basic metabolic panel (BMP) LFTs ABG Thoracentesis if pleural effusion present Sputum Gram Stain, culture, sensitivity

11 X-ray criteria for conformation of pneumonia (plain chest radiograph, preferably posterior-anterior and lateral films): inflammatory infiltration (opacities) of the parenchyma in 1-2, sometimes 3-5 segments large confluent foci of inflammation, spotted, not clearly defined opacities

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14 Haemophilus influenzae CAP Image in a 48-year-old patient with Haemophilus influenzae pneumonia. The chest radiograph shows bilateral opacities with a predominantly peripheral distribution.

15 А community-acquired Staphylococcal

16 Figure 1: (a)chest X-ray PA view multiple rounded homogenous parenchymal shadows of varying size, 2-5 cm in diameter in both lung fields. Some of these shadows coalesce with each other and surrounding mediastinal structures

17 Klebsiella pneumonia. (A) Air-space consolidation involving much of the right upper lobe. (B) Progression of the necrotizing infection produces a large abscess cavity with an air-fluid level (arrows).

18 Mycoplasmа pneumoniaе CAP

19 Chlamydia pneumoniae

20 Legionella pneumophila CAP.

21 Viral pneumonia ARDS

22 Small criteria: RR 30 / min; impaired consciousness, Sat O2<92%, ро2 <60 mm Hg. ; SBP<90 mm Hg.; Multifocal or bilateral lung opacities, collapse, pleural effusion. Big criteria: Necessity of mechanical ventilation; rapid progression of focal infiltrative changes in the lungs (> 50% larger within 2 days); septic shock or the necessity of vasopressors 4 h; acute renal failure (urine <80 ml for 4 h or serum creatinine level> 0.18 mmol / l in the absence of chronic renal failure).

23 SEVERE COMMUNITYACQUIRED PNEUMONIA = presence of 2 small or 1 big criteria, all big criteria significantly increases the risk of death.

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26 Differential diagnosis Tuberculosis Destructive pneumonia

27 Tuberculosis.

28 Differential diagnosis Mitral stenosis, pulmonary edema Paraneoplastic pneumonia

29 Atelectasis.

30 CAP Patient Stratification

31 Empirical antibacterial CAP patients treatment group I-st line Alternative І Monotherapy PO: - Amoxicillin (Ospamoks); - Macrolide: azithromycin, clarithromycin, Midecamycin, spiramycin PO: - If Amoxicillin is ineffective macrolide or doxycycline or fluoroquinolone III-IV generation; - If macrolide is ineffective aminopenicillin or fluoroquinolone III-IV generation ІІ Monotherapy PO: - protected aminopenicillins (amoxicillin + clavulanic acid: amoxiclav) - second-generation cephalosporin (cefuroxime) Monotherapy PO: ADD macrolide to β-lactame or or instead a fluoroquinolone III-IV generation (monotherapy)

32 Antibacterial CAP patients treatment Group I-st line Alternative ІІІ Parenteral (i.m, i.v): - Protected aminopenicillin or cephalosporins II-III generation + Macrolide I.V.: ІV I.V.: - Protected aminopenicyllin or I.V.: In susp. P. аeruginosa: - i.v. antypseudomonas In susp. P. аeruginosa: - i.v. carbapenem + cephalosporins II-III generation + Macrolide cephalosporins III, IV g. + aminoglycoside + levofloxacin (ciprofloxacin) fluoroquinolons III-IV generation or carbapenem fluoroquinolone III-IV generation + β- lactam aminoglycoside + macrolide

33 Duration of Therapy 5-7 days - outpatients 7-10 days inpatients, S. pneumoniae days Mycoplasma, Chlamydia, Legionella 14+ days - chronic steroid users Am J Respir Crit Care Med 163: , 2001

34 HAP Pneumonia occurring 48 h post admission Excludes infection incubating at time of admission

35 Definitions 1)Hospital-acquired pneumonia (HAP) is pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission. 2)Ventilator-associated pneumonia (VAP) refers to pneumonia that develops more than 48 to 72 hours after endotracheal intubation. 3)Healthcare-associated pneumonia (HCAP) includes any patient who was either hospitalized in an acute care hospital for two or more days within 90 days of the infection; or resided in a long term care facility; or received intravenous antimicrobial therapy, chemotherapy, or wound care within the 30 days prior to the current infection; or attends a hospital or hemodialysis clinic

36 ETIOLOGY HAP, VAP, and HCAP aerobic gram-negative bacilli (eg, Escherichia coli, Klebsiella pneumoniae, Enterobacter spp, Pseudomonas aeruginosa, Acinetobacter spp) gram-positive cocci (eg, Streptococcus spp, Staphylococcus aureus, including MRSA) viruses or fungi is significantly less common except in the immunocompromised patient.

37 HAP Stratification Am J Respir Crit Care Med 153: , 1995

38 HAP Stratification Am J Respir Crit Care Med 153: , 1995

39 HAP Stratification

40 HAP Stratification Am J Respir Crit Care Med 153: , 1995

41 Optimal Antibiotic Therapy MRSA pneumonias: - prolonged intubation periods - prior use of antibiotics linezolid Pseudomonas aeruginosa pneumonias: - Combination piperacillin/tazobactam + structural pulmonary disease ciprofloxacin, or 1 week of prior hospitalization amikacin + imipenem, meropenem prolonged periods of intubation (>5 days) or an antipseudomonal prior exposure to antibiotics cephalosporin. A. Baumannii VAP: - neurosurgery - ARDS - head trauma - large-volume pulmonary aspiration. carbapenems, sulbactam, tigecycline, colistin

42 HAP Failure of Therapy Incorrect diagnosis it is not pneumonia Pathogen resistance Host factors that increase mortality Atelectasis, CHF, PE with infarction, lung contusion, chemical pneumonitis, ARDS, pulmonary hemorrhage Age > 60, prior pneumonia, chronic lung disease immunosuppression Antibiotic resistance Am J Respir Crit Care Med 153: , 1995

43 HAP - Prevention Hand washing Vaccination Influenza Pneumococcus Isolation of patients with resistant respiratory tract infections Enteral nutrition Choice of GI prophylaxis Subglottoc secretion removal? Am J Respir Crit Care Med 153: , 1995

44 Pneumocystis Carinii /Pneumocystis jiroveci Pneumonia (PCP) 1 Uncommon until 1980 s with emergence of HIV disease Caused by organism most closely related to fungi Mode of transmission unclear, possibly reactivation of latent infection PCP reference = Harrison s Principles of Internal Medicine 1

45 PCP Pneumonia Gradual onset of symptoms Common symptoms include fever, cough, progressive dyspnea Many patients asymptomatic May present as a spontaneous pneumothorax

46 PCP - Treatment TMP/SMX (trimethoprim/sulfamethoxazole) Drug of choice High incidence of side effects in HIV+ pts Dapsone + TMP Clindamycin + primaquine