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Pneumonia

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Pneumonia

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  1. Pneumonia • Very common (1-10/1000), significant mortality • Severity assessment, aided by score, is a key management step • Caused by a variety of different pathogens • Antibiotic treatment initially nearly always empirical, local guidelines and microbial resistance rates may support it

  2. 2009.05.18

  3. 2009.05.26

  4. 2009.10.26

  5. 2009.11.02

  6. 2009.11.02

  7. Evidence-based health policy (Science 1996; 274:740-743.)

  8. Definition Acute, infectious inflammation of the lower respiratory tract parenchyma (distal to bronchiolus terminalis).

  9. Pathogens • Bacteria /aerobic,anaerobic, atypical/ • Virus /influenza ,parainfluenza, adenovirus, herpesvirus,cytomegalovirus, RSV/ • Fungi /Aspergillus,Candida/ • Parasites /Pneumocystis jiroveci, Toxoplasma gondii,Ascaris lumbricoides/

  10. Clinical classification • Community-acquired, CAP • Nosocomial, hospital-acquired, HAP, VAP • Aspiration and anaerobic • Pneumonia in the immuncompromised host • AIDS-related • Reccurent • Pneumonias peculiar to specific geographical areas

  11. Epidemiology of CAP Mycoplaspa pn. Chlamydia pn.

  12. Pathogenesis • Inhalation of infected droplets • Aspiration /residents from nasopharynx/ • Spread through bloodstream • Direkt spread (concomittant)

  13. Risk factors • Prolonged supine position • Antibiotics, antacids • Patient contact • Decreased defense mechanisms • Infected health care materials

  14. Etiology • 1.Streptococcus pneumoniae 40-60% • 2. Mycoplasma pneumoniae 10-20% • 3. Haemophilus influenzae 6-10% • 4.Influenza A 5-8%

  15. Clinical features I. • General symptoms • malaise, anorexia • sweating, rigors • myalgia, arthralgia • headache • fast (bacteremia) vs. slow (Mycoplasma) progression • marked confusion (Legionella, psittacosis) • acute abdominal or urinary problem (lower lobe, age!)

  16. Clinical features II. • Respiratory symptoms - cough, dsypnea, pleural pain - purulent sputum, hemoptysis • Physical signs - high fever and rigor (Pneumococus) - little or no fever (elderly, seriously ill) - herpes labialis (Pneumococcus) - dullness, inspiratory crackles, bronchial breathing - upper abd. tenderness (lower lobe) - rash (antibiotic, mycoplasma, psittacosis)

  17. Differential diagnosis • Pulmonary infarction • Atypical pulmonary oedema • Less common: pulmonary eosinophilia, acute allergic alveolitis, lung tumours • Diseases below the diaphragm: hepatic abscess, appendicitis, pancreatitis, perforated ulcer

  18. Investigations • Chest x-ray (lateral!, neoplasm) – compulsory • WBC , >30 or < 4 G/L: poor prognosis • Sputum Gram stain and culture • Blood culture (20-25% positive) • Pleural fluid (25%, exclude empyema: pH!) • Serology (atipical, viral), antigen detection (Legionella, Pneumococcus) • Invasive tests: uncontaminated LRT secretions (BAL,PBS) or lung biopsies

  19. Radiological features • Lobar or segmental opacification • Patchy shadows • Small pleural effusions • Cavitation (infrequent, Staphylococcus, Pneumococcus serotype 3) • Spread to more than one lobe (Legionella. Mycoplasma) • Clearance of shadow may last for months

  20. Treatment at home or in hospital ?

  21. male age female age – 10 elderly’s home +10 Neoplasia +30 Liver dis. +20 CHF +10 Cerebrovasc. +10 Renal dis. +10 Confusion +20 Pleuriy +10 Resp.rate > 30 +20 RR<90 +20 Temp.<35 v. >40 +15 Pulse>125 +10 pH<7,35 +30 UN>11 +20 Na<130 +20 Se glucose>13,9 +10 Htk<30% +10 PaO2<60 Hgmm +10 CAP PORT (NEJM 1997, 40 000beteg)

  22. PORT categories • I.-II. <70, mortality < 1%, outpatient • III. 70-90, mortality 2,8%, short hospital, sequential ATB • IV. 91-130, mortality 8,2%, hospital • V. >130, mortality 29,2%, consider ICU

  23. CURB65 score (1-1point) Mild: 0-1point, 1.5% mortality Moderate: 2point, 9% mortalility Severe: 3-5 point, 22% mortalitty

  24. Only a few pathogens are involved Always cover Pneumococcus Consider epidemiology, age and health status Mycoplasma during epidemics, Staph.aur. in flu Do not delay starting antibiotics Assess prognostic factors and severity early Establish etiology quickly Adequate oxygen, hydration and nutrition Careful monitoring – transfer early to ICU Initial antibiotics must cover all the likely pathogens “Ten commandments” of CAP treatment Severe All

  25. Treatment of CAP 1) <65 year, no comorbidity, home: macrolide, doxycyclin, amoxycillin/clavulanic acid, 2. gen. cephalosporin 2) >65 year, comorbidity, home: amoxycillin/clavulanic acid, 2-3 gen. cephalosporin +- macrolide, respiratory fluoroquinolon (levofloxacin, moxifloxacin) 3) hospital: amoxycillin/clavulanic acid, 2-3 gen. cephalosporin + macrolide, resp.fluoroquinolon 4) ICU: ceftriaxon/cefotaxim, cefepim, carbapenemes (imipenem, meropenem), piperacillin/tazobactam + macrolides, resp. fluoroquinolon

  26. Risk factors of nosocomial pneumonia, HAP

  27. Pathogens and treatment of non-severe HAP

  28. Pathogens and treatment of non-severe HAP with additional risk factors

  29. Pathogens and treatment of severe HAP

  30. Reccurent pneumonia (GERD)

  31. Streptococcus pneumoniae • Most common bacterium in adults • Significant morbidity and mortality • Polysaccharide capsule impairs phagocytosis  need of opsonization  risk population: lymphoma, hyposplenia, hypogammaglobulinaemia • Abrupt onset, cough, rigors, high fever, tachycardia, tachypnoe, sticky pink sputum, focal crackles, • Sputum Gram stain: diplococcus, blood culture (20% pos.) • Good sputum sample: LRT: > 25 PMN, < 10 EC (low power field) • X-ray: homogenouos consolidation • Complications: pleura, pericardium, meninges, joints, endocardium, Type 3: abscess, lung scarring

  32. Streptococcus pneumoniae

  33. Streptococcus pneumoniae II. • Treatment: • Penicillin, ampicillin, amoxycillin • Cephalosporins 2-3 gen. • Macrolides • Carbapenems (imipenem, meropenem) • Prevention • 23-valent vaccine, 90% adult types • Chronic lung, heart, liver, renal disease, HIV • Diabetes, after spelenctomy, sickle-cell disease

  34. Mycoplasma pneumoniae(Atypical pneumonia) • Atypical pathogen, moderate morbidity, low mortality • Close communities (schools, barracks, dormitories) • Intracellular pathogen (Chlamydia, Legionella) • Patchy shadowing on X-ray • Extrapulmonary manifestations: lymphadenopathy, cardiac, neurological, skin lesions, gatrointestinal,haematological, musculoskeletal • Treatment: macrolides, tetracyclin, fluoroquinolones

  35. Mycoplasma pneumoniae

  36. Legionella pneumophila

  37. Staphylococcus aureus • High morbidity and mortality (30-70% in bacterae-mia) • 30% of adults carry in the anterior nares • Intravascular tubes (catheters, cannules) • Usually follows influenza infections • Toxins  tissue necrosis  abscess • Treatment: beta-lactamase resistant penicillins (oxacillin), cephalosporins, MRSA: vancomycin

  38. Staphylococcus aureus

  39. Lung abscess Key points • many other cavitating lesions than abscess • careful review of chest x-ray to distinguish from empyema • most are secondary to aspiration of oropharyngeal secretions • exclude malignancy or other cause, bronchoscopy! • a single microbe is unusual unless abscesses developed after bacterial pneumonia. More commonly, there is a mixed growth, including anaerobes

  40. Causes of lung abscess • Aspiration from the oropharynx • Bronchial obstruction • Pneumonia • Blood-borne infection • Infected pulmonary infarct • Trauma • Transdiagphragmatic spread

  41. Diff. dg of lung abscess • Cavitated tumour • Infected bulla or cyst • Localised saccular bronchiectatsis • Aspergilloma • Wegener’s granulomatosis • Hydatid cyst • Coal workres’ pneumoconiosis - progressive massive fibrosis - Caplan’s sy • Cavitated rheumatoid nodule • Gas-fluid level in oesophagus, stomach or bowel

  42. Treatment of lung abscess • Based on bacteriologic findings • Penicillin (amoxicillin/clavulanic acid) • Clindamycin + aminoglycosid (mixed flora) • moxifloxacin