بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. Update Management Of PneumoniabyProf. Entesar Sayed AhmedProfessor Of Chest Diseases Faculty Of Medicine For GirlsAl-Azhar Universty2007

3. Pneumonia • Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi

4. CLASSIFICATION • Pneumonia is often classified into two categories • Community-Acquired Pneumonia(CAP) • Hospital-Acquired Pneumonia.

5. Community Acquired Pneumonia (CAP) DEFINITION: CAP is commonly defined as an acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection

6. Accompanied by the presence of an acute infiltrate on a chest x-ray • And occurs in a patient who is not hospitalized or residing in a long-term care facility • for 14 or more days before the onset of symptoms.

7. Type Of Community Acquired Pneumonia • Typical pneumonia usually is caused by bacteria such asStreptococcus pneumoniae. • Atypical pneumonia usually is caused by the influenza virus, mycoplasma, chlamydia, legionella, adenovirus, or other unidentified microorganism.

8. Table :Identified Pathogens inCommunity-acquired Pneumonia • Streptococcus pneumoniae20-60% • Haemophilus influenzae3-10% • Staphylococcus aureus 3-5% • Gram-negative bacilli 3-10%

9. Legionellaspecies 2-8% • Mycoplasma pneumoniae 1-6% • Chlamydia pneumoniae 4-6% • Viruses 2-15% • Aspiration 6-10% • Others3-5%

10. New pathogens • The SARS coronavirus • Human metapneumovirus • Community-acquiredmethicillin-resistantStaphylococcus aureus

11. The SARS coronavirus • A new human pathogen, SARS-associated coronavirus, emerged and spread worldwide in the winter of 2002-2003

12. It was hypothesized that a previously unknown animal coronavirus had mutated and developed the ability to infect humans.

13. There is no specific treatment for SARS, and managementis mainly supportive, combined with aggressive measuresto institute infection control procedures to prevent spread of the disease.

14. Human metapneumovirus • This is a paramyxovirus first isolated in 2001 in hospitalized children with acute respiratory tract infections • More recently, HMPV has been reported in patients of all age-groups

15. who have a variety of medical findings • Like the SARS coronavirus, HMPV has no specific treatment

16. Community-acquired methicillin-resistantStaphylococcus aureus • CA-MRSA displays combinations of virulence factors and resistance traits that allow it to cause outbreaks of serious infections, including skin and soft tissue infections and severe pneumonia with necrotizing features

17. A finding of methicillin resistance is determined by the presence of a penicillin-binding protein with reduced affinity to penicillin.

18. On the basis of in vitro susceptibility testing, appropriate drugs include vancomycin (Vancocin, Vancoled) and linezolid (Zyvox) and also possibly trimethoprim-

19. sulfamethoxazole (TMP-SMZ) and clindamycin (Cleocin). • It is not clear at this time if the addition of rifampin (Rifadin, Rimactane) makes any difference.

20. PATHOPHYSIOLOGY

21. Diagnosis • Symptoms • Physical examination • Chest x-rays • Blood test • sputum Gram stain

22. sputum cultures • two sets of blood cultures • urine antigens. • serologic testing • molecular techniques

23. Symptoms • Common clinical symptoms of CAP include cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain • Other presentations may include headache and myalgia. • Certain etiologies, such as legionella, also may produce gastrointestinal symptoms.

24. Physical Examination • Physical examination may reveal dullness to percussion of the chest, crackles or rales on auscultation, bronchial breath sounds, tactile fremitus, and egophony ("E" to "A" changes). • The patient also may be tachypneic.

25. Radiography • Chest radiography may reveal a lobar consolidation, which is common in typical pneumonia; • Or it could show bilateral, more diffuse infiltrates than those commonly seen in atypical pneumonia • However, chest radiography performed early in the course of the disease could be negative.

31. Blood Count • Ablood countmay show ahigh white blood cells count, indicating the presence of an infection or inflammation. • In some people withimmune system problems, the white blood cell count may appear deceptively normal.

32. Blood tests may be used to evaluatekidneyfunction (important when prescribing certain antibiotics) or to look forlow blood sodium • Low blood sodium in pneumonia is thought to be due to extraanti-diuretic hormoneproduced when the lungs are diseased (SIADH) .

33. Cultures • Once the clinical diagnosis of CAP has been made, • Consideration should be given to microbiological diagnosis with bacteriologic Studies of sputum and blood • The etiologic diagnosis can be useful for both prognostic and therapeutic purposes.

34. Serologic Testing • Serologic testing for such pathogens as Legionella species, Mycoplasma species, and C pneumoniae should include sera drawn in both the A acute and convalescent phases for comparison.

35. MOLECULAR BIOLOGY • Powerful molecular techniques are now being applied to the early diagnosis of pneumonia. • DNA probes have been used for the detection ofLegionellaspecies, M pneumonia, andM tuberculosisin sputum.

36. Oxygen Assessment • All admitted patients should have oxygen saturation assessed by oximetry. • Artial blood gas should be obtained in any patient with severe illness or in any patientwith chronic lung disease, to assess both the level of oxygenation and the degree of carbon dioxide retention.

37. Invasive diagnostic techniques • Fiberoptic brochoscopy • Bronchoalveolar lavage • Transbronchial biopsy of lung • open-lung biopsy

38. Severe community acquired pneumonia • Severe CAP is defined by the presence of 2 minor or 1 major criteria. • Admission to an ICU may be appropriate.

39. Major criteria • The need for mechanical ventilation • Rapid enlarging infiltrates (>50% within 48 hours) • Septic shock • Acute renal failure (Creatinine >2.0 in the absence of chronic renal • insufficiency or urine output <80 mL in 4 hours)

40. Minor Criteria • Respiratory rate >30 • Pa02/FIO2 <250 • Multi-lobar pneumonia • Systolic BP <90mm Hg • Diastolic BP <60mm

41. Nosocomial pneumonia and hospital-acquired pneumonia • Nosocomial pneumonia and hospital-acquired pneumonia are used to describe infections acquired in the hospital setting

42. Risk factors • End tracheal intubation • Previous antibiotic treatment • High gastric pH • Postoperative pneumonia • Cardiac, pulmonary, hepatic and renal insufficiency

43. Common Pathogens • The most common pathogens are gram-negative bacilli andStaphylococcus aureus • Drug-resistant organisms are animportant concern

44. S. aureus,pneumococcus, andHaemophilus influenzaeare most commonly implicated when pneumonia develops within 4 to 7 days of hospitalization

45. Whereas enteric gram-negative organisms become more common with increasing duration of intubation.

46. Symptoms and Signs • Symptoms and signs are the same as those for community-acquired pneumonia, • Pneumonia in critically ill, mechanically ventilated patients more typically causes fever and increased respiratory and/or heart rate or changes in respiratory parameters, such as an increase in purulent secretions or worsening hypoxemia.

47. Diagnosis • Clinical presentation • Chest x-ray • And is confirmed by blood culture or bronchoscopic sampling of the lower respiratory tract.

48. Differential Diagnosis • Upper & lower respiratory tract infections • Reactive airways disease • Atelectasis • Congestive heart failure • Bronchiolitis obliterans with organizing pneumonia • Vasculitis • Pulmonary embolism • Pulmonary malignancy

49. MANAGEMENT • When managing a patient with pneumonia one should • Assess the severity of the pneumonia • Decide whether it is community or nursing home acquired • Determine if the patient is over 65 or has a comorbid illness • Decide whether to treat orally or with IV meds

50. COMMUNITY-ACQUIRED PNEUMONIA • Patient outcome Research Team • (PORT) system