(PULMO) - Pneumonia PDF
(PULMO) - Pneumonia PDF
(PULMO) - Pneumonia PDF
EPIDEMIOLOGY
Community-Acquired Pneumonia (CAP) Children younger • S. pneumoniae
• True incidence: uncertain than 2 years • Respiratory syncytial virus (RSV)
• Only 20-50% of patients require hospitalization. Older children and • M. pneumoniae
• ~2 to 15 cases/1000 persons/yr (higher in elderly) young adult
• Severity of disease is largely determined by Elderly - particularly • Pneumococcal pneumonia
o Subject's age at risk for o GBS
o Presence and type of any coexisting illness o Moraxella catarrhalis
o H. influenzae
CAP Age-Related Factors o L. pneumophila
o Gram-negative bacilli
• Children - one of major causes of morbidity
o C. pneumoniae
• Adults - ↑age is associated with
o Polymicrobial infections
o a change in distrib of microbial causes and
Older than 80 years • Higher incidence of aspiration
o ↑frequency and ↑severity of pneumonia
pneumonia
• Although absolute rate of infection by M. pneumonia
• Lower incidence of Legionella spp.
o does not decrease with age
o h/e accounts for a smaller proportion of
pneumonia in elderly than in younger populations.
Lecture 2 mra
Med3C Abarra - Pneumonia Pulmo
Lecture 3 mra
Med3C Abarra - Pneumonia Pulmo
Lecture 4 mra
Med3C Abarra - Pneumonia Pulmo
PATIENT EVALUATION
Chest X ray (PA-Lateral views)
Clinical Evaluation • New parenchymal infiltrate
• Best differentiate CAP from other acute RTI: • Confirms diagnosis
o Cough, fever, tachypnea, tachycardia, and • Assess severity / prognostication
pulmonary crackles • May suggest the etiology
o CAP is present in 20% to 50% of persons who
have all four factors
• Must look for presence of cx such as
o Pleural effusion, pericarditis, endocarditis,
arthritis, and CNS involvement
o Which may necessitate further dx procedures
and/or change in therapy
Lecture 5 mra
Med3C Abarra - Pneumonia Pulmo
The PSI (Pneumonia Severity Index) PSI Score Mgmt and Prognosis
• Point scoring system 70
or
less
(class
I
or
II)
71
to
90
(class
III)
• Retrospective analysis of a cohort of 14,199 CAP pts • Attributable
risk
of
death
• 30-‐day
mortality
rate
of
up
to
(1989) within
30
days
of
<
1%
2.8%
• Prospectively validated in a separate cohort of 38,039 • Outpatient
treatment
is
• May
benefit
from
brief
recommended.
hospitalization.
CAP pts (1991)
• Age - most significant risk factor
o 1 point given for each year of age (−10 points in
women). 91
to
130
(class
IV)
More
than
130
(class
V)
• Other risk factors: pt demographics, comorbid conditions, • 30-‐day
risk
of
death
of
8.2-‐9.3%,
• 30-‐day
risk
of
death
of
27.0-‐
PE findings, and lab results • Hospital
care
is
appropriate
31.1%.
• Hospitalization
is
appropriate
• Safely and effectively applied in clinical practice
• Less useful at extremes of age, ∴aged-based criteria have
been developed for children and elderly.
• < 50 = candidates for outpatient tx
• 70–90 = careful application of clinical judgment. CURB 65
• > 90 = warrant hospitalization • Grading the severity of CAP by the British Thoracic
Society
T32-9 Scoring System for Determining Risk of Complications • 1 point for each of the following findings upon
in Pts w/CAP presentation
(1) Confusion
Factors/Findings Pt Characteristic Points
Assigned (2) Urea higher than 7mmol/L
(3) Respiratory rate of 30/min or more
Demographic Males Age (in yr)
(4) Low systolic (<90mmHg) or low diastolic
Females Age (in yr) – (≤60mmHg) BP
10 (5) Age 65 years or older.
Nursing home Age (in yr) + Group Curb 65 30-day mortality rates (MR) for
residents 10 Score patients
Comorbid Neoplastic dse +30
1 0 or 1 1.5% outpatient
Illnesses Liver dse +20 2 2 9.2% brief inpatient /supervised
Congestive heart +10 outpatient
failure 3 3–5 22% inpatient
Cerebrovascular dse +10 ICU care for scores of 4 or 5
Renal dse +10
PE Altered mental status +20 American Thoracic Society Criteria for
RR ≥30cpm +20
Admission of Pts w/CAP to an ICU
Systolic BP <90mmHg +20 ICU admission warranted for 3 minor criteria or 1
Temp <35°C or ≥40°C +15 major criterion
Pulse ≥125bpm +10 Minor Criteria Major Criteria
Lab pH <7.35 +30
• RR ≥30 cpm • Invasive mechanical
BUN >10.7 mmol/L +20 • PaO2/FiO2 ratio <250 ventilation
Sodium <130 mEq/L +20 • Multilobar radio involvement • Septic shock with
Glucose >13.9 mmol/L +10 • Confusion or disorientation need for
Hematocrit <30% +10 • Uremia (BUN > 20 mg/dL) vasopressors
pO2 <60mmHg or +10 • Leukopenia (WBC ct <4000
O2Sat <90% cells/dL)
Pleural effusion +10 • Thrombocytopenia (platelet ct
<100,000 cell/dL)
• Hypothermia (core temp
<36°C)
• Hypotension req aggressive
fluid resuscitation
Lecture 7 mra
Med3C Abarra - Pneumonia Pulmo
• Stable vital signs • Unstable vital signs Any of clinical ft of moderate risk CAP plus
o RR<30 cpm o RR ≥ 30 cpm any on ff:
o PR <125 bpm o PR ≥ 125 bpm • 1. Shock or signs of hypoperfusion
o SBP ≥ 90mmHg o Temp ≥ 40C or >35C o Hypotension
o DBP ≥ 60 mmHg • Unstable comorbid condition, i.e. o Altered mental state
• No or stable comorbid conditions o uncontrolled DM o Urine output < 30ml/hr
• No evidence of extrapulmonary o active malignancies • 2. Hypoxia (PaO2<60mmHg) or Acute
sepsis o progressing neuro dse Hypercapnea (PaO2>50mmHg)
o CHF Class II-IV, unstable CAD
o renal failure on dialysis
o uncompensated COPD
o decompensated liver dse
Lecture 8 mra
Med3C Abarra - Pneumonia Pulmo
Guidelines for Empirical Oral Outpatient Treatment of Immunocompetent Adults with Community-Acquired Pneumonia
British
Thoracic
Society
Drug
Resistant
S.
pneumoniae
American
Thoracic
Society
Infectious
Dses
Society
of
Canadian
Infectious
Dse
Society
&
Therapeutic
Working
Group
America
Canadian
Thoracic
Society
Primary No modifying factor
Amoxicillin Macrolide, doxycycline, Advanced macrolide or Advanced macrolide or Macrolide or doxycycline
cefuroxime, amoxicillin, doxycycline doxycycline
amoxi-clav
Alternatives Comorbidities/modifying factors: COPD
Erythromycin or Fluoroquinolone β-lactam macrolide or Fluoroquinolone or Advanced macrolide or
clarithromycin doxycycline, or fluoroquinolone advanced macrolide doxycycline
alone IDSA Co-morbidities:
ATS Co-morbidities: • COPD
• Cardiopulmonary dse and • Diabetes
age > 65yo • Renal failure
• β-lactam antbx w/in last • Congestive heart
3mo failure
• Alcoholism • Malignancy
• Prior immunosuppressive tx Antibiotics within 3mo: COPD plus recent antibiotics or
• Multiple medical steroids:
comorbidities Fluoroquinolone alone or Fluoroquinolone alone, amoxi-clav,
nd
• Exposure to a child in a advanced macrolide β- macrolide, 2 –gen
daycare center lactam cephalosporin, macrolide
• Residence in a nursing Nursing home patient:
home Fluoroquinolone alone or Fluoroquinolone alone or
nd
amoxi-clav, advanced macrolide plus amoxi-clav or 2 -
macrolide gen cephalosporin
Suspected aspiration:
Clindamycin or amoxi-clav Amoxi-clav, macrolide, or
fluoroquinolone, clindamycin or
metronidazole
Influenza with bacterial
superinfection:
β-lactam or
fluoroquinolone
Guidelines for Empirical Oral Outpatient Treatment of Immunocompetent Adults with CAP: MILD TO MODERATE or SEVERE DSE
British
Thoracic
Society
Drug
Resistant
S.
pneumoniae
American
Thoracic
Society
Infectious
Dses
Society
of
Canadian
Infectious
Dse
Therapeutic
Working
Group
America
Society
and
Canadian
Thoracic
Society
Primary No modifying factors: Primary:
(Ampicillin or penicillin) a (Cefuroxime, cefotaxime, Azithromycin alone, doxycycline, (Cefotaxime, ceftriaxone, Fluoroquinolone or
macrolide ceftriaxone, or ampicillin- β-lactam or fluoroquinolone alone ertapenem, or (cephalosporin
sulbactam) macrolide ampicillin/sulbactam) macrolide)
advanced macrolide or
fluoroquinolone alone
(Cefuroxime, cefotaxime, or (Cefotaxime or ceftriaxone) (Cefotaxime, ceftriaxone,
ceftriaxone) macrolide, (azithromycin or fluoroquinolone) ertapenem, or
rifampin ampicillin/sulbactam)
(advanced macrolide or
fluoroquinolone)
Alternative: With modifying factors: Suspected aspiration:
Fluoroquinolone Fluoroquinolone (Cefotaxime or ceftriaxone or Fluoroquinolone,
ampicillin-sulbactam or high-dose antianaerobic agent
ampicillin) (macrolide or
doxycycline) or fluoroquinolone
alone
Fluoroquinolone, penicillin IV At risk for Pseudomonas β-Lactam allergy:
aeruginosa: antipseudomonal β- fluoroquinolone,
,
lactam ciprofloxacin or clindamycin
antipseudomonal, β-lactam Pseudomonas risks:
,
aminoglycoside plus (azithromycin (antipseudomonal β-lactam
or fluoroquinolone) ciprofloxacin) or
antipseudomonal β-lactam
aminoglycoside
(fluoroquinolone or a
macrolide)
Pseudomonas risks and β-
lactam allergy: (aztreonam
levofloxacin) or aztreonam
(moxifloxacin or
gatifloxacin) an
aminoglycoside
Lecture 9 mra
Med3C Abarra - Pneumonia Pulmo
OTHER STREPTOCOCCI
S. pyogenes (group A β-hemolytic Group B streptococci (S. Streptococcus milleri
streptococcus) agalactiae) group C streptococci
• In oropharynx of over 20% of children • Major cause of neonatal sepsis • S. intermedius, S. anginosis,
o Smaller %age of adults and pneumonia and S. Constellatus
• Easily transferred btwn contacts • Most adults are debilitated and • Predominantly causing
o à Epidemics of group A strep pneumonia in develop pneumonia d/t aspiration. empyema and lung
military recruits, nursing homes, and other abscesses
crowding situations
• Most often - late winter and spring months
o ~post- influenza, measles, or varicella
• Risk factors: ↑age, alcohol abuse, DM, cancer, and HIV • Diabetes, hepatic cirrhosis, stroke, • Males, periodontal dse, and
infection. breast cancer, decubitus ulcer, alcoholism
neurogenic bladder
• Unilobar involvement is common • •
• Empyema and/or pericarditis occur in 5% to 30% with • •
GABS pneumonia
• Glomerulonephritis- only classic non-suppurative
complication post-S. pyogenes pneumonia
Lecture 11 mra
Med3C Abarra - Pneumonia Pulmo
Epidemiology Epidemiology
• Accounts for less than 10% of cases of CAP CAP
•
nd rd
2 -3 most common in CAP requiring ICU admission. • P. aeruginosa is an uncommon cause of CAP.
• S. aureus, esp MRSA à up to 30% of nosocomial • Major risk factor is structural lung disease
pneumonias. o Cystic fibrosis, bronchiectasis, and severe COPD
• Nasal or skin colonization - major source (FEV1 < 30%).
o 30-50% of healthy adults carry transiently in • Another common risk factor in outpatient is frequent
anterior nares antibiotic use.
o MRSA pneumonia - nasal colonization on • Very rarely, in a normal hosts, perhaps related to aerosols
admission in 67% of contaminated water
§ Noncolonized have <5% risk of HAP and VAP
subsequent MRSA pneumonia • A leading cause of nosocomial pneumonia and a
o HCWs may have even higher carriage rates particularly frequent cause of VAP
• Easily person to person by direct hand contact • Primary risk factors in VAP
o Prolonged ET intubation
MRSA-CAP o Prior antibiotic therapy, esp w/broad-spectrum
• Community-acquired strain of MRSA has recently become antibiotics
an important CAP pathogen in the US o Other: administration of aerosols from
o D/t antibiotic resistance + Virulence factors contaminated respiratory therapy equipment.
§ Combo is assoc w/sig higher mortality. • Other nonfermenters, such as S. maltophilia and B.
o DNA cassette containing mecA gene also cepacia, carry the same nosocomial risk factors
included other virulence factors, such as the o most commonly prolonged broad-spectrum
Panton-Valentine leukocidin (PVL). antibiotic therapy
• Typical HAP strains of MRSA have also caused episodes o are associated with a high MR
of CAP but usu occur in pts with risk factors for HCAP o B. cepacia is also found in CF, outpt
• Difficult to differentiate clinically btwn HAP and CAP
o Risk factors, e.g. antibiotic therapy overlap. Clinical Manifestations
• Largely indistinguishable from that of pneumonia
Risk Factors due to one of the Enterobacteriaceae
• Bacteremic pneumonia appears much more toxic.
• Underlying pulmonary disease (e.g., COPD, carcinoma, CF)
• PE: ecthyma gangrenosum and leukopenia
• Chronic illness (e.g., diabetes mellitus, renal failure)
• CXR: often bilateral patchy bronchopneumonia in lower
• Viral infection (e.g., influenza, measles).
lobes
Postinfluenza bacterial pneumonia
• Labs & PE: ~resemble pulmonary thromboembolism.
• S. aureus (incl MRSA-CAP), is 2 n d to S. pneumoniae as a
o Because of its propensity to invade vascular
cause
tissue
• MRSA-CAP is particularly virulent.
• Pseudomonas HAP is the most common cause of
• By hematogenous spread usu as consequence of
cavitary pneumonia in hospitalized or
o IV drug abuse
immunocompromised
o Septic embolization (endocarditis setting)
o Empyema is not uncommon
o Infected vascular site
Microbiologic Diagnosis
Clinical Manifestations • GS of sputum: purulence and many slender, gram-
• Acquired hematogenously, s/sx related to underlying
negative bacilli
endovascular infection predominate
o Complicated by colonization of oropharynx in
o If pulmonary infarction d/t septic embolism à
hospitalized or debilitated
pleuritic chest pain and hemoptysis
• In ET intubated, absence of Pseudomonas on culture is
• RT sx - mild or absent
strong evidence that it is NOT involved in the pneumonia.
o H/e, radiographic evidence of multiple
• Invasive diagnostic procedure
pulmonary opacities
o Esp useful in immunocompromised or
• Severe manifestations - more common if infected by S.
neutropenic patients
aureus w/PVL toxin
o B/c sputum may be minimal or nondiagnostic
o High-grade fever, massive hemoptysis,
• Blood cultures are often positive in neutropenic patients.
neutropenia, pulmonary necrosis, and mortality
o Often cavitary dse already at presentation à
confusion with lung abscess or hematogenous S. Clinical Course
aureus • MR of P. aeruginosa CAP is up to 28%
o Rapid progression of pulmonary opacities and • MR of P. aeruginosa VAP is 40-70%
massive pleural effusions is also common. • Prognosis in neutropenic pts is particularly poor
• CXR in hematogenous - multiple, discrete, and often
cavitary shadows with a predilection for the lower lobes
Lecture 12 mra
Med3C Abarra - Pneumonia Pulmo
KEY POINTS
All
patients
with
suspected
pneumonia
should
have
a
chest
radiograph.
Gram stains and cultures of blood, sputum, and other sites should be obtained in hospitalized patients prior to treatment.
Infection by aerosolization route occurs with the intracellular bacteria -‐ M. pneumoniae, Chlamydophila spp., and C. Burnetii
Infection occurs by aspiration with S. pneumoniae, H. influenzae, gram-‐negative bacilli
Aside
from
inhalational
pneumonia
due
to
Legionella
or
contaminated
medical
aerosols,
aspiration
is
the
cause
of
HAP,
especially
in
intubated
patients
In
elderly
and
immunocompromised
ps,
s/sx
of
pneumonia
may
be
muted
and
overshadowed
by
nonspecific
complaints.
Elderly
patients
with
pneumonia
who
present
with
altered
mental
status
without
fever
have
a
delay
in
receiving
antibiotics
and
this
delay
affects
mortality
Treatment
for
pneumonia
should
be
pathogen-‐directed,
but
pathogens
are
rarely
identified
initially.
Therefore,
the
setting
in
which
the
patient
resides
(e.g.,
community,
hospital,
nursing
home),
the
severity
of
the
disease,
the
age
of
the
patient,
the
presence
of
comorbidities
and
immunosuppression,
previous
antimicrobial
therapy,
and
specific
clinical
and
radiologic
manifestations
of
the
illness
must
be
considered
If
etiologic
agent
has
been
reliably
identified,
the
antimicrobial
regimen
should
be
adjusted
based
on
the
results
of
in
vitro
susceptibility
testing.
The
ideal
drug
for
a
known
pathogen
has
the
narrowest
spectrum
of
activity
and
is
the
most
efficacious,
least
toxic,
and
least
costly
Lecture 14 mra