Pneumonia

Dr. Md. Khairul Hassan Jessy
Associate Professor, Respiratory Medicine
National Institute of Diseases of the Chest and Hospital (NIDCH)
Mohakhali, Dhaka
Pneumonia

Blood Shed For Language And Independence Is The
Glorious History Of Bangladesh

Out lines Of Presentation
Definition
Classification of pneumonia
Mode of transmission
Predisposing factors
Pathophysiology
Clinical manifestations
Diagnostic tests
Medical management
Prognosis
Complications

Pneumonia
An acute respiratory illness associated with recently
developed radiological pulmonary shadowing which
may be segmental, lobar or multilobar.
Or,
Inflammation in the lung characterized by accumulation
of secretions and inflammatory cells in alveoli.

Pneumonia: Classifications
Clinically
Community-acquired pneumonia (CAP):
Onset in community or during 1st 2 days of hospitalization
(Strep. pneumoniae most common)
Hospital-acquired Pneumonia(HAP/nosocomial):
Occurring 48 hrs after hospitalization
Suppurative & Aspiration pneumonia
Pneumonia in immunocompromised patient: caused by
opportunistic organisms (Pneumocystis jirovecii).

Pneumonia: Classifications..
Anatomically
Lobar pneumonia if one or more lobe is involved
Broncho-pneumonia (Lobular)
1.more patchy alveolar consolidation associated with
bronchial and bronchiolar inflammation often affecting both
lower lobes
2.the pneumonic process has originated in one or more
bronchi and extends to the surrounding lung tissue

According to causes
Bacterial (the most common cause of pneumonia)
Viral pneumonia
Fungal pneumonia
Aspiration pneumonia
Chemical pneumonia (ingestion of kerosene or inhalation of
irritating substance)

Typical pneumonia:
Respiratory symptoms are
more than constitutional
symptoms
Atypical pneumonia:
Constitutional symptoms are
more than respiratory
symptoms
(Behaviourist's classification)
Easy pneumonia (responds
to initial treatment)
Difficult pneumonia (fails to
do so)

COMMUNITY-ACQUIRED PNEUMONIA
(CAP)

Community-acquired pneumonia (CAP)
Onset in community or during 1st 2 days of hospitalization
Strep. pneumoniae most common 50%
It affects all age groups but is particularly common at the
extremes of age.
Worldwide, CAP continues to kill more children than any other
illness, and its propensity to ease the passing of the frail and
elderly led to pneumonia being known as the ‘old man’s friend’.

Community-acquired pneumonia (CAP)..
Most cases are spread by droplet infection.
May occur in previously healthy individuals.
Streptococcus pneumoniae remains the most common infecting
agent.
Other organisms may be involved which depends on the age of the
patient and the clinical context.
Viral infections are important causes of CAP in children, and their
contribution to adult CAP is increasingly recognized

Mycoplasma pneumoniae is more common in young people and
rare in the elderly.
Haemophilus influenzae is more common in the elderly, particularly
when underlying lung disease is present.
Legionella pneumophila occurs in local outbreaks centred on
contaminated cooling towers in hotels, hospitals and other industrial
buildings.
Staphylococcus aureus is more common following an episode of
influenza.

Cigarette smoking
Upper respiratory tract
infections
Alcohol
Corticosteroid therapy
Old age
Recent influenza infection
Pre-existing lung disease
HIV
Indoor air pollution
Factors that predispose to pneumonia

Bacteria
• Streptococcus pneumoniae
• Mycoplasma pneumoniae
• Legionella pneumophila
• Chlamydia pneumoniae
• Haemophilus influenzae
• Staphylococcus aureus
• Chlamydia psittaci
• Coxiella burnetii
(Qfever, ‘querry’fever)
• Klebsiella pneumoniae
(Freidländer’s bacillus)
• Actinomyces israelii
Viruses
Influenza, parainfluenza
Measles
Herpes simplex
Varicella
Adenovirus
Cytomegalovirus (CMV)
Coronavirus (Urbani SARS-
associated coronavirus)
Organisms causing CAP

Pneumonia: mode of transmission
Bacteria and viruses living in your nose, sinuses, or mouth
may spread to your lungs
You may breathe some of these germs directly into your
lungs (droplets infection)
You breathe in (inhale) food, liquids, vomit, or fluids from
the mouth into your lungs (aspiration pneumonia)

Pathophysiology
The streptococci reach the alveoli and lead to
inflammation and pouring of an exudates into the air
spaces
WBCs migrates to alveoli, the alveoli become more thick
due to its filling consolidation, involved areas by
inflammation are not adequately ventilated, due to
secretion and edema
This will lead to partial occlusion of alveoli and bronchi
causing a decrease in alveolar oxygen content

Pathophysiology..
Venous blood that goes to affected areas without being
oxygenated and returns to the heart (ventilation-perfusion
mismatch)
 This will lead to arterial hypoxemia and even death due to
interference with ventilation

Clinical features
Pneumonia, particularly lobar pneumonia, usually presents as an
acute illness.
Systemic features such as fever, rigors, shivering and malaise
predominate and delirium may be present.
The appetite is invariably lost and headache frequently reported.

Clinical features..
Pulmonary symptoms include cough, which at first is
characteristically short, painful and dry, but later accompanied by
the expectoration of mucopurulent sputum.
Rust-coloured sputum may be seen in patients with Strep.
pneumoniae, and the occasional individual may report
haemoptysis.
Pleuritic chest pain may be a presenting feature and, on

Clinical features..
Upper abdominal tenderness is sometimes apparent in patients
with lower lobe pneumonia or if there is associated hepatitis.
Less typical presentations may be seen in the very young and
the elderly.

Clinical features..
On examination,
The respiratory and pulse rate may be raised and the blood pressure
low, while an assessment of the mental state may reveal a delirium.
These are important indicators of the severity of the illness
Not all patients are pyrexial but this is a helpful diagnostic clue if
present.
Oxygen saturation on air may be low, and the patient cyanosed and
distressed.

Clinical features..
On examination..
Chest signs vary, depending on the phase of the inflammatory
response.
When consolidated, the lung is typically dull to percussion and,
as conduction of sound is enhanced, auscultation reveals
bronchial breathing and whispering pectoriloquy; crackles are
heard throughout.
However, in many patients, signs are more subtle with reduced
air entry only, but crackles are usually present.

Clinical features..
On examination..
An assessment of nutrition is important as, if poor, the
response to treatment will be impaired, particularly in the
elderly.
On occasion, inferences as to the likely organism may be drawn
from clinical examination. For example, the presence of herpes
labialis may point to streptococcal infection, as may the finding
of ‘rusty’ sputum.
The presence of poor dental hygiene should prompt
consideration of Klebsiella or Actinomyces israelii.

Clinical features..
Chronic Pneumonia
Symptoms creep in slowly
Fever that lasts a week
Coughing for three weeks
Enlarged cervical & axillary lymphnodes
Haemoptysis
Recurrence of symptoms after finishing antibiotic course

Differential diagnosis of pneumonia
Pulmonary infarction
Pulmonary/pleural TB
Pulmonary oedema (can be unilateral)
Pulmonary eosinophilia
Malignancy: bronchoalveolar cell carcinoma
Rare disorders: cryptogenic organising pneumonia/
bronchiolitis obliterans organising pneumonia (COP/BOOP)
Venous thromboembolism, Pulmonary haemorrhage
ARDS
Drug toxicity

Fishing, Village of Bangladesh

Investigations
The aims of investigation are
Confirm the diagnosis
Exclude other conditions
Assess the severity
Identify the development of complications

Investigations..
Full blood count
 Very high (> 20 × 109/L) or low (< 4 × 109/L) white cell
count: marker of severity
 Neutrophil leucocytosis > 15 × 109/L: suggests bacterial
aetiology
 Haemolytic anaemia: occasional complication of Mycoplasma
Erythrocyte sedimentation rate/C-reactive protein: Non-
specifically elevated
Blood culture: Bacteraemia: marker of severity

Investigations..
Urea and electrolytes:
Urea > 7 mmol/L (~20 mg/dL): marker of severity
Hyponatraemia: marker of severity
Liver function tests:
Abnormal if basal pneumonia inflames liver
Hypoalbuminaemia: marker of severity
Serology: Acute and convalescent titres for Mycoplasma,
Chlamydia, Legionella and viral infections
Cold agglutinins: Positive in 50% of patients with Mycoplasma
Arterial blood gases: Measure when SaO2 < 93% or when
severe clinical features to assess ventilatory failure or acidosis

Investigations..
Sputum
Sputum samples
Gram stain, culture and antimicrobial sensitivity
testing. Gram stain of sputum showing Gram-
positive diplococci characteristic of Strep.
pneumoniae.
Oropharynx swab
PCR for Mycoplasma pneumoniae and other
atypical pathogens

Investigations..
Urine
Pneumococcal and/or Legionella antigen
Pleural fluid
Always aspirate and culture when present in more
than trivial amounts, preferably with ultrasound
guidance

Investigations..
Other markers of severity of Pneumonia
CXR :> One lobe involved
Pao2 <8kPa
Low albumin(<35gm/L)
WBC(<4000/cmm or >20000/cmm)
Blood culture positive

Investigations..
Chest X-ray
Lobar pneumonia
Patchy opacification evolves into homogeneous consolidation
of affected lobe
Air bronchogram (air-filled bronchi appear lucent against
consolidated lung tissue) may be present.
Bronchopneumonia: Typically patchy and segmental shadowing
Complications: Para-pneumonic effusion, intrapulmonary
abscess or empyema
Staph. aureus: Suggested by multilobar shadowing, cavitation,
pneumatocoeles and abscesses

Investigations..
For evaluation of PSI
CBC
HCT, TC, DC
RBS
Blood Urea
Serum electrolytes
CXR
ABG Analysis
Pulse oximetry

Management
The principles of management focusing on
Adequate oxygenation
Appropriate fluid balance
Antibiotics
In severe or prolonged illness,
Nutritional support may be required
Evaluate the effectiveness of administered medications
Explain all procedures to the patient and family

Management…
Oxygen
Oxygen should be administered to all patients
with
tachypnoea,
hypoxaemia,
hypotension or
acidosis
The aim of maintaining the PaO2 at or above 8
kPa (60 mmHg) or the SaO2 at or above 92%.

Management….
Oxygen
High concentrations (35% or more), preferably
humidified, should be used in all patients who do not
have hypercapnia associated with COPD.
Continuous positive airway pressure (CPAP) should be
considered in those who remain hypoxic despite this
and these patients should be managed in a high-
dependency or intensive care environment, where
mechanical ventilation can be rapidly employed.

Management…
Intravenous fluids
These should be considered in patients with severe
illness, older patients and those who are vomiting.
Otherwise, an adequate oral intake of fluid should be
encouraged.
Inotropic support may be required in patients with
shock

Management…
Antibiotics
Prompt administration of antibiotics improves the outcome. The
initial choice of antibiotic is guided by
clinical context,
severity assessment,
local knowledge of antibiotic resistance patterns
any available epidemiological information.
The choice of empirical antibiotic therapy is considerably more
challenging, due to
Diversity of pathogens
Drug resistance.

Management…
Antibiotics : Uncomplicated CAP:
Amoxicillin 500 mg 3 times daily orally
If patient is allergic to penicillin: Clarithromycin 500 mg twice daily orally
or Erythromycin 500 mg 4 times daily orally
If Staphylococcus is cultured or suspected: Flucloxacillin 1–2 g 4 times
daily IV plus Clarithromycin 500 mg twice daily IV
If Mycoplasma or Legionella is suspected: Clarithromycin 500 mg twice
daily orally or IV or Erythromycin 500 mg 4 times daily orally IV plus
Rifampicin 600 mg twice daily IV in severe cases

Management…
Antibiotics : Severe CAP:
Clarithromycin 500 mg twice daily IV or
Erythromycin 500 mg 4 times daily IV
plus
Co-amoxiclav 1.2 g 3 times daily IV or
Ceftriaxone 1–2 g daily IV or
Cefuroxime 1.5 g 3 times daily IV or
Amoxicillin 1 g 4 times daily IV plus flucloxacillin 2 g 4 times daily IV

Management…
Antibiotics: Oral antibiotics are usually adequate unless the
patient has a
severe illness,
impaired consciousness,
loss of swallowing reflex, or
functional or anatomical reasons for malabsorption.
In most patients with uncomplicated pneumonia, a 7-day course is
adequate, although treatment is usually required for longer in
those with Legionella, staphylococcal or Klebsiella pneumonia.

Management…
Antibiotics:
Duration of therapy
5 -7 days - outpatients
10-14 days – Mycoplasma, Chlamydia, Legionella
14+ days - chronic steroid users
14-21days – Staph. aureas, Legionella spp
[Am J Respir Crit Care Med 163:1730-54, 2001]

Management…
Pain
It is important to relieve pleural pain, as it may prevent the
patient from breathing normally and coughing efficiently.
For the majority, simple analgesia with paracetamol, co-codamol
or NSAIDs is sufficient.
In some patients, opiates may be required but these must be
used with extreme caution in patients with poor respiratory
function, as they may suppress ventilation.
Physiotherapy
May help expectoration in those who suppress cough because of
pleural pain.

Management…
Maintain a patent airway and adequate oxygenation
Use suction if the patient can’t produce a specimen
Provide a high calorie, high protein diet & soft foods
Provide a quiet, calm environment, with frequent rest periods
Monitor the patient’s ABG levels, especially if he’s hypoxic
Assess the patient’s respiratory status
Auscultate breath sounds at least every 4 hours

Management…
Delayed resolution means
Physical signs persist for more than 2 weeks and
Radiological features persist for more than 4 weeks after
antibiotic therapy.
Non-resolution means
If radiological opacity persists after 8 weeks (with
treatment/after antibiotic therapy).

Management…
Delayed resolution suggests
I. the diagnosis is incorrect
II. Incorrect microbiological diagnosis
III. Fungal, tubercular or atypical pneumonia
IV. recurrent aspiration
V. Improper antibiotic or insufficient dose
VI. pneumonia may be secondary to a proximal bronchial obstruction
VII. complication has occurred (Empyema or atelectasis)
VIII. Bronchial obstruction (bronchial carcinoma, adenoma, foreign body)
IX. Immunocompromised patient (HIV, DM, lymphoma, leukemia, multiple
myeloma).

Indications for referral to ITU
CURB score of 4–5, failing to respond rapidly to
initial
management
Persisting hypoxia (PaO2 < 8 kPa (60 mmHg)),
despite high concentrations of oxygen
Progressive hypercapnia
Severe acidosis
Circulatory shock
Reduced conscious level

Recurrent Pneumonia
≥2 episodes of pneumonia within 6 months
or
≥3 episodes in a lifetime
Episodes separated by an asymptomatic interval of at
least 1 month
or
Radiographic clearing of densities between episodes

Causes of Recurrent Pneumonia
 Bronchial obstruction (bronchial carcinoma, adenoma, foreign
body)
 Lung disease (Bronchial asthma, bronchiectasis, lung abscess,
cystic fibrosis, sequestrate segment of lung—commonly left lower
lobe)
 Aspiration (achalasia cardia, scleroderma, pharyngeal pouch)
 Immunocompromised patient (HIV, DM, lymphoma, leukemia,
multiple myeloma)

Discharge and follow-up
Depends on their home circumstances and the likelihood of
complications.
A chest x-ray need not be repeated before discharge in
those making a satisfactory clinical recovery.
Clinical review should be arranged around 6 weeks later
A chest x-ray obtained if there are persistent symptoms,
physical signs or reasons to suspect underlying malignancy.

Criteria for discharge
To discharge, the patient should be clinically stable with no
more than one of the following clinical signs:
Temperature > 37.8 ºC
Heart rate > 100/min
Respiratory rate > 24/min
Systolic BP < 90 mm Hg
SaO2 < 90%
Inability to maintain oral intake
Abnormal mental status.

Remember
Before Discharge!!!!
Influenza Vaccine
Pneumococcal Vaccine
After Discharge!!!
Follow up CXR to exclude cancer

Preventive measures
Current smokers should be advised to stop smoking
Influenza Vaccine & Pneumococcal Vaccine should be
considered in selected pts
In developing countries, tackling malnutrition & Indoor air
pollution
Immunization against measles, pertussis & Haemophillus
influenzae type b in children
Legionella pneumophila has important public health
implications and usually requires notification to the
appropriate health authority.

Complication of pneumonia
Para-pneumonic effusion – common
Empyema
Retention of sputum causing lobar collapse
Deep vein thrombosis and pulmonary embolism
Pneumothorax, particularly with Staph. aureus
Suppurative pneumonia/lung abscess
ARDS, renal failure, multi-organ failure
Pleurisy

Complication of pneumonia…
Hypoxemia
Atelectasis
Respiratory failure (which requires mechanical ventilator)
Sepsis, which may lead to organ failure
Ectopic abscess formation (Staph. aureus)
Hepatitis, pericarditis, myocarditis, meningoencephalitis
Pyrexia due to drug hypersensitivity

Pneumonia severity index..
The pneumonia severity index [PSI] or PORT [pneumonia
patient outcomes research team]score is a clinical
prediction rule that medical practitioners can use to
calculate the
Probability of morbidity and mortality among patients with
community acquired pneumonia
Despite sometimes being used to predict the need for
hospitalization in people with pneumonia,
The PORT score was not developed to do so and should
not be used in that way
Mortality prediction is similar to that when using CURB-65

Development of the PSI:
The rule uses demographics (whether
someone is older, and is male or female)
The coexistence of co-morbid illnesses
Findings on physical examination and vital
signs
Essential laboratory findings

Development of the PSI:
This study demonstrated that patients could
be stratified into five risk categories, risk
classes I-V
These classes could be used to predict 30-
day survival

Usage & Application of the PSI:
The purpose of the PSI is to classify the severity of
a patient's pneumonia to determine the amount of
resources to be allocated for care
 Most commonly, the PSI scoring system has been
used to decide
whether patients with pneumonia can be treated
as outpatients or as (hospitalized) in patients

Usage & Application of the PSI:
A risk class I pneumonia patient can be sent home
on oral antibiotics
A risk class II-III pneumonia patient may be sent
home with IV antibiotics or
Treated and monitored for 24 hours in hospital
Patients with risk class IV-V pneumonia patient
should be hospitalized for treatment

Pneumonia Severity Index (PSI) for Adults
Demographic factors
Sex
Male (0 points)
Female (-10 points)
Age (1 point for each year)
Nursing home resident (10 points)

Pneumonia Severity Index (PSI) for Adults
Comorbid illnesses
Neoplastic disease (30 points)
Liver disease (20 points)
Congestive heart failure (10 points)
Cerebrovascular disease (10 points)
Renal disease (10 points)

Pneumonia Severity Index (PSI) for Adults..
Physical examination findings
Altered mental status (20 points)
Respiratory rate >= 30/minute (20 points)
Systolic blood pressure < 90 mmHg (20 points)
Temperature <35 degrees C or >= 40 degrees C (15 points)
Pulse >= 125/minute (10 points)

Laboratory and radiographic findings
Arterial pH < 7.35 (30 points)
Blood urea nitrogen >= 30 mg/dL (11 mmol/L) (20 points)
Sodium < 130 mEq/L (20 points)
Glucose >= 250 mg/dL (14 mmol/L) (10 points)
Hematocrit < 30 percent (10 points)
PO2< 60 mmHg or oxygen saturation < 90% (10 points)
Pleural effusion (10 points)

Pneumonia Score Interpretation
0-50 Points Class I 0.1% Mortality
51-70 Points Class II 0.6% Mortality
71-90 Points Class III 0.9% Mortality
91-130 Points Class IV 9.3% Mortality
131-395 Points Class V 27.0% Mortality

Influenza and pneumococcal vaccines in old age
Influenza vaccine reduces the risk of influenza
and death in elderly people.
Polysaccharide pneumococcal vaccines do
not appear to reduce the incidence of
pneumonia or death but may reduce the
incidence of invasive pneumococcal disease.
(Andrew R, et al.(Cochrane Review). Cochrane Library, issue
4, 2003. Oxford: Update software.)

Most patients respond promptly to antibiotic therapy and
will improve within 2 weeks
Elderly or very sick patients may need longer treatment.
However, fever may persist for several days and the chest
X-ray often takes several weeks or even months to resolve,
especially in old age.
The mortality rate of adults with non-severe pneumonia is
very low (< 1%); hospital death rates are typically between 5
and 10% but may be as high as 50% in severe illness.

HAP (Hospital Acquired Pneumonia)

HAP (Hospital-acquired pneumonia)
Hospital-acquired or nosocomial pneumonia is a new
episode of pneumonia occurring at least 2 days after
admission to hospital.
New episode of pneumonia occurring at least 48 h post
admission to hospital, excludes infection incubating at time
of admission (Am J Respir Crit Care Med 153:1711-25, 1995).
Second most common hospital-acquired infection.
leading cause of HAI-associated death.

HCAP & VAP
Healthcare-associated pneumonia (HCAP):
Development of pneumonia in a person who has spent at least 2 days in
hospital within the last 90 days,
Has attended a haemodialysis unit
Received intravenous antibiotics, or home infusion therapy
Resident in a nursing home or other long-term care facility
Home wound care
Family member with multidrug-resistant pathogen
Ventilator-associated pneumonia(VAP):
The elderly are particularly at risk, along with patients in intensive
care units, especially when mechanically ventilated; in the latter
case, the term ‘ventilator-associated pneumonia’ (VAP) is used.

HAP (Hospital-acquired pneumonia)..
Early-onset HAP (occurring within 4–5 days of admission)
are similar to those involved in CAP.
Late onset HAP is associated with a different range of
pathogens to CAP
The organisms
Gram-negative bacteria (e.g. Escherichia, Pseudomonas,
Klebsiella species and Acinetobacter baumannii),
Staph. aureus (including the meticillin resistant type
(MRSA))
anaerobes.

Factors predisposing to hospital-acquired pneumonia
Aspiration of nasopharyngeal or gastric secretions
Immobility or reduced conscious level
Vomiting, dysphasia (N.B. stroke disease), achalasia or severe reflux
Nasogastric intubation
Bacteria introduced into lower respiratory tract
Endotracheal intubation/ tracheostomy
Infected ventilators/nebulisers /bronchoscopes
Dental or sinus infection

Factors predisposing to hospital-acquired pneumonia…
Reduced host defenses against bacteria
 Reduced immune defenses (e.g. corticosteroid treatment,
diabetes, malignancy)
 Reduced cough reflex (e.g. post-operative)
Disordered mucociliary clearance (e.g. anaesthetic agents)
 Bulbar or vocal cord palsy
Bacteraemia
Abdominal Sepsis,
IV Cannula Infection,
Infected Emboli

Factors predisposing to hospital-acquired pneumonia…
Chronic lung disease (COPD, bronchiectasis)
Frequent suction
Other serious illness such as heart disease, liver cirrhosis,
and DM
Recent cold, laryngitis or flu
Immuno-suppressed patients
Difficult swallowing (due to stroke, dementia,parkinsons
disease, or other neurological conditions)
Impaired consciousness ( loss of brain function due to
dementia, stroke, or other neurological conditions)

Clinical features
The diagnosis should be considered in any hospitalized or
ventilated patient who develops
Purulent sputum (or endotracheal secretions),
New radiological infiltrates,
An otherwise unexplained increase in oxygen requirement,
A core temperature of more than 38.3°C, and
A leucocytosis or leucopenia.

Management
In early-onset HAP
Patients who have received no previous antibiotics can be
treated with
Co-amoxiclav or Cefuroxime.
If the patient has received a course of recent antibiotics,
then
Piperacillin / Tazobactam or
a third generation Cephalosporin should be considered

Management..
In late-onset HAP
the choice of antibiotics must cover the
Gram-negative bacteria,
Staph. aureus (including MRSA) and
 anaerobes.
Antipseudomonal cover may be provided by a
carbapenem (meropenem) or
a third-generation cephalosporin combined with an
aminoglycoside.

Management..
 MRSA cover may be provided by
 glycopeptides, such as Vancomycin or Linezolid
 Physiotherapy is important to aid expectoration in
 the immobile and
 elderly
 nutritional support is often required.

Antimicrobial options for common infecting bacteria
Organism Antimicrobial options
Staph. aureus Flucloxacillin, Clindamycin
Pseudomonas
aeruginosa
Ciprofloxacin, Piperacillin-tazobactam,
Aztreonam, Meropenem, Aminoglycosides,
Ceftazidime/Cefepime
Enterobacter
spp.
Ciprofloxacin, Meropenem,
Aminoglycosides
Anti microbial
option for
MRSA
Clindamycin, Vancomycin, Rifampicin
(Never used as monotherapy), Linezolid,
Daptomycin, Tetracyclines, Tigecycline, Co-
trimoxazole.

Prevention: HAP
Despite appropriate management, the mortality from HAP is
approximately 30%, so prevention is very important.
Good hygiene is paramount, particularly with
handwashing
equipment used.
To minimise the chances of aspiration
To limit use of stress ulcer prophylaxis with PPI
Oral antiseptic/mouth wash

Prevention: HAP…
The risk of aspiration should be minimized
Oral antiseptic (chlorhexidine 2%) may be used to
decontaminate the upper airway,
Some intensive care units employ selective
decontamination of the digestive tract when the anticipated
requirement for ventilation will exceed 48 hours.

Prevention: HAP…
 Frequent turning of bed ridden patients and early
ambulation as much as possible
 Coughing and breathing techniques
 Sterilization of respiratory therapy equipment
 Suctioning of secretion in the unconscious who have
poor cough and swallowing reflexes, to prevent aspiration
of secretions and its accumulation

Prevention: HAP…
To prevent aspiration during nasogastric tube feedings
check the position of tube and administer feedings slowly
To control the spread of infection, dispose secretions
properly.

Prevention: HAP…
Vaccination
Influenza & Pneumococcus
Isolation of patients with resistant respiratory tract infections
Enteral nutrition
Choice of GI prophylaxis
Subglotic secretion removal

HAP – Failure of Therapy
Incorrect diagnosis (it is not pneumonia): Atelectasis, CHF,
PE with infarction, lung contusion, chemical pneumonitis,
ARDS, pulmonary hemorrhage
Pathogen resistance
Host factors that increase mortality
Age > 60, prior pneumonia, chronic lung disease
immunosuppression
Antibiotic resistance
Am J Respir Crit Care Med 153:1711-25, 1995

Respiratory Infection In Old Age

Respiratory infection in old age
Increased risk of and from respiratory infection: because of
reduced immune responses, increased closing volumes,
reduced respiratory muscle strength and endurance, altered
mucus layer, poor nutritional status and the increased
prevalence of chronic lung disease.
Predisposing factors: other medical conditions may
predispose to infection. e.g. swallowing difficulties due to
stroke increase the risk of aspiration pneumonia.

Respiratory infection in old age…
Atypical presentation: Older patients often present with
confusion, rather than breathlessness or cough.
Mortality: The vast majority of deaths from pneumonia in
developed countries occur in older people.
Influenza:
Higher complication rate, morbidity and mortality.
Vaccination significantly reduces morbidity and mortality
in old age but uptake is poor.

Respiratory infection in old age…
Tuberculosis:
Most TB cases in old age represent reactivation of previous,
often unrecognized disease
Precipitated by steroid therapy, diabetes mellitus and the factors
above.
Cryptic miliary TB is an occasional alternative presentation.
Older people more commonly suffer adverse effects from
antituberculous chemotherapy and require close monitoring.

Risk Factors For Multidrug-resistant Pathogens
Causing HAP,HCAP,VAP
 Antimicrobial therapy in preceding 90 days
 Current hospitalization of 5 days or more
 High frequency of antibiotic resistance in the community or
in the specific hospital unit
 Immunosuppressive disease and/or therapy

HAP – Modifying Factors
Penicillin-resistant and drug-resistant pneumococci
 Age > 65 yr
 B-Lactam therapy within the past 3 months
 Alcoholism
 Immune-suppressive illness (including therapy w/
corticosteroids)
 Multiple medical comorbidities
 Exposure to a child in a day care center
Am J Respir Crit Care Med 163:1730-54, 2001

Enteric gram-negatives
 Residence in a nursing home
 Underlying cardiopulmonary disease
 Multiple medical comorbidities
 Recent antibiotic therapy

Pseudomonas aeruginosa
Structural lung disease (bronchiectasis)
Corticosteroid therapy (10 mg of prednisone per day)
Broad-spectrum antibiotic therapy for > 7 d in the past
month
Malnutrition

Pneumonia: Risk Factors
CAP
Older adult
Chronic/coexisting
condition
Recent history or exposure
to viral or influenza
infections
History of tobacco or
alcohol use
HAP
Older adult
Chronic lung disease
Aspiration
ET, Trach, NG / GT
Immunocompromised
Mechanical ventilation

Pneumonia In The
Immunocompromised Patient

Pneumonia in the immunocompromised patient…
 Patients immunocompromised by drugs or disease (particularly
HIV) are at high risk of pulmonary infection.
 The majority of cases are caused by the same pathogens that
cause pneumonia in non-immunocompromised individuals.
 Patients with more profound immunosuppressant, unusual
organisms or those normally considered to be of low virulence or
non-pathogenic may become ‘opportunistic’ pathogens.

Pneumonia in the immunocompromised patient…
Patients with more profound immunosuppression, unusual organisms or
those normally considered to be of low virulence or non-pathogenic
may become ‘opportunistic’ pathogens. Infection is often due to more
than one organism.
Gram-negative bacteria, especially Pseudomonas aeruginosa,
viral agents,
fungi,
mycobacteria, and
less common organisms such as Nocardia asteroides has to be considered.

Causes of immune suppression-associated lung infection
Defective Phagocytic function
Causes Infecting organisms
Acute leukaemia
Cytotoxic drugs
Agranulocytosis
Gram-positive bacteria including Staph.
aureus
Gram-negative bacteria
Fungi, e.g. Candida albicans, Aspergillus
fumigatus

Causes of immune suppression-associated lung infection…
Defects in cell-mediated immunity
Immunosuppressive drugs
Cytotoxic chemotherapy
Lymphoma
Thymic aplasia
Viruses
Cytomegalovirus ,Herpesvirus,
Adenovirus ,Influenza
Fungi
Pneumocystis jirovecii (formerly
carinii)
Candida albicans
Aspergillus fumigatus

Causes of immune suppression-associated lung infection…
Defects in antibody production
Multiple myeloma
Chronic lymphocytic leukaemia
Haemophilus influenzae
Mycoplasma pneumoniae

Clinical features
of Pneumonia in the immunocompromised patient…
Influenced by the degree of immunosuppression.
Symptoms are less specific in the more profoundly
immunosuppressed.
The speed of onset tends to be less rapid in patients with
opportunistic organisms such as Pneumocystis jirovecii and
mycobacterial infections than with bacterial infections
Typically include fever, cough and breathlessness.
 In P. jirovecii pneumonia,symptoms of cough and
breathlessness can be present for several days or weeks
before the onset of systemic symptoms or the appearance
of X-ray abnormalities.

Diagnosis
 The approach is informed by the clinical context and
severity of the illness.
 Invasive investigations, such as bronchoscopy, BAL,
transbronchial biopsy or surgical lung biopsy, are often
impractical, as many patients are too ill to undergo these
safely.
 ‘Induced sputum’ offers a relatively safe method of obtaining
microbiological samples

Diagnosis
HRCT is useful in differentiating the likely cause:
 Focal unilateral airspace opacification favours bacterial
infection, mycobacteria or Nocardia.
 Bilateral opacification favours. P. jirovecii pneumonia,
fungi, viruses and unusual bacteria, e.g. Nocardia.
Cavitation may be seen with N. asteroides, mycobacteria
and fungi.
The presence of a ‘halo sign’ may suggest Aspergillus.
Pleural effusions suggest a pyogenic bacterial infection and
are uncommon in P. jirovecii pneumonia.

Diagnosis
In theory, treatment should be based on the identified
causative organism but in practice, this is frequently unknown
and broad-spectrum antibiotic therapy is required, such as
a third-generation cephalosporin or
A quinolone, plus an antistaphylococcal antibiotic, or
 an antipseudomonal penicillin plus an aminoglycoside.

Management
 Thereafter, treatment may be tailored according to the
results of investigations and the clinical response.
 These may dictate the addition of antifungal or antiviral
therapies.

Suppurative Pneumonia, Aspiration
Pneumonia And Pulmonary Abscess

Suppurative Pneumonia, Aspiration Pneumonia And
Pulmonary Abscess
Suppurative pneumonia is characterized by destruction of the lung
parenchyma by the inflammatory process and micro abscess
formation is a characteristic histological feature.
 Pulmonary abscess is usually taken to refer to lesions in which
there is a large localized collection of pus, or a cavity lined by
chronic inflammatory tissue, from which pus has escaped by rupture
into a bronchus.
 Site: Dependent areas of the lung, such as the apical segment of the
lower lobe in a supine patient.

Risk Factors
 Often develop after the inhalation of septic material during
operations on the nose, mouth or throat under general anaesthesia,
 Vomitusduringanaesthesiaorcoma,particularlyiforalhygieneispoor.
 Bulbar or vocal cord palsy,
 Stroke,
 Achalasia or oesophageal reflux,
 Alcoholism.

Risk Factors
 may also complicate local bronchial obstruction from a neoplasm or
foreign body.
 Bacterial infection of a pulmonary infarct or a collapsed lobe may
also produce a suppurative pneumonia or lung abscess.
 Injecting drug-users are at particular risk of developing
haematogenous lung abscess, often in association with endocarditis
affecting the pulmonary and tricuspid valves.

Clinical features of suppurative pneumonia
Symptoms
 Cough with large amounts of sputum, sometimes fetid and blood-
stained
 Pleural pain common
 Sudden expectoration of copious amounts of foul sputum if abscess
ruptures into a bronchus

Clinical features of suppurative pneumonia
Clinical signs
 High remittent pyrexia.
 Profound systemic upset.
 Digital clubbing may develop quickly (10-14 days).
 Chest examination usually reveals signs of consolidation; signs of
cavitations rarely found.
 Pleural rub common.
 Rapid deterioration in general health with marked weight loss if
not adequately treated.

Organisms
Infections are usually due to a mixture of anaerobes and aerobes in
common with the typical flora encountered in the mouth and upper
respiratory tract.
Isolates of bacteroides melaninogenicus, fusobacterium necrophorum,
anaerobic or micro-aerophilic cocci, and bacteroides fragilis may be
identified.

Organisms…
When suppurative pneumonia or a pulmonary abscess occurs in a
previously healthy lung, the most likely infecting organism is
staph.aureus or klebsiella pneumoniae.
The organisms isolated from the sputum include strep. Pneumoniae,
staph. Aureus, strep. Pyogenes, H. Influenzae and, in some cases,
anaerobic bacteria.
No pathogen can be isolated, particularly when antibiotics have been
given.
Strains of community-acquired mrsa (ca-mrsa) responsible for
suppurative skin infection but may be associated with rapidly
progressive,severe, necrotising pneumonia.

Organisms…
 Lemierre’s syndrome is a rare cause of pulmonary abscesses. The usual
causative agent is the anaerobe, F. necrophorum.
 The illness typically commences as a sore throat, painful swollen neck,
fever, rigor, haemoptysis and dyspnoea, and spread into the jugular veins
leads to thrombosis and metastatic spread of the organisms.
 A non-infective form of aspiration pneumonia – exogenous lipid
pneumonia – may follow the aspiration of animal, vegetable, or mineral
oils.

Investigation
Radiological features of suppurative pneumonia include
 homogeneous lobar or segmental opacity consistent with
consolidation or collapse.
 Abscesses are characterised by cavitation and fluid level.
 Occasionally, a preexisting emphysematous bulla becomes infected
and appears as a cavity containing an air–fluid level.

Treatment
 Intravenous co-amoxiclav 1.2 g 3 times daily.
 If an anaerobic bacterial infection is suspected (e.g. from fetor of
the sputum), oral metronidazole 400 mg 3 times daily should be
added.
 Further modification of antibiotics may be required, depending on
the clinical response and the microbiological results.

Treatment…
 CA-MRSA is usually susceptible to oral non-β-lactam antibiotics,
such as trimethoprim/sulfamethoxazole, clindamycin, tetracyclines
and linezolid.
 Parenteral therapy with vancomycin or daptomycin can also be
considered.
 F.necrophorum is highly susceptible to β-lactam antibiotics, and to
metronidazole, clindamycin and third-generation cephalosporins

Treatment…
 Prolonged treatment for 4–6 weeks may be required in some
patients with lung abscess.
 Physiotherapy is of great value, especially
 when suppuration is present in the lower lobes or
 when a large abscess cavity has formed.
 Surgery should be contemplated if no improvement occurs,
despite optimal medical therapy.
 Removal or treatment of any obstructing endobronchial lesion is
essential.

Pneumonia

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