Pneumonia and Pulmonary Infections 2025 PDF

Pneumonia and Pulmonary Infections 1 Learning Objectives for Today Discuss both community and hospital acquired pneumonia with respect to their epidemiology, etiologic agents, clinical presentation, laboratory findings, and treatment. Discuss the risk factors, presen...

Pneumonia and Pulmonary Infections 1 Learning Objectives for Today Discuss both community and hospital acquired pneumonia with respect to their epidemiology, etiologic agents, clinical presentation, laboratory findings, and treatment. Discuss the risk factors, presentation, physical exam findings, lab findings, work-up and treatment of lung abscesses. Discuss the host factors which predispose to opportunistic pulmonary infections. Discuss the presentation, clinical findings and most common etiologies of bronchiectasis. Discuss the pulmonary infections seen in patients with AIDS, including PCP and mycobacterium tuberculosis infections Discuss pulmonary infections associated with animal exposure. Discuss the presentation, workup and management of a patient with pulmonary TB List the common fungal pulmonary infections and their presentation and treatment 2  Acute Bronchitis Most cases are viral Signs and Symptoms: Cough, fever, scattered rhonchi and wheezing. Treatment: rest, fluids, analgesics, bronchodilators 3  Pneumonia Infection of the lung parenchyma Frequent cause of death (especially in older adults with chronic diseases)  Community-acquired pneumonia (CAP)  Nursing home pneumonia  Hospital-acquired pneumonia (Nosocomial) 4  Pathophysiology Mechanisms  Inhalation of infectious particles (common)  Aspiration of oropharyngeal or gastric contents (common)  Hematogenous deposition (uncommon)  Direct inoculation (uncommon)  Invasion from infection in contiguous structures (rare)  Re-activation (more common in immunocompromised patients) Decreased Resistance  Defects in pulmonary defenses  Decreased cellular and humoral immune response www.clevelandclinicmeded.c5  “Typical” CAP Pathogens Classic presentation with Streptococcus fever, a productive cough with purulent sputum, pneumoniae dyspnea, and pleuritic chest  most common pain. Haemophilus Characteristic pulmonary influenzae findings:  Tachypnea Moraxella  Rales heard over the involved lobe or segment catarrhalis  Increased tactile fremitus, bronchial breath sounds, and egophony, etc. may be present if consolidation has occurred. 6  “Atypical” CAP Pathogens  Mycoplasma pneumoniae often subacute and  Chlamydophila ( Chlamydia) pneumoniae  Legionella pneumophila (Legionnaires disease)  Respiratory viruses, including the following: frequently indolent.  Influenza A and B  Rhinovirus Patients may  Respiratory syncytial virus  Human metapneumovirus  Adenovirus 4 and 7 present with more   Parainfluenza virus Other rare CAP pathogens: subtle pulmonary  Viruses   Coxsackievirus Echovirus findings, nonlobar    Coronavirus (COVID-19, MERS-CoV, SARS-CoV) Hantavirus Epstein-Barr virus infiltrates on  Cytomegalovirus  Herpes simplex virus  Human herpesvirus 6 radiography, and  Varicella-zoster virus  Metapneumovirus  Bacteria various  Chlamydophila psittaci (psittacosis)  Coxiella burnetii (Q fever)  Francisella tularensis (tularemia) extrapulmonary  Mycobacteria  Mycobacteria tuberculosis  Nontuberculous mycobacteria (uncommon) manifestations (eg,  Endemic fungi (causing subacute or chronic pneumonia)  Histoplasma capsulatum  Cryptococcus neoformans neoformans and neoformans gattii diarrhea, otalgia).  Coccidioides immitis 7  Nursing home pneumonia Increased incidence of gram negative & staph aureus 8  Hospital-Acquired Pneumonia Pathogens Aerobic gram-negative bacilli Pseudomonas aeruginosa Staphylococcus aureus MRSA Oral anaerobes 9  History and Physical Exam Typical Symptoms: Hyperthermia or hypothermia, chills, tachypnea*, tachycardia or bradycardia, productive cough (Note: elderly may present atypically) Atypical pneumonia symptoms may also include: Confusion (Legionella), Diarrhea (Legionella), Rash (Mycoplasma) 10  History and Associated Pulmonary Pathogens History Associated Organisms COPD H influenzae or M catarrhalis Alcoholism or Diabetes Mellitus Klebsiella pneumoniae with “current jelly sputum” Asplenia S. pneumoniae, H. influenzae HIV infection “Typical” bacterial pathogens, M. tuberculosis, Pneumocystis jiroveci, cytomegalovirus, Cryptococcus spp., Histoplasma spp., Coccidioides spp. Bronchiectasis or cystic fibrosis or Pseudomonas aeruginosa ventilator related Aspiration Mixed aerobic, anaerobic 11  History and Pulmonary Pathogens History Associated Organisms Exposure to birds Chlamydia psittaci Exposure to rabbits Francisella tularensis Travel to Mississippi, Ohio river Histoplasma capsulatum valley; Exposure to bat or bird droppings, construction sites, caves Travel to desert, southwest United Coccidioides spp., Hantavirus States Contact with person known to COVID-19 have COVID-19 Postinfluenza S. Aureus or S. pneumoniae, 12  History and Pulmonary Pathogens History Associated Organisms Cough >2 wk w/ whoop or Bordetella pertussis posttussive vomiting Hotel or cruise ship stay in the Legionella spp previous 2 weeks GI symptoms, headache CNS symptoms Bioterrorism Bacillus anthracis 13  Character of sputum S pneumoniae is classically associated with a cough productive of rust-colored sputum. Pseudomonas, Haemophilus, and S pneumonia species may produce green sputum. Klebsiella species pneumonia is classically associated with a cough productive of red currant jelly sputum. Anaerobic infections often produce foul- smelling or bad-tasting sputum 14  Physical Exam Typicalsigns: localized to a specific lung zone. May include:  Rales  Rhonchi  Bronchial breath sounds  Dullness to percussion  Increased tactile fremitus  Positive egophony, bronchophony, & whisper pectorilloquy. 15  Physical Exam Additional ATYPICAL signs and symptoms may be seen with ATYPICAL Pneumonia Organisms  Mental confusion  Prominent headaches  Myalgias  Ear pain  Abdominal pain  Diarrhea  Rash (Horder spots in psittacosis; erythema multiforme in Mycoplasma pneumonia)  Nonexudative pharyngitis  Hemoptysis  Splenomegaly  Relative bradycardia 16  CXR Patterns Radiographic Pattern Pathogen Focal infiltrate Usually bacterial Large pleural effusion Usually bacterial Cavitary Bacterial abscess, fungal, Nocardia, TB Miliary Fungal, Miliary TB Interstitial Viruses, Pneumocystis, Mycoplasma, Chlamydia psittaci Mediastinal Widening without Inhalation anthrax infiltrate Note: patients who present very early with CAP may have a negative CXR…repeat CXR within 24 hours may be beneficial 17 RLL Pneumonia 18 RML Pneumonia 19 Large Pleural Effusion 20 Miliary Tuberculosis 21 Bilateral Interstitial Infiltrates 22 Widened Mediastinum in Anthrax 23  Other Tests 1. Pulse oximetry 2. Complete blood count 3. Complete metabolic profile 4. Rapid influenza molecular assay if influenza season 24 Additional Tests if severe CAP Sputum gram stain and culture Blood cultures Lactic acid level C-reactive protein Lactate dehydrogenase Procalcitonin and CRP? (may identify patients at risk for worse outcomes, but these are controversial) Urinary antigen testing for Legionella species Molecular diagnostics, ie polymerase chain reaction (PCR) testing 25 Gram Stain Results 26 S. Pneumoniae Gram Stain 27 S. Aureus Gram Stain 28 Pseudomonas Gram Stain 29 Haemophilus influenzae Gram Stain 30 Klebsiella pneumonia Gram Stain 31 Moraxella catarrhalis 32  Diagnostic Testing for Select Patients Legionella serology (urinary antigen) Mycoplasma serology Chlamydophila serology Stains or cultures for fungi: i.e. Pneumocystis jiroveci SARS-associated coronavirus serology or PCR Cultures of pleural fluid via thoracentesis 33  Diagnostic Testing If the patient is deteriorating and there is no definite pathogen identified Bronchoscopy  Bronchoalveolar lavage, Transbronchial biopsy Thoracoscopic or open-lung biopsy Radiographically-guided transthoracic aspirate 34 When should you admit a patient? 35  Pneumonia Severity Index Calculator (preferred over CURB-65) http://www.mdcalc.com/psi-port-score-pneum onia-severity-index-adult-cap/ 36  Pneumonia Severity Index Risk of 30 Day Mortality Risk Point Mortality Class I and II Class Score %  Outpatient therapy I No Points 0.1% (assuming no previous II 130 29.2% comply to the treatment) Class III  Per clinical judgment - Outpatient or brief inpatient therapy IV and V  Hospital admission 37  CURB-65 criteria Confusion Uremia (BUN >20mg/dL) Respiratory rate (> 30/min) Low Blood pressure (SBP