Pneumonia .docx

**Pneumonia** **ILOs** ***At the end of this session, the student will be able to:*** - ***Define pneumonia and its different classification.*** - ***Describe the clinical picture of pneumonia.*** - ***Identify the management plan of both HAP and CAP*** - Bacterial: - Anaerobic, int...

**Pneumonia** **ILOs** ***At the end of this session, the student will be able to:*** - ***Define pneumonia and its different classification.*** - ***Describe the clinical picture of pneumonia.*** - ***Identify the management plan of both HAP and CAP*** - Bacterial: - Anaerobic, intra cellular, T.B, gram positive (+ve), gram negative (-ve), - Nocardia, Actinomyces, Typhoid - Viral: RSV -- CMV -- Influenza -- Herpes - Fungal - Protozoal: Pneumocystis Carinii, Toxoplasma - Rickettsial: Typhus -- Q Fever - Lobar: Lobar or segmental consolidation. - Bronchopneumonia: Bilateral patchy or lobular consolidation. - **Community-Acquired Pneumonia (CAP):** pneumonia occurring in patients who have not been hospitalized or living in a nursing home during the 2 weeks prior to the onset of symptoms. - **Hospital Acquired Pneumonia (Nosocomial)**: Pneumonia occurring \> 48 hours after admission and excluding any infection incubating at the time of admission. Other subtypes: ventilator associated pneumonia (VAP), health associated pneumonia (HCAP). - Streptococcus Pneumonia (*[30 - 40 %)]*, Streptococcus pyogenes, Staphylococcus Aureus - Haemophilus influenza 2-11 % - Moraxella catarrhalis2% - Klebsiella -- Pseudomonas -- E coli - Legionella pneumophilia1-16% - Chlamydia Pneumoniae11-17 % - Mycoplasma Pneumoniae 6-15 % - **General symptoms:** malaise -- fever -- rigors -- myalgia -- fatigue -- body aches and loss of appetite - **Specific symptoms:** cough -- sputum production -- dyspnea --pleuritic chest pain --hemoptysis - **General:** cyanosis -- herpes labialis --tachypnea (respiratory rate \> 20 breaths/min) -- tachycardia - **Local:** Signs of consolidation (bronchial breathing, bronchophony, egophony, whispering pectoriloquy, crepitations and also could be wheezes)- pleural rub in cases of dry pleuritis - Headache. - Confusion. - Diarrhea. - Incontinence. - Cyanosis - Tachycardia - Tachypnoea - Rash (skin, mucous, membrane) - Parapneumonic effusion - Empyema - Lung abscess - Unresolving pneumonia - **Respiratory failure, which requires a breathing machine or ventilator.** - **Acute respiratory distress syndrome (ARDS), a severe form of respiratory failure.** - Septic extra thoracic complications: arthritis -- cellulitis -- pericarditis --endocarditis - meningitis -- brain abscess - Abnormal liver function tests - Hemolytic anemia - Circulatory failure - Renal failure - Thrombophlebitis - Glomerulonephritis - Herpes labialis - **Sepsis, a condition in which there is uncontrolled inflammation in the body, may lead to widespread organ failure.** - **Pneumonia severity Score:** - High blood urea - WBC \< 4000 or \> 30000 - Serum albumin \< 3.5 gm - Low PaO~2~ - Multiple lobes involved in X-ray. - The presence of at least 3 minor criteria or any of the major criteria is an indication for ICU admission. - **Clinical evaluation** - **Laboratory evaluation** - **Radiographic evaluation:** Initially plain chest x-ray which is mandatory for the diagnosis. - Confirm Diagnosis - Rule out complications. - **Chest computed tomography (CT) scan can show the extension of pneumonia.** - **Microbiologic evaluation** - Gram stain, culture, and sensitivity of the sputum if: - Drug resistant pathogen is suspected. - Organisms not covered by empiric therapy is suspected. - Pleural fluid and blood Culture - **Serologic testing (atypical bacteria, viruses)** - **Urinary antigen for** legionella pneumophila and streptococcus pneumoniae - **Invasive diagnostic techniques (bronchoscopy): If treatment is inefficient, this procedure may be needed.** - **Pleural fluid sample: in case of associated pleural effusion or empyema for culture can be taken using a procedure called thoracentesis, which is when a doctor uses a needle to take a sample of fluid from the pleural space.** - **Two rules are to be considered:** - It's an empirical therapy according to guidelines till results of culture & sensitivity are available. - All patients should be treated for the possibility of atypical infection. - **Patient stratification:** according to the following: - Place of therapy \- ICU - Presence of cardiopulmonary disease or comorbidity - Presence of modifying factors - **Oxygen therapy: If the patient is hypoxic, a provider may give external oxygen.** - **IV fluids: Fluids delivered directly (IV) treat or prevent dehydration.** - **Draining of fluids: If patient has (pleural effusion), it can be drained.** 1. Previously healthy and no comorbidities and no recent antibiotic use in the previous 3 months: - Advance generation macrolide e.g., Azithromycin - Or Doxycycline 2. Patients with comorbidities or recent antibiotic use in the previous 3 months (an alternative from a different class should be selected): - A respiratory fluroquinolone e.g., levofloxacin 750 mg or Moxifloxacin daily - B- lactam (amoxicillin-clavulanic acid 2 gm twice daily) + macrolide (azithromycin or clarithromycin) - A respiratory fluroquinolone e.g., levofloxacin 750 mg or Moxifloxacin daily - B- lactam (amoxicillin-clavulanic acid 2 gm twice daily) + macrolide (azithromycin or clarithromycin) - A b-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin or a respiratory fluoroquinolone - Add vancomycin or linezolid**.** Once the etiology of CAP has been identified on the basis of reliable microbiological methods antimicrobial therapy should be directed at the pathogen. - Minimum 5 days - Afebrile for 48 -- 72 hours - Should have no more than 1 CAP-associated signs of instability before discontinuation of therapy. - Temp \< 37.8 - HR \< 100 beats/m - RR \< 24 breath/m - Sys BP \> 90 mmHg - O~2~ sat \> 90% - Ability to maintain oral intake. - Normal mental status - Fever 2- 4 days - Leukocytosis 4 days - Crackles 7 days - X -- Ray weeks - **[\ ]** - Pneumonia occurring ≥ 48 hours after admission and excluding any infection incubating at the time of admission. - Ventilator associated pneumonia (VAP): among mechanically ventilated patients. - Health associated pneumonia (HCAP): among those living in nursing home or patients on dialysis or immunocompromised patients. - Early: before 5 days - Late: after 5 days - 13 --18 % of hospital acquired infection are HAP - 10 -- 25 % of ICU patients. - Mortality up to 70% - G-ve Bacilli (60%) : as Pseudomonas aerugeinosa -- Klebsiella pneumoniae--Proteus --Escherichia coli -- Haemophilus influenzae -- Moraxella catarrhalis - G +ve Cocci (20 - 40%) :as Staphylococcus aureus (especially *Methicillin-resistant Staphylococcus aureus* (MRSA)-- Steptcoccus pneumoniae - Anaerobic bacteria - Mycobacterium tuberculosis - Viruses - Fungi - Bacterial colonization of the aero digestive tract by gram negative enteric bacteria (core organism) and aspiration of the contaminated secretions into the normally sterile lower reparatory tract within the first 5 days (early onset) - Cross transmission between patients through healthcare personnel (late onset i.e., after 5 days) - Alveolar infiltrates on chest X ray plus two or more of: - Hypo / hyperthermia (\< 36 or \> 38 °C) - Leucopenia or leukocytosis - Purulent tracheal secretions - Decreased PaO~2~ - Blood culture (low sensitivity, specificity) - Qualitative culture of endotracheal tubes or aspiration material - Quantitative culture using invasive methods (bronchoscopy and bronchoalveolar lavage) - Recent abdominal surgery - Witnessed aspiration. - Diabetes mellitus - Prolonged stay in ICU - Coma - Corticosteroids - Head trauma - Prior antibiotics - Renal failure - Structure lung disease - Mechanical ventilation (ventilator -- associated pneumonia) - Anti-pseudomonal cephalosporin e.g., Cefepime or ceftazidime - *[OR]* - Carbapenems e.g., Imipenem or Meropenem - *[OR]* - Anti-pseudomonal fluroquinolone e.g., Levofloxacin or ciprofloxacin - If associated factors Increasing the Likelihood of MRSA add Anti MRSA as Linezolid *[OR]* Vancomycin - Anti-pseudomonal cephalosporin e.g., Cefepime or ceftazidime - *[OR]* - Anti-pseudomonal penicillin e.g., Piperacillin-tazobactam - *[OR]* - Carbapenems e.g., Imipenem or Meropenem - Plus - Antipseudomonal fluroquinolone e.g., Levofloxacin, ciprofloxacin - *[OR]* - Aminoglycoside e.g., Amikacin, gentamycin - Plus - Anti-MRSA e.g., Linezolid - *[OR]* - Vancomycin - Antipseudomonal cephalosporin e.g., Cefepime or ceftazidime - *[OR]* - Anti-pseudomonal penicillin e.g., Piperacillin-tazobactam [ ] - *[OR]* - Carbapenems e.g., Imipenem or Meropenem - Plus - Anti-pseudomonal fluroquinolone e.g., Levofloxacin, ciprofloxacin - *[OR]* - Aminoglycoside e.g., Amikacin, gentamycin - *[OR]* - Polymyxins e.g., Colistin or Polymyxin B *[OR]* - Plus - Anti-MRSA e.g., Linezolid *[OR]* Vancomycin +-----------------------------------+-----------------------------------+ | - **Wrong diagnosis** | - **Wrong organism** | +===================================+===================================+ | - Atelectasis | - Drug resistant pathogen | | | (bacteria, mycobacteria, | | - Pulmonary embolism | virus, fungi) | | | | | - ARDS | - Inadequate antimicrobial | | | therapy | | - Pulmonary hemorrhage | | | | | | - Underlying disease | | | | | | - Neoplasm | | +-----------------------------------+-----------------------------------+ - Empyema - Lung abscess - Clostridium defficile colitis - Occult infection - Drug fever