Pneumonia D2 Part1 2022 PDF

Pneumonia Pneumonia is an infection of the alveoli, distal airways, and interstitium of the lung Community-acquired or hospital-acquired (nosocomial) Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide CAP – treated in an am...

Pneumonia Pneumonia is an infection of the alveoli, distal airways, and interstitium of the lung Community-acquired or hospital-acquired (nosocomial) Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide CAP – treated in an ambulatory setting – severe enough to require admission to the hospital Nosocomial /hospital acquired pneumonia (HAP) – ventilator-associated (after endotracheal intubation) – or non-ventilator-associated  Pathogenesis in legionella and coxiella species we see aerosol inhalation. Ø * respiratory pathogens are transmitted from person to person via droplets or, less commonly, via aerosol inhalation (eg, as with Legionella or Coxiella species) Microbial * the pathogen colonizes the nasopharynx and Factors then reaches the lung alveoli via microaspiration * when the inoculum size is sufficient and/or host immune defenses are impaired, infection results. Ø lung microbiome (similar to oral flora): competition, modulate the host immune response Host to the infecting pathogen, alveolar dysbiosis Factors  Routes of Infection gross aspiration, microaspiration, aerosolization, hematogenous spread from a distant infected site, direct spread from a contiguous infected site  Epidemiology CAP is one of the most common and morbid conditions encountered in clinical practice CAP is the second most common cause of hospitalization and the most common infectious cause of death in US  Risk factors Older age: ≥65 years old, 3x higher Chronic comorbidities: chronic lung disease, chronic heart disease, stroke, diabetes mellitus, malnutrition, and immunocompromising conditions Viral respiratory tract infection: secondary bacterial pneumonia (e.g. after influenza) Impaired airway protection: alteration in consciousness, esophageal diseases Smoking and alcohol overuse Other lifestyle factors: crowded living conditions, exposure to environmental toxins The pathologic and roentgenographic patterns of pneumonia lobar pneumonia Segmental – lobar consolidation with air bronchograms Inflamation in the conducting bronchopneumonia airways and surrounding alveoli - patchy consolidation involving one or several lobes interstitial pneumonia Reticular radiographic appearence miliary pneumonia Diffusely distributed 2- to 3-mm lesions lobar pneumonia eg. S.pneumoniae Bronchopneumonia – staph, S.pneu. Patchy - staph Staph pneumonia Patchy - Chlamydia  Reticular – patchy / Mycoplasma which one of below in correct about penumonia ? patchy is seen in the chlamidiya and sthp reticular pattern intertina;l pneuomina seen in mycoplasma İnterstitial Viruses, Mycoplas ma Pneumoc ystis jiroveci PCP Miliary tuberculosis  CAP – Etiology Typical bacteria cause brachospmas and loblar pneu S. pneumoniae (most common bacterial cause) Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus Group A streptococci Aerobic gram-negative bacteria (eg, Enterobacteriaceae such as Klebsiella spp or Escherichia coli) Microaerophilic bacteria and anaerobes (associated with aspiration)  CAP – Etiology Atypical bacteria they can infec t via arerols Legionella spp Mycoplasma pneumoniae reticular pattern Chlamydia pneumoniae Chlamydia psittaci Coxiella burnetii  CAP – Etiology Respiratory viruses Influenza A and B viruses Severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) Other coronaviruses (eg, CoV-229E, CoV-NL63, CoV-OC43, CoV-HKU1) Rhinoviruses Parainfluenza viruses Adenoviruses Respiratory syncytial virus Human metapneumovirus Human bocaviruses CDC EPIC Study (2010-12) N Engl J Med 2015;373:415-27.  CLINICAL MANIFESTATIONS pateint persents with fever cills and rigors and respiratory distrees Severity ranging from mild pneumonia characterized by fever and productive cough to severe pneumonia characterized by respiratory distress and sepsis. Onset may be sudden and dramatic or insidious Typical manifestations of pneumonia – Fever, cough (nonproductive or productive of purulent sputum), pleuritic chest pain, chills or rigors, and shortness of breath – Other: headache, nausea, vomiting, diarrhea, myalgia, arthralgia, and/or fatigue  Primary Symptoms of COVID-19 Headache Congestion or runny nose, new loss of taste or smell Cough, sore throat “Symptoms may appear 2-14 days Shortness of breath after exposure to Fatigue, muscle or difficulty breathing the virus” or body aches, fever or chills Nausea or vomiting, diarrhea Li. J Med Virol. 2020;92:577. cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html Slide credit: clinicaloptions.com 23  Physical signs tachypnea, dullness to percussion, increased tactile and vocal fremitus, egophony, whispering pectoriloquy, rales/crackles and rhonchi pleural friction rub. - positive predictive value of the combination of fever, tachycardia, rales, and hypoxia (SO2 30/min) low Blood pressure (< 90/60) Also consider reliability, oral age 65 years or greater intake, outpatient support > 2, more-intensive treatment 30 day mortality (0-5): 0.7%, 2.1%, 9.2%, 14.5%, 40%, 57%  Severe CAP – ICU admission Minor criteria 1. Respiratory rate > 30 breaths/min Major criteria 2. PaO2/FiO2 ratio < 250 3. Multilobar infiltrates 4. Confusion/disorientation 1. Invasive mechanical 5. Uremia (BUN level, > 20 mg/dL) ventilation 6. Leukopenia (WBC count, < 4000 cells/mm3) 2. Septic shock with 7. Thrombocytopenia (platelet count, the need for < 100,000 cells/mm3) vasopressors 8. Hypothermia (core temperature, < 36ºC) Any major or 3 9. Hypotension requiring aggressive minor – direct fluid resuscitation admission to ICU  Treatment Generally, the etiology is not known at the time of diagnosis Empiric treatment, directed at the most likely pathogens – severity of illness – local epidemiology – risk factors for infection with drug-resistant organisms  Treatment - 1 which one of the drugs below is perscirbted to a patient with MRSA or pseudimonas aeruginosa? amoxicillin doxocyclin macolides Outpatient; Amoxicillin or Previously healthy and no comorbidities doxycycline or or risk factors for MRSA or macrolide (if local Pseudomonas pneumococcal aeruginosa resistance is < 25%) ATS/IDSA guideline 2019  Treatment - 2 how to treat a pateint with comorbidities with penimina Outpatient Presence of comorbidities Combination therapy with amoxicillin/clavulanate or chronic cephalosporin (cefpodoxime 200 Ø heart mg twice daily, or cefuroxime 500 Ø lung mg twice daily) AND Ø liver or macrolide (azithromycin Ø renal disease or clarithromycin) diabetes mellitus or doxycycline or alcoholism monotherapy with respiratory malignancies fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily, or asplenia gemifloxacin 320) ATS/IDSA guideline 2019  Treatment - 3 Nonsevere inpatient pneumonia A b-lactam (SAM, cefotaxime, ceftaroline, or ceftriaxone) plus a macrolide or A respiratory quinolone Severe inpatient pneumonia b-Lactam + macrolide no risk factors for MRSA or or Pseudomonas aeruginosa b-lactam + fluroquinolone infection Risk factors for MRSA or Add coverage for MRSA or P. aeruginosa P.aeruginosa (prior identification, recent vancomycin or linezolid hospitalization and exposure to or parenteral antibiotics) antipseudomonal b-lactam ATS/IDSA guideline 2019  Prevention smoking cessation Vaccination – influenza for the general population – PCV13 for at-risk populations – PPSV23 Nosocomial pneumonia / Healthcare associated pneumonia VAP Non-VAP