Pneumonia.

Pneumonia (P) is one of the most wide-spread disease of human. In spite of

wide prevalence of P, knowledge of modern methods of diagnostics and treatment

of disease are not enough.

PNEUMONIA - is acute infectious disease, mainly bacterial etiology, which

causes the air sacs in the lungs (called the alveoli), and the smaller bronchial tubes

to become inflamed and fill with fluid. From data of official statistics in Ukraine in

2005, morbidity of adults of P. was 4,26 on 1000 population, and death rate – 13,5

% per 100 thousand persons, it means that about 3,2 % of all people who

developed pneumonia subsequently died from the infection.

Etiology.

Many different organisms can cause P, including bacteria (Str. Pneumoniae, Staf.

pyogenus, Staf. albus, Klebsiella pneumoniae is a pneumobacillus, Neisseria

cataralis, Proteus vulgaris, Haemophilus influenzae, Psevdomonas aeruginosa,

Legionella pneumophilia,, Micoplasma pneumoniae,, Bacteroides fragilis), the

viruses of Citomegalovirus, and fungi of Candida albicans. Pneumonia can range

from mild to severe. The severity depends on the type of organism causing

pneumonia, as well as your age and underlying health.

The basic patogenetic links of development of pneumonia are:

- penetration of infection in pulmonary tissue (by inhalation, bronchogenic

way, hematogenic way – at a sepsis, direct distribution of infection in lungs from

nearby organs, lymphogenic way).

- a change of the system of local bronchopulmonary protection -the state of

mucociliary transport, bronchopulmonary immune system, factors of unspecific

resistance (lysozyme , lactoferrin, IGA, interferon, system of surfactant),

- development of local inflammatory process and his distribution on

pulmonary tissue , that depends on the type of infection:

Str. Pneumoniae, Klebsiella pneumoniae, Haemophilus influenzae and E.

coli producing endotoxins and during persistence in air-cells they cause a serosal

edema. This serosal edema is their reproducing environment and helps them to

penetrate through the Kon’s pores to nearby air-cells. In such way segmentary

and croupous pneumonias are developed.

Streptococci, staphylococcuss producing exotoxins, which promote

limitation of inflammation by fibrin, and smaller bronchial tubes to become

inflamed and fill with fluid with formation of microatelectasis. In such way focal

pneumonia is developed.

Production by leucocytes and epithelial cells bioactive substances

(cytokines) plays important role in development of inflammation. Cytokines

influence on chemotaxis of macrophages, neutrophils and other cells, which are

taking part in local inflammatory reaction.

Classification

Select the followings types of pneumonias:

community-acquired pneumonia

nosocomial or hospital-acquired pneumonia

Aspiration pneumonia

Pneumonia in an immunocompromised host

Pneumonia that develops outside the hospital setting is considered

community-acquired pneumonia. Pneumonia developing 72 hours or more

after admission to the hospital is termed nosocomial or hospital-acquired

pneumonia. Pneumonia can be mild, moderate and severe.

Severe P. is the special form of disease of different etiology, which shows

up a heavy intoxication syndrome, haemodynamic changes, expressed respiratory

insufficiency and signs of septic shock.

Recommend to select the large and small criteria of severe pneumonia.

SMALL CRITERIA :

- breathing frequency 30 in 1 mins and more,

- unconsciousness, - pressure of oxygen below 60 ,

- a systole arterial blood pressure below 90

- bilateral or polifocal defeat, cavities of disintegration, pleura effusion.

LARGE CRITERIA:

- requirement of artificial ventilation of lungs,

- rapid progress of focal infiltration, infiltration more than on 50% during the

nearest 2 days,

- septic shock or necessity of introduction of vasopressor medicines

during 4 hours and more. We can say about severe P. if we have 2

small and 1 large criteria. In such cases must be immediate

hospitalization.

M. pneumoniae is a common cause of mild pneumonia that usually affects people

younger than 40. Various studies suggest that it causes 15-50% of all pneumonia in

adults and an even higher percentage of pneumonia in school-aged children.

People at highest risk for mycoplasma pneumonia include those living or working

in crowded areas such as schools and homeless shelters, although many people

who contract mycoplasma pneumonia have no identifiable risk factor.

The symptoms are generally mild and appear over a period of 1 to 3 weeks. They

may become more severe in some people.

Common symptoms include the following:

Headache, fever (may be high),Chills, excessive sweating, Cough (usually dry

and without phlegm or blood), chest pain, sore throat

Less frequently seen symptoms include:

Skin lesions or rash

Eye pain or soreness

Muscle aches and joint stiffness

Neck lump

Rapid breathing

Ear pain

A physical examination may reveal enlarged lymph nodes and inflammation of the

eardrum. An examination of the chest with a stethoscope (auscultation) reveals

crackles.

Legionella pneumophila.

Most infection occurs in middle-aged or older people, although it has been reported

in children. Typically, the disease is less severe in children. Symptoms tend to get

worse during the first 4 to 6 days. They typically improve in another 4 to 5 days.

Symptoms may include:

Muscle aches and stiffness

Joint pain

Loss of energy

General discomfort, uneasiness, or ill feeling (malaise)

Headache

Fever

Shaking chills

Nonproductive cough

Coughing of blood

Shortness of breath

Chest pain,

Diarrhea

Chlamydophila pneumonia occurs year round and accounts for 5-15% of all

pneumonias. It is usually mild with a low mortality rate.

Community acquired pneumonia

Community-acquired pneumonia develops in people with limited or no contact

with medical institutions or settings. The most commonly identified pathogens are

Streptococcus pneumoniae , Haemophilus influenzae , and atypical organisms (ie,

Chlamydia pneumoniae , Mycoplasma pneumoniae , Legionella sp). Symptoms

and signs are fever, cough, dyspnea, tachypnea, and tachycardia. Diagnosis is

based on clinical presentation and chest x-ray. Treatment is with empirically

chosen antibiotics. Prognosis is excellent for relatively young and/or healthy

patients, but many pneumonias, especially when caused by S. pneumoniae and

influenza virus, are fatal in older, sicker patients.

Symptoms and Signs

Symptoms include malaise, cough, dyspnea, and chest pain. Cough typically is

productive in older children and adults and dry in infants, young children, and the

elderly. Dyspnea usually is mild and exertional and is rarely present at rest. Chest

pain is pleuritic and is adjacent to the infected area. Pneumonia may manifest as

upper abdominal pain when lower lobe infection irritates the diaphragm.

Symptoms become variable at the extremes of age; infection in infants may

manifest as nonspecific irritability and restlessness; in the elderly, as confusion and

obtundation.

Symptoms and signs were previously thought to differ by type of pathogen, but

presentations overlap considerably. In addition, no single symptom or sign is

sensitive or specific enough to predict the organism. Symptoms are even similar

for noninfective lung diseases such as pulmonary embolism, pulmonary

malignancy, and other inflammatory lung diseases.

Diagnosis

The most important diagnostic tool for pneumonia is the stethoscope. Sounds in

the chest that may indicate pneumonia include:

- Rales, a bubbling or crackling sound. Rales on one side of the chest

or that are heard while the patient is lying down strongly suggest

pneumonia.

- Abnormal rumblings indicating that there is sputum in the large

airways.

- A dull thud. The physician will use a test called percussion, in which

the chest is tapped lightly. A dull thud, instead of a hollow drum-like

sound, indicates certain conditions that suggest pneumonia. These

conditions include consolidation (in which the lung becomes firm

and inelastic) and pleural effusion (fluid build-up in the space

between the lungs and the lining around it).

Diagnosis is suspected on the basis of clinical presentation and is confirmed by

chest x-ray .Chest x-ray almost always demonstrates some degree of infiltrate;

rarely, an infiltrate is absent in the first 24 to 48 h of illness. In general, no specific

findings distinguish one type of infection from another, though multilobar

infiltrates suggest S. pneumoniae or Legionella pneumophila infection, and

interstitial pneumonia suggests viral or mycoplasma etiology.In severe cases, a

doctor needs to use invasive diagnostic measures to identify the cause of the

infection. Standard lab tests used to help diagnose pneumonia include:

Sputum Tests. The color of the mucus (sputum) sample coughed up from the lungs

can reveal the severity of the disease. Only a sputum sample will reveal the

organism causing the infection.The patient coughs as deeply as possible to bring

up mucus from the lungs, since a shallow cough produces a sample that usually

only contains normal mouth bacteria. Some people may need to inhale a saline

spray to produce an adequate sample. In some cases, a tube will be inserted

through the nose into the lower respiratory tract to trigger a deeper cough.

The physician will check the sputum for:

- Blood, which means an infection is present.

- Color and consistency: If it is yellow, green, or brown, an infection

is likely.

The sputum sample is sent to the laboratory, where it is analyzed for the presence

of bacteria and to determine whether the bacteria are Gram-negative or Gram-

positive.

Blood Tests. The following blood tests may be performed:

- White blood cell count (WBC). High levels indicate infection.

- Blood cultures. Cultures are done to determine the specific organism

causing the pneumonia, but they usually cannot distinguish between

harmless and dangerous organisms. They are accurate in only 10 -

30% of cases. Their use is generally limited to severe cases.

- Detection of antibodies to S. pneumoniae. Antibodies are immune

factors that target specific foreign invaders. One type of

immunohistochemical test for S. pneumoniae is showing tremendous

promise. The presence of antibodies that are responding to

mycoplasma or chlamydia infection are not present early enough in

the course of pneumonia to allow for prompt diagnosis and

treatment.

Patients with CAP can be categorized into 1 of 4 groups based on information

collected at the time of the initial evaluation. The risk factors for stratification

include the need for hospitalization, the severity of illness, the presence of

coexisting disease, and the patient's age. The 4 major categories not only speculate

the microbial etiology but also predict ultimate prognosis and outcome. These

categories are

(1)CAP occurring in patients aged 60 years or younger who have no evidence

of comorbidity and who can be treated in an outpatient setting,

(2) CAP occurring in patients with evidence of comorbidity and/or who are

aged 60 years or older who can be treated in an outpatient setting,

(3)CAP requiring hospitalization but not admission to an intensive care units

(ICU),

(4) severe CAP requiring ICU care.

Treatment

Because organisms are difficult to identify, antibiotics are selected based on likely

pathogens and severity of illness

A/b for empiric treatment, divide into medicines of the first choice (medicines of 1

choice and alternative medicines) and second row.

EMPIRIC ANTIBAKTERIAL THERAPY

PATIENTS OF CAP IN AMBULATORY

Group of

patients

Possible exciter

Antibiotic

first row Antibiotic of the

second rowDrugs of

choice

Alternative

Drugs

1 group

(with the

unsevere

CAP,

without

concomitant

pathology

and other

modifying

factors

M. pneumoniae

S. рneumoniae

H. influenzae

Peroral

reception:

amoxycillin

or

macrolide

Peroral

reception:

fluoroquinolones

III-IV

generation

Peroral

reception:

1. Makrolide or

doxycycline at

uneffectiveness

of

aminopenicillin

2.

Aminopenicillin

or

fluoroquinolones

III-IV

generation at

uneffectiveness

of macrolide

11 group

With the

unsevere

CAP, with

the

presence of

concomitant

pathology

M. pneumoniae

S. рneumoniae

H. influenzae

S. aureus

M. catarrhalis

family

Enterobacteriaceae

A peroral

reception is

amoxycillin

or

cefuroxym

ethanol

Peroral

reception:

fluoroquinolones

III-IV

generation

Or

Ceftriakson

Peroral

reception:

To add to в-

lactam macrolide

or

monotherapy

Fluoroquinolones

III-IV generation

or other

modifying

factors

Note: * - parenterally introduction of Ceftriakson is appointed at

impossibility of peroral reception of preparations of choice.

Estimation of efficiency of antibacterial therapy is conducted in 48 hours

from the beginning of treatment.

Duration of antibacterial therapy:

For patients with the unsevere CAP antibacterial therapy can be completed

after achievement of normalization of temperature during 3-5 days. As a rule in

such cases treatment takes 7-10 days.

Criteria of efficiency of antibacterial therapy

- Temperature of body below 37,5

- absence of symptoms of intoxication,

- absence of signs of respiratory failure (breathing frequency below 20 in 1

mins),

- absence of festering sputum,

- there is a less than amount of leucocytes in blood, neutrocytes less than

80%, young forms –less 6%,

- absence of negative dynamics from data of roentgenologic research.

If patient saved high temperature of body, intoxication or symptomatology

makes progress, treatment is considered ineffective, and it is necessary to change

antibacterial therapy to the antibiotic of the second row . U should remember some

sings that are not necessary to change therapy.

Clinical signs and states which are not necessary to change therapy

or make its modifications

Clinical sign

temperature of body of 37,0-37,5оС In absence of other signs of bacteria

infection can be the sign of non-

bacterial inflammation, postinfectious

asthenia, medicinal fever

Maintainance of remaining changes on a

x-rays (infiltration, increasing of

pulmonary vasculature)

Can be saved during 1-2 months and

more after carried P

(a roentgenologic dynamics is carried

out more slowly, for 60% patients

regress in the first 4 weeks. and these

information can not be criteria for

determination of duration of à/b

therapy)

Dry cough Can be saved during 1-2 months.

Maintainance of wheezes during

auscultation

Dry wheezes can be saved during 3-4

weeks and more

Increase of erythrocyte sedimentation

rate, ESR

Heterospecific index, is not only the

sign of bacteria infection

Weakness, sweating Displays of postinfectious asthenia

It is necessary to conduct differential diagnosis with the empyema of pleura,

cancer of lungs, tuberculosis.

Empiric à/b therapy of patients of CAP in the hospital.

To the patients 1 and 2 groups which are hospitalized on social testimonies,

appoint the proper à/b therapy.

To the patients 3 groups must be appointed the combined à/b therapy with

the parenterally setting of preparations.

Antibacterial THERAPY OF PATIENTS with CAP IN HOSPITAL

Group of

patients

Possible exciter

Antibiotic

first row Antibiotic of the

second rowPreparation

choice

Alternative

preparation

3

group

(with the

unsevere

CAP)

S. рneumoniae

H. influenzae,

Atipichnye

exciters,

Gramnegativny

e

enterobacteria

Application of

intravenous

introduction or

intramuscular

introduction of:

protected

aminopenicillin +

macrolide (per

os)

or

cephalosporin II-

IIIgenerations +

macrolide (per

os)

Intravenous

application:

Fluoroquinolones

III-IV generation

Intravenous

application of

Fluoroquinolones

III-IV generation

or carbapenems

IV

group

with

severe CAP

S. рneumoniae

H. influenzae

S. aureus,

Legionella spp.,

Polimikrobnye

associations

intravenous

introduction of

protected

aminopenicillin +

macrolide

or

cephalosporin III

generations +

macrolide

Intravenous

application:

Fluoroquinolones

III-IV generation

+ в-lactam

Intravenous

application of

Fluoroquinolones

III-IV generation

+ carbapenems

Or

carbapenems

+

Macrolide

At suspicion on

P. aeruginosa

cephalosporin

III-IV +

aminoglycoside +

cyprofloxaciny

Intravenous

application:

cephalosporin

III-IV

generation +

aminoglycoside

+ Macrolide

Intravenous

application

Meropenem

+ aminoglycoside

+cyprofloxaciny

Estimation of efficiency – on those criteria in 48-72 hours from the

beginning of therapy.

Duration of à/b therapy – at treatment of patients with the severe CAP– 10

days. In this term mark disappearance of leukocytosis .

For patients with an early adequate clinical answer for à/b therapy it is

possible to change parenterally injection to taking antibiotics per os.. In default of

answer for treatment during the first 3 days it’s necessary make the correction of

treatment and additional inspection.

COMPLICATIONS OF NP

- pleura effusion,

- empyema of pleura,

- destruction / abscess of pulmonary tissue ,

- acute respiratory failure,

- infectious toxic shock,

- pericarditis, myocarditis..

Risk factors:

- age more 50 years

- concomitant diseases

- severe pneumonia,

-smoking.

Hospital-acquired pneumonia (HAP) or Nosocomial pneumonia

refers to any pneumonia contracted within 48-72 hours of being admitted in

hospital. In practice, hospital-acquired pneumonia is often suspected on the basis

of the appearance of a new infiltrate on a chest x-ray.

Classification

Select:

Early HAP – arises up during the first 5 days from the moment of hospitalization

and caused by infection which patient had before hospitalization -S. Rneumoniae,

H. Influenzae, methicillinsensetive S. aureus and other representatives of normal

microflora of cavity of mouth. More frequent these agents are sensible to antibiotic

drugs, and pneumonia has more favourable prognosis.

Late – develops not earlier 6 day of hospitalization and caused actually by hospital

microflora with more high risk of development of high-virulent and polyresistant

bacterias, such as P. Aeruginosa, Enterobacteriaceae, methicillinresistant culture

of S. aureus. Such HAP has a less favourable prognosis.

Risk factors:

Endotracheal intubation with mechanical ventilation poses the greatest overall

risk; ventilator-associated pneumonia constitutes > 85% of all cases, with

pneumonia occurring in 17 to 23% of ventilated patients. Endotracheal intubation

breaches airway defenses, impairs cough and mucociliary clearance, and facilitates

microaspiration of bacteria-laden secretions that pool above the inflated

endotracheal tube cuff. In addition, bacteria form a biofilm on and within the

endotracheal tube that protects them from antibiotics and host defenses.

In nonintubated patients, risk factors include previous antibiotic treatment, high

gastric pH (from stress ulcer prophylaxis therapy), and coexisting cardiac,

pulmonary, hepatic, and renal insufficiency. Major risk factors for postoperative

pneumonia are age > 70, abdominal or thoracic surgery, and dependent functional

status.

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