Pneumonia

Danielle M Hansen, DO, MS

PNEUMONIAPNEUMONIA

Definition: Infection of Lung ParenchymaDefinition: Infection of Lung Parenchyma 1/6 of All Deaths in USA 1/6 of All Deaths in USA

Most Common Infectious Cause of DeathMost Common Infectious Cause of Death

Pneumonia Defense Mechanisms

Defense Mechanism Things that Impair the Defense Mechanism

Cough Reflex AnesthesiaNeuromuscular DisorderComa

Mucociliary Apparatus Cigarette SmokeCorrosive Gases

Phagocytic Action of Alveolar Macrophages

AlcoholTobacco

Secretion Clearance Cystic Fibrosis

Innate, Humoral, Cell-Mediated Immunity

Classification of Pneumonia

Community-Acquired, AcuteS. pneumoniaeH. influnzaeM. catarrhalisStaph aureusEnterobacteriacea

Community-Acquired, AtypicalMycoplasmaChlamydiaLegionellaCoxiella burnettiViruses

NosocomialEnterobacteriacea

PseudomonasS. Aureus (MRSA)

AspirationAnaerobic oral floraAerobic bacteria

ChronicNocardiaActinomycesGranulomatous

Necrotizing and Abscess AnaerobicStaph aureusKlebsiellaStrep pyogenes

Immunocompromised HostCMVPCPMACAspergillosisCandidiasis

CAP - ACUTECAP - ACUTE

Clinical Presentation: High Fever, Shaking ChillsHigh Fever, Shaking Chills Cough Productive of Mucopurulent SputumCough Productive of Mucopurulent Sputum Pleuritic Chest Pain, Pleural Friction RubPleuritic Chest Pain, Pleural Friction Rub

Clinical Course: Marked Improvement

in Symptoms after 48-72

Hours of Antibiotics <10% Mortality

Pathogenesis of Acute CAP

Invasion of Lung Parenchyma

Inflammatory Exudate Fills Alveoli

Consolidation

Normal Alveoli

Pneumonia

Morphology of Acute CAP

Bronchopneumonia Patchy Consolidation

Lobar Pneumonia Fibrinosuppurative

Consolidation of Entire Lobe or Large Portion of Lobe

Pathogens of Acute CAP

S. pneumoniae H. influnzae M. catarrhalis Staph aureus Enterobacteriacea <10 epi’s/lpf

Streptococcus Pneumoniae

= Pneumococcus Most Common Cause of CAP Colored Sputum False Positive Sputum Cultures

Normal Flora of Nasopharynx Blood Cultures More Specific

30% Mortality if Bacteremic Treatment:

Fluoroquinolones, Amoxil, PCN, Macrolides Some Resistant Strains

Immunization

Up to 50%Up to 50%

Staphylococcus Aureus

Follows Influenza or ABX Colored Sputum Treatment:

1st Generation Cephalosporin or PCN Vanco (if MRSA suspected)

High Incidence of Complications Lung Abscess Empyema Glomerulonephritis Pericarditis

Enteric Gram-Negatives

Most Frequent Cause of GN Pneumonia Debilitated and Malnourished

Chronic Alcoholics ECF

Sputum Treatment:

Fluoroquinolones Pip+Tazo

Klebsiella, E. Coli, Proteus

Haemophilus Influenzae

Gram-Negative Coccobacilli Encapsulated Form > Unencapsulated Form

Infections from Unencapsulated Forms Elderly, COPD Bronchopneumonia Treatment:

Ampicillin, Augmentin, Doxycycline,

3rd Generation Cephalosporins, Fluoroquinolones, TMP/SMX

Immunization for b Serotype

Moraxella Catarrhalis

Gram Negative Cocci COPD, DM, CA Treatment:

Doxycycline Macrolide Cephalosporin Augmentin

CAP - ATYPICALCAP - ATYPICAL

Clinical Presentation: Symptoms out of Proportion to PE Findings

Less Sputum No Consolidation

Moderate WBCs Clinical Course:

Sporadic Form < 1% Mortality Interstitial Form has been Epidemic Secondary Bacterial Infections

Pathogenesis of Atypical CAP

Organism Attaches to Upper Respiratory Tract Epithelium

Cell Necrosis and Inflammatory Response

Interstitial Inflammation

Predispose to

Secondary

Bacterial

Infections

Morphology of Atypical CAP

Patchy or Lobar No Pleural Involvement

Pathogens of Atypical CAP

Mycoplasma Chlamydia Pneumoniae Legionella Coxiella Burnetti (Q Fever) Viruses:

Influenza Respiratory Syncytial Virus Adenovirus Rhinovirus Rubeola Varicella

Mycoplasma Pneumoniae Most Common Cause of Atypical CAP Children and Young Adults Sporadic or Epidemic 2-3 Week Incubation Period Extrapulmonary Manifestations:

Hemolytic Anemia Splenomegaly Erythema Multiforme Arthritis Myringitis Bullosa Pharyngitis Tonsillitis Mental Status Change

Diagnosis: Complement Fixation to Measure IgM Antibody Treatment: Macrolide, Doxycycline Up to 6 Months Recovery

Legionella Pneumophila

Artificial Aquatic Environments Transmitted by Inhalation or Aspiration Associated Diarrhea, Neuro Sx Na and Phos Fatality Rate 50% in Immunosuppressed Diagnosis:

Antigen in Urine +Fluorescent Antibody Test on Sputum Culture is Gold Standard

Treatment: Macrolides or Quinolones

Chlamydophilia Pneumoniae

Young Adults Laryngitis precedes Pneumonia by 2-3 Wks Diagnosis:

IgM titer > 1:16 Positive Culture PCR 4x Increase in IgG

Treatment: x 3 Wks Doxycycline Macrolides

Influenza Virus

8 Helices of Single-Stranded RNA Encodes Nucleoprotein Determines Type (A, B, C)

Lipid Bilayer = Envelope Containing Hemagglutinin and Neuraminidase Determines Subtype (H1-3, N1-2)

Type A is Major Cause of Human Infections Epidemics

Antigenic Drift (Mutations of Hemagglutinin and Neuraminidase)

Pandemics Antigenic Shift (Hemagglutinin and Neuraminidase

Replaced with Animal Virus RNA Segments) Type B, C Infect Children Treatment: Oseltamir (Tamiflu) and Zanamivir (Relenza)

Severe Acute Respiratory Syndrome

Pandemic of 2002 started in China > 8,000 Cases 774 Deaths

Coronavirus from Animals Diffuse Alveolar Damage, Multinucleated Giant Cells Clinical Presentation:

Incubation Period 2-10 Days Dry Cough, Malaise, Myalgias, Fever, Chills

Clinical Course: 1/3 Resolve 2/3 Progress to SOB, Tachypnea, Pleurisy 10% Mortality

NOSOCOMIAL PNEUMONIANOSOCOMIAL PNEUMONIA

Types: Hospital Acquired (HAP)

>48 hours after Admission Ventilator Associated (VAP)

>48 hours after Intubation Healthcare Associated (HCAP)

Hospitalized >2 Days within 90 Days Resident of ECF IV ABX, Chemo, Wound Care within 30 Days Hemodialysis

Pathogens: GNR (Enterobacteriaceae and Pseudomonas) Staph Aureus (MRSA)

Life-Threatening

Pseudomonas Aeruginosa

Risk Factors: ICU Steroids ABX > 7 Days in Past Month CHF Malnutrition Cystic Fibrosis

Extrapulmonary Spread Hematogenously Treat with 2 Antipseudomonals

Aminoglycoside + Antipseudomonal Beta-Lactam

ASPIRATION PNEUMONIAASPIRATION PNEUMONIA

Abnormal Gag and/or Swallowing Reflex

Pneumonia from Oral Flora Aerobes > Anaerobes

Chemical Pneumonitits from Gastric Acid

Necrotizing, Fulminant Course

Lung Abscess or Empyema are Common Complications

Treatment: Augmentin or Clindamycin

CHRONIC PNEUMONIACHRONIC PNEUMONIA

Localized Lesion with/without Nodes Immunocompetent Granulomatous Inflammation Fungal

Histoplasma Capsulatum Blastomyces Dermatitidis Coccidioides Immitis

Histoplasmosis Ohio and Mississippi Rivers and

Caribbean Inhalation of Bird and Bat

Droppings Contaminated with Spores

Primary Stage: Self-Limited or Latent Coin Lesion on Chest X-Ray

Secondary Stage: Chronic, Progressive Cough, Fever, Night Sweats Lung Apices

Extrapulmonary Manifestations: Adrenals Liver Meninges

No Treatment Indicated unless Disseminated

Blastomycosis

Central and SE U.S., Canada, Mexico, Africa, India, and the Middle East

Male : Female 10:1 Clinical Presentation:

Abrupt Onset Productive Cough Headache Chest Pain, Abdominal Pain Weight Loss, Anorexia Fever, Chills, Night Sweats

May Resolve, Persist, or Progress to Chronic Treatment: Itraconazole

Coccidioidomycosis

SW and Far West U.S. and Mexico Deserts

>80% of Population in Endemic Areas are Infected

Only 10% are Symptomatic Lung Lesions Fever Cough Pleuritic Pain Erythema Nodosum or

Multiforme Treat if Hemoptysis or Abnormal

CXR with Fluconazole or Amphotericin B

IDSA/ATS CAP Guidelines 2007

Pneumonia Severity Index – Step 1

Pneumonia Severity Index – Step 2Risk Factors Points

Age (M) Years

Age (F) Years-10

ECF 10

Active Neoplasm 30

Chronic Liver Dz 20

CHF 10

Cerebrovascular Dz 10

CKD 10

Altered Mental Status 20

Resp > 30 20

SBP < 90 20

Temp < 35 or > 40 15

Pulse > 125 10

pH < 7.35 30

BUN > 30 20

Na < 130 20

Glucose > 250 10

Hematocrit < 30 10

PaO2 < 60 10

Pleural Effusion 10

De

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La

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PE

PM

Hx

Pneumonia Severity Index – Step 3

Class Points Mortality Treatment

I 0.1 Outpatient

II < 70 0.6 Outpatient

III 71-90 2.8 Observation

IV 91-130 8.2 Inpatient

V > 130 29.2 Inpatient

CURB-65

Confusion (disorientation to person, place, or time) Urea (blood urea nitrogen) >7 mmol/L (20 mg/dL) Respiratory rate >30 breaths/minute Blood pressure (systolic <90 or diastolic <60) Age >65 years

Score Mortality Treatment

0-1 0.7-2.1 Outpatient

2 9.2 Inpatient

>3 >14.5 ICU

Indications for Etiology Testing

Empiric Outpatient Treatment

Healthy and No ABX within 3 months: MacrolideOr Doxycycline

Comorbidities (chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs) or ABX within 3 months FluoroquinoloneOr B-Lactam Plus Macrolide

For Macrolide-Resistant Streptococcus pneumoniae FluoroquinoloneOr B-Lactam Plus Macrolide

Empiric Inpatient Treatment

Non-ICU: Fluoroquinolone

Or B-Lactam

Plus

Macrolide

ICU: B-Lactam (cefotaxime,

ceftriaxone, or ampicillin-sulbactam)

Plus

Azithromycin

Or

Fluoroquinolone

For Penicillin-Allergy: Fluoroquinolone and

Aztreonam

Special Circumstances

For Pseudomonas: Piperacillin-tazobactam, cefepime, imipenem, or

meropenemPlus Ciprofloxacin or LevofloxacinOr Aminoglycoside and AzithromycinOr Aminoglycoside and Fluoroquinolone

For Penicillin-Allergy, Substitute Aztreonam for B-Lactam

For CA-MRSA: Vancomycin or Linezolid

Extras

First Dose of ABX in ER IV to PO when:

Hemodynamically Stable Clinically Improving Able to Ingest RX Functioning GI Tract

Length of Treatment: Minimum of 5 days Afebrile for 48–72 hours Clinically Stable

Immunizations: Influenza Pneumococcal

Smoking Cessation

Questions???