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PNEUMONIA Prof T Rogers. THE IMPORTANCE OF PNEUMONIA A major killer in both developed and developing countries Accounts for more deaths than other infectious

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Text of PNEUMONIA Prof T Rogers. THE IMPORTANCE OF PNEUMONIA A major killer in both developed and developing...

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  • PNEUMONIA Prof T Rogers
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  • THE IMPORTANCE OF PNEUMONIA A major killer in both developed and developing countries Accounts for more deaths than other infectious diseases Mortality rates vary but can be as high as 25% A major cause of death in children in developing countries Incidence here (?) 2-5/1000 population
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  • PNEUMONIA Neither radiological or microbiological criteria are specific for predicting the cause of pneumonia A better approach is to first consider the clinical circumstances under which pneumonia acquired Add the clinical background of the particular patient
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  • Classification of pneumonia Community-acquired Hospital-acquired Aspiration and anaerobic Pneumonia in immunocompromised AIDS-related Geographically restricted Recurrent
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  • COMMUNITY-ACQUIRED PNEUMONIA: INTRODUCTORY POINTS More common at the extremes of age Twice as common in winter months A General Practitioner is likely to see up to 10 cases per yr Represent
  • British Thoracic Society CAP severity assessment: CURB 65 score Any of: confusion, urea> 7mmol/l, respiratory rate>30/min, blood pressure systolic 65 years Low (0-1), moderate (2), high (3+) severity Will help determine where treated (home vs hospital), and likely mortality. ICU admission indicated by CURB score of 4-5
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  • COMMUNITY ACQUIRED PNEUMONIA: WHATS CAUSING IT?
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  • MICROBIOLOGICAL CAUSES (%) OF COMMUNITY ACQUIRED PNEUMONIA FROM HOSPITAL BASED STUDIES (N=3,000) CAPSevere CAP No cause found3633 Pneumococcus2527 Influenza virus82.3 Legionella spp*.717 Haem. Influenzae55 Other viruses58 Psittacosis/Q fever32 Gram neg. bacilli2.72 Staph aureus*25
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  • INVESTIGATIONS FOR DIAGNOSIS OF PNEUMONIA Non-invasive: blood count, urea, albumin,LFTs, sputum gram, chest X-ray, CT scan Culture of sputum, blood, pleural fluid Serology: pneumococcal, Legionella antigen Invasive: induced sputum, bronchoscopy, open lung biopsy
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  • TYPICAL GRAM APPEARANCE OF Strep pneumoniae IN SPUTUM GRAM POSITIVE CHAINS DIPLOCOCCI
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  • Streptococcus pneumoniae (pneumococcus) A gram positive coccus that grows in short chains Alpha haemolytic on blood agar Identified by its susceptibility to optochin Polysaccharide capsule confers pathogenicity-at least 80 serotypes There are multivalent vaccines for prevention of pneumococcal disease
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  • SOME COMPLICATIONS OF PNEUMOCOCCAL SEPSIS Bacteraemia (10%+) Empyema (1%) Meningitis (
  • Pneumococcal vaccine is recommended for: Age >65 years Underlying chronic lung disease Asplenia Alcoholism Diabetes mellitus Chronic renal failure HIV infection
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  • VIRUSES THAT CAUSE COMMUNTIY ACQUIRED PNEUMONIA
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  • INFLUENZA
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  • March Issue of Epi-Insight, Vol 6, Issue 3, Health Protection Surveillance Centre, Ireland
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  • Pandemic influenza H1N1 An acute respiratory illness Sudden onset of: fever (>38 o C), headache, cough, sore throat, muscle aches, pneumonia Transmitted by respiratory droplets from coughing, sneezing, and from infected surfaces. 1,613 cases confirmed with 4 deaths in Ireland up to 3 rd October
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  • Underlying diseases with an increased risk of severe influenza Chronic lung, liver, CNS, conditions, Immunosuppression Diabetes mellitus Asthma Age 65 years Severely obese (BMI 40 or more) Pregnancy haemoglobinopathies
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  • Preventing the spread of pandemic (swine) influenza Wash hands with soap and water Avoid unnecessary contact with cases Avoid touching eyes, nose, mouth Cover mouth and nose with tissue Patients admitted to hospital who have a confirmed diagnosis will be nursed in a negative pressure room HCWs wear protective clothing
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  • Treatment and prevention of pandemic influenza H1N1 Oseltamivir treatment of severe cases Can also be considered as antiviral prophylaxis in selected high risk patients Should be used prudently because of risk of drug resistance Vaccine about to be issued, will include provision for health care workers
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  • A V I A N F L U
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  • OTHER VIRAL CAUSES Respiratory syncytial virus (RSV) Parainfluenza viruses Enteroviruses (Cytomegalovirus)
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  • July 2003 issue of Virus Alert, bulletin of the National Virus Reference Laboratory S A R S
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  • Severe Acute Respiratory Syndrome (SARS) oIdentified in Guangdong Province, China, in November 2002 oRapidly spread to Hong Kong, South East Asia, North America..The World oBy the end of outbreak in June 2003 more than 8,000 cases had occurred with >800 deaths oPerson to person transmission demonstrated
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  • CAUSES OF ATYPICAL PNEUMONIA Mycoplasma pneumoniae Chlamydia pneumoniae Legionella pneumophila Coxiella burnetii
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  • Mycoplasma pneumoniae Has no cell wall, therefore doesnt respond to beta lactams Causes atypical pneumonia in adolescents and young adults Dry hacking cough, low grade fever, headache feature Isolation by culture of the organism is difficult therefore diagnosis is confirmed by a high CFT or rising titre of specific antibodies Cold agglutinins also typical Macrolides or tetracyclines most active
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  • Chlamydia pneumoniae An obligate intracellular bacterium Causes mild pneumonia but may cause protracted symptoms Sore throat, hoarseness, URT symptoms feature Serological diagnosis rather than culture Tetracyclines, macrolides, quinolones active
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  • Legionnaires disease A severe pneumonia due to Legionella pneumophila Can be community or hospital acquired Organism is acquired from environmental sources eg, humidified air conditioning, showers Usually attacks debilitated individuals
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  • Radiology
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  • Microbiology Gram ve, flagellated rod, aerobic Facultative intracellular parasite in both amoeba and human monocytes/macrophages
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  • RISK FACTORS Male sex Advanced age Cigarette smokers Alcoholism Chronic lung disease Immmunosuppression, malignancy
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  • Legionnaires disease Hyponatremia, confusion, nausea, vomiting, abnormal LFTs a feature Diagnosis often confirmed by urinary antigen test (specific for serogroup 1) Can be cultured on special media Must be notified to Public Health as it can cause outbreaks Most active antibiotics are: macrolides, quinolones, rifampicin
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  • Antibiotic Treatment of Community Acquired Pneumonia The priority is to cover pneumococcus Penicillin, amoxycillin, cephalosporins, new quinolones and macrolides have all been used as monotherapy Choice will be influenced by local resistance rates for pneumococcus
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  • Examples of antibiotics for CAI Benzylpenicillin Penicillin V Ampicillin, amoxycillin, Augmentin Cefuroxime, cefotaxime, ceftriaxone Moxifloxacin (a quinolone) Erythromycin, clarythromycin, azithromycin
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  • ACID ALCOHOL FAST RODS SUGGESTING TUBERCULOSIS
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  • KLEBSIELLA PNEUMONIA (RARE)
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  • COMMUNITY ACQUIRED PNEUMONIA IN INFANTS AND CHILDREN Group B streptococcus and E coli cause pneumonia in neonates RSV an important pathogen in infants Bordetella pertussis (cause of whooping cough) important in young children As is Haemophilus influenzae type b
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  • SOME FEATURES OF NOSOCOMIAL PNEUMONIA Often ventilator associated, therefore seen in ITU most commonly Due to both endogenous organisms and others acquired by cross infection MRSA, gram negatives predominate High associated mortality because of co- morbidity and antibiotic resistance
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  • HOSPITAL ACQUIRED PNEUMONIA: Pseudomonas aeruginosa
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  • TREATMENT OF HOSPITAL ACQUIRED PNEUMONIA Will depend on the local epidemiology of the unit/hospital Often require good cover for MRSA and gram negative enterobacteria Therefore vancomycin and carbapenem or Tazocin may be used
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  • PNEUMONIA IN THE IMMUNOCOMPROMISED HOST Cause depends on the underlying immunodeficiency More likely to present as a diffuse interstitial pneumonia Treatment often empirical as establishing the cause is often difficult
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  • MAJOR CAUSES OF PNEUMONIA IN IMMUNOCOMPROMISED Pneumocystis jiroveci (carinii) Cytomegalovirus Other respiratory viruses Tuberculosis Fungi
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  • Pneumocystis jiroveci (Lung biopsy) Cyst stage
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  • NOCARDIOSIS (Cause: Nocardia asteroides, acid fast rod)
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  • Geographically restricted pneumonias Typhoid Melioidosis Brucellosis Endemic mycoses: histoplasmosis Helminthic: paragonimiasis
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  • Recurrent pneumonia May be caused by local bronchial or pulmonary abnormality Obstruction due to eg, foreign body, carcinoma, lymph node Chronic obstructive lung disease: