1 pneumonia mk 2009 underg

Pneumonias for
undergradute
By
Prof. Mohammad Khairy
ElBadrawy
Professor Of Chest Medicine
April 2009
www.MansFans.com
2 pneumonia mk 2009 underg
 )Pneumonia )definition
• Inflammation of the respiratory
zone of the lung )consolidation)
• The cause may be infectious or
non infectious.
• It may be acquired in the
community or hospital.
• It may occur in the
immunocompetent or in the
immunocompromized.
3 pneumonia mk 2009 underg
 Bacterial causes of
pneumonia
• Streptococcus pneumoniae: the most
common cause )35% of causes).
• Gram negative organisms
• Staph aureus.
• Atypical pneumonia.
• Anaerobic organisms )aspiration
pneumonia).
• TB.
• Rare causes: Strept pyogenes,
rickettsia, Yersinia pestis )plague).
www.MansFans.com
4 pneumonia mk 2009 underg
 Viral causes of
pneumonia:
• Influenza. - Parainfluenza.
• Measles. - Coxsackie
virus.
• Adenoviruses. -
Rhinoviruses.
• Varicella. - Epstein-
Barr virus.
• Cytomegalovirus. - Herpes
simplex.
• Respiratory syncytial www.MansFans.com
- Corona
5
viruses. pneumonia mk 2009 underg
 :Fungal pneumonia
– Pneumocystis carinii.
– Aspergillus.
– Coccidiomycosis.
– Histoplasmosis.
– Candidiasis.

www.MansFans.com
6 pneumonia mk 2009 underg
 Non infectious causes of
pneumonia
• Chemical pneumonia:
Air pollution with gases and fumes.
• Physical pneumonia:
– Radiation pneumonitis: following
radiotherapy of the chest.
– Burns.

7 pneumonia mk 2009 underg

 Predisposing factors
1. Decreased resistance: General/immune
2. Virulent organisms.
3. Defective Clearing mechanism:
– Cough/gag Reflex: Coma, paralysis, addiction
– Mucosal Injury: smoking, toxin, aspiration
– Pulmonary edema: Cardiac, ARDS.
– Obstructions: foreign body, tumors
– Bronchial dilatation: as bronchiectasis.

8 pneumonia mk 2009 underg

 Sources of infection
Person to Person Environment
• S. •Psittacosis )pet birds)
pneumoniae, •Legionella )water)
• M. tuberulosis, •Aspergillosis )air,
water)
• Chlamydia
•Histoplasmosis )bird
• Group A strep droppings & bat caves)
• Influenza, •Anthrax )soil)
• SARS CoV,
• Varicella www.MansFans.com
9 pneumonia mk 2009 underg
 Oganism entery into the
lungs
• Aspiration.
• Inhalation.
• Inoculation.
• Colonization.
• Hematogenous
spread.
• Direct spread.

10 pneumonia mk 2009 underg

 Normal
Lung

11 pneumonia mk 2009 underg

 :Pathogenesis

www.MansFans.com
12 pneumonia mk 2009 underg
 Grey
Hepatization
Resolution

Pathogenesis of Pneumonia

Congestion
13 Redpneumonia
Hepatisation
mk 2009 underg
 :Pneumonia Types
1. Etiologic Types:
3. Clinical Types:
• Infective
• Community
– Bacterial acquired
– Tuberculosis pneumonia:
– Viral – Acquired in the
– Fungal community.
• Hospital
• Non Infective acquired
– Toxins – In the hospital.
– chemical • Pneumonia in
– Aspiration the ICH.
2. Morphologic
types:
• Lobar
www.MansFans.com
• Bronchopneumonia
14 pneumonia mk 2009 underg
• Interstitial
 Lobar Bronchopn
Pneumoni eumonia Interstiti
a al

www.MansFans.com
15 pneumonia mk 2009 underg
16 pneumonia mk 2009 underg
 Pathological description of
pneumonia

www.MansFans.com
17 pneumonia mk 2009 underg
 :Clinical types
This classification is a useful guide for the
empiric therapy of pneumonia
• (1) Community acquired pneumonia
(CAP).
Pneumonia occurring in the community.
Causative organisms:
• In younger healthy patient:
– Strept pneumoniae
– Atypical organisms.
• In elder patients )> 60y), or unhealthy young patients
– Gram negative bacilli
– Staph aureus
– atypical organisms.
• In aspiration pneumonia:
– Mixed organisms
– Anaerobic bacteria.
18 pneumonia mk 2009 underg
 :Clinical types
(2) Hospital acquired pneumonia
(HAP):
Pneumonia occurring after 48-72h of
hospital admission.
Causative organisms:
– Early onset HAP (first 5 days):
• Strept. Pneumoniae
• Hemophilus influenzae.
• Moraxella catarrhalis.
– Late onset HAP (>5 days):
• Gram negative organisms )Klebsiella pneumonia,
Pseudomonas aerogenosa).
www.MansFans.com
– Aspiration pneumonia in HAP:
19 • Mixed organisms
pneumonia mk 2009 underg
• Anaerobes.
 :Clinical types
3) Pneumonia in
immunocompromised host:
Any organism can cause
pneumonia in this group of
patients with atypical clinical and
radiological pictures.

20 pneumonia mk 2009 underg

 Legionella pneumonia (L.
Pneumonia):
• Caused by inhalation of droplets of
contaminated water by the aquatic organism
L. pneumophila.
• The source of infection include domestic hot
and cold water systems, humidifires etc.
• It is more common in summer, majority of
cases are sporadic and community acquired.
• Attack rate is higher in:
– Elderly,
– Tobacco smokers,
– Chronic lung disease,
– Alcoholism diabetics,
– Immune-compromised patients.
21 pneumonia mk 2009 underg
 Diagnosis of Pneumonia

• History
• Examination
• Lab tests
• Chest X-Ray

Enough for Therapy ?

Diagnostic“ •
Microbiolog
”y www.MansFans.com
22 pneumonia mk 2009 underg
 Symptoms of
pneumonia
1. Fever.
2. Cough: at first it will be dry then it become
productive of sputum.
– Sputum may be yellowish, brownish, rusty, green
or mucopurulent sputum according to the
causative organism(s).
– Sputum may be of offensive odor as in anaerobic
pneumonia.
3. Dyspnea in:
– Severe cases (more than one lobe or bilateral
pneumonia)
– Or if there is pleural effusion of empyema.
4. Chest pain: pleuritic pain due to inflammation of
the parietal pleura.

23 pneumonia mk 2009 underg

 General signs of
pneumonia
• Tachypnea and tachycardia.
• Temp: 38.5 - 39.5oC.
• Myalgia with or without rigors.
• Flushed face.
• Cyanosis in severe cases.
• Herpes labialis )in Strept pneumonia).
• Respiratory distress with working alae nasi.
• In Mycoplasma pneumina:
– Bulbous myringitis )painful haemorrhagic blisters
on the external auditory canal and ear drum).
– Generalized lymphadenopathy and splenomegaly.

24 pneumonia mk 2009 underg

 Local signs of
pneumonia
Inspection: diminished respiratory movement and
limited chest expansion of the affected side.
Palpation: central trachea and increased TVF over the
affected lobe.
Percussion: impaired note or dullness over the
affected lobe.
Auscultation:
– Bronchial breath sounds and increased vocal
resonance over the affected lobe.
– Crepitations:
– The type of crepitations are at first fine late
inspiratory crepitation in the stage of lung
congestion, then become coarse inspiratory
www.MansFans.com
crepitations in the stage of gray hepatization and
stage of resolution.
25 pneumonia mk 2009 underg
:CP of Staph aureus pneumonia

• High fever
• Clinical picture of severe
pneumonia
• Purulent sputum
• Hemoptysis.
• C/P of multiple lung abscesses
)pneumatoceles)
• Pleural involvement )effusion,
empyema, pleurisy,
26
pyopneumothorax)
pneumonia mk 2009 underg
 Clinical picture of atypical
:pneumonia
• It differs from that of classical
pneumonia in the following points:
– Non-respiratory symptoms are
dominating, e.g. headache, confusion,
loss of mental clarity, abdominal pain,
diarrhoea.
– The usual auscultatory findings of
consolidation may be absent or
difficult to detect making a chest x-
ray is essential for diagnosis
27 pneumonia mk 2009 underg
 Clinical picture of viral
:pneumonia
It occurs mainly in ICH,
characterized by:
– Severe illness with prostration
general malaise.
– Minimal local chest signs.
– CXR is essential for diagnosis.

www.MansFans.com
28 pneumonia mk 2009 underg
Laboratory investigations:

• Leucocytosis or leucopenia.
• Lymphocytosis.
• Thrombocytopenia.
• Hypoxemia hypocapnea and in late
stages may be hypercapnea.
• Hypokalemia
• Elevated liver enzymes and /or
29
bilirubin. pneumonia mk 2009 underg
Microbiological diagmosis
Commonly available Less Commonly available
• Sputum and pleural • Urine antigen detection
(legionella,
fluid gram and pneumococcus)
culture. • Serum ag detection
• Sputum acid fast (Aspergillus,
stains Histoplasma,
Cryptococcus)
• Blood Cultures (>1) • PCR for virus,
• Nasal cultures for chlamydia,
Mycobacterium
virus
• Serology for Psittacosis
• Ag detection for
viruses (RSV,
Influenza)
30 pneumonia mk 2009 underg
• Special stains for PCP
 Radiological diagnosis

www.MansFans.com
31 pneumonia mk 2009 underg
 www.MansFans.com
32 pneumonia mk 2009 underg
33 pneumonia mk 2009 underg
 www.MansFans.com
34 pneumonia mk 2009 underg
35 pneumonia mk 2009 underg
 www.MansFans.com
36 pneumonia mk 2009 underg
Broncho
Pneumonia

37 pneumonia mk 2009 underg

 www.MansFans.com
38 pneumoniaLUNG ABSCESS
mk 2009 underg
 Air-fluid level

39 pneumonia mk 2009 underg

 www.MansFans.com
40 RIGHT EMPYEMA
pneumonia mk 2009 underg
Criteria for severe pneumonia:
Minor criteria
1. Respiratory rate> 30 breaths/min
2. PaO2/FiO2 ratio< 250
3. Multilobar infiltrates
4. Confusion/disorientation
5. Uremia )BUN level 20 mg/dL)
6. Leukopenia: )WBC count <4000 cells/mm3)
7. Thrombocytopenia )platelet count <100,000
cells/mm3)
8. Hypothermia )core temperature <36C)
9. Hypotension requiring aggressive fluid
resuscitation
Major criteria
1. Invasive mechanical ventilation
www.MansFans.com
2. Septic shock with the need for vasopressors
41 pneumonia mk 2009 underg
 Atypical bacterial
pneumonia
• Mycoplasma,
• Legionella,
• Chlamydia
– Unusual presentation
– Extrapulmonary
features
– CXR often normal
early in infection
– WCC normal

– Diagnosis:
• serology,

– Treatment-
macrolides, newer
42 quinolones pneumonia mk 2009 underg
 www.MansFans.com
43 pneumonia mk 2009 underg
 Complications of
Pneumonia
Local complications:
• Pleural effusion and
empyema.
• Lung abscess.
• Delayed resolution.
• Incomplete resolution
• Bronchiectasis later on
specially in viral
pneumonia )e.g., post
measles).
• ARDS
• Resp failure in severe
cases.
44 pneumonia mk 2009 underg
 Complications of
Pneumonia
1. Bacteraemia and metastatic abscess,
widely disseminated infection includes
purulent pericarditis, meningitis,
peritonitis, endocarditis, septic
arthritis, brain abscess, septic shock
and toxic capillaritis.
2. Shock and prerenal faluire.
3. Disseminated intravascular
coagulopathy )DIC).
4. Multiorgan dysfunction syndrome.
www.MansFans.com
45 pneumonia mk 2009 underg
 Causes of delayed
resolution:
1. Inadequate treatment in type or dose of
antibiotics.
2. Specific etiology e.g., Tuberculosis.
3. Underlying tumor, foreign body or
bronchiectasis.
4. Local complications as empyema.
5. Immunosuppression.

If pneumonia did not respond to treatment

in the expected time.

46 pneumonia mk 2009 underg

 Recurrent pneumonia
Definition:
Two or more separate attacks of
pneumonia with complete
resolution for at least 1 month
between the attacks during one
year.

47 pneumonia mk 2009 underg

 Causes of recurrent
pneumonia
a- Recurrent at the same site:
- Endobronchial tumor.
- Endobronchial foreign body.
- Bronchiectasis.
b- Recurrent at different sites:
- Bilateral bronchiectasis.
- Cystic fibrosis.
- Immunosuppression.
48 pneumonia mk 2009 underg
 Management Issues for
CAP
• Hospitalize or Not
• Isolation – when appropriate
• What antibiotics to use )IV or
oral)
• Supportive treatment as MV,
O2 therapy, nutrition..
• When to Discharge www.MansFans.com
49 pneumonia mk 2009 underg
 Treatment of
pneumonia
Till the results of Gram stain and/ or
cultures, the antibiotics are used on
empirical base according to the
international guidelines. The drug choice
were adopted according to the following:
– Whether infection is severe or not.
– Presence of co morbid disease.
– Age of the patient.
– Previous intake of antimicrobials.
– Severe pneumonia always necessitates
hospitalization and intensive care management.
50 pneumonia mk 2009 underg
 Treatment of
pneumonia
A- Community acquired pneumonia:
Outpatient treatment:
1- Mild to moderate CAP in young patients
without co-morbidity:
IV benzylpencillin 1.2g/kg/6h and macrolide
antibiotic as azithromycin, or clarithromycin.

If inadequate response add one of the following:

Fluroquinolone e.g., ciprofloxacin.
2nd generation cephalosporin.
Amoxicillin-clavulanic acid.

51 pneumonia mk 2009 underg

 Treatment of
pneumonia
2- Mild or moderate CAP in
young patients with co-
morbidity or in elderly:
Macrolid antibiotic with any of the
following:
Second generation cephalosporin
or third generation cephalosporin
or amoxicillin-clavulanic acid.
www.MansFans.com
52 pneumonia mk 2009 underg
 Treatment of
pneumonia
Inpatient treatment of CAP:
1- Not severely ill:
- I.V 2nd generation cephalosporin
)cefuroxime) or I.V 3rd generation
cephalosporin as cefotaxime or
ceftriaxone and macrolide if there
is suspected atypical organism.

53 pneumonia mk 2009 underg

 Treatment of
pneumonia
2- Severe ill-hospitalized patient with CAP:
Therapy must be intravenous and combined
antibiotic therapy are used including a
macrolid and one or two anti-pseudomonal
agents e.g:
- Aminoglycosides.
- 3rd generation cephalosporin: ceftazidime.
- Fluroquinolone )ciprofloxacin).
- Antipseudomonas pencillin )Pipracillin).
- β-lactame β-lactamase inhibitor combination
clavulanate or pipracillin-tazobactam.
54 pneumonia mk 2009 underg
 Treatment of
pneumonia
B- Hospital acquired pneumonia:
1- Non severe HAP:
Fluoroquinolone )ofloxacin or
ciprofloxacin) and one of the following:
2nd generation cephalosporin: cefuroxine
or
3rd generation cephalosporin )ceftriaxone
or cefotaxime).
β-lactam β-lactamase inhibitor
combination )ampicillin- sulbactam, or
pipracillin tazobactam).
55 pneumonia mk 2009 underg
2- Severe or late onset HAP:
The I.V antibiotic therapy must cover
pseudomonas aeuroginosa.
Any line of the following may be used:
Gentamycine )or ciprofloxacin) and
antipseudomonal pencillin )pipracillin) or,
Gentamycine )or ciprofloxacin) and
antipseudomonal 3rd generation cephalosporin
)ceftazidim) or,
Gentamycine )or ciprofloxacin) and B-lactam
carbapenen )impenem or meropenem) or,
Gentamycine )or ciprofloxacin) and
antipseudomonal pencillin B-lactamase inhibitor
combination )pipracillin / tazobactam) or,
Or combination of ciprofloxacin with
aminoglycoside if there is pencillin allergy.
Vancomycin is used if resistant staph aureus is
56
suspected. pneumonia mk 2009 underg
 The antibiotic used in
treatment of
pneumonia must be
changed to that
resulted in culture
and sensitivity for
samples taken from
www.MansFans.com
57 the patient on
pneumonia mk 2009 underg
 As the atypical organisms can
not be detected by culture or gram
stains the following drugs can be
used:
Macrolid group of antibiotics e.g.
erythromycin, azithromycin,
clarithromycin.
Quinolone group )e.g. ciproflxacin).

58 pneumonia mk 2009 underg

 Treatment of Staph aureus
pneumonia must include: antistaph
antibiotics such as:
• fusidic acid,
• vancomycin,
• fluoroquinolones such as
ciprofloxacin,
• antistaph penicillin such as
flucloxacillin, oxacillin or nafcillin.

59 pneumonia mk 2009 underg

 Supportive treatment
Fluid and electrolyte replacement.
Corticosteroids and inotropic agents as dopamine
and dobutamine in shocked patients.
Total parenteral nutrition in severe pneumonias in
whom mechanical ventilation is likely to be
prolonged.
Respiratory support:
a- Oxygen inhalation.
b- Mechanical ventilation if:
- PaO2 < 60 mmHg.
- Rising PaCO2 or PaCO2 > 50mmHg.
- Respiratory acidosis.
(3) Other problems
www.MansFans.com
- Pleuritic pain: simple analgesics.
60 pneumonia mk 2009 underg
 www.MansFans.com
61 pneumonia mk 2009 underg