Community Acquired Pneumonia

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Pneumonia:

Pneumonia Prof AKM Mosharraf Hossain MBBS FCCP FCPS PhD Professor of Respiratory Medicine Bangabandhu Sheikh Mujib Medical University

Definition LRTI:

Definition LRTI ● LRTI includes symptoms like cough , dyspnoea , wheezing,coughing up sputum, pain in the chest etc. ● Types include pneumonia, acute bronchitis,AECB and viral.

Pneumonia? Crofton’s 5th edition:

Pneumonia? Crofton’s 5 th edition Pneumonia is a syndrome caused by acute infection, usually bacterial, characterized by clinical & /or radiological signs of consolidation of a part or parts of one or both lung. Pneumonitis is occasionally used as a synonym for pneumonia, particularly when the cause of inflammation is non-infectious, such as chemical or radiation injury.

Pneumonia classification:

Pneumonia classification Anatomist’s classification Lobar pneumonia Segmental Subsegmental Bronchopneumonia Clinical Pneumonia Community acquired Hospital acquired Immunocompromised Microbiologist classification Bacterial Nonbacterial- viral,Fungal,Ricketssia Chemical, Radiation Behaviorist pneumonia Easy pneumonia Difficult pneumonia

CAP-Incidence:

CAP-Incidence The annual incidence in the community is 5–11 per 1000 adult population . CAP accounts for 5–12% of all cases of adult LRTI managed by GPs in the community. The incidence varies markedly with age, being much higher in the extremes of age- in the very young and elderly, Between 22% to 42% of adults with CAP needs hospitalization. Between 1.2% and 10% of adults admitted to hospital with CAP are managed on an ICU.

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CAP-community definition:

CAP-community definition CAP in the community has been defined as- symptoms of an acute lower respiratory tract illness (cough and at least one other lower respiratory tract symptom like tachypnoea, pleuritic chest pain, SOB); + new focal chest signs on examination; + at least one systemic feature (either a symptom complex of sweating, fevers, shivers, aches and pains and/or temperature of 38°C or more); + no other explanation for the illness, which is treated as CAP with antibiotics.

CAP-hospital definition:

CAP-hospital definition CAP in hospital has been defined as: symptoms and signs consistent with an acute lower respiratory tract infection associated with new radiographic shadowing for which there is no other explanation (e.g. not pulmonary oedema or infarction);

Atypical pneumonia:

Atypical pneumonia The term “atypical pneumonia” has outgrown its historical usefulness and BTS does not recommend its use as it implies, incorrectly, a distinctive clinical pattern . The term “atypical pathogens” are defined as infections caused by Mycoplasma pneumoniae, C pneumoniae, C psittaci, and Coxiella burnetii.

BSMMU-Respiratory OPD 2004 (n=1947) Total pts (June2001-Aug2004)=4953 :

BSMMU-Respiratory OPD 2004 (n=1947) Total pts (June2001-Aug2004)=4953

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Comparison of aetiology-CAP & Nosocomial

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Gram-ve bacilli: Legionella pneumophila, Klebsiella pneumonie, Pseodomonas aurigenosa, Acinetobacter

Pathogens in special situations:

Pathogens in special situations Elderly: M pneumoniae & Legionella  ,H influenzae  COPD: H influ, M catarrhalis, S pneumoniae, Enterobactericae & P aeruginosa  DM: Pneumococcus pneumonia  Oral steroid: Legionella  Aspiraton: Anerobic & gm-ve enteric bacilli  Alcoholic: Aspiration, Legionella, atypical pathogen, C pneumoniae, mixed infection 

Pathogenesis and Pathology:

Pathogenesis and Pathology CAP is usually spread by droplet infection Most cases occur in previously healthy individuals predisposed by several factors- 1.Cigarette smoking 2.Upper respiratory tract infections 3.Alcohol 4.Corticosteroid therapy 5.Old age 6.Recent influenza infection 7.Pre-existing lung disease Once the organism settles in the alveoli, an inflammatory response ensues. The classical pathological response evolves through the phases of congestion, red and then grey hepatisation, and finally resolution with little or no scarring.

Pneumonia-clinical features:

Pneumonia-clinical features Typical presentation- sudden onset of fever, cough productive of purulent sputum, pleuritic chest pain, signs of consolidation Atypical presentation- gradual onset dry cough prominent extrapulmonary sympto (headache, myalgia, GIT upset, fatigue) minimal sign in the lung except rhonchi abnormalities in the CXR

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Severity of Pneumonia:

Severity of Pneumonia Low Severity Moderate Severity High Severity

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Score ≤ 8 is confusion; recently new-onset of disorientation in place,person and time is confusion

Differential Diagnosis of Pneumonia:

Differential Diagnosis of Pneumonia Pulmonary infarction Pulmonary/pleural TB Pulmonary oedema (can be unilateral) Pulmonary eosinophilia Malignancy: bronchoalveolar cell carcinoma Rare disorders: cryptogenic organising pneumonia/bronchiolitis obliterans organising pneumonia (COP/BOOP)

CAP-How to investigate?:

CAP-How to investigate? Full blood count Chest radiograph Examination of sputum should be considered for patients who do not respond to empirical antibiotic treatment . Urea, electrolytes and liver function tests . ABG- when SaO2 <92% or with features of severe pneumonia

Investigations for OPD pts:

Investigations for OPD pts

Investigations for Hosp Pts:

Investigations for Hosp Pts

CAP-special investigations:

CAP-special investigations CT lung scans may be useful in subjects where the diagnosis is in doubt, Bronchoscopy should be considered in patients with persisting signs,symptoms, and radiological abnormalities at around 6 weeks after completing treatment Serological test: Legionella antigen in urine. Pneumococcal antigen in sputum and blood. Immediate IgM for Mycoplasma. Cold agglutinins-positive in 50% of patients with Mycoplasma

Gm+ve Diplococci:

Gm+ve Diplococci

CXR findings:

CXR findings No unique radiological pattern was found although some differences were reported. The lower lobes were affected most commonly, regardless of aetiology. Bacterimic pneumococcal pneumonia: multilobar, Pl effusion Mycoplasma: lymphadenopathy, less common homogenous shadow S aureus: multilobar shadowing, cavitation, pneumatoceles, or spontaneous pneumothorax. K pneumoniae: predilection for upper lobes (especially the right), a bulging interlobar fissure, and abscess formation with cavitation.

Staphylococcal pneumonia:

Staphylococcal pneumonia

Pneumatocele:

Pneumatocele

Mycoplasma pneumonie:

Mycoplasma pneumonie

Klebsiella:

Klebsiella

Pseudomonas-multiple abscess:

Pseudomonas-multiple abscess

CXR-resolution:

CXR-resolution Lags behind clinical improvement particularly following legionella and bacteraemic neumococcal infection . Pneumonia caused by atypical pathogens clears more quickly . Resolution is slower in the elderly and in multilobar involvement

Pneumonia-General measures:

Pneumonia-General measures Stop smoke, rest,drink plenty of fluids . Pleuritic pain : paracetamol, opiates Nutritional supplements Pulse oximetry Review after 48 hours or earlier if clinically indicated. if no improvement after 48 hours, consider hospital admission or chest radiography

Empirical Treatment:

Empirical Treatment

Empiric antibiotic-Inpatient:

Empiric antibiotic-Inpatient

Empric antibiotics-Ps/Staph:

Empric antibiotics-Ps/Staph

Route of antibiotic:

Route of antibiotic

Oral switch:

Oral switch Most patients show a clinical response within 3 to 5 days of IV antibiotic therapy. Criteria to consider when switching from IV to oral therapy: Patient has a functioning GI tract for adequate absorption. Patient is currently receiving a soft or regular diet and/or is taking other oral medications. Patient's condition is improving as indicated from clinical findings (e.g., temperature and white blood cell count). In the case of the parenteral cephalosporins, the oral switch to co-amoxiclav 625 mg tds is recommended rather than to oral cephalosporins For those treated with benzylpenicillin plus levofloxacin, oral levofloxacin with or without oral amoxicillin 500 mg – 1.0 g tds is recommended.

Indicators of Improvement:

Indicators of Improvement

Duration of Treatment:

Duration of Treatment

Complications:

Complications Para-pneumonic effusion-common Empyema Retention of sputum causing lobar collapse Development of thromboembolic disease Pneumothorax-particularly with Staph. aureus Suppurative pneumonia/lung abscess ARDS, renal failure, multi-organ failure Ectopic abscess formation (Staph. aureus) Hepatitis, pericarditis, myocarditis, meningoencephalitis Pyrexia due to drug hypersensitivity

CAP-mortality:

CAP-mortality The reported mortality rate of adults with CAP managed in the community is very low at less than 1% . The reported mortality rate of adults admitted to hospital with CAP has varied between 5.7% and 12% The mortality rate of patients with severe CAP requiring admission to an ICU is high at over 30% . The long-term mortality of CAP is between 35.8% and 39.1% at 5 years.

Prevention-vaccination:

Prevention-vaccination Influenzae vaccine: In the UK recommended for all ages with: chronic respiratory disease including asthma; chronic heart disease; chronic renal disease; immunosuppression due to disease or treatment; diabetes mellitus; all those aged 65 years or older; those in long stay residential care. Pneumococcal vaccine: In UK recommended for 2 yrs and older with- asplenia; severe splenis dysfunction in sickle cell disease and coeliac disease; chronic renal disease or nephrotic syndrome; chronic heart disease; chronic lung disease; chronic liver disease diabetes mellitus; immunodeficiency or immunosuppression

RISK FACTORS FOR MDR-RESISTANT PATHOGENS:

RISK FACTORS FOR MDR-RESISTANT PATHOGENS Antimicrobial therapy in preceding 90 d Current hospitalization of 5 d or more High frequency of antibiotic resistance in the community or in the specific hospital unit Presence of risk factors for HCAP: 1.Hospitalization for 2 d or more in the preceding 90 d 2.Residence in a nursing home or extended care facility 3.Home infusion therapy (including antibiotics) 4.Chronic dialysis within 30 d 5.Home wound care 6.Family member with multidrug-resistant pathogen Immunosuppressive disease and/or therapy

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