Pneumonia

1. Pneumonia Andriy Lepyavko, MD, PhD Department of Internal Medicine № 2

2. Plan of the lecture • Definition • Classification • Diagnostic criteria • CAP – clinical signs, treatment • Nasocomial pneumonia • Aspiration pneumonia • Pneumonia in the immunocompromised host

3. “The most wide spread and fatal of all acute diseases, pneumonia, is now Captain of the Men of Death” Sir William Osler The Principles and Practice of Medicine, 1901

4. Clinical and economic importance of acute pneumonia (USA) • Sixth most common cause of death • The most common cause of infection-related mortality • Incidence 170-280/10 000 • Costs of treatment exceed $12 billion • Inpatient treatment costs 25 times more than outpatient treatment

5. Definition • Pneumonia – this is an inflammation in the lung parenchyma caused by bacteria, viruses or fungi which is characterized by intraalveolar exudation

6. Morphology

7. Classification • Etiology (if it is known) • Variants: • Community-acquired pneumonia • Nosocomial pneumonia – when patient was hospitalized with any another diagnosis, and after 48 hours in the hospital (not earlier!) pneumonia was diagnosed, or pneumonia after artificial lung ventilation • Pneumonia due to aspiration. It results from the aspiration of gastric contents in addition to aspiration of upper respiratory flora in secretions. • Pneumonia in immunocompromised host – patients with AIDS or immunodeficit of other origin. Causes of pneumonia – viruses, fungi of saprofites (E.coli etc.)

8. Classification III. Localization (side, lobe, segment) IV. Stages of severity: • Mild stage –conciousness is clear, t less than 38, heart rate less than 90, BP normal, dyspnea mild in case of physical activity, CXR – small infiltration • Moderate – conciousness is clear, sweating, general weakness, t 38-39, heart rate 90-100, moderate dccreased BP, dyspnea, large size of infiltration • Severe – t 39-40, conciousness is not clear, heart rate more than 100, low BP, severe dyspnea, cyanosis, large size of infiltration and presence of complications V. Complications.

9. Clinical groups (for CAP) • I – patients in the age 2-65 without concomitant diseases, are outpatients • II – patients <2 or >60, with concomitant diseases, are outpatients, but near 25 % of them treatment will not be effective, and they will need hospitalization • II – patients <2 or >60, with concomitant diseases, are inpatient • II – patients <2 or >60, with concomitant diseases, have to be treated in the Emergency department

10. Clinical groups (for NCP) • I – patients without risk factors, with mild or moderate severity pneumonia which was diagnosed at any day of hospitalization or severe early pneumonia (at first 5 days of hospitalization) • II – patients with risk factors + I • III – patients with risk factors and severe pneumonia or late pneumonia

11. Pathogenesis • Route of entry - Inhalation - Aspiration - Bloodborne • Host/ organism dynamics tipped by - Defect in host defences - Virulent organism - Overwhelming inoculum

12. Host Defences • Nasal hair • Dynamics of airflow • Cough • Mucous • Mucociliary apparatus • Bacterial interference • Immunoglobulin • Surfactant • Fibronectin • Complement • Cytokines • Alveolar macrophages • Polymorphonuclear leucocytes • Cell-mediated immunity

13. Diagnostic criteria • Predisposition – CHF, diabetes, alcoholism, COPD • Classic symptoms – cough, fever, sputum production, dyspnea • Clinical syndrome – fever, pleuritic chest pain, productive cough with mucopurulent sputum • Focal pulmonary findings (rales, crapitation or signs of consolidation) – less sensitive than CXR • General blood analysis – increased ESR, leucocytosis, shift to the left • Sputum analysis – causative microorganism and its sencitivity to antibiotics may be found

14. Diagnostic criteria • CXR with infiltrates – diagnosis “pneumonia” is invalid without it

20. Community-acquired pneumonia Most common pathogens: • Streptococcus pneumoniae (9% to 75%; mean, 33%), • Haemophilus influenzae (0 to 50%; mean, 10%), • Legionella species (0 to 50%; mean, 7%), • Chlamydia pneumoniae (0 to 20%; mean, 5%). • Mycoplasma pneumoniae

21. CAP - treatment • Macrolide Claritromycin (Clacid) 0,5 g 2-3 t/day, Azitromycin (Sumamed) 0,5 g 1t/d Roxitromycin (Rulid) 0, 15 g 2t/d Midekamycin (Macropen) 0,4 g 3 t/d • Amoxicillin + clavulonic acid 0, 625 g 2-3-4 t/d “+” – there is i/v form as well • Doxycyclin 0,1 g 2 t/d

22. CAP - treatment • Cephalosporin Cefuroxim 0,75-1,7 g i/m 3 times per day Cefatoxini 1-2 g i/m, i/v 2 t/d Ceftazidini 1 g i/m, i/v 2-3 t/d • Respiratory fluoroquinolone Cyprofloxacini (Cyprobai) 0,2 g 2 t/d or 0,5 g 2 t/d i/v

23. Treatment according groups • I – Macrolide, doxacyclin (?) • II – Cefalosporine, Amoxiclav, Macrolide • III - Cefalosporine, Amoxiclav, Macrolide • IV - Cefalosporine, Amoxiclav, Macrolide, Fluoroquinolone

24. Duration of treatment • At least 5 days • Until afebrile for 48-72 hours • Stable vital signs • Longer course needed if Initial antibiotic choice did not cover the pathogen Extrapulmonary infection (meningitis) Lung abscess, cavitation or empyema Gram negative pathogen or S.aureus

25. Nosocomialpneumonia • Staphylococcus aureus • Gram-negative microorganisms - Pseudomonas, Klebsiella, Proteus, enterobacteria, E.coli • Fungi - Candida, Aspergillus, Rizopus.

26. Nosocomialpneumonia • Clindamicini i/m, i/v every 6 hours, total - 1 g/day • Aztreonam (Azactam) – i/v, i/m every 8 hours, average – 3-6 g/day • Vancomycini – i/v every 8-12 hrs, average – 30 mg/kg/d, max – 3 g/d • Rifampicini – orally 0,15 g 2 t/d, i/m 1,5-3 g every 8-12 hrs Useful combinations: • Clindamycini+Aztreonam • Clindamycin+Vancomycin • B-lactam+Vancomycin • Floroquinolon+Rifampicin

27. Aspiration pneumonia Most effective are: • Aminoglycozyde (tobramycin, sizomycin)+ Metronidazol • Cephalosporini III-IV generation+Metronidazol

28. Pneumonia in immunocompromised host • Cephalosporine III-IV generation • Aminoglycozyde (tobramycin, sizomycin)

29. Prevention • Annual Influenza immunization

30. Thanks for your attention!