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Dept.Pulmonology, University of Szeged, Deszk, Hungary

Attila Somfay. Dept.Pulmonology, University of Szeged, Deszk, Hungary. Pneumonia. Pneumonia. Very common (1-10/1000) , significant mortality S everity assessment, aided by score, is a key management step Caused by a variety of different pathogens

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Dept.Pulmonology, University of Szeged, Deszk, Hungary

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  1. Attila Somfay Dept.Pulmonology, University of Szeged, Deszk, Hungary Pneumonia

  2. Pneumonia • Very common (1-10/1000), significant mortality • Severity assessment, aided by score, is a key management step • Caused by a variety of different pathogens • Antibiotic treatment initially nearly always empirical, local guidelines and microbial resistance rates may support it

  3. Left middle lobe pneumonia (situs inversus) Kong, NEJM 2017

  4. 2009.05.18

  5. 2009.05.26

  6. 2009.10.26

  7. 2009.11.02

  8. 2009.11.02

  9. Evidence-based health policy (Science 1996; 274:740-743.)

  10. Definition Acute, infectious inflammation of the lower respiratory tract parenchyma (distal to bronchiolus terminalis).

  11. Pathogens • Bacteria /aerobic,anaerobic, atypical/ • Virus /influenza ,parainfluenza, adenovirus, herpesvirus,cytomegalovirus, RSV/ • Fungi /Aspergillus,Candida/ • Parasites /Pneumocystis jiroveci, Toxoplasma gondii,Ascaris lumbricoides/

  12. Clinical classification • Community-acquired, CAP • Nosocomial, hospital-acquired, HAP, VAP • Aspiration and anaerobic • Pneumonia in the immuncompromised host • AIDS-related • Reccurent • Pneumonias peculiar to specific geographical areas

  13. Epidemiology of CAP Mycoplaspa pn. Chlamydia pn.

  14. Pathogenesis • Inhalation of infected droplets • Aspiration /residents from nasopharynx/ • Spread through bloodstream • Direkt spread (concomittant)

  15. Risk factors • Prolonged supine position • Antibiotics, antacids • Patient contact • Decreased defense mechanisms • Infected health care materials

  16. Etiology • 1.Streptococcus pneumoniae 40-60% • 2. Mycoplasma pneumoniae 10-20% • 3. Haemophilus influenzae 6-10% • 4.Influenza A 5-8%

  17. Clinical features I. • General symptoms • malaise, anorexia • sweating, rigors • myalgia, arthralgia • headache • fast (bacteremia) vs. slow (Mycoplasma) progression • marked confusion (Legionella, psittacosis) • acute abdominal or urinary problem (lower lobe, age!)

  18. Clinical features II. • Respiratory symptoms - cough, dsypnea, pleural pain - purulent sputum, hemoptysis • Physical signs - high fever and rigor (Pneumococus) - little or no fever (elderly, seriously ill) - herpes labialis (Pneumococcus) - dullness, inspiratory crackles, bronchial breathing - upper abd. tenderness (lower lobe) - rash (antibiotic, mycoplasma, psittacosis)

  19. Differential diagnosis • Pulmonary infarction • Atypical pulmonary oedema • Less common: pulmonary eosinophilia, acute allergic alveolitis, lung tumours • Diseases below the diaphragm: hepatic abscess, appendicitis, pancreatitis, perforated ulcer

  20. Investigations • Chest x-ray (lateral!, neoplasm) – compulsory • WBC , >30 or < 4 G/L: poor prognosis • Sputum Gram stain and culture • Blood culture (20-25% positive) • Pleural fluid (25%, exclude empyema: pH!) • Serology (atipical, viral), antigen detection (Legionella, Pneumococcus) • Invasive tests: uncontaminated LRT secretions (BAL,PBS) or lung biopsies

  21. Radiological features • Lobar or segmental opacification • Patchy shadows • Small pleural effusions • Cavitation (infrequent, Staphylococcus, Pneumococcus serotype 3) • Spread to more than one lobe (Legionella. Mycoplasma) • Clearance of shadow may last for months

  22. Treatment at home or in hospital ?

  23. male age female age – 10 elderly’s home +10 Neoplasia +30 Liver dis. +20 CHF +10 Cerebrovasc. +10 Renal dis. +10 Confusion +20 Pleurisy +10 Resp.rate > 30 +20 RR<90 +20 Temp.<35 v. >40 +15 Pulse>125 +10 pH<7,35 +30 UN>11 +20 Na<130 +20 Se glucose>13,9 +10 Htk<30% +10 PaO2<60 Hgmm +10 CAP PORT (NEJM 1997, 40 000 patients)

  24. PORT categories • I.-II. <70, mortality < 1%, outpatient • III. 70-90, mortality 2,8%, short hospital, sequential ATB • IV. 91-130, mortality 8,2%, hospital • V. >130, mortality 29,2%, consider ICU

  25. CURB65 score (1-1point) Mild: 0-1point, 1.5% mortality Moderate: 2point, 9% mortalility Severe: 3-5 point, 22% mortalitty

  26. Only a few pathogens are involved Always cover Pneumococcus Consider epidemiology, age and health status Mycoplasma during epidemics, Staph.aur. in flu Do not delay starting antibiotics Assess prognostic factors and severity early Establish etiology quickly Adequate oxygen, hydration and nutrition Careful monitoring – transfer early to ICU Initial antibiotics must cover all the likely pathogens “Ten commandments” of CAP treatment Severe All

  27. Treatment of CAP 1) <65 year, no comorbidity, home: macrolide, doxycyclin, amoxycillin/clavulanic acid, 2. gen. cephalosporin 2) >65 year, comorbidity, home: amoxycillin/clavulanic acid, 2-3 gen. cephalosporin +- macrolide, respiratory fluoroquinolon (levofloxacin, moxifloxacin) 3) hospital: amoxycillin/clavulanic acid, 2-3 gen. cephalosporin + macrolide, resp.fluoroquinolon 4) ICU: ceftriaxon/cefotaxim, cefepim, carbapenemes (imipenem, meropenem), piperacillin/tazobactam + macrolides, resp. fluoroquinolon

  28. Risk factors of nosocomial pneumonia, HAP

  29. Pathogens and treatment of non-severe HAP

  30. Pathogens and treatment of non-severe HAP with additional risk factors

  31. Pathogens and treatment of severe HAP

  32. Reccurent pneumonia (GERD)

  33. Streptococcus pneumoniae

  34. Streptococcus pneumoniae • Most common bacterium in adults • Significant morbidity and mortality • Polysaccharide capsule impairs phagocytosis  need of opsonization  risk population: lymphoma, hyposplenia, hypogammaglobulinaemia • Abrupt onset, cough, rigors, high fever, tachycardia, tachypnoe, sticky pink sputum, focal crackles, • Sputum Gram stain: diplococcus, blood culture (20% pos.) • Good sputum sample: LRT: > 25 PMN, < 10 EC (low power field) • X-ray: homogenouos consolidation • Complications: pleura, pericardium, meninges, joints, endocardium, Type 3: abscess, lung scarring

  35. Streptococcus pneumoniae II. • Treatment: • Penicillin, ampicillin, amoxycillin • Cephalosporins 2-3 gen. • Macrolides • Carbapenems (imipenem, meropenem) • Prevention • 23 or 8-valent vaccines, 90% adult types • Chronic lung, heart, liver, renal disease, HIV • Diabetes, after spelenctomy, sickle-cell disease

  36. Mycoplasma pneumoniae

  37. Mycoplasma pneumoniae(Atypical pneumonia) • Atypical pathogen, moderate morbidity, low mortality • Close communities (schools, barracks, dormitories) • Intracellular pathogen (Chlamydia, Legionella) • Patchy, inhomogenousconsolidation on X-ray • Extrapulmonary manifestations: lymphadenopathy, cardiac, neurological, skin lesions, gatrointestinal,haematological, musculoskeletal • Treatment: macrolides, tetracyclin, fluoroquinolones

  38. Legionella pneumophila

  39. Staphylococcus aureus

  40. Staphylococcus aureus • High morbidity and mortality (30-70% in bacterae-mia) • 30% of adults carry in the anterior nares • Intravascular tubes (catheters, cannules) • Usually follows influenza infections • Toxins  tissue necrosis  abscess • Treatment: beta-lactamase resistant penicillins (oxacillin), cephalosporins, MRSA: vancomycin

  41. Lung abscess Key points • many other cavitating lesions than abscess • careful review of chest x-ray to distinguish from empyema • most are secondary to aspiration of oropharyngeal secretions • exclude malignancy or other cause, bronchoscopy! • a single microbe is unusual unless abscesses developed after bacterial pneumonia. More commonly, there is a mixed growth, including anaerobes

  42. Causes of lung abscess • Aspiration from the oropharynx • Bronchial obstruction • Pneumonia • Blood-borne infection • Infected pulmonary infarct • Trauma • Transdiagphragmatic spread

  43. Diff. dg of lung abscess • Cavitated tumour • Infected bulla or cyst • Localised saccular bronchiectatsis • Aspergilloma • Wegener’s granulomatosis • Hydatid cyst • Coal workres’ pneumoconiosis - progressive massive fibrosis - Caplan’s sy • Cavitated rheumatoid nodule • Gas-fluid level in oesophagus, stomach or bowel

  44. Treatment of lung abscess • Based on bacteriologic findings • Penicillin (amoxicillin/clavulanic acid) • Clindamycin + aminoglycosid (mixed flora) • moxifloxacin

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