pneumonia

2.  Acute infection of pulmonary parenchyma in pts
who has acquired infection in community

3.  Commonly caused by : streptococcus pneumoniae
Other organisms : hemophilus influenzae
Atypical bacteria ( Mycoplasma
pneumoniae, Chlymadophila pneumoniae ,legionella )
Respiratory viruses
Gram negetive bacteria(
enteobacteriaceae , pseudomonas aeruginosa)
Rarely mycobacterium tuberculosis,
C.psittaci, C. burnetii,endemic fungi
Recently increased incidence of
S.aureus is noted (methicillin resistant strains)

4.  Clinical evaluation
Chest radiography { with or without
microbiological testing}

5.  Cough
 Fever
 Pleuritic chest pain(30%)
 Dyspnea
 Sputum production
 GI symptoms-nausea,vomiting,diarrhoea
 Mental status changes
 Chills & Rigors

6.  Pt is febrile
 Respiratory rate :- > 24 cpm
 Auscultation :- rales are present
 1/3 rd pts present with signs of
consolidation
 Blood examination :- leucocytosis (
15,000 – 30,000/mm3)
 Leucopenia – poor prognosis.

7.  Infiltrates on plain chest x-ray – gold standard
for diagnosing pneumonia
 Radiological appearances CAP :
lobar consolidation(typical bacteria)
interstitial infiltrates(pneumocystis carinii
& viruses)
CT scan – higher sensitivity for CAP

10.  Treatment is best when it is pathogen-directed
 Includes:- blood - culture & sensitivity.
 sputum – Gram staining & culture.
 urinary antigen tests (legionella &
pneumococcus)
 Newer tests :- PCR

11.  Based on severity of disease
 Other features – ability to maintain oral intake
 likelihood of compliance
 h/o substance abuse
 cognitive impairement
 living situation
 functional status of pt.

12. Commonly used prediction rules
i)PSI (pneumonia severity index)
 ii) CURB 65
 Confusion (based on specific mental test,
disorientation to time place or person)
 blood urea > 7mmol/lit (20 mg/dl)
 respiratory rate > 30cpm
 blood pressure (systolic < 90mm hg
diastolic <60mm hg)
 age >= 65 yrs
 Score : 0-1 – treated on outpatient basis
 2-3 – admitted in hospital
 >3 – admitted in icu

13.  Choice of initial treatment complicated by
emergence of antibiotic resistance of S. pneumoniae
 Antibiotic therapy started on empiric basis since
causative organism is not identified in proportinate
no. of pts.

14.  In pts without risk factors or microbiological
eveidence of pseudomonas aeruginosa or MRSA :
 Combination of I.V. beta lactam { ceftrioxone
:1-2 gms daily cefotaxim : 1-2 gms every 8th hrly or
ampicillin :1.5-3 gms 6th hrly.}
PLUS
 Either Macrolide {azithromycin 500mg daily} or
fluoroquinolone {levofloxicin 750 mg daily or
moxifloxicin 400mg daily}

15.  In pts who may be infected with pseudomonas
aeruginosa or other resistant pathogens ( those with
COPD or Bronchiectasis or frequent antimicrobial or
glucocorticoid use) combination therapy with beta
lactam and fluoroquinolones is used :
 Piperacillin-Tazobactam(4.5 gms every 6 hrs) or
 Imipenem (500mg every 6 hours) or
 Meropenam (1 gm every 8 hrs) or
 Cefipime ( 2gms every 8 hrs) or
 Ceftazidime (2gms every 8 hrs)
PLUS
Ciprofloxacin (400mg every 8 hrs) or
Levofloxacin( 750 mg daily)

16.  In pts allergic to penicillin by skin testing
cephalosporins can be continued ( 3rd generation)
 In cases of mild reaction ( not IgE mediated)
initially 1/10 of dose is given observed for 1 hr, then
remaining 9/10 dose is given & observed for
another hr.
 In pts with past allergic reaction to cephalosporins,
Aztreonam (2mg I.V every 6-8 hrs) can be
given.(exception to those allergic to ceftazidime)

17.  Empirical treatment to CA-MRSA should be given to
hospitalised pts with severe CAP.
 It includes addition of vancomycin (15mg/kg I.V
every 12 hrs). In severly ill pts loading dose of 25-
30 mg/kg is given .
 OR
 Linezolid (600mg I.V every 12 hrs)
 Clindamycin (600mg I.V/oral 3 times daily) can be
given if pathogen is susceptable.
 If sputum culture reveals meticillin suscptible
staphylococcus therapy can be changed to nafcillin
(2gm I.V every 4hrs) or oxacillin (2gm I.V every 4
hrs)

18.  Switch to oral therapy – initially hospitalized pts
are treated intravenously. Oral treatment can be
syarted once pt is hemodynamically stable,improving
clinically,able to take oral medicines & have
normally functioning GIT.

19.  Pts treated with intravenous betalactam &
macrolides have high risk of developing drug
resistant s. pneumoniae(DRSP).
 High dose of amoxicillin ( 1gm orally 3 times daily)
is given instead of I.V beta lactams
 An alternative to pts without risk of DRSP, is to
give macrolide or doxycyclin alone to complete
course.
 Doses for macrolides and doxycyclin is:
Azithromycin : 500mg once daily
Clarithromycin :500mg once daily
Clarithromycin XL :500mg two tablets once daily
Doxycyclin : 100mg twice daily

20.  Duration of therapy :- recommended duration for pts
with good response in first 2-3 days is 5-7 days.
 Before stopping therapy- pt should be afebrile for 48-
72 hrs , breathing without supplement oxygen ,and have
no more than one clinical instability factor (i.e PR >
100bpm RR > 24cpm , systolic BP < 90mmhg)
 Longer treatment is required in cases of :
initial treatment not efficient against subsequent
isolated pathogen
in extrapulmonary infection (meningitis or
endocarditis)
if pt has empyema or lung abscess
pneumonia caused by P.aeruginosa S.aureus legionella
or other unusual pathogens

21.  Procalcitonin can be evaluated for guiding decision
of stopping antibiotic treatment as its level
correlate with likelihood of bacterial infection.
 Follow up chest radiography- x-ray findings clear
more slowly than clinical features.pts responding
clinically do not require follow up x-ray.
 Follow up x-ray is adviced for pts > 50 yrs , males ,
smokers. 7- 12 wks following treatment

22. Treatment failure:-may be due to
 delayed host response despite appropiate
treatment
 infection with organism not covered in initial
antibiotic regimen
 drug resistant organisms
 pt related factors – neoplasia ,aspiration
pneumonia severity of illness, neurologic disease
etc.
 infectious complications – lung abscess, empyema

23.  Further evaluation :
 repeat histroy, x-ray , blood cultures , sputum
cultures ,
 Chest CT
 Broncoscopy
 Lung biopsy

24.  Adjuvant therapy :-
 Glucocorticoids
 Tissue factor pathway inhibitors (Tifacogin –
systemic inhibitor of coagulation)
 Statins – antiinflammatory
 Vaccination - against influenza & pnemococcal
infections.
 Smoking cessation