Pneumonia

1. Pneumonia

2. Definition
• Pneumonia is an acute
infection of the
parenchyma of the
lung, caused by bacteria,
fungi, virus, parasite etc.
• Pneumonia may also be
caused by other factors
including X-ray,
chemical, allergen

3. Epidemiology
The morbidity and mortality of pneumonia
are high especially in old people.

4. Etiology
There are two factors
involved in the
formation of
pneumonia , including
pathogens and host
defenses.

5. Sponsored
Medical Lecture Notes – All Subjects
USMLE Exam (America) – Practice

7. Classification
Classification of anatomy
Classification of pathogen
Classification of acquired environment

8. Ⅰ.Classification by pathogen
Pathogen classification is the most useful
to treat the patients by choosing effective
antimicrobial agents

9. Bacterial pneumonia
(1) Aerobic Gram-positive bacteria,such
as streptococcus pneumoniae, staphy-
lococcus aureus, Group A hemolytic
streptococci
(2) Aerobic Gram-negative bacteria, such
as klebsiella pneumoniae, Hemophilus
influenzae, Escherichia coli
(3) Anaerobic bacteria

10. Atypical pneumonia
Including Legionnaies pneumonia ,
Mycoplasmal pneumonia ,chlamydia pneumonia.

11. Fungal pneumonia
Fungal pneumonia is commonly caused by
candida and aspergilosis
pneumocystis jiroveci

12. Viral pneumonia
Viral pneumonia may be caused by
adenoviruses, respiratory syncytial
virus, influenza, cytomegalovirus,
herpes simplex

13. Pneumonia caused by
other pathogen
Rickettsias (a fever rickettsia),
parasites
protozoa

14. Ⅱ.Classification by anatomy
1. Lobar: Involvement of an entire lobe
2. Lobular: Involvement of parts of the lobe
only, segmental or of alveoli contiguous to
bronchi (bronchopneumonia).
3. Interstitial

15. Lobar pneumonia

16. Lobular pneumonia

17. Interstitial pneumonia

18. Classification by acquired
environment
Community acquired pneumonia ， CAP
Hospital acquired pneumonia ， HAP ，
NP
Nursing home acquired pneumonia, NHAP
Immunocompromised host pneumonia,
(ICAP)

19. Diagnosis
Give a definite diagnosis of pneumonia
To evaluate the degree of the pneumonia
To definite the pathogen of the pneumonia

20. Diagnosis
History and physical examination
X-ray examination
Pathogen identification

21. Differentiation
Pulmonary tuberculosis
Lung cancer
Acute lung abscess
Pulmonary embolism
Noninfectious pulmonary infiltration

22. Pathogen identification
Sputum: More than 25 white blood cells
(WBCs) and less than 10 epithelial cells.
Nasotracheal suctioning
BAL, ETA, PSB, LA
Blood culture or pleural effusion culture
Serologic testing (immunological testing)
Molecular Techniques

23. The principal of therapy
Select antibiotics
According to guideline

24. Therapy
The therapy should always follow
confirmation of the diagnosis of pneumonia
and should always be accompanied by a
diligent effort to identify an etiologic agent.
Empiric therapy,(4-8h)
Combined empiric therapy to target therapy

25. It is important to evaluate the
severity degree of pneumonia
The critical management decision is
whether the patient will require hospital
admission. It is based on patient
characteristics, comorbid illness, physical
examinations, and basic laboratory findings.

26. The diagnostic standard of sever
pneumonia
Altered mental status
Pa02<60mmHg. PaO2/FiO2<300, needing MV
Respiratory rate>30/min
Blood pressure<90/60mmHg
Chest X-ray shows that bilateral infiltration,
multilobar infiltration and the infiltrations enlarge
more than 50% within 48h.
Renal function: U<20ml/h, and <80ml/4h

27. Community acquired pneumonia
CAP refers to pneumonia acquired outside of
hospitals or extended-care facilities .
Streptococcus pneumoniae remains the most
commonly identified pathogen.
Other pathogens include Haemophilus influenzae,
mycoplasma pneumoniae, Chlamydophilia
pneumoniae, Moraxella catarrhalis and ects.
Drug resistance streptococcus pneumoniae(DRSP)

28. Clinical manifestation
The onset is acute
Respiratory symptoms
Extrapulmonary symptoms

29. signs
Consolidation signs
Moist rales
Respiratory rate or heart rate

30. Laboratory examination
WBC
X-ray features

31. Diagnosis
Clinical diagnosis
Pathogen diagnosis
Evaluate the severity degree of pneumonia

32. Therapy
Antiinfectious therapy (Combined empiric
therapy to target therapy)
Supportive therapy

33. Empiric therapy (1)
Outpatient<60 years
old and no comorbid
diseases
Common pathogens:
S pneumoniaes,
M pneumoniae,
C pneumoniae,
H influenzae and
viruses
A new generation
macrolide
A beta-lactam: the first
generation
cephlosporin
A fluoroquinolone

34. Empiric therapy (2)
Outpatient>65 years old
or having comorbid
diseases or antibiotic
therapy within last 3
months
Common pathogens: S
pneumoniae(drug-
resistant), M pneumoniae,
C pneumoniae, H
pneumoniae, H
influenzae, Viruses,
Gram-negative bacilli and
S aureus
A fluoroquinolone
A beta-lactam / beta-
lactamase inhibitor
The second generation
cephalosporin
or combination of a
macrolide

35. Empiric therapy (3)
Inpatient : Not
severely ill.
Common pathogen:S
pneumoniae, H
influenzae,
polymicrobial,
Anaerobes, S aureus,
C pneumoniae, Gram-
negative bacilli.
The second or third
generation
cephalosporin plus A
macrolide
A beta-
lactam/betalactamase
inhibitor.
A newer
fluoroquinolone

36. Empiric therapy (4)
Inpatient severely ill
Common pathogens:S
pneumoniae, Gram-
negative bacilli, M
pneumoniae, S aureus and
viruses
The second or third
generation cephalosporin
plus A macrolide
A beta-
lactam/betalactamase
inhibitor.
A newer fluoroquinolone
Vancomycin

37. Empiric therapy (5)
Patients in ICU without
Pneudomonas aeruginosa
infection
The second or third
generation cephalosporin
plus A macrolide
A beta-
lactam/betalactamase
inhibitor.
A newer fluoroquinolone
Vancomycin

38. Empiric therapy (6)
Patients in ICU with
Pneudomonas
aeruginosa infection
A antipneudomonas
aeruginosa beta-
lactam/betalactamase
inhibitor plus
fluoroquinolone

39. HAP （ Hospital acquired
pneumonia ）
HAP refers to pneumonia acquired in the
hospital setting.
Enteric Gram-negative organisms, S.
aureus, Pneudomonas aeruginosa, ects.

40. The pathogen of HAP
 Gram-negative bacteria (GNB) account for
55% to 85% of HAP infections
 gram-positive cocci account for 20% to
30% and some other pathogens.

41. EPIDEMIOLOGY
General risk factors for developing
HAP include age more than 70
years, serious comorbidities,
malnutrition, impaired
consciousness, prolonged
hospitalization, and chronic
obstructive pulmonary diseases.

42. EPIDEMIOLOGY
HAP is the most common infection occurring in
patients requiring care in an intensive care unit
(ICU), with incidence rates ranging from 6% up to
52%, much higher than the 0.5% to 2% incidence
reported for hospitalized patients as a whole.
This increased incidence is due to the fact that
patients located in an ICU often require
mechanical ventilation, and mechanically
ventilated patients are 6 to 21 times more likely to
develop HAP than are nonventilated patients.
Mechanical ventilation is associated

43. PATHOGENESIS
Aspiration :Microaspiration of
contaminated oropharyngeal secretions
seems to be the most important of these
factors, as it is the most common cause of
HAP.
Inhalation
Contamination

44. Clinical manifestations
The onset is acute or insidious
Respiratory symptoms
Physical signs

45. Laboratory examinations
Chest X-ray

46. diagnosis
Clinical diagnosis
Pathogen diagnosis
Evaluate the severity degree of pneumonia

47. Treatment (1)
Antibiotic therapy: antimicrobial therapy begin
promptly because delays in administration of
antibiotics have been associated with worse
outcomes.
The initial selection of an antimicrobial agent is
almost always made on an empiric basis and is
based on factors such as severity of infection,
patient-specific risk factors, and total number of
days in hospital before onset.

48. Treatment (2)
All empiric treatment regimens should
include coverage for a group of core
organisms that includes aerobic gram
negative bacilli (Enterobacter spp,
Escherichia coli, Klebsiella spp, Proteus
spp, Serratia marcescens, and Hemophilus
influenzae) and gram-positive organisms
such as Streptococcus pneumoniae and
Staphylococcus aureus.

49. Treatment (3)
In patients with mild or moderate infections and
no specific risk factors for resistant or unusual
pathogens, monotherapy with a second-generation
cephalosporin such as cefuroxime; a
nonpseudomonal third-generation cephalosporin
such as ceftriaxone; or a beta-lactam/beta-
lactamase inhibitor such as ampicillin/sulbactam,
ticarcillin/clavulanate, or piperacillin/tazobactam
may be appropriate.
For patients in this low-risk category who have an
allergy to penicillin, it is appropriate to initially
use a fluoroquinolone

50. Treatment (4)
Patients with severe infections with specific risk factors
should have broadened empiric coverage.
Combination therapy should be employed in these cases
because of the high rate of acquired resistance among these
organisms.
Appropriate combinations for this group of patients
include an aminoglycoside or ciprofloxacin in addition to a
beta-lactam with antipseudomonal coverage.
Additionally, vancomycin should be considered if the
patient has risk factors that suggest methicillin-resistant
Staphylococcus aureus could be a pathogen.

51. Prevention
Release aspiration
Washing hands
vaccination

52. ICHP (Nursing home acquired
pneumonia)
Pneumonia in an immunocompromised host
describes a lung infection that occurs in
a person whose ability to fight infection is
greatly impaired.
(Non-HIV-ICH)

53. Causes, incidence, and risk factors
Immunosuppression can be caused by HIV
infection, leukemia, organ transplantation,
bone marrow transplant, and medications to
treat cancer.
Microorganisms include all kinds of
bacteria and virus (CMV), candida and
aspergilosis,
pneumocystis carinii （ PCP ）

54. Symptoms
The onset is incidous , but clinical
Symptoms are severe.
Fever
Nonproductive (dry) cough or cough with
mucus-like, greenish, or pus-like sputum
PCP
Fungal infection

55. Diagnosis
Earlier finding and diagnosis
Pathogen diagnosis
Chest x-ray
Sputum gram stain, other special stains, and
culture
Arterial blood gases
Bronchoscopy
Chest CT scan,
Tissue diagnosis

56. Treatment
Antimicroorganism therapy
The goal of treatment is to get rid of the infection
with antibiotics or antifungal agents. The specific
drug used will depend on what kind of organism
is causing the problem. One drug may kill one
type of organism, but not another.
Respiratory treatments (to remove fluid and
mucus) and oxygen therapy are often needed.

57. Pneumococcal pneumonia

58. Abstraction
• Pneumococcal
pneumonia is produced
by streptococcal
pneumoniae
• It is the most commonly
occurring bacterial
pneumonia

59. Etiology
• Streptococcus pneumonia
are encapsulated,
gram-positive cocci that
occur in chains or
pairs
• The capsule which is a
complex polysaccharide
has specific antigenicity
• Type 3 is the most virulent,
usually causing
severe pneumonia in adults,
but type 6,14,19
and 23 are virulents is
children

60. Bacteria are introduced into the lungs
by the four routes
Source Route Response Outcome
colonization aspiration
Air inhalation
Non-pulmonary blood lung pneu.
infection stream defenses
Contiguous direct
infection extention

61. pathogenesis
Pneumococci usually
reach the lungs by
inhalation or
aspiration. They lodge
in the bronchioles,
proliferation and
initiate an
inflammatory process.

62. Pathology
Congestion
red hepatization
grey hepatization
resolution)

63. Pathology
Red hepatilization

64. ◆ All of the four main stages of the inflammatory
reaction described above may be present at the
same time
◆ In most cases, recovery is complete with
restoration of normal pulmonary anatomy

65. Clinical manifestations

66. Clinical manifestations (1)
• Many patients have had an upper respiratory
infection for several days before the onset of
pneumonia
• Onset usually is sudden, half cases with a
shaking chill
• The temperature rises during the first few
hours to 39-40℃

67. Clinical manifestations (2)
Typically, patients have the symptoms of
high fever , shaking chill, sharp chest
pain, cough, dyspnea and blood-flecked
sputum.
But in some cases, especially those at age
extremes symptoms may be more
insidious.

68. • The pulse accelerates
• Sharp pain in the involved hemi thorax
• The cough is initially dry with pinkish or
blood-flecked sputum
• Gastrointestinal symptoms such as,
anorexia, nausea, vomiting abdominal
pain, diarrhea may be mistaken as acute
abdominal inflammation
Clinical manifestations (3)

69. Signs 1
• The acutely ill patient is tachypneic, and
may be observed to use accessory muscles
for respiration, and even to exhibit nasal
flaring
• Fever and tachycardia are present, frank
shock is unusual, except in the later stages
of infection or DIC

70. Signs 2
• Auscultation of the chest reveals
bronchovesicular or tubular breath
sounds and wet rales over the
involved lung
• A consolidation occurs, vocal and
tactile fremitus are increased

71. Laboratory examinations

72. Laboratory examinations (1)
• The peripheral white blood cell (WBC) count
• Before using antibiotic, the culture of blood and
of expectorated purulent sputum between 24-48
hours can be used to identify pneumococci
• Colony counts of bacteria from bronchoalveolar
lavage washings obtained during endoscopy are
seldom available early in the course of illness
• Use of the PCR may amplify pneumococcal
DNA and improve potential for detection

73. X-ray examination
• Chest radiographs is more sensitive than
physical examination
• PA and lateral chest radiographs are
invaluable to detect pneumonia

74. X-ray examination
• Usually lobar or
segmental
consolidation
suggests a bacterial
cause for pneumonia
• If blunting of the
costophrenic angle is
noted, pleural
effusion may be exist.

75. The features of CT
Air-bronchogram sign

76. Complications
In 5% to 10% of patients, infection may extend into the pleural
space and result in an empyema
In 15% to 20% of patients, bacteria may enter
the blood stream (bacteremia) via the lymphatics
and thoracic dust.
Invasion of the blood stream by pneumococci
may lead to serious metastatic disease at a
number of extra pulmonary sites (meningitis,
arthritis, pericarditis, endocarditis, peritonitis,
ostitis media etc).

77. Complications
sepsis
lung abscess or empyema
pleural effusion
pleuritis
ARDS
ARF
pneumothorax
Extrapulmonary infections

78. Diagnosis
According to history, the clinical signs ,
physical examinations, laboratory
examinations and radiographic features
it is not difficult to make the diagnosis

79. Differential diagnosis
• pulmonary tuberculosis
• Other microbial pneumonias:
klebsiella pneumonia,
staphylococal pneumonia,
pneumonias due to G (-) bacilli,
viral and mycoplasmal
• Acute lung abscess
• Bronchogenic carcinoma
• Pulmomary infarction

80. Treatments
Antibiotics
Support therapy
Therapy of complications

81. Antibiotic therapy (1)
• All patients with suspected pneumococcal
pneumonia should be treated as promptly as
possible with penicillin G
• The dose and route of delivery may have to
be on the basis of patients status adverse rea-
ction or complication that occur

82. • For patients who are believed to be allergic to
penicillin, one may select the first or second
generation cephalosporin or advanced
macrolide+ β -lactam or respiratory
fluoroquinolone alone.
For patients with PRSP, one may select the
second and third generation cephalosporin or
advanced macrolide+ β -lactam or respiratory
fluoroquinolone alone.
In some cases, vancomycin may be used.
Antibiotic therapy (2)

83. Antibiotic therapy
• Treatment with any effective agent
should be given for at least 5 to 7 day or
after the patients have been afebrile for
2-3 days

84. Supportive measure
Supportive measure are generally used in
the initial management of acute pneumo-
coccal pneumonia, such measures include
• Bed rest
• Monitoring vital signs and urine output
• Administering an occasional analgesic to
relieve pleuritic pain
• Replacing fluids, if the patient is dehydrated
• Correcting electrolytes
• Oxygen therapy

85. Treatment of complications
• Empyema develops in appoximately 5% of patients
with pneumococcal pneumonia, although pleural
effusion commonly develop in 10%- 20% patients
• Chest X-ray with lateral decubitus films are often
useful in the early recognition of pleural effusion,
pleural fluid that is removed should be subjected to
routing examination
• If pneumococcal bacteremia occurs, extra pulmonary
complications such as arthritis, endocarditis must be
excluded, because the therapy requires higher dosages
• Treatment of infections shock

86. Prognosis
Prognosis is much better
Any of the following factors makes the prognosis
less favorable and convalescence more prolonged
elderly:
• involvement of 2 or more lobes
• underlying chronic diseases (heart lung
kidney) normal temperature and WBC
count <5000
• immunodeficiency with severe complication

87. Prevention
The most important
preventive tool available
is using a poly valent
pneumococcal vaccine
in those with chronic
lung diseases, chronic
liver diseases,
splenectomy, diabetes
mellitus
and aged

88. Staphylococcus pneumonia
• Staphylococcal
pneumonia is usually
caused by
staphylococcus aureus
• It is often a complication
of influenza, but may be
primary, particularly in
infants and the aged
•

89. It occurs in immunocompromissed patients such as
diabetes mellitus
hematologic disease ( leukemia, lymphoma,
leukopenia )
AIDS, liver disease, malnutrition, alcoholism
• Staphylococcal bacteremia complicating infections
at
other sites (furuncles, carbuncles) may cause
hematogenous pulmonary involvement (due to
blood
spread)

90. • Some or all of the symptoms of pneumococcal
pneumonia (high fever, shaking chill, pleural pain,
productive cough) may be present, sputum may be
copious and salmon-colored
• Prostration is often marked
• According the symptoms, signs of pneumonia,
leukocytosis and a positive sputum or blood
culture, the diagnosis can be made

91. • Gram stain of the
sputum provides earliest
diagnostic clue
• Chest X-ray early in
the disease shows
many small round
areas of densities that
enlarge and coalesce
to from abscess, and
leave evidence of
multiple cavities

92. • Until the sensitivity results are know, a
penicillinase–resistant penicillin or a
cephalosporin should be given
• Therapy is continued for 2 weeks after
the patient has become afebrile and the
lungs have shown signs of clearing
• Vancomycin is the drug of choice for
patients allergic to penicillin and cepha-
losporin and for those not responding to
other antistaphylococcal drugs, mainly used
in MRSA.

93. Pneumonia caused by klebsiella
Klebsiella pneumonia ( also named Friedlander
pneumonia) is an acute lung infection, caused by
Klebsiella pneumoniae 1, it occurs much more in
aged, malnutrition, chronic alcoholism, and in
whom with bronchial pulmonary disease

94. • This pneumonia is most likely to be found in
man with middle age, onset usually is sudden,
with high fever, cough, pleuritic pain, abundant
sputum, cyanosis, tachycardia my be present,
half cases with a shaking chill
• Shock appears in early stage

95. • Clinical manifestations are similar to sever
pneumococcal pneumonia
• The sputum is viscid and “ropy”, and may be
“brick red” in color
• Chest X-ray shows a downward curve of the
horizontal interlobar fissure, if the right
upper lobe is involved
• Areas of increased radiance whithin dense
consolidation suggest cavitation
• It constitutes 2% of bacterial pneumonia,
but mortality may be as high as 30%

96. • When an elderly patient suffered from acute
pneumonia with sever toxic symptom, viscid
and “brick red”, sputum must consider this
disease
• The diagnosis is determined by bacterial
examination of sputum
• Early using antimicrobial therapy is im-
portant for patients with survivable ill-
illnesses, aminoglycoside (Kanamycin, Amikacin,
Gentamycin ) and the third generation
cephalosporin are often used.

97. Mycoplasmal pneumonia
• Mycoplasmal pneumonia is
caused by Mycoplasmal
pneumoniae
• Mycoplasmal pneumoniae
is one of the smallest
organisms 125-150 μm
capable of replication in
cell-free media
• Infection is spread form
person to person by
respiratory secretions
expelled during bouts of
coughing, causing epidemic

98. • It commonly occurs in children, adolescent, mainly
in fall and winter
• It constitutes more than 1/3 of non bacterial
pneumonias, or 10% of pneumonias from all cause
• Cellular infiltrate around bronchioles, and in
alveolar interstitium, consists mostly of mono-
nuclear elements

99. Clinical findings
• The illness begins insidiously with
constitutional
symptomatology:
malaise, sore throat, cough, fever,
myalgia
• Half of cases have no symptom
•

100. Chest X-ray
Chest X-ray findings are
manifold
• Most patients have
unilateral lower lobe
segmental abnormalities
• The earliest signs are an
interstitial accentuation
of marking with
subsequent patch air space
consolidation and thickened
bronchial shadows

101. • The pneumonia may persist for 3-4 weeks
a slight leukocytosis is seen, with a normal
differential count
• The diagnosis is generally proved by a single
antibody titer of 1:32 or greater, a titer of
cold agglutinins of 1:32 or greater a single
Ig M determination
• The most promising in terms of speed,
sensitivity and specificity is PCR although
cost and lack of general availability limit its
routine use

102. Therapy
A definite clinical response
is seen to erythromycin and some
other newer macrolide

103. Legionnaies Pneumonia
Legionella can be an opportunistic
pathogen.
Patients with immunosuppression are at
increased risk for infection. But
sometimes outbreaks do occur in
previously healthy individuals.

104. Legionellae are small,
gram-negative,
obligately aerobic baclli.
.

105. Legionnaires’ disease is acquried
by inhaling aerosolized water
containing Legionella
organisms or possibly by
pulmonary aspiration of
contaminated water.
The contaminated water are
derived from humidifiers,
shower heads, respiratory
therapy equipment, industrail
cooling water.
Because of the frequently use of
air conditioner, Legionnaies
pneumonia is also seen in
CAP

106. Clinical manifestations
The onset of L.pneumonia is sometimes
severe.
High fever, rigors, and significant
hypoxemia are usually seen in patients
with L.pneumonia.
Failure to rapidly appropriate therapy in
these cases is likely to result in a poor
outcome.

107. Common signs include cough, dyspnea,
pleuritic chest pain, gastrointestinal
symptoms, especially diarrhea or
localized abdominal pain, nausea,
vomitting are a prominent finding in
20% to 40% of patients with
L.pneumonia.

108. Physical examination
Physical finding are often similar to
other pneumonias.
Rales are usually present over involved
areas
Pulse rate is not coincide to the body
temperate.

109. Chest X-ray
No diagnostic features on
the chest X-ray
distinguish it from other
pneumonia
Infiltrates can be
unilateral, bilateral,
patchy, or dense, and can
spread very quickly to
involve the entire lung,
pleural effusion, usually
small in volume occurs
Routine laboratory tests
also are nonspecific.

110. Laboratory examination
Serologic testing is the most often used
for establishing a diagnosis.
A fourfold or greater rise in antibody is
considered definitively exist for
Legionella.

111. Diagnosis
According to history, clinical signs, X-ray
features and serologic testing, we can
diagnose it.

112. Therapy
Erythromycin is considered the drug of
choice.It should be given until clinical
improvement is seen.It usually lasts 2-3
weeks.

113. Candidiasis
Candidiasis is an opportunistic disease, it is
caused by candida.

114. Clinical signs
Respiratory signs: fever,cough, sputum
production, dyspnea.
X-ray shows no specific.It is similar to
acute pneumonia.

115. diagnosis
Mainly according to sputum culture or
biopsy of lung.

116. Therapy
Nystatin or various azole drugs

117. Aspergillosis
Aspergillosis refers to infection with any of
species of the genus Aspergillus

118. Clinical signs
The disease generally occurs in
immunosuppressed and anticancer
therapy patients.
There are four types of pulmonary
aspergillosis.

119. Clinical signs of Pulmonary
aspergillosis
Presents as chronic productive cough,
hemoptysis, dyspnea, weight loss, fatigue, chest
pain, or fever
Sometimes patients with pulmonary
aspergillosis accompany with prior chronic
lung disease.
Typical picture of an aspergilloma is a fungus
ball in a cavity in an upper lobe
The sputum culture is positive in most patients.

120. Diagnosis
The repeated isolation of Aspergillus
from sputum or the demonstration of
hyphae in sputum or BALF suggests
endobronchial infection.

121. Treatment
With intravenous amphotericin B (1.0 to
1.5 mg/kg daily)
Patients with severe hemoptysis due to
fungus ball of lung may benefit from
lobectomy

122. Therapy to Infectious Shock
Treatment in intensive care units
cardiac rhythm, blood pressure, cardiac performance, oxygen
delivery, and metabolic derangements can be monitored
Adequate oxygenation and ventilatory support
(sometimes mechanical ventilation)
Effective antibiotic therapy
Maintain blood pressure, including maintain
circulation blood volume, use of dopamine