Pneumonia

1. Pneumonia
Abhishek Achar
Ly Tran

6. Epidemiology
 More than 3 million cases occur annually in US
 Pneumonia is most relevant in winter months
 Incidence of Pneumonia is greater in Males than in females
 Total number of deaths due to pneumonia has been higher in
females since 1980s
 Individuals 65 years and older : Pneumonia and Influenza were
6th leading death in 2005
 Close to 90% of deaths due to pneumonia and influenza occur in
this age group
 Adjusted death rates for females: 17.9 deaths per 100,000
population
 23.9 deaths per 100,000 population for males

17. CAP HAP/VAP
 S. Pneumonia
 M.Pneumonia
 H. Influenza
 C. Pneumonia
 Legionella
 RSV
P.
Aeruginosa
K.
Pneumonia
E.Coli
S.
Marcescens

18. Pneumonia
Diagnosis
Treatment
Prevention

19. Diagnosis
● CAP vs. HCAP
– Community Acquired Pneumonia
● Pneumonia in a patient without extensive healthcare contact.

20. Diagnosis
● CAP vs. HCAP
– Healthcare Associated Pneumonia
● Associated with a higher risk of multidrug resistant bacteria.
● Pneumonia in a patient with extensive healthcare contact
– IV Drug/Chemo therapy within last 30 days
– Attendance at hospital/hemodialysis clinic within last 30 days
– Hospitaliztion for >2 days within last 90 days
– Residence in long term care facility

21. Diagnosis
● Common Clinical Symptoms
– Cough
– Pleuritic Chest Pain
– Dyspnea
– GI Upset
● Common Clinical Signs
– Fever
– Tachychardia
– Crackles in lungs
– Sputum Production
– AMS
Even combined, Signs and
Symptoms have a
sensitivity of <50%

22. Diagnosis
Gold Standard
CXR with presence of infiltrate

23. Diagnosis

24. Diagnosis
● Largely a clinical diagnosis
● Testing
– Outpatient: Optional
– Hospitalized: CBC (Leukocytes), Blood cultures, Sputum
Gram Strain
– Refractory: Legionella UAT, Pneumococcal UAT

25. Diagnosis
● Indications for Hospitalization/ICU
– CURB-65
● Confusion
● Urea (BUN > 20mg/dL)
● Respiratory Rate > 30bpm
● BP Systolic <90; Diastolic <60
● Age >65
– Score >2 – Hospitalization
– Score >3 – Consider ICU

26. Treatment
● Empiric Treatment should be started on ALL
clinically suspected cases.
– Early diagnosis and treatment significantly reduced
Mortality and Length of Stay
● Antimicrobial choice based on:
– Most likely pathogens
– Clinical data
– Risk Factors for resistance
– Comorbidities

27. CAP Treatment
● Empiric Outpatient
– Previously healthy patient
1.Macrolides (A.C.E) OR
2.Doxycycline
– Comorbidities, DM, Alcoholism, Immunosuppression,
Prior ABx use
1.Fluoroquinolones (-floxacins, [Levaquin]) OR
2.Beta-lactam(Amoxicillin/Ceftriaxone) AND Macrolides
● Consider Antipseudomonal for COPD

28. CAP Treatment
● Empiric Inpatient
– Non-ICU
1.Respiratory Fluoroquinolones OR
2.Antipseudomonal Beta-Lactam AND Macrolide
– Ceftriaxone, Cefotaxime; A.C.E.
– ICU
● Antipseudomonal B-Lactam AND Azithromycin
● Antipseudomonal B-Lactam AND Fluoroquinolone
● Fluoroquinolone AND Azetreonam
– MRSA
● Add Vancomycin OR Linezolid

29. CAP Treatment
● Empiric Inpatient
– Discharge appropriate when:
● Stable from pneumonia
● Tolerates PO meds
● No active medical conditions
● Safe environment for discharge
– There is no need for overnight observations when
switching from IV to PO meds.

30. HAP/VAP Treatment
● Empiric Inpatient
– One of the following (Gram Positive coverage):
● Antipseudomonal Cephalosporin: Cefepime, etc.
● Antipseudomonal Cabepenem: Imipenem, etc.
● Pipercillin-Tazobactam
● Penicillin Allergies
– Mild: Simple Graded Challenge
– Severe: Azetreonam

31. HAP/VAP Treatment
● Empiric Inpatient
– PLUS One of the following (B-lactam resistant Gram
Negative coverage):
● Antipseudomonal Fluoroquinolone: Ciprofloxacin
● Aminoglycoside: Gentamycin
– PLUS One of the following (MRSA coverage):
● Linezolid
● Vancomycin
● Telavacin

32. HAP/VAP Treatment
● Targeted Treatment
– MSSA: Naficillin, Oxacillin
– Legionella: Fluoroquinolone
– Anerobes (Aspiration): Clindamycin, Carbapenem

33. Prevention
● Risk Factor Reduction
– Smoking Cessation
– Vaccination
● Influenza
– Yearly, all patients
● Pneumococcal
– Once, Age <65, w/ indications
● Asplenia, Immunocomp., Smoker, Alcoholism, Cochlear Implants,
DM, etc
– Once/Again, Age >65, w/o indication

34. END