pneumonia comunity medicine

1. Pneumonia
Pneumonia
2016
Estabraq
Al−Khursan

2. • Pneumonia is an inflammation of the parenchyma of
the lung.
- Most cases of pneunomin are
caused by microorganism.
- non infectious causes include
aspiration of food or
gastric acid foreign bodies
hydrocarbons and lipoid
substances. hypersensitivity
reaction and drug or radiation
induced pneumonitis.
PNEUMONIA

3. • Classification .
1 : Anatomical classification.
A – lobar pneumonia .
The consolidalion involves all or part of lobe
B – Bronchopneumonia
is infection of the terminal bronchioles that extends into theis infection of the terminal bronchioles that extends into the
surrounding alveoli resulting in patchy consolidation of thesurrounding alveoli resulting in patchy consolidation of the
lung.lung.
C - Interstitial pneumonia .
As in viral pneumonia where inflammatory .
Infiltrate involve mainly interstitial tissue between alveli.
PNEUMONIA

4. PNEUMONIA
o Causes of infectious pneumonia.
1.Bacterial.
Common.
- streptococcus pneumoniae
Group B streptococci
Group A streptococci .
- Mycoplasma pneumoniae
- chlamydia pneumoniae  Adolescent.
- chlamydia trachomatis  infant.
-Mixed anaerobes  Aspiration
pneumonia
- Gram-negative enteric.
2 : Etiological classfication.

5. Uncommon.
- Haemphilus influenza  Unimmunized.
- Staphylococcus aureus
- Moraxella catarrhalis
- Neisseria meningitides
- Francisella tularensis  animal fly contact
- Nocardia species  Immunosuppressed person.
- Chlamydia psittaci  Bird contact.
- Yersinia pestis  Plague
- Legionella species  Exposure to contamianted
water.
PNEUMONIA

6. PNEUMONIA
2-Viral
-Common
Respiratory syncytial virus
Parainflueza type 1 – 3
Influeza A . B
Adenovirus
Metapneumovirus
-Un Common
Rhinovirus
Enterovirus Neonates
Herpes simplex Neontes
Cytomegalovirus Immunosuppressed person.
Measles
Varicella
Hantavirus
Sars agent.
3-Fungal.
Histoplasma capsulatum  Bird
bat contact
Cryptococcus neoformans  Bird
contact.
Aspergillus species 
Immunosuppressed.
Mucomycosis 
Immunosuppressed
4.Rickettsial
Coxiella burnetii  Goat
sheep cattle exposure
Rickettsia rickettsiae

7. PNEUMONIA
5.Mycobacterial
Nycobacterium Tuberculosis  Developed countries
Nycobacterium avium-inteacellulare  Immunosuppressed.
•Parasitic
Pneumocystis Carini  Immunosuppressed. Steroid.
Eosinophilic  Ascaris .
Loeffler syndrom
•Non infectious causes
-Aspiration Of food.
-Gastric acid.
-foreign body.
-Hydrocarbon  Kerosen
-Lipoid substances
- Aspiration of amniotic fluid.

8. PNEUMONIA
Age group Frequent Pathogens
Neonate <1mo Group B straptococcus – E coli
streptococcus Pneumoniae – H influeza.
1-3 mo
febrile Pneu
Rsv . Influenza viruses para fluenza viruses – adenovirus
S. pneumoniae . H . influenza
Afebrile Pneu Chlamydia trachomatis Mycoplasma hominis cytomegalovirus.
3 – 12 mo R.S.V Influenza viruses para fluenza viruses adenovirus
S. pneumoniae H . Influenza Chlamydia trachomatis Mycoplasma
pneumoniae Group A straptococcus
2 – 5 yr Influenza viruses para fluenza viruses adenovirus S. pneumoniae
H . Influenza Mycoplasma pneumoniae Chlamydia pneumoniae
Group A straptococcus S . Aureus.
5 – 18 yr Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae
H . Influenza Influenza viruses adenovirus
> 18 yr Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae
H . Influenza Influenza viruses adenovirus.

9. Community-AcquiredCommunity-Acquired
PneumoniaPneumonia ( CAP )( CAP )
 = pneumonia in person= pneumonia in person
notnot
hospitalized or residing inhospitalized or residing in
a long-term care facilitya long-term care facility
for ≥14 days.for ≥14 days.

10. EtiologyEtiology
 Typical: up to 70%Typical: up to 70%
– Usually caused byUsually caused by StreptococcusStreptococcus
pneumoniaepneumoniae
 Atypical: 30-40%Atypical: 30-40%
– ““MMyy LLungsungs CContainontain VViruses”iruses”
 MMycoplasma pneumoniaeycoplasma pneumoniae
 LLegionella pneumophilaegionella pneumophila
 CChlamydia pneumoniaehlamydia pneumoniae
 VViruses: Influenza, Adenovirusiruses: Influenza, Adenovirus
– May be co-pathogens in other casesMay be co-pathogens in other cases

11. Presentation and pathogens in typicalPresentation and pathogens in typical
community-acquired pneumoniacommunity-acquired pneumonia
 typically presents as acute illness with fever,typically presents as acute illness with fever,
rigors, sweating, vomiting, anorxia & headache.rigors, sweating, vomiting, anorxia & headache.
Pulmonary == cough, sputum, pleuritic chest painPulmonary == cough, sputum, pleuritic chest pain
& confusion.& confusion.
O/E pyrexi, tachycardia, tachypnea, hypotension,O/E pyrexi, tachycardia, tachypnea, hypotension,
after 2 days, the consolidation will appear withafter 2 days, the consolidation will appear with
dull on percussiondull on percussion
& bronchial breathing, whispering pectorilquy& bronchial breathing, whispering pectorilquy
& aegophony. When resolution occur,& aegophony. When resolution occur,
fine crackles & then coarse whichfine crackles & then coarse which
indicate liquefaction of alveolar exudates.indicate liquefaction of alveolar exudates.

12. he clinical presentation of so-calledhe clinical presentation of so-called
“atypical” CAP is often subacute and“atypical” CAP is often subacute and
frequently indolent. In addition, patientsfrequently indolent. In addition, patients
with atypical CAP may present with morewith atypical CAP may present with more
subtle pulmonary findings, nonlobarsubtle pulmonary findings, nonlobar
infiltrates on radiography, and variousinfiltrates on radiography, and various
extrapulmonary manifestations (eg,extrapulmonary manifestations (eg,
diarrhea, otalgia).diarrhea, otalgia).

15. Why Community Acquired PneumoniaWhy Community Acquired Pneumonia
is a Important diseaseis a Important disease

16. Pneumonia is a common illness that affects millions of people
each year in the United States.
Epidemiologic data may provide clues to the specific pathogen
causing CAP, as follows:
The most common overall pathogen is S pne um o niae
Underlying chronic obstructive pulmonary disease (COPD)
: H
.influenzaeor Mcatarrhalis
Recent influenza infection : Staphylo co ccus aure us
Alcoholic patient presenting with “currant jelly” sputum :
Klebsiella pneumoniae.

17. .Streptococcus pneumoniae is the most commonly
isolated
pathogen identified in 20%-60% of cases in adults
with
community-acquired pneumonia. The incidence
peaks in the winter and spring, when carrier rates
in the general population may be as high as 70%. It
is most common in infants, elderly, alcoholic and
immunocompromised Chlamydia pn:Chlamydia pn: (5-15%(5-15%((
Mycoplasma pn:Mycoplasma pn: (9%(9%((
Legionella pneumophilia:Legionella pneumophilia: (5%(.(5%(.
****Haemophilus infleunzae:Haemophilus infleunzae: (3%(.(3%(.
****Staph aureus:Staph aureus: (2-5%((2-5%(
****Chlamydia psittaci:Chlamydia psittaci:(<1%(<1%((.

18. In Iraq
Over 18-month period 485 throat swabs and sputum
samples were taken from patients admitted to Basra
General Hospital, Iraq, with a clinical diagnosis of
pneumonia. Most patients (94.0%) had community-
acquired pneumonia; 29 (6.0%) had hospital-acquired
pneumonia. Patients aged < or = 15 years and males
had the highest incidence of pneumonia. Cases were
analysed by type of pneumonia: bronchial (76.3%)
versus lobar (23.7%), and primary (81.0%) versus
secondary (19.0%). The most common pathogen was
Streptococcus pneumoniae (43.9%) followed by
Mycoplasma pneumoniae (19.4%); a low percentage
were Proteus spp. (1.2%). Twenty patients were
infected with Mycobacterium tuberculosis.
.

19. Specific features of pnSpecific features of pn::
****pneumococcal pneumonia:pneumococcal pneumonia: (30%((30%( caused bycaused by strept. Pneumonia,strept. Pneumonia, rustyrusty
sputum, herpetic features, lobar or multilobar on CXR.sputum, herpetic features, lobar or multilobar on CXR.
****Chlamydia pn:Chlamydia pn: (5-15%( pharyngitis, sinusitis, increase LFT, diagnose(5-15%( pharyngitis, sinusitis, increase LFT, diagnose
serologically, CXR show small segmental infilterates.serologically, CXR show small segmental infilterates.
****Mycoplasma pn:Mycoplasma pn: (9%( insidious onset, few signs on chest with systemic(9%( insidious onset, few signs on chest with systemic
features complicated by myocarditis, pericarditis, meningoencephalitis,features complicated by myocarditis, pericarditis, meningoencephalitis,
hemolytic anemia, stevens johnson syndrom, erythema nodusum & GB.hemolytic anemia, stevens johnson syndrom, erythema nodusum & GB.
CXR lobar consolidation with hilar LAP.CXR lobar consolidation with hilar LAP.
****Legionella pneumophilia:Legionella pneumophilia: (5%( traveler history with systemic symptoms(5%( traveler history with systemic symptoms
like headache, confusion, malaise, myalgia& diarrhea. Hyponatremia,like headache, confusion, malaise, myalgia& diarrhea. Hyponatremia,
hypoalbuminemia, high LFT & CK. CXR consoli slow to resolve.hypoalbuminemia, high LFT & CK. CXR consoli slow to resolve.
****Haemophilus infleunzae:Haemophilus infleunzae: (3%( COPD, Bronchiactasis, CXR bronchopn.(3%( COPD, Bronchiactasis, CXR bronchopn.
****Staph aureus:Staph aureus: (2-5%( may cause osteomyelitis, endocarditis & brain abscess(2-5%( may cause osteomyelitis, endocarditis & brain abscess
CXR cavitation.CXR cavitation.
****Chlamydia psittaci:Chlamydia psittaci:(<1%(contact with bird, hepatosplenomegally , CXR(<1%(contact with bird, hepatosplenomegally , CXR
lower lobe consolidation.lower lobe consolidation.

20. Diagnosis
Clinical diagnosisClinical diagnosis
0 HistoryHistory
0 Signs & symptomsSigns & symptoms
0 Chest x-rayChest x-ray
0 Sputum Gram Stain and cultureSputum Gram Stain and culture
0 Routine lab testing – CBC, BMP,Routine lab testing – CBC, BMP,
LFTs• ABGLFTs• ABG
0 Thoracentesis if pleural effusion presentThoracentesis if pleural effusion present
0 CTCT
Pneumonia

21. Diagnosis: Radiography
0CXR (PA and Lateral):
0 appear within 12-18 h
0 American Thoracic Society (ATS) guidelines,
“all patients with suspected CAP should
have a chest radiograph to establish the
diagnosis and identify complications
(pleural effusions, multilobar disease)”
0 Lobar consolidation – more common in
typical pneumonia
0 Bilateral, diffuse infiltrates – commonly
seen in atypical pneumonia

22. – CT scan could be performed in patients with a negative chest
radiograph when there is a high clinical suspicion for
pneumonia
– CT scan, especially high resolution CT (HRCT), is more
sensitive than plain films for the evaluation of interstitial
disease, bilateral disease, cavitation, empyema, and hilar
adenopathy
Laboratory Tests WBC, sputum cultures, two sets of blood
cultures, and urine antigens.
– Sputum samples are adequate in only 52% of patients with
CAP, and only 44 % of those samples contain pathogens
• Likely due to problems with retrieving samples from lower
respiratory tract, previous antibiotics, contamination from upper
airways, or viral etiology
– Positive blood cultures obtained in only 5-10% of patients,
including those with severe disease
• Positive blood culture has no correlation with severity of illness or
outcome.
• 2 setsis usually requred.

23. )()(Assessement of disease severity:Assessement of disease severity:
hospital CURB-65:hospital CURB-65: *Confusion*Confusion
*Urea > 7 mmol/l*Urea > 7 mmol/l
* RR > 30/M* RR > 30/M
* B Pr <90 or < 60 mmHg* B Pr <90 or < 60 mmHg
*65 years of age*65 years of age
if 0-1 treated at homeif 0-1 treated at home
if 2 consider hospital treatmentif 2 consider hospital treatment
if 3 or > for ICU admission.if 3 or > for ICU admission.
)( features of high mortality:)( features of high mortality:
A- clinical: B- LabA- clinical: B- Lab
*age>60 years, male *Pa O2<8kPa*age>60 years, male *Pa O2<8kPa
*RR > 30 min * WBC < 4000/mm3*RR > 30 min * WBC < 4000/mm3
*Bpr < 90 mmHg, <90 mmHg *WBC > 20 000/mm3*Bpr < 90 mmHg, <90 mmHg *WBC > 20 000/mm3
*confusion *BU > 7 mmol/l*confusion *BU > 7 mmol/l
*multilobar on CXR * positive blood culture*multilobar on CXR * positive blood culture
*underlying diseases * hypoalbuminemia*underlying diseases * hypoalbuminemia

24. )()(management:management:
1-general:1-general:
2- O2:2- O2:
3- Ventilation:3- Ventilation: indications for RCU:indications for RCU:
*CURB score > 3 not respond to treatment*CURB score > 3 not respond to treatment
*persistent hypoxia < 8 kPa despite high conc O2*persistent hypoxia < 8 kPa despite high conc O2
*progressive hypercapnea*progressive hypercapnea
*severe acidosis*severe acidosis
*shock*shock
*depressed conciousness*depressed conciousness
4- fluid balance:4- fluid balance:
5- antibiotic treatment:5- antibiotic treatment:
*uncomplicated pn 7-10 days, but 14 days*uncomplicated pn 7-10 days, but 14 days
for Legionella, or Klebseillafor Legionella, or Klebseilla
*oral Ab are adequate unless has severe illness, impaired conc, loss*oral Ab are adequate unless has severe illness, impaired conc, loss
swallowing reflex or malabsorptionswallowing reflex or malabsorption..

25. Uncomplicated CAP
• Amoxicillin 500 mg 8-hourly orally
• If patient is allergic to penicillin
– Clarithromycin 500 mg 12-hourly orally or
– Erythromycin 500 mg 6-hourly orally
• If Staphylococcus is cultured or suspected
– Flucloxacillin 1-2 g 6-hourly i.v. plus
– Clarithromycin 500 mg 12-hourly i.v.
• If Mycoplasma or Legionella is suspected
– Clarithromycin 500 mg 12-hourly orally or i.v. or
– Erythromycin 500 mg 6-hourly orally or i.v. plus
– Rifampicin 600 mg 12-hourly i.v. in severe cases.
– if chlamydia: tetracycline or erythromycine.
– if H. infleunzae: ampicillin plus 3rd
generation cephalosporin.
– if Klebsialla: cephalosporin plus fluoroquinolone or aminoglycoside.

26. Severe CAP
• Clarithromycin 500 mg 12-hourly i.v. o
• Erythromycin 500 mg 6-hourly i.v. plus
• Co-amoxiclav 1.2 g 8-hourly i.v. or
• Ceftriaxone 1-2 g daily i.v. or
• Cefuroxime 1.5 g 8-hourly i.v. or
• Amoxicillin 1 g 6-hourly i.v. plus flucloxacillin 2
g 6-hourly i.v.

27. Duration of TherapyDuration of Therapy
 5 -7 days - outpatients5 -7 days - outpatients
 7-10 days – inpatients, S. pneumoniae7-10 days – inpatients, S. pneumoniae
 10-14 days – Mycoplasma, Chlamydia,10-14 days – Mycoplasma, Chlamydia,
Legionella.Legionella.
 14+ days - chronic steroid users14+ days - chronic steroid users

28. Response to treatment:
Patient with uncomplicated bacterial pneumonia respond to therapy with
improvement in clinical symptom )fever, cough, tachypnea, chest pain( within
48-96 hrs.
 The chest radiograph usually cleared within four weeks in patients
younger than 50 years of age without underlying pulmonary disease.
failure to respond to therapy may indicate:
1- wrong AB 2- mixed infection 3- bronchial obstruction
4- wrong diagnosis 5- complications as follow:
* para-pneumonic effusion *empyma *lobar collapse
*thromboembolic disease *pneumothorax *lung abcess
*ARDS, renal failure, multi-organ failure *ectopic abcess
*hepatitis, pericarditis, myocarditis, meningoencephalitis.

29. Discharge & Follow-up:
@ discharge depend on no more than one of the followings:
1- RR > 24/m 2- systolic Bpr < 90 mmHg 3- Sa O2< 90%.
4- inability to intake oral 5- abnormal mental state
)( Prevention:
1- influenza vaccine: )yearly( for:
elderly, chronic lung or heart diseases, DM, AIDS, health
care worker, sickle cell diseases.
2- polyvalent Pneumococcal poly saccharide vaccine: )5
years( for:
elderly, chronic heart or lung diseases, sickle cell diseases,
asplenic patients, Hodgkin disease, multiple myloma,
cirrhosis, DM, AIDS.

30. Community Acquired Pneumonia andCommunity Acquired Pneumonia and
Vaccination for PneumococcalVaccination for Pneumococcal
infectioninfection
 The pneumococcal vaccineThe pneumococcal vaccine
(the ‘pneumonia shot’) protects(the ‘pneumonia shot’) protects
against 23 types ofagainst 23 types of
pneumococcal bacteria.pneumococcal bacteria.
 Research proves the vaccineResearch proves the vaccine
is not 100% effective inis not 100% effective in
preventing pneumonia, butpreventing pneumonia, but
found that if you arefound that if you are
vaccinated you are less likelyvaccinated you are less likely
to die from pneumonia.to die from pneumonia.

31. Preventing InfluenzaePreventing Influenzae
 According to the U.S.According to the U.S.
Centers for DiseaseCenters for Disease
Control and PreventionControl and Prevention
(CDC), anyone who(CDC), anyone who
wants to reduce their riskwants to reduce their risk
of getting the flu shouldof getting the flu should
have a flu vaccine.have a flu vaccine.
 Older children and adultsOlder children and adults
require only a single shotrequire only a single shot
each year. However,each year. However,
children under age 9 maychildren under age 9 may
need two dosesneed two doses

32. WHO responseWHO response
 The WHO and UNICEF integrated Global action plan for pneumoniaThe WHO and UNICEF integrated Global action plan for pneumonia
and diarrhoea (GAPPD) aims to accelerate pneumonia control withand diarrhoea (GAPPD) aims to accelerate pneumonia control with
a combination of interventions to protect, prevent, and treata combination of interventions to protect, prevent, and treat
pneumonia in children with actions to:pneumonia in children with actions to:
 protectprotect children from pneumonia including promoting exclusive children from pneumonia including promoting exclusive
breastfeeding and adequate complementary feeding;breastfeeding and adequate complementary feeding;
 preventprevent pneumonia with vaccinations, hand washing with soap, pneumonia with vaccinations, hand washing with soap,
reducing household air pollution, HIV prevention and cotrimoxazolereducing household air pollution, HIV prevention and cotrimoxazole
prophylaxis for HIV-infected and exposed children;prophylaxis for HIV-infected and exposed children;
 treattreat pneumonia focusing on making sure that every sick child has pneumonia focusing on making sure that every sick child has
access to the right kind of care -- either from a community-basedaccess to the right kind of care -- either from a community-based
health worker, or in a health facility if the disease is severe -- andhealth worker, or in a health facility if the disease is severe -- and
can get the antibiotics and oxygen they need to get well;can get the antibiotics and oxygen they need to get well;

33. General Health MeasuresGeneral Health Measures
 Smoking cessation isSmoking cessation is
important not only forimportant not only for
treatment of anytreatment of any
underlying lung disease,underlying lung disease,
but alsobut also
because because cigarettecigarette
smoke interferes withsmoke interferes with
many of the body'smany of the body's
natural defencesnatural defences
against CAP.against CAP.

34. Future goals on reducing childFuture goals on reducing child
deathsdeaths –– 2015 by2015 by Hand washingHand washing
 Handwashing withHandwashing with
soapsoap is among the most is among the most
effective and inexpensiveeffective and inexpensive
ways to prevent diarrhealways to prevent diarrheal
diseases anddiseases and
pneumonia,pneumonia, whichwhich
together are responsibletogether are responsible
for the majority of childfor the majority of child
deaths. deaths.

35. Viral pneumonia:Viral pneumonia:
() causes: influenza, parainfleunza, measles, RSV, varicella, CMV.() causes: influenza, parainfleunza, measles, RSV, varicella, CMV.
() risk factors:() risk factors:
*old age & children*old age & children
*chronic disease of the heart, lung or kidney*chronic disease of the heart, lung or kidney
*women in the last trimester of pregnancy.*women in the last trimester of pregnancy.
() clinical features:() clinical features:
*dry cough, dyspnea & malaise.*dry cough, dyspnea & malaise.
*unremarkable physical examination*unremarkable physical examination
*CXR= interstitial pattern*CXR= interstitial pattern
()complication: influenza-induced necrosis()complication: influenza-induced necrosis
of resp epithelium predisposes to bacterialof resp epithelium predisposes to bacterial
colonization, like strep. Pneumoniacolonization, like strep. Pneumonia
or staph. Aureus.or staph. Aureus.

36. Pneumocystis CariniiPneumocystis Carinii
//Pneumocystis jiroveciPneumocystis jiroveci11
PneumoniaPneumonia
(PCP)(PCP) Uncommon until 1980’s with emergence of HIV diseaseUncommon until 1980’s with emergence of HIV disease
 Caused by organism most closely related to fungiCaused by organism most closely related to fungi
 Mode of transmission unclear, but felt to representMode of transmission unclear, but felt to represent
reactivation of latent infectionreactivation of latent infection

37. PCP PneumoniaPCP Pneumonia
 Gradual onset of symptomsGradual onset of symptoms
 Common symptoms include fever, cough,Common symptoms include fever, cough,
progressive dyspneaprogressive dyspnea
 Many patients asymptomaticMany patients asymptomatic
 May present as a spontaneousMay present as a spontaneous
pneumothoraxpneumothorax

38. PCP – Lab WorkPCP – Lab Work
 CD4 <200CD4 <200
 LDHLDH
– Elevated in HIV+ persons w/ PCPElevated in HIV+ persons w/ PCP
– Very high values and increasing levels in face ofVery high values and increasing levels in face of
therapy correlate w/ poorer prognosistherapy correlate w/ poorer prognosis
 ABGABG
– PaO2 <70 indication for steroidsPaO2 <70 indication for steroids
 Lung samplingLung sampling
– Definitive diagnosis dependent on isolation ofDefinitive diagnosis dependent on isolation of
PneumocystisPneumocystis

39. PCP - TreatmentPCP - Treatment
 TMP/SMX (trimethoprim/sulfamethoxazole)TMP/SMX (trimethoprim/sulfamethoxazole)
– Drug of choiceDrug of choice
– High incidence of side effects in HIV+ ptsHigh incidence of side effects in HIV+ pts
 Dapsone + TMPDapsone + TMP
 Clindamycin + primaquineClindamycin + primaquine
 AtovaquoneAtovaquone
 Pentamadine IVPentamadine IV
ProphylaxisProphylaxis
 TMP/SMX* – DS 3x/wk or SS qdTMP/SMX* – DS 3x/wk or SS qd
 Dapsone +/- pyrimethamine*Dapsone +/- pyrimethamine*
 Aerosolozed pentamadineAerosolozed pentamadine
 AtovaquoneAtovaquone
*= also prophylaxis for*= also prophylaxis for ToxoplamaToxoplama

40. THANKS ALOT