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1. Pneumonia
SAMIR EL ANSARY

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. 2014.05.18

4. 2014.05.26

5. 2014.10.26

6. 2014.11.02

7. 2014.11.02

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

9. Pathogens
• Bacteria /aerobic,anaerobic, atypical/
• Virus /influenza ,parainfluenza,
adenovirus, herpes virus,cytomegalo virus,
RSV/
• Fungi /Aspergillus,Candida/
• Parasites /Pneumocystis jiroveci,
Toxoplasma gondii,Ascaris lumbricoides/

10. 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

11. Epidemiology of CAP
Mycoplaspa pn.
Chlamydia pn.

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

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

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

15. 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!)

16. • 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)
Clinical features II.

17. 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

18. 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

19. 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

20. Treatment at home or in hospital ?

21. CURB65 score (1-1point)
C Mental confusion
U UN > 7 mM/L
R Respiratory rate > 30/min
B RR<90/60 mmHg
65 Age > 65 years
Mild: 0-1point, 1.5% mortality
Moderate: 2point, 9% mortalility
Severe: 3-5 point, 22% mortalitty

22. “Ten commandments” of CAP treatment
• 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
All Severe

23. 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)

24. Treatment of CAP
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

25. Risk factors of nosocomial pneumonia, HAP

26. Pathogens and treatment of non-severe HAP
‘Core’ pathogens ‘Core’ antibiotics
Gram-neg.
Enterobacteriaceae:
E. coli, Klebsiella spp.,
Proteus spp,
Serratia marcescens,
Enterobacter spp.
‘Usual’ community pa-
thogens:Pneumococcus,
H.influenzae,Staph.aureus
2nd
- or 3 rd- gen
cephalosporins,
beta-lactam/lactamase
inhibitor,
fluoroquinolones

27. Pathogens and treatment of non-severe HAP with
additional risk factors
‘Core’ path.
plus
Risk factor ‘Core’ ant. plus
Anaerobes Surgery, impaired swal-
loing, aspiration, dental
sepsis
clindamycin,beta-
lactam + inhibitor,
moxifloxacin
Staph.aureus Diabetes,renal failure, coma,
head trauma, neurosurgery
add vancomycin if
MRSA susp.
Legionella
spp
High dose steroid, endemic
in hospital
macrolides +-fluo-
roquinolones+- rifam.
Pseuodomonas
aeruginosa
prior ant., high dose ster.
ICU, CF,bronchiectasia
ciprofloxacin,amino-
glycoside,3rd
gen ceph.
with antipseud. act.

28. Pathogens and treatment of severe HAP
‘Core’ pathogens plus ‘Core’ antibiotics
Pseudomonas aeruginosa,
Acinetobacter spp,
MRSA
ciprofloxacin or
aminoglycoside,
plus one of:
antipseudomonal beta-lactam,
meropenem,
vancomycin

29. Reccurent pneumonia (GERD)

30. 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, tachypnea, sticky pink sputum, focal
crackles.

31. Streptococcus pneumoniae
• 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

32. Streptococcus
pneumoniae

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

34. Mycoplasma pneumoniae
(Atypical pneumonia)
• Atypical pathogen, moderate morbidity, low
mortality
• Close communities (schools, barracks,
dormitories)
• Intracellular pathogen (Chlamydia, Legionella)
• Patchy shadowing on X-ray

35. Mycoplasma pneumoniae
(Atypical pneumonia)
• Extrapulmonary manifestations:
lymphadenopathy, cardiac, neurological, skin
lesions, gatrointestinal, haematological,
musculoskeletal
• Treatment: macrolides, tetracyclin,
fluoroquinolones

36. Mycoplasma pneumoniae

37. Legionella
pneumophila

38. 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

39. Staphylococcus
aureus

40. Lung abscess
• 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

41. ABSCESS

42. ABSCESS

43. ABSCESS

44. ABSCESS

45. ABSCESS

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

47. Diff. dg of lung abscess
• Cavitated tumour
• Infected bulla or cyst
• Localised saccular bronchiectatsis
• Aspergilloma
• Wegener’s granulomatosis
• Hydatid cyst

48. Diff. dg of lung abscess
• Coal workres’ pneumoconiosis
- progressive massive fibrosis
- Caplan’s sy
• Cavitated rheumatoid nodule
• Gas-fluid level in oesophagus, stomach or
bowel

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

50. GOOD LUCK
SAMIR EL ANSARY