community acquired pneumonia in pregnancy

management of pneumonia in pregnancy

1. PNEUMONIA Infection of the lungs is a leading cause of death in the United States Pneumonia is fortunately a rare complication of pregnancy, occurring in 1 of 118 to 2288 deliveries In most cases of CAP, the offending pathogen is not identified. In a study from the Centers for Disease Control and Prevention (CDC), pathogens were identified in only 38 percent of nearly 2500 adults with pneumonia viruses in 23%, bacteria in 11 %, both in 3 %, fungi or protozoa in 1 %. 18/11/2023 6:30 am Endegena

2. … Pregnancy itself does not appear to predispose to pneumonia pneumonia follow viral upper respiratory illnesses, worsening or persistence of symptoms may represent developing pneumonia Pregnant suspected of having pneumonia should undergo chest radiography 18/11/2023 6:30 am Endegena

3. Bacterial Pneumonia Streptococcus pneumoniae is the most common bacterial pathogen that causes pneumonia in pregnancy, and H.influenzae is the next most common Clinically they will have fever, chills, and a purulent, productive cough Streptococcal pneumonia produces a “rusty” sputum, with gram-positive diplococci on Gram stain, and it demonstrates asymmetrical consolidation with air bronchograms on the chest radiograph 18/11/2023 6:30 am Endegena

4. … H. influenzae is a gram-negative coccobacillus consolidation with air bronchograms, often in the upper lobes. Klebsiella pneumoniae, is a gram-negative rod bacteria that causes extensive tissue destruction, air bronchograms, pleural effusion, and cavitation seen on the chest radiograph. Staphylococcus aureus pneumonia Patients will present with pleuritis, chest pain, purulent sputum, and consolidation without air bronchograms identified on the chest radiograph. 18/11/2023 6:30 am Endegena

5. … Atypical pneumonia , present with gradual onset of symptoms. They have a low grade temperature, appear less ill, and have mucoid sputum, and a patchy or interstitial infiltrate is seen on the chest radiograph. The severity of the findings on the chest radiograph is usually out of proportion to the mild clinical symptoms. Mycoplasma pneumoniae, Legionella pneumophila, and Chlamydia pneumoniae 18/11/2023 6:30 am Endegena

6. Diagnosis Clinically patients will have fever, cough, dyspnea, sputum production, and pleuritic chest pain. physical examination, Arterial blood gas determinations, CBC (leukocytosis) a chest radiograph, Sputum cultures, PCR tests, serological testing, cold agglutinin identification, and tests for bacterial antigens are not routinely recommended Exceptions are rapid PCR testing of nasal swab samples for influenza A and B and for COVID-19 18/11/2023 6:30 am Endegena

7. Management pneumonia severity index (PSI) and the CURB-65 scoring system are guides to admission At Parkland Hospital, they hospitalize all gravidas with radiographically proven pneumonia. Outpatient therapy or 23-hour observation with optimal follow-up are reasonable options. With severe disease, admission to an ICU or intermediate care unit is advisable. 18/11/2023 6:30 am Endegena

8. Risk Factors for Early Deterioration in CAP 18/11/2023 6:30 am Endegena

9. …. Initial antimicrobial and antiviral treatment is empirical Usually with a third-generation cephalosporin (ceftriaxone or cefotaxime) and a macrolide (azithromycin ) During influenza season, oseltamivir should be administered 18/11/2023 6:30 am Endegena

10. Empirical Inpatient Antimicrobial Treatment for Community- Acquired Pneumonia in Pregnancy 18/11/2023 6:30 am Endegena

11. …. For women with more severe disease, the recommendation is: a respiratory fluoroquinolone or a macrolide plus a preferred β-lactam . If MRSA is suspected, IV vancomycin, 15 mg/kg every 12 hours, or linezolid, 600 mg every 12 hours, is added Clinical improvement is usually evident in 48 to 72 hours . With improvement, patients can be transitioned to oral forms Radiographic abnormalities may take up to 6 weeks to completely resolve 18/11/2023 6:30 am Endegena

12. Pregnancy Outcome prematurely ruptured membranes preterm delivery low-birthweight neonates. In one population-based study from Taiwan of nearly 219,000 births, incidences of preterm and growth-restricted newborns and of preeclampsia and caesarean delivery were significantly higher 18/11/2023 6:30 am Endegena

13. Prevention Two pneumococcal vaccines are available— 60- to 70-percent protective. Neither vaccine is recommended for healthy pregnant women. chronic diabetes mellitus and with chronic heart, lung, or liver disease: one lifetime dose of PPSV23 is suggested, if not previously provided. Moreover, for women with chronic immunocompromise, malignancy, chronic renal disease, cochlear implant, or asplenia, such as with sickle-cell disease, one lifetime PCV13 dose is followed by one PPSV23 dose at least 8 weeks later and then again 5 years later if not provided previously 18/11/2023 6:30 am Endegena

14. Influenza pneumonia Influenza A and B are RNA viruses that cause potentially epidemic respiratory infection Each year, 10 percent of pregnant women develop influenza. Disease onset follows 1 to 4 days after exposure. common symptoms include fever, cough, myalgia, and chills secondary or mixed pneumonia develop from bacterial superinfection after 2 to 3 days of initial clinical improvement. 18/11/2023 2:44 pm Endegena

15. Diagnosis Rapid PCR testing of nasal swab samples for influenza A and B . radiographic interstitial infiltrates. Treatment Supportive treatment is recommended for uncomplicated influenza, and Early antiviral therapy is effective( o seltamivir , PO, 75 mg BID/5 days ) Prevention Inactivated influenza vaccines (IIV) or recombinant influenza vaccine (RIV) 18/11/2023 2:50 pm Endegena

16. TUBERCULOSIS It is estimated that a third of the world population is infected with Mycobacterium tuberculosis In >90 percent of patients, infection is contained and is dormant for long periods In those who are immunocompromised, tuberculosis becomes reactivated to cause clinical disease Tuberculosis (TB) terminology is inconsistent in the literature ;frequently used term Tuberculosis infection (newer term for latent tuberculosis) Tuberculosis disease (newer term for active tuberculosis) 18/11/2023 6:30 am Endegena

17. Natural history Tuberculosis infection is caused by inhalation of viable bacilli, which may persist in a clinically inactive state (known as TB infection [TBI]) or progress to TB disease. Individuals with TBI are asymptomatic and not contagious. Latent TB bacilli remain viable and may reactivate, causing symptomatic TB disease, which can be transmitted via airborne spread. Postpartum patients with TB disease can transmit infection to their infants Maternal TB disease may be associated with congenital infection by hematogenous dissemination via the placenta .  18/11/2023 6:30 am Endegena

18. CLINICAL MANIFESTATIONS Pregnant patients with pulmonary TB have the same clinical manifestations as nonpregnant patients; these may include fever, cough, weight loss, night sweats, and malaise. Pulmonary TB disease may be transmitted via airborne spread. TB in pregnant patients can present insidiously since malaise and fatigue may be attributed to pregnancy rather than disease In addition, during pregnancy, it can be difficult to recognize weight loss . 18/11/2023 6:30 am Endegena

19. DIAGNOSIS clinical suspicion for TB disease, based on clinical manifestations epidemiologic factors The approach to diagnosis for TB disease in pregnant patients is the same as in nonpregnant individuals; clinical history (including epidemiologic assessment) physical examination chest radiography 18/11/2023 6:30 am Endegena

20. … Chest imaging suggestive of pulmonary TB should prompt submission of three sputum specimens (coughed or induced) for acid-fast bacilli smear and culture as well as at least one sputum specimen for  Mycobacterium tuberculosis  nucleic acid amplification testing . 18/11/2023 6:30 am Endegena

21. … A positive  tuberculin skin test  (TST) or interferon-gamma release assay (IGRA) supports a diagnosis of TB infection in the absence of other evidence, is not sufficient for diagnosis of TB disease. a negative TST or IGRA result does not rule out TB disease. Diagnosis of TB disease should prompt evaluation for HIV infection 18/11/2023 6:30 am Endegena

22. Outcomes Rate of Low birthweight, preterm delivery, and preeclampsia increased The perinatal mortality rate was almost tenfold higher. Outcomes for TB in pregnancy may be worse among patients with HIV infection; In one study including 80 pregnant patients with HIV and TB and 155 pregnant patients with HIV but not TB, those with TB had higher rates of preeclampsia, their infants had higher rates of mortality and low birth weight, and 12 percent of these infants were born with TB Treated tuberculosis is usually associated with good pregnancy outcomes 18/11/2023 6:30 am Endegena

23. Adverse Maternal and Perinatal Outcomes in 3384 Pregnancies Complicated by Active Tuberculosis 18/11/2023 6:47 am Endegena

24. TREATMENT Latent Infection In nonpregnant, younger than 35 years with no evidence of active disease, rifamycin-based regimens with or without isoniazid for 3 to 4 months duration treatment is given Alternatively, isoniazid, 300 mg orally daily, is given for 6 to 9 months. However, for gravidas with latent infection, most recommend that isoniazid therapy be delayed until after delivery . Some even recommend withholding treatment until 3 to 6 months after delivery 18/11/2023 6:47 am Endegena

25. … Indication for ante partum latent TB treatment Recent skin test convertors Skin-test-positive women exposed to active infection women with HIV infection 18/11/2023 6:47 am Endegena

26. TB Disease treatment The preferred initial treatment regimen is INH, rifampin (RIF), and ethambutol (EMB) daily for 2 months, followed by INH and RIF daily, or twice weekly for 7 months (for a total of 9 months of treatment). Pyridoxine is added to help prevent isoniazid-associated neuropathy Streptomycin should not be used because it has been shown to have harmful effects on the fetus. Pyrazinamide (PZA) is not recommended to be used because its effect on the fetus is unknown . 18/11/2023 6:47 am Endegena

27. Neonatal Tuberculosis Congenital TB is acquired in utero through haematogenous spread or at the time of delivery through aspiration or ingestion of infected amniotic fluid or cervicovaginal secretions. Congenital TB usually presents in the first 3 weeks of life and has a high mortality rate. Neonatal TB is TB acquired after birth through exposure to a person with infectious TB (usually the mother but sometimes another close contact). It is often difficult to distinguish between congenital and neonatal TB 18/11/2023 6:47 am Endegena

28. …. Neonatal tuberculosis simulates other congenital infections and manifests with hepatosplenomegaly, respiratory distress, fever, and lymphadenopathy Neonatal infection is unlikely if the mother with active disease is treated before delivery or if her sputum culture is negative. If the mother is infectious, 3 to 6 months of isoniazid prophylaxis is given to the newborn. The untreated infant born to a woman with active infection was 50 percent have disease risk in the 1 st year. 18/11/2023 6:47 am Endegena

29. … BREASTFEEDING Breastfeeding may be encouraged after at least two weeks of treatment for TB disease . The small concentrations of first-line anti tuberculous drugs in breast milk do not produce toxic effects in the nursing infant Exclusively breastfed infants receiving isoniazid (either via breast milk or as directed therapy) should receive supplemental pyridoxine 18/11/2023 6:47 am Endegena

30. CYSTIC FIBROSIS Cystic fibrosis is an autosomal recessive exocrinopathy Cystic fibrosis is caused mutations in a 230-kb gene on the long arm of chromosome 7 The normal peptide gene product functions as a chloride channel and is termed the cystic fibrosis transmembrane conductance regulator (CFTR) Mutations in the chloride channel alters epithelial transport of electrolytes in CFTR-secretory cells. Affected sites include the sinuses, lung, pancreas, liver, and reproductive tract. Lung involvement is common place and is usually the cause of death. Bronchial gland hypertrophy with mucous plugging and small-airway obstruction . 18/11/2023 6:47 am Endegena

31. … Women with clinical cystic fibrosis are sub fertile because of tenacious cervical mucus. North American cystic fibrosis foundation estimated that 4% of affected women become pregnant every year . the endometrium and tubes express some CFTR but are functionally normal The ovaries do not express the CFTR gene. Both intrauterine insemination and in vitro fertilization can be successful for affected women . 18/11/2023 6:47 am Endegena

32. Pregnancy Outcome Pregnancy outcome is inversely related to severity of lung dysfunction.. In some women, pancreatic dysfunction may cause malnutrition. Approximately 10 percent have pregestational diabetes . normal pregnancy induced insulin resistance frequently results in gestational diabetes after mid pregnancy. In one study of 48 pregnancies, half had pancreatic insufficiency, and a third required insulin Cystic fibrosis is not affected by pregnancy. No effects on long-term survival 18/11/2023 6:47 am Endegena

33. Management pulmonary function testing assists management and estimates prognosis If the FEV 1 is at least 50 percent, women usually tolerate pregnancy well β- Adrenergic bronchodilators help control airway constriction. Inhaled recombinant human deoxyribonuclease I . Inhaled 7-percent saline . Nutritional status is assessed, and appropriate dietary counselling given. Calcium and vitamin D are given for poor bone mineralization. Pancreatic insufficiency requires replacement of oral pancreatic enzymes 18/11/2023 6:30 am Endegena