community acquired pneumonia.pptx

community acquired pneumonia

1. Pneumonia Dr. M ohammad Zannatul Rayhan Pulmonologist Chest Disease Hospital, Rajshahi

2. Out lines Of Presentation Definition Classification of pneumonia Predisposing factors Pathophysiology Clinical manifestations Diagnostic tests Medical management Complications Prognosis

3. Definition An acute respiratory illness associated with recently developed radiological pulmonary shadowing which may be segmental, lobar or multilobar Inflammation in the lung characterized by accumulation of secretions and inflammatory cells in alveoli

4. Classifications Clinically Community-acquired pneumonia (CAP): c ommunity or within 48 hour of admission Hospital-acquired Pneumonia(HAP/nosocomial): after 48 hour of admission Suppurative & Aspiration pneumonia Pneumonia in immunocompromised patient: by opportunistic organisms

5. Classifications… Anatomically Lobar pneumonia if one or more lobe is involved Broncho-pneumonia (Lobular) According to causes Bacterial (the most common cause of pneumonia) Viral pneumonia Fungal pneumonia Aspiration pneumonia Chemical pneumonia

6. Community-acquired pneumonia (CAP) Onset in community or during 1 st 2 days of hospitalization common at the extremes of age Known as ‘old man’s friend ’ Most cases are spread by droplet infection May occur in previously healthy individuals 5-12% of lower respiratory tract infections

7. Factors that predispose to pneumonia Cigarette smoking Upper respiratory tract infections Alcohol Corticosteroid therapy/ immune suppressive drugs Old age Recent influenza infection Pre-existing lung disease HIV Indoor air pollution

8. Organisms causing CAP Bacteria Streptococcus pneumoniae Mycoplasma pneumoniae Legionella pneumophila Chlamydia pneumoniae Haemophilus influenzae Staphylococcus aureus Chlamydia psittaci Coxiella burnetii ( Q fever, ‘ querry ’ fever) Klebsiella pneumoniae ( Freidländer’s bacillus) Actinomyces israelii Viruses Influenza, parainfluenza Measles Herpes simplex Varicella Adenovirus Cytomegalovirus (CMV) Coronavirus ( Urbani SARS-associated coronavirus ) Fungus

9. Pathophysiology Microorganism reach the alveoli-inflammation and pouring of an exudates WBCs migrates to alveoli- more thick due to its filling consolidation Occlusion of alveoli and bronchi- causing a decrease in alveolar oxygen content V:Q mismatch

10. Clinical features Symptoms Systemic features: fever , rigors, shivering, malaise and delirium may be Cough Pleuritic chest pain SOB Sputum, hemoptysis etc. May atypical: extreme of ages Examinatons Fever Tachypnoea Tachycardia Crackles Bronchial breathing Hypotension Confusion Herpes labialis etc.

11. Diagnostic pointers Streptococcus pneumoniae Increasing age Comorbidity (especially cardiovascular) Acute High fever Rusty sputum Pleuritic chest pain Winter Legionella Younger Smoker Absence of comorbidity More severe Neurological symptoms Evidence of multi-system disease ( e.g Abnormal liver enzymes and raised CK), Hyponatremia Autumn Local outbreak- contaminated water systems.

12. Diagnostic pointers… Mycoplasma pneumoniae Younger patients Prior antibiotics Extra pulmonary involvement: Hemolysis Cold agglutinins Hepatitis Skin and joint problems Staphylococcus aureus Recent influenza-like illness 50% those in ICU Multiple abscess

13. Diagnostic pointers… Chlamydophila psittaci Longer duration Headache Exposure to bird Coxiella burnetii (Q fever) Dry cough High fever Headache Animal exposure: Sheep and goats

14. Diagnostic pointers… Klebsiella pneumoniae : older, alcohol, DM, Low platelet count and leucopenia Acinetobacter : Older patients, alcoholism, high mortality Streptococcus millerri group : Dental or abdominal source of infection Streptococcus viridans : Aspiration is a risk factor Anaerobes: unconscious/anesthesia

15. Investigations CBC RBS LFT, RFT Blood Urea Serum electrolytes Blood culture Sputum CXR & other imaging modalities ABG Analysis Role of invasive techniques: FOB, FNAC

16. Test for specific pathogens Pneumococcal pneumonia : Urinary antigen Legionella pneumophilia : Urinary antigen, serology—antibody levels Mycoplasma pneumoniae : PCR,CFT Chlamydophila : PCR , antigen detection using DIF Influenza A and B, adenovirus, RSV: PCR or serological Coxiella burnetii : indirect immunofluorescence antibody test

17. Markers of severity CXR :> One lobe involved Pao2 <8kPa Low albumin(< 3.5gm/ dL ) WBC(<4000/ cmm or >20000/ cmm ) Blood culture positive Urea > 7 mmol /L (~20 mg/ dL ) Hyponatraemia

18. Referral to ITU

19. Management principles Adequate oxygenation Antibiotics Appropriate fluid balance

20. General management Hypoxia correction: target SpO2 > 94% (unless risk of type 2 failure) Adequate fluid balance Adequate analgesia Nutritional support Physiotherapy VTE prophylaxis Role of NIV Role of FOB

21. Antibiotics Low severity CAP( CURB-65:0-1) Amoxicillin 500 mg 3 times daily orally( IV if necessary) If patient is allergic to penicillin: Clarithromycin 500 mg twice daily orally or Doxycycline 200 mg loading then 100mg/day orally Moderate severity CAP(CURB-65:2) Amoxicillin 500mg-1 gm 3 times daily orally(or IV) or benzylpenicillin 1.2 gm 4 times daily IV Plus Clarithromycin 500 mg BD orally or IV If patient is allergic to penicillin: Doxycycline 200 mg loading then 100mg/day orally or levofloxacin 500mg/day orally --BTS guideline--

22. Antibiotics… Severe CAP(CURB 65:3-5) Co- amoxiclav 1.2 g 3 times daily IV or Ceftriaxone 1–2 g daily IV or Cefuroxime 1.5 g 3 times daily IV or plus Clarithromycin 500 mg twice daily IV or Benzylpenicillin 1.2g 4 times daily plus levofloxacin 500 mg twice daily IV If legionella is strongly suspected: c onsider adding levofloxacin 500 mg twice daily IV -- BTS guideline- -

23. Antibiotics…

24. Antibiotics…

25. Antibiotics…

26. Duration of antibiotics In most a 7-day course is adequate, although treatment is usually required for longer in those with Legionella, staphylococcal or Klebsiella pneumonia. Duration of therapy 5 -7 days - outpatients 10-14 days – Mycoplasma, Chlamydia, Legionella 14+ days - chronic steroid users 14-21days – Staph. aureas , Legionella spp [ Am J Respir Crit Care Med 163:1730-54, 2001]

27. Bangladesh ?

28. BSMMU guideline Preferred drug Inj. Azithromycin (500 mg) I/V OD 5 days, or Inj. Clarithromycin (500 mg) 12 hourly for 7-14 days Inj. Quinolone 7-14 days or Inj. Linezolid (600 mg) 12 hourly 7-14 days (if gram positive infection), or Inj. Ticoplzmin (400 mg) stat and (200 mg) 12 hourly for 7-14 days, or Cap. Fluclonazole (50-100 mg/day) if fungal infection Alternative drug Inj. Ceftazidine (1 gm) 8 hourly for 7-14 days, plus/ or Inj. Clindamycin (600 mg)I/V 8 hourly for 7-14 days Inj. Piperacillin / Tazobactam (4.5 gm) 6-8 hourly for 7-14 days Inj. Vancomycin (1 gm) I/V 12 hourly 7-14 days (if gram positive infection) Inj. Amphotericin -B if fungal infection

29. Causes of failure to improve Slow clinical response, particularly in the elderly patient Incorrect initial diagnosis 2° complication: Inappropriate antibiotics or unexpected pathogen Impaired immunity

30. Discharge Criteria for discharge: Clinically stable with no more than one of the following clinical signs: Temperature > 37.8 ºC Heart rate > 100/min Respiratory rate > 24/min Systolic BP < 90 mm Hg SaO2 < 90% Inability to maintain oral intake Abnormal mental status.

31. Follow up Radiographic improvement lags behind clinical improvement CXR follow-up is recommended around 6 weeks after CAP: Persisting symptoms or clinical signs Higher risk of underlying lung malignancy, i.e. smokers and those over the age of 50

32. Complications Para-pneumonic effusion Empyema lobar collapse DVT and pulmonary embolism Pneumothorax Suppurative pneumonia/lung abscess ARDS, renal failure , multi- organ failure Pleurisy Hypoxemia Atelectasis Respiratory failure Sepsis Ectopic abscess ( Staph . aureus) Hepatitis, pericarditis, myocarditis, meningoencephalitis

33. Prevention Smoking cessation Vaccine: Influenza , pneumococcal , measles, pertussis & haemophillus influenzae type B Tackling malnutrition & indoor air pollution Legionella pneumophila requires notification to the appropriate health authority.

34. Prognosis Most will improve within 2 weeks Elderly or very sick patients may need longer treatment Fever may persist for several days and the chest X-ray often takes several weeks or even months to resolve, especially in old age The mortality rate of adults with non-severe pneumonia is very low (< 1%); hospital death rates are typically between 5 and 10% but may be as high as 50% in severe illness It correlates with scoring system

35. Pneumonia severity index(PSI)

36. Interpretation of PSI

37. Future of Pulmonology?????

38. Thank you