MANAGEMENT OF PNEUMONIA

1. MANAGEMENT OF PNEUMONIA PRIYATMA KHINCHA

2. INVESTIGATIONS

3. SPUTUM MICROSCOPY COLLECTION >25 NEUTROPHILS / LPF <10 SQUAMOUS EPITHELIAL CELLS / LPF DISCARD SALIVA BACTERIA – GRAM STAINING

4. Streptococcus pneumoniae

5. Staphylococcus aureus

6. Klebsiella pneumoniae

7. Mycobacterium tuberculosis

8. FUNGI – WET MOUNT PREPARATION

9. Pneumocystis carinii GROCOTT – GOMORI METHENAMINE SILVER

10. OTHER TESTS ON SPUTUM - PNEUMOCOCCAL ANTIGEN DETECTION LEGIONELLA PNEUMOPHILIA – DFA TEST PNEUMOCYSTIS – SPECIFIC FLUORESCEIN LABELLED MONOCLONAL ANTIBODIES NOT AFFECTED BY PRIOR ANTIBIOTIC USE RAPID VIRAL DIAGNOSIS BY DFA

11. SPUTUM CULTURE DELAY IN GIVING RESULT CONTAMINATION - NORMAL FLORA PRIOR ANTIBIOTIC USE  INHIBITS GROWTH

12. Legionella pneumophilia BUFFERED CHARCOAL YEAST EXTRACT (BCYE) AGAR – 5 OR MORE DAYS

13. FUNGAL CULTURE IN IMMUNOCOMPROMISED  OPPORTUNISTIC FUNGI ( CRYPTOCOCCUS, ASPERGILLUS ) VIRAL ISOLATION INDICATIONS NOT RESPONDING TO ANTIBACTERIAL R X IDENTIFY OUTBREAK OF INFLUENZA ESTABLISH RSV IN YOUNG CHILDREN IMMUNOCOMPROMISED

14. HIGHEST SENSITIVITY IN PNEUMOCOCCAL PNEUMONIA POSITIVE CULTURE  HIGH SPECIFICITY MORE PROGNOSTIC : BACTERIMIA  SEVERE INFECTION BLOOD CULTURE

15. BACTERIAL ANTIGEN DETECTION Streptococcus pneumoniae Quellung reaction Latex agglutination ELISA  MOST SENSITIVE COUNTER IMMUNOELECTROPHORESIS SENSITIVITY : 80% 40% 25% Sputum urine blood

16. Legionella pneumophilia RADIO-IMMUNO ASSAY 89 – 95% SENSITIVE 99% SPECIFIC ENZYME LINKED IMMUNOASSAY

17. VIRAL ANTIGEN DETECTION DFA – INFLUENZA A & B, RSV, CMV, HSV EIA PCR ASSOCIATED CLINICAL AND LAB FINDINGS TO BE TAKEN INTO ACCOUNT FOR DIAGNOSIS

18. SEROLOGICAL TESTS WHEN CAUSATIVE ORGANISM IS HARD TO ISOLATE RAPID DIAGNOSIS HELP IN INITIATION OF TREATMENT INCREASE IN TITRES 4 FOLD LEGIONELLA, MYCOPLASMA, Q FEVER PNEUMONIA, MYCOTIC PATHOGENS, VIRAL (RETROSPECTIVE DIAGNOSIS)

19. MOLECULAR DIAGNOSTIC TESTING PCR Mycobacterium Chlamydia Mycoplasma HSV ADENOVIRUS CMV EBV Pneumocystis Legionella H1N1 – MOST RECENT  REVERSE TRANSCRIPTASE PCR

20. SKIN TESTS FOR DELAYED HYPERSENSITIVITY TUBERCULIN SKIN TEST FUNGAL SKIN TEST (COCCOIDIODIN) ?? CURRENT OR PAST INFECTION ??

21. CHEST RADIOGRAPHY PATTERN OF INFILTRATION – LOBAR PATCHY INTERSTITIAL CAVITARY LARGE EFFUSION RESPONSE TO TREATMENT LAGS WELL BEHIND CLINICAL IMPROVEMENT

22. CAVITY

23. STAGES OF LEGIONELLA PNEUMONIA

24. PLEURAL EFFUSION

25. CT SCAN IN NON-RESPONDING PATIENTS

26. INVASIVE DIAGNOSTIC PROCEDURES FIBRE-OPTIC BRONCHOSCOPY WITH TRANSBRONCHIAL LUNG BIOPSY BRONCHO-ALVEOLAR LAVAGE IN VAP – PROTECTED SPECIMEN BRUSHING PERCUTANEOUS TRANSTHORACIC NEEDLE LUNG BIOPSY OPEN LUNG BIOPSY / VATS

27. OTHERS ARTERIAL O 2 SATURATION AND BLOOD GAS ANALYSIS WBC COUNT HIGH BLOOD UREA HIGH BILIRUBIN HIGH ALKALINE PHOSPHATASE HYPONATREMIA  LEGIONELLA PROTEIN, RBC AND WBC IN URINE

28. MARKERS FOR SEVERE ILLNESS ALTERED MENTAL STATE / CONFUSION TACHYPNOEA >/= 30 BREATHS/MIN HYPOTENSION <90/60 mm Hg ARTERIAL HYPOXEMIA CXR -- > 1 LOBE INVOLVED / RAPID PROGRESSION RENAL INSUFFICIENCY

29. COMMUNITY ACQUIRED PNEUMONIA

30. TREATMENT HOSPITALISATION ?? PNEUMONIA SEVERITY INDEX (PSI) CURB - 65

31. PSI calculates the probability of MORBIDITY AND MORTALITY AMONG THE COMMUNITY ACQUIRED PNEUMONIA PATIENTS. USES DEMOGRAPHICS, ASSOCIATED CO-MORBIDITIES, PHYSICAL EXAMINATION, VITAL SIGNS AND LAB FINDINGS Risk group I – R x at home Risk group II and III – home r x with iv antibiotics or 1 day hospital stay Risk group IV and V – inpatient R x

32. C – CONFUSION U – UREMIA > 7 mmol /L R – RESPIRATORY RATE > 30/min B – BP < 90/60 mm Hg 65 – years old / more

33. IDSA / ATS GUIDELINES FOR EMPIRICAL ANTIBIOTIC THERAPY

34. SPECIAL CONCERNS Pseudomonas aeruginosa B – LACTAM + AMINOGLYCOSIDE + ANTIPNEUMOCOCCAL FLUOROQUINOLONE Legionella pneumophilia MACROLIDE /CIPROFLOXACIN + IV RIFAMPICIN CA – MRSA ADD LINEZOLID (600mg IV 12 hrly ) OR VANCOMYCIN ( 1 g IV 12 hrly )

35. SUPPORTIVE TREATMENT RESPIRATORY SUPPORT FLUID AND ELECTROLYTE REPLACEMENT TOTAL PARENTERAL NUTRITION OTHERS ANALGESICS CORTICOSTEROIDS INOTROPICS

36. PREVENTION PNEUMOCOCCAL CAPSULAR POLYSACCHARIDE VACCINE INFLUENZA VACCINE FOR NOSOCOMIAL INFECTION – SURVEILLANCE EDUCATION & AWARENESS HANDWASHING GOOD DISINFECTION CONTROLLED USE OF ANTIBIOTICS

37. WORLD PNEUMONIA DAY NOVEMBER 2 TH

38. THANK YOU!