Nosocomial Pneumonias | Jindal Chest Clinic

Pneumonia is characterized by the emergence of new lung infiltrates, accompanied by clinical signs such as fever, purulent sputum, leukocytosis, and decreased oxygenation and Nosocomial Pneumonia is a non-incubating lower respiratory infection that presents clinically two or more days after hospitalization. In this presentation "Nosocomial Pneumonias" has been described including their causes, therapy, Principles, diagnosis, symptoms, management, etc. For more information, please contact us: 9779030507.

1. Nosocomial Pneumonias

2. Nosocomial Pneumonias Hospital-acquired pneumonia - pneumonia 48 hours or more after admission, and was not incubating at the time of admission Ventilator-associated pneumonia - pneumonia that arises more than 48-72 hours after endotracheal intubation Health Care Associated Pneumonia (HCAP) i . hospitalized in an acute care hospital ≥ 2days in preceding 90 days; ii. nursing home or long-term care facility resident; iii. recent iv chemotherapy, or wound care within past 30 days iv. attended a hospital or hemodialysis clinic

3. ENVIRONMENT Infected air,water , fomites,instruments Cross-contamination HOST Impaired immune function Comorbid illness Prior surgery/antibiotics PATHOGEN Inoculum - Virulent strain (MDR) PATHOGENESIS NOSOCOMIAL PNEUMONIA

4. DIAGNOSIS OF HAP Clinical + Microbiology New onset fever Purulent expectoration Tachycardia Tachypnoea Leukocytosis / Leukopenia Need of higher FiO 2 + Chest X ray Clinical diagnosis, high sensitivity, low specificity empiric treatment Microbiology T o identify etiology De-escalate therapy Decide duration of therapy

5. Drug Resistance: Factors   Sicker inpatient population Immuno -compromised patients New procedures & instrumentation Emerging pathogens Complacency regarding antibiotics Ineffective infection control and compliance Increased antibiotic use

6. Principles of therapy Start empiric therapy pending reports of culture and drug-sensitivity test Choose antibiotics based on probable organisms as cause of infection Combination therapy is preferred Parenteral route should be chosen Adequate dosages must be used Change the drug/s after culture and sensitivity reports Monitor for effects & side efffects of drugs

7. SUMMARY Nosocomial Pneumonias are frequent & associated with excess mortality initiate prompt appropriate & adequate therapy Pathogens distinct from one hospital to another, specific sites within the hospital, and from one time period to another Avoid overuse of antibiotics, focus on accurate diagnosis, tailor therapy to recognized pathogen and shorten duration of therapy to the minimum effective period Apply prevention strategies aimed at modifiable risk factors

8. Suppurative Lung Disease Lung Abscess Bronchiectasis Empyema

9. Lung Abscess Localized collection of pus in the lung parenchyma surrounded by a fibrous tissue wall. Single or Multiple Necrotizing pneumonia may simulate an abscess; it lacks a wall May precede lung abscess development

10. Classification Primary Lung Abscess (Usually single) Occurs in healthy individuals, e.g. following aspiration, pneumonia (cavitation) Secondary Abscess (May be multiple) Pre-existing lung disease, e.g. Bronchogenic cancer, COPD , lung cysts etc Systemic : Immunosuppression Metastatic ( eg . Infective endocarditis)

11. Factors contributing to the development of lung abscess 1. Oral cavity disease Periodontal disease Gingivitis 2. Altered consciousness Alcoholism Coma Drug abuse Anesthesia Seizures 3. Immunocompromise Steroid therapy Chemotherapy Malnutrition Multiple trauma 4 . Esophageal disease Achalasia Reflux disease Esophageal obstruction 5. Bronchial obstruction Tumor Foreign body Stricture 6. Generalized sepsis

12. Pathogenesis Aspiration of infectious material i . Poor oro -dental hygiene (infected gums, tonsils, etc ) ii . Predisposition to aspiration: Dysphagia , Alcoholism , seizure, stroke, trauma , unconsciousness Colonization of organisms in the lung. C ellular infiltration and exudation Local liquefaction necrosis , destruction Bronchial communication, air in the abscess cavity. May extend to pleural cavity - pyopneumothorax Repair mechanisms and fibrosis - containment

13. Microorganisms responsible for lung abscess 1. Aerobic Klebsiella , Pseudomonas Staphylococci , others Anaerobic Bacteroides , Clostridia Fungal Aspergillus Mycobacterial Parasitic Entamoeba Echinococcus ( Hydatid Cyst)

14. Clinical Features Symptoms: - Acute or insidious onset - Fever with rigors, night sweats, Chest pain/ dullness , Cough, S putum production ( Sputum is large volume, thick, muco -purulent or purulent; blood stained, foul smelling) Signs: - Presence of per/ sidontal disease, other risk-factor - Febrile , toxic patient, Finger clubbing Chest exam: - May be normal. - Localized impairment of percussion note - Breath sounds diminished; bronchial breathing, egophony , Crackles

15. Differential diagnosis ( cavitary lung lesion) 1. Cavitating lung cancer 2. Localized empyema 3. Infected bulla containing a fluid level 4. Infected bronchogenic cyst or sequestration 5 . Pulmonary hematoma 6. Cavitating pneumoconiosis 7. Hiatus hernia 8 . Lung parasites (e.g. hydatid cyst, Paragonimus infection) 9. Actinomycosis 10. Wegener’s granulomatosis and other vasculitides 11. Cavitating lung infarcts 12. Cavitating sarcoidosis

16. Investigations Polymorphonuclear leukocytosis Sputum examination: Smear and culture for different etiological agents Chest radiography: CXR, CT scans Bronchoscopy for bronchial assessment (Obstruction, ulceration etc); br secretions for microbiology

17. Radiographic findings CXR: - Smooth or irregularly walled cavity, fluid level; dependent part commonly. - Klebsiella abscess mostly in upper lobe, bulging fissure sign. - Staph abscesses: Multiple, sometimes thin walled CT scans: Clear demonstration of wall, localization of site within the lung, pleural communication – - presence of empyema; other underlying lung problem . - CT is also helpful for guidance for per- cutaneous aspiration

18. Pulmonary Samples For Microbiological Demonstration (Uncontaminated) • Transtracheal aspirate • Transthoracic pulmonary aspirate • Fiberoptic bronchoscopy with protected specimen brush • Bronchoalveolar lavage fluid for quantitative culture • Surgical specimens • Pleural fluid (if empyema present )

19. Lemierre’s Syndrome Rare cause of lung abscesses Infection with anaerobe (F. necrophorum ) Cl Features: - Sore throat, fever, rigors, neck-swelling , hemoptysis , dyspnea - Thrombophlebitis & thrombosis of neck veins, - Metastatic spread to other organs.

20. Complications Erosion/ rupture – Broncho -pleural fistula and empyema formation Spread into surroundings – Metastatic spread – Brain, Liver, Spleen Sepsis Long-term sequelae : Bronchiectasis, Fibrosis Systemic amyloidosis

21. Management General measures Antibiotic therapy: parenteral Aspiration pn . Co- amoxiclav Metronidazole Staphylococcal : CA-MSSA Oral co- amoxilav CA-MRSA Clindamycin, Linezolid , Vancomycin etc Surgical management

22. Bronchiectasis Definition Permanent destructive dilatation of the bronchi (following infection, destruction and fibrosis) Types Cystic Cylindrical Localized or diffuse

23. Etiology of bronchiectasis Post-infectious , e.g. tuberculosis, pneumonia; childhood infection such as measles, mumps, whooping cough Connective tissue diseases, e.g. SLE, rheum arthritis , Sjögren’s syndrome, relapsing polychondritis Secondary to inhalation or aspiration, e.g . a foreign body Inflammatory bowel disease, e.g. ulcerative colitis Allergic bronchopulmonary aspergillosis Immune deficiency e.g. Secondary to ch lymphatic leukemia

24. Congenital causes of Bronchiectasis Cystic fibrosis Ciliary defects, e.g. primary ciliary dyskinesia, Young’s syndrome Kartagener’s syndrome Immune deficiency, e.g . IgA deficiency, X-linked agammaglobulinemia , Common variable immunodeficiency Congenital defects e.g. tracheobronchomegaly ( Mounier -Kuhn syndrome), pulmonary sequestration

25. Clinical Features Chronic cough and expectoration Sputum: Purulent/ muco -purulent, foul-smelling, large volume, thick and tenacious Haemoptysis , sometimes massive Recurrent exacerbations SIGNS: - General malnutrition, pallor, edema - Digital clubbing, osteoarthropathy Chest: - Depends on site and extent of involvement - If large, signs of lung volume reduction - May be areas of bronchial breathing - Coarse crepitations , Occasional rhonchi

26. Investigations General: Anemia, Hypoglobulinemia Chest radiography: CXR, CT scan (HRCT) Bronchography Sputum examination – For exacerbations. - AFB to exclude TB, if suspected Smear for culture - ECG , ECHO for cardiac evaluation in suspected chronic cor-pulmonale

27. Differential Diagnosis Pulmonary tuberculosis Cystic fibrosis COPD Allergic broncho -pulmonary aspergillosis Interstitial lung diseases Eosinophilic lung diseases Hypersensitivity pneumonias

28. Radiological features CXR: May appear normal in early, limited disease, left lower lobe hidden behind the heart in PA film. Thickened bronchial lines- tram lines Cystic shadows/ cavities with fluid levels HRCT : Almost diagnostic. Clear demonstration of site of involvement, Type of lesions, surrounding lung parenchyma, focal pneumonitis, areas of atelectasis. Clue to the underlying etiology ( eg ABPA)

29. Complications Recurrent pneumonias Recurrent hemoptysis, sometimes massive Local lung destruction and cavitation Aspergilloma formation (fungal ball) in a cavity Metastatic spread Pulmonary hypertension and chronic cor pulmonale Chronic malnutrition Amyloidosis Chronic respiratory failure if extensive lung destruction and fibrosi

30. Management Bronchial hygiene: Postural drainage, Chest physiotherapy Antibiotics for infections Expectorant and mucolytics Management of complications, e.g hemoptyis , pulmonary hypertension ( Chronic or pulmonale ), respiratory failure Nutritional supplementation Surgical management: - Resection , if localized - Management of hemoptysis - Lung transplantation

31. Recommendation for antibiotics use Bacterial infection First choice Second line Haemophilus influenzae Doxycycline , or Moraxella catarrhalis Co- amoxiclav ciprofloxacin Streptococcus pneumoniae Amoxicillin Clarithromycin MRSA Rifampicin and Rifampicin and trimethoprim doxycycline or or IV vancomycin linezolid or teicoplanin Ps aeruginosa Ciprofloxacin Ceftazidime and tobramycin or colistin

32. Prevention of infections Preventive vaccinations Bronchial hygiene measures - Chest physiotherapy - Nebulization /steam inhalation - Respiratory muscle exercises Long term antibiotic use - Oral Nebulized

33. Kartagener’s Syndrome Ciliary dyskinesia i.e. abnormal ciliary movements Genetic abnormality Clinical features: - Bronchiectasis - Situs inversus , dextrocardia - Chronic sinusitis - Infertility

34. Allergic Broncho Pulmonary Aspergillosis Hypersensitivity to aspergillus in the tracheo -bronchial tree in patients with chronic asthma. Clinical Features: Severe attacks, sputum production; hard brown plugs; hemoptysis Radiology: CXR and HRCT: Fleeting opacities, typical patterns; bronchiectasis – proximal bronchi Diagnosis: Skin test: Immediate & delayed + ve Sputum for aspergillus + ve Serology + ve ; Total & Asperg specific IgE levels Treatment: Anti-inflammatory drugs (steroids), Anti- biotics , anti- fungals

35. Cystic Fibrosis A common condition in Caucasians – 1 in 2500 live births Genetic anomaly: Autosomal recessive mutation on chromosome 7; leads to protein Cystic Fibrosis Transmembrane Regulator, CFTR) abnormality Clinical Features: Multi-organ problem Bronchiectasis – thick viscid sputum Pancreatic insufficiency - diarrhoea Liver disease – biliary cirrhosis Sweat glands function abnormality Infertility Low bone mass

36. Cystic Fibrosis- Diagnosis Clinical features – Failure to thrive Intestinal obstruction Adults: Respiratory infections Radiological investigations, CXR, HRCT scans etc Positive sweat Test – High sweat chloride & Na levels on pilocarpine stimulation Gene analysis – demonstration of CFTR mutations

37. Cystic Fibrosis- Treatment Treatment of respiratory infection with antibiotics: Anti-pseudomonas cover Reduce sputum viscosity- mucolytics Improve airway clearance Management of pancreatic insufficiency Correction of malnutrition – high calorie, high fat diet; supplemental vitamins Gene therapy Lung transplantation

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