Pneumonia

Dr. Md. Khairul Hassan Jessy
Associate Professor, Respiratory Medicine
National Institute of Diseases of the Chest and Hospital (NIDCH), Mohakhali, Dhaka.

Acknowledment:
Davidson’s Principles and Practice of Medicine

1. Dr. Md. Khairul Hassan Jessy Associate Professor, Respiratory Medicine National Institute of Diseases of the Chest and Hospital (NIDCH) Mohakhali, Dhaka Pneumonia

2. Blood Shed For Language And Independence Is The Glorious History Of Bangladesh

3. NIDCH My Hope

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

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

6. Classification

7. Pneumonia: Classifications Clinically Community-acquired pneumonia (CAP): Onset in community or during 1 st 2 days of hospitalization (Strep. pneumoniae most common) Hospital-acquired Pneumonia(HAP/ nosocomial ): Occurring 48 hrs after hospitalization Suppurative & Aspiration pneumonia Pneumonia in immunocompromised patient: caused by opportunistic organisms ( Pneumocystis jirovecii ).

8. Pneumonia: Classifications.. Anatomically Lobar pneumonia if one or more lobe is involved Broncho -pneumonia (Lobular) more patchy alveolar consolidation associated with bronchial and bronchiolar inflammation often affecting both lower lobes the pneumonic process has originated in one or more bronchi and extends to the surrounding lung tissue

9. Pneumonia: Classifications.. According to causes Bacterial (the most common cause of pneumonia) Viral pneumonia Fungal pneumonia Aspiration pneumonia Chemical pneumonia (ingestion of kerosene or inhalation of irritating substance)

10. Pneumonia: Classifications.. Typical pneumonia: Respiratory symptoms are more than constitutional symptoms Atypical pneumonia: Constitutional symptoms are more than respiratory symptoms ( Behaviourist's classification ) Easy pneumonia (responds to initial treatment) Difficult pneumonia (fails to do so)

11. Community-acquired pneumonia (CAP)

12. Community-acquired pneumonia (CAP) Onset in community or during 1 st 2 days of hospitalization Strep. pneumoniae most common 50% It affects all age groups but is particularly common at the extremes of age. Worldwide, CAP continues to kill more children than any other illness, and its propensity to ease the passing of the frail and elderly led to pneumonia being known as the ‘old man’s friend ’.

13. Community-acquired pneumonia (CAP).. Most cases are spread by droplet infection. May occur in previously healthy individuals. Streptococcus pneumoniae remains the most common infecting agent. Other organisms may be involved which depends on the age of the patient and the clinical context. Viral infections are important causes of CAP in children, and their contribution to adult CAP is increasingly recognized

14. Community-acquired pneumonia (CAP).. Mycoplasma pneumoniae is more common in young people and rare in the elderly. Haemophilus influenzae is more common in the elderly, particularly when underlying lung disease is present. Legionella pneumophila occurs in local outbreaks centred on contaminated cooling towers in hotels, hospitals and other industrial buildings. Staphylococcus aureus is more common following an episode of influenza.

15. Community-acquired pneumonia (CAP).. Cigarette smoking Upper respiratory tract infections Alcohol Corticosteroid therapy Old age Recent influenza infection Pre-existing lung disease HIV Indoor air pollution Factors that predispose to pneumonia

16. Community-acquired pneumonia (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 ) Organisms causing CAP

17. Pathophysiology

18. Pneumonia: mode of transmission Bacteria and viruses living in your nose, sinuses, or mouth may spread to your lungs You may breathe some of these germs directly into your lungs (droplets infection) You breathe in (inhale) food, liquids, vomit, or fluids from the mouth into your lungs (aspiration pneumonia)

19. Pathophysiology The streptococci reach the alveoli and lead to inflammation and pouring of an exudates into the air spaces WBCs migrates to alveoli, the alveoli become more thick due to its filling consolidation, involved areas by inflammation are not adequately ventilated, due to secretion and edema This will lead to partial occlusion of alveoli and bronchi causing a decrease in alveolar oxygen content

20. Pathophysiology.. Venous blood that goes to affected areas without being oxygenated and returns to the heart (ventilation-perfusion mismatch) This will lead to arterial hypoxemia and even death due to interference with ventilation

21. Pathophysiology..

22. Clinical features

23. Clinical features Pneumonia, particularly lobar pneumonia, usually presents as an acute illness. Systemic features such as fever, rigors, shivering and malaise predominate and delirium may be present . The appetite is invariably lost and headache frequently reported.

24. Clinical features.. Pulmonary symptoms include cough, which at first is characteristically short, painful and dry , but later accompanied by the expectoration of mucopurulent sputum. Rust- coloured sputum may be seen in patients with Strep. pneumoniae , and the occasional individual may report haemoptysis . Pleuritic chest pain may be a presenting feature and, on occasion, may be referred to the shoulder or anterior abdominal wall.

25. Clinical features.. Upper abdominal tenderness is sometimes apparent in patients with lower lobe pneumonia or if there is associated hepatitis. Less typical presentations may be seen in the very young and the elderly.

26. Clinical features.. On examination, The respiratory and pulse rate may be raised and the blood pressure low, while an assessment of the mental state may reveal a delirium . These are important indicators of the severity of the illness Not all patients are pyrexia l but this is a helpful diagnostic clue if present. Oxygen saturation on air may be low, and the patient cyanosed and distressed.

27. Clinical features.. On examination.. Chest signs vary, depending on the phase of the inflammatory response. When consolidated, the lung is typically dull to percussion and, as conduction of sound is enhanced, auscultation reveals bronchial breathing and whispering pectoriloquy ; crackles are heard throughout. However, in many patients, signs are more subtle with reduced air entry only, but crackles are usually present.

28. Clinical features.. On examination.. An assessment of nutrition is important as, if poor, the response to treatment will be impaired , particularly in the elderly. On occasion, inferences as to the likely organism may be drawn from clinical examination. For example, the presence of herpes labialis may point to streptococcal infection , as may the finding of ‘rusty’ sputum. The presence of poor dental hygiene should prompt consideration of Klebsiella or Actinomyces israelii .

29. Clinical features.. Chronic Pneumonia Symptoms creep in slowly Fever that lasts a week Coughing for three weeks Enlarged cervical & axillary lymphnodes Haemoptysis Recurrence of symptoms after finishing antibiotic course

30. Differential diagnosis of pneumonia Pulmonary infarction Pulmonary/pleural TB Pulmonary oedema (can be unilateral) Pulmonary eosinophilia Malignancy: bronchoalveolar cell carcinoma Rare disorders: cryptogenic organising pneumonia/ bronchiolitis obliterans organising pneumonia (COP/BOOP) Venous thromboembolism , Pulmonary haemorrhage ARDS Drug toxicity

31. Fishing, Village of Bangladesh

32. Investigations

33. Investigations The aims of investigation are Confirm the diagnosis Exclude other conditions Assess the severity Identify the development of complications

34. Investigations.. Full blood count Very high (> 20 × 109/L) or low (< 4 × 109/L) white cell count: marker of severity Neutrophil leucocytosis > 15 × 109/L: suggests bacterial aetiology Haemolytic anaemia : occasional complication of Mycoplasma Erythrocyte sedimentation rate/C-reactive protein: Non-specifically elevated Blood culture: Bacteraemia : marker of severity

35. Investigations.. Urea and electrolytes: Urea > 7 mmol /L (~20 mg/ dL ): marker of severity Hyponatraemia : marker of severity Liver function tests: Abnormal if basal pneumonia inflames liver Hypoalbuminaemia : marker of severity Serology: Acute and convalescent titres for Mycoplasma , Chlamydia, Legionella and viral infections Cold agglutinins: Positive in 50% of patients with Mycoplasma Arterial blood gases: Measure when SaO2 < 93% or when severe clinical features to assess ventilatory failure or acidosis

36. Investigations.. Sputum Sputum samples Gram stain, culture and antimicrobial sensitivity testing. Gram stain of sputum showing Gram-positive diplococci characteristic of Strep. pneumoniae . Oropharynx swab PCR for Mycoplasma pneumoniae and other atypical pathogens

37. Investigations.. Urine Pneumococcal and/or Legionella antigen Pleural fluid Always aspirate and culture when present in more than trivial amounts, preferably with ultrasound guidance

38. Investigations.. Other markers of severity of Pneumonia CXR :> One lobe involved Pao2 <8kPa Low albumin(<35gm/L) WBC(<4000/ cmm or >20000/ cmm ) Blood culture positive

39. Investigations.. Chest X-ray Lobar pneumonia Patchy opacification evolves into homogeneous consolidation of affected lobe Air bronchogram (air-filled bronchi appear lucent against consolidated lung tissue) may be present. Bronchopneumonia: Typically patchy and segmental shadowing Complications: Para-pneumonic effusion, intrapulmonary abscess or empyema Staph. aureus : Suggested by multilobar shadowing, cavitation , pneumatocoeles and abscesses

40. Investigations.. For evaluation of PSI CBC HCT, TC, DC RBS Blood Urea Serum electrolytes CXR ABG Analysis Pulse oximetry

41. Management

42. Management The principles of management focusing on Adequate oxygenation Appropriate fluid balance Antibiotics In severe or prolonged illness, Nutritional support may be required Evaluate the effectiveness of administered medications Explain all procedures to the patient and family

43. Management… Oxygen Oxygen should be administered to all patients with tachypnoea , hypoxaemia , hypotension or acidosis The aim of maintaining the PaO2 at or above 8 kPa (60 mmHg) or the SaO 2 at or above 92%.

44. Management…. Oxygen High concentrations (35% or more), preferably humidified, should be used in all patients who do not have hypercapnia associated with COPD. Continuous positive airway pressure (CPAP) should be considered in those who remain hypoxic despite this and these patients should be managed in a high-dependency or intensive care environment, where mechanical ventilation can be rapidly employed.

45. Management… Intravenous fluids These should be considered in patients with severe illness, older patients and those who are vomiting. Otherwise, an adequate oral intake of fluid should be encouraged. Inotropic support may be required in patients with shock

46. Management… Antibiotics Prompt administration of antibiotics improves the outcome. The initial choice of antibiotic is guided by clinical context, severity assessment, local knowledge of antibiotic resistance patterns any available epidemiological information. The choice of empirical antibiotic therapy is considerably more challenging, due to Diversity of pathogens Drug resistance.

47. Management… Antibiotics : Uncomplicated CAP: Amoxicillin 500 mg 3 times daily orally If patient is allergic to penicillin: Clarithromycin 500 mg twice daily orally or Erythromycin 500 mg 4 times daily orally If Staphylococcus is cultured or suspected: Flucloxacillin 1–2 g 4 times daily IV plus Clarithromycin 500 mg twice daily IV If Mycoplasma or Legionella is suspected: Clarithromycin 500 mg twice daily orally or IV or Erythromycin 500 mg 4 times daily orally IV plus Rifampicin 600 mg twice daily IV in severe cases

48. Management… Antibiotics : Severe CAP: Clarithromycin 500 mg twice daily IV or Erythromycin 500 mg 4 times daily IV plus 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 Amoxicillin 1 g 4 times daily IV plus flucloxacillin 2 g 4 times daily IV

49. Management… Antibiotics: Oral antibiotics are usually adequate unless the patient has a severe illness, impaired consciousness, loss of swallowing reflex, or functional or anatomical reasons for malabsorption . In most patients with uncomplicated pneumonia, a 7-day course is adequate, although treatment is usually required for longer in those with Legionella , staphylococca l or Klebsiella pneumonia.

50. Management… Antibiotics: 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]

51. Management… Pain It is important to relieve pleural pain, as it may prevent the patient from breathing normally and coughing efficiently. For the majority, simple analgesia with paracetamol , co- codamol or NSAIDs is sufficient. In some patients, opiates may be required but these must be used with extreme caution in patients with poor respiratory function, as they may suppress ventilation. Physiotherapy May help expectoration in those who suppress cough because of pleural pain.

52. Management… Maintain a patent airway and adequate oxygenation Use suction if the patient can’t produce a specimen Provide a high calorie, high protein diet & soft foods Provide a quiet, calm environment, with frequent rest periods Monitor the patient’s ABG levels, especially if he’s hypoxic Assess the patient’s respiratory status Auscultate breath sounds at least every 4 hours

53. Management… Delayed resolution means Physical signs persist for more than 2 weeks and Radiological features persist for more than 4 weeks after antibiotic therapy. Non-resolution means If radiological opacity persists after 8 weeks (with treatment /after antibiotic therapy ).

54. Management… Delayed resolution suggests the diagnosis is incorrect Incorrect microbiological diagnosis Fungal, tubercular or atypical pneumonia recurrent aspiration Improper antibiotic or insufficient dose pneumonia may be secondary to a proximal bronchial obstruction complication has occurred (Empyema or atelectasis ) Bronchial obstruction (bronchial carcinoma, adenoma, foreign body) Immunocompromised patient (HIV, DM, lymphoma, leukemia, multiple myeloma).

55. referral to ITU

56. Hospital CURB-65

57. Indications for referral to ITU CURB score of 4–5, failing to respond rapidly to initial management Persisting hypoxia ( PaO2 < 8 kPa (60 mmHg)), despite high concentrations of oxygen Progressive hypercapnia Severe acidosis Circulatory shock Reduced conscious level

58. Recurrent Pneumonia

59. Recurrent Pneumonia ≥2 episodes of pneumonia within 6 months or ≥3 episodes in a lifetime Episodes separated by an asymptomatic interval of at least 1 month or R adiographic clearing of densities between episodes

60. Causes of Recurrent Pneumonia Bronchial obstruction (bronchial carcinoma, adenoma, foreign body ) Lung disease (Bronchial asthma, bronchiectasis , lung abscess, cystic fibrosis, sequestrate segment of lung—commonly left lower lobe) Aspiration (achalasia cardia , scleroderma, pharyngeal pouch ) Immunocompromised patient (HIV, DM, lymphoma, leukemia, multiple myeloma )

61. Discharge

62. Discharge and follow-up Depends on their home circumstances and the likelihood of complications. A chest x-ray need not be repeated before discharge in those making a satisfactory clinical recovery. Clinical review should be arranged around 6 weeks later A chest x-ray obtained if there are persistent symptoms, physical signs or reasons to suspect underlying malignancy.

63. Criteria for discharge To discharge, the patient should be 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 SaO 2 < 90% Inability to maintain oral intake Abnormal mental status.

64. Remember Before Discharge!!!! Influenza Vaccine Pneumococcal Vaccine After Discharge!!! Follow up CXR to exclude cancer

65. Prevention

66. Preventive measures Current smokers should be advised to stop smoking Influenza Vaccine & Pneumococcal Vaccine should be considered in selected pts In developing countries, tackling malnutrition & Indoor air pollution Immunization against measles, pertussis & Haemophillus influenzae type b in children Legionella pneumophila has important public health implications and usually requires notification to the appropriate health authority.

67. Complications

68. Complication of pneumonia Para-pneumonic effusion – common Empyema Retention of sputum causing lobar collapse Deep vein thrombosis and pulmonary embolism Pneumothorax, particularly with Staph. aureus Suppurative pneumonia/lung abscess ARDS, renal failure , multi- organ failure Pleurisy

69. Complication of pneumonia… Hypoxemia Atelectasis Respiratory failure (which requires mechanical ventilator) Sepsis, which may lead to organ failure Ectopic abscess formation ( Staph . aureus) Hepatitis, pericarditis , myocarditis , meningoencephalitis Pyrexia due to drug hypersensitivity

70. Assessment Of Severity

71. Pneumonia severity index.. The pneumonia severity index [PSI] or PORT [pneumonia patient outcomes research team]score is a clinical prediction rule that medical practitioners can use to calculate the Probability of morbidity and mortality among patients with community acquired pneumonia Despite sometimes being used to predict the need for hospitalization in people with pneumonia, The PORT score was not developed to do so and should not be used in that way Mortality prediction is similar to that when using CURB-65

72. Pneumonia severity index.. Development of the PSI: The rule uses demographics (whether someone is older, and is male or female) The coexistence of co-morbid illnesses Findings on physical examination and vital signs Essential laboratory findings

73. Pneumonia severity index.. Development of the PSI: This study demonstrated that patients could be stratified into five risk categories, risk classes I-V These classes could be used to predict 30-day survival

74. Pneumonia severity index.. Usage & Application of the PSI: The purpose of the PSI is to classify the severity of a patient's pneumonia to determine the amount of resources to be allocated for care Most commonly, the PSI scoring system has been used to decide whether patients with pneumonia can be treated as outpatients or as (hospitalized) in patients

75. Pneumonia severity index.. Usage & Application of the PSI: A risk class I pneumonia patient can be sent home on oral antibiotics A risk class II-III pneumonia patient may be sent home with IV antibiotics or Treated and monitored for 24 hours in hospital Patients with risk class IV-V pneumonia patient should be hospitalized for treatment

76. The PSI Algorithm

77. Stratification of Risk Score

78. Pneumonia Severity Index (PSI) for Adults Demographic factors Sex Male (0 points) Female (-10 points) Age (1 point for each year) Nursing home resident (10 points)

79. Pneumonia Severity Index (PSI) for Adults Comorbid illnesses Neoplastic disease (30 points) Liver disease (20 points) Congestive heart failure (10 points) Cerebrovascular disease (10 points) Renal disease (10 points)

80. Pneumonia Severity Index (PSI) for Adults.. Physical examination findings Altered mental status (20 points) Respiratory rate >= 30/minute (20 points) Systolic blood pressure < 90 mmHg (20 points) Temperature <35 degrees C or >= 40 degrees C (15 points) Pulse >= 125/minute (10 points)

81. Pneumonia Severity Index (PSI) for Adults.. Laboratory and radiographic findings Arterial pH < 7.35 (30 points) Blood urea nitrogen >= 30 mg/ dL (11 mmol /L) (20 points) Sodium < 130 mEq /L (20 points) Glucose >= 250 mg/ dL (14 mmol /L) (10 points) Hematocrit < 30 percent (10 points) PO 2 < 60 mmHg or oxygen saturation < 90% (10 points) Pleural effusion (10 points)

82. Pneumonia Severity Index (PSI) for Adults.. Pneumonia Score Interpretation 0-50 Points Class I 0.1% Mortality 51-70 Points Class II 0.6% Mortality 71-90 Points Class III 0.9% Mortality 91-130 Points Class IV 9.3% Mortality 131-395 Points Class V 27.0% Mortality

83. Vaccination

84. Influenza and pneumococcal vaccines in old age Influenza vaccine reduces the risk of influenza and death in elderly people. Polysaccharide pneumococcal vaccines do not appear to reduce the incidence of pneumonia or death but may reduce the incidence of invasive pneumococcal disease. (Andrew R, et al.(Cochrane Review). Cochrane Library, issue 4, 2003. Oxford: Update software.)

85. Prognosis

86. Most patients respond promptly to antibiotic therapy and will improve within 2 weeks Elderly or very sick patients may need longer treatment. However, 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.

87. HAP ( Hospital Acquired Pneumonia )

88. HAP (Hospital-acquired pneumonia ) Hospital-acquired or nosocomial pneumonia is a new episode of pneumonia occurring at least 2 days after admission to hospital. New episode of pneumonia occurring at least 48 h post admission to hospital, excludes infection incubating at time of admission (Am J Respir Crit Care Med 153:1711-25, 1995). Second most common hospital-acquired infection. leading cause of HAI-associated death.

89. HCAP & VAP Healthcare-associated pneumonia (HCAP): Development of pneumonia in a person who has spent at least 2 days in hospital within the last 90 days, Has attended a haemodialysis unit Received intravenous antibiotics, or home infusion therapy Resident in a nursing home or other long-term care facility Home wound care Family member with multidrug-resistant pathogen Ventilator-associated pneumonia(VAP): The elderly are particularly at risk, along with patients in intensive care units, especially when mechanically ventilated; in the latter case, the term ‘ventilator-associated pneumonia’ (VAP) is used.

90. HAP (Hospital-acquired pneumonia).. Early-onset HAP (occurring within 4–5 days of admission) are similar to those involved in CAP. Late onset HAP is associated with a different range of pathogens to CAP The organisms Gram-negative bacteria (e.g. Escherichia, Pseudomonas, Klebsiella species and Acinetobacter baumannii ), Staph. aureus (including the meticillin resistant type (MRSA)) anaerobes.

91. Factors predisposing to hospital-acquired pneumonia Aspiration of nasopharyngeal or gastric secretions Immobility or reduced conscious level Vomiting, dysphasia (N.B. stroke disease), achalasia or severe reflux Nasogastric intubation Bacteria introduced into lower respiratory tract Endotracheal intubation/ tracheostomy Infected ventilators/ nebulisers /bronchoscopes Dental or sinus infection

92. Factors predisposing to hospital-acquired pneumonia… Reduced host defenses against bacteria Reduced immune defenses (e.g. corticosteroid treatment, diabetes, malignancy) Reduced cough reflex (e.g. post-operative) Disordered mucociliary clearance (e.g. anaesthetic agents) Bulbar or vocal cord palsy Bacteraemia Abdominal Sepsis, IV Cannula Infection, Infected Emboli

93. Factors predisposing to hospital-acquired pneumonia… Chronic lung disease (COPD, bronchiectasis) Frequent suction Other serious illness such as heart disease, liver cirrhosis, and DM Recent cold, laryngitis or flu Immuno -suppressed patients Difficult swallowing (due to stroke, dementia,parkinsons disease, or other neurological conditions) Impaired consciousness ( loss of brain function due to dementia, stroke, or other neurological conditions)

94. Clinical features The diagnosis should be considered in any hospitalized or ventilated patient who develops Purulent sputum (or endotracheal secretions), New radiological infiltrates, An otherwise unexplained increase in oxygen requirement, A core temperature of more than 38.3°C, and A leucocytosis or leucopenia.

95. Management In early-onset HAP Patients who have received no previous antibiotics can be treated with Co- amoxiclav or Cefuroxime . If the patient has received a course of recent antibiotics, then Piperacillin / Tazobactam or a third generation Cephalosporin should be considered

96. Management.. In late-onset HAP the choice of antibiotics must cover the Gram-negative bacteria, Staph. aureus (including MRSA) and anaerobes. Antipseudomonal cover may be provided by a carbapenem ( meropenem ) or a third-generation cephalosporin combined with an aminoglycoside .

97. Management.. MRSA cover may be provided by glycopeptides, such as Vancomycin or Linezolid Physiotherapy is important to aid expectoration in the immobile and elderly nutritional support is often required.

98. Antimicrobial options for common infecting bacteria Organism Antimicrobial options Staph. aureus Flucloxacillin , Clindamycin Pseudomonas aeruginosa Ciprofloxacin, Piperacillin-tazobactam , Aztreonam , Meropenem , Aminoglycosides , Ceftazidime / Cefepime Enterobacter spp. Ciprofloxacin, Meropenem , Aminoglycosides Anti microbial option for MRSA Clindamycin , Vancomycin , Rifampicin (Never used as monotherapy ), Linezolid , Daptomycin , Tetracyclines , Tigecycline , Co- trimoxazole .

99. Prevention: HAP Despite appropriate management, the mortality from HAP is approximately 30%, so prevention is very important. Good hygiene is paramount, particularly with handwashing equipment used. To minimise the chances of aspiration To limit use of stress ulcer prophylaxis with PPI Oral antiseptic/mouth wash

100. Prevention: HAP… The risk of aspiration should be minimized Oral antiseptic ( chlorhexidine 2%) may be used to decontaminate the upper airway, Some intensive care units employ selective decontamination of the digestive tract when the anticipated requirement for ventilation will exceed 48 hours.

101. Prevention: HAP… Frequent turning of bed ridden patients and early ambulation as much as possible Coughing and breathing techniques Sterilization of respiratory therapy equipment Suctioning of secretion in the unconscious who have poor cough and swallowing reflexes, to prevent aspiration of secretions and its accumulation

102. Prevention: HAP… To prevent aspiration during nasogastric tube feedings check the position of tube and administer feedings slowly To control the spread of infection, dispose secretions properly.

103. Prevention: HAP… Vaccination Influenza & Pneumococcus Isolation of patients with resistant respiratory tract infections Enteral nutrition Choice of GI prophylaxis Subglotic secretion removal

104. HAP – Failure of Therapy Incorrect diagnosis (it is not pneumonia): Atelectasis , CHF, PE with infarction, lung contusion, chemical pneumonitis , ARDS, pulmonary hemorrhage Pathogen resistance Host factors that increase mortality Age > 60, prior pneumonia, chronic lung disease immunosuppression Antibiotic resistance Am J Respir Crit Care Med 153:1711-25, 1995

105. Respiratory Infection In Old Age

106. Respiratory infection in old age Increased risk of and from respiratory infection: because of reduced immune responses, increased closing volumes, reduced respiratory muscle strength and endurance, altered mucus layer, poor nutritional status and the increased prevalence of chronic lung disease. Predisposing factors: other medical conditions may predispose to infection. e.g. swallowing difficulties due to stroke increase the risk of aspiration pneumonia.

107. Respiratory infection in old age… Atypical presentation: Older patients often present with confusion, rather than breathlessness or cough. Mortality: The vast majority of deaths from pneumonia in developed countries occur in older people. Influenza: Higher complication rate, morbidity and mortality. Vaccination significantly reduces morbidity and mortality in old age but uptake is poor.

108. Respiratory infection in old age… Tuberculosis: Most TB cases in old age represent reactivation of previous, often unrecognized disease Precipitated by steroid therapy, diabetes mellitus and the factors above. Cryptic miliary TB is an occasional alternative presentation. Older people more commonly suffer adverse effects from antituberculous chemotherapy and require close monitoring.

109. HAP – Risk Factors

110. Risk Factors For Multidrug-resistant Pathogens Causing HAP,HCAP,VAP Antimicrobial therapy in preceding 90 days Current hospitalization of 5 days or more High frequency of antibiotic resistance in the community or in the specific hospital unit Immunosuppressive disease and/or therapy

111. HAP – Modifying Factors Penicillin-resistant and drug-resistant pneumococci Age > 65 yr B- Lactam therapy within the past 3 months Alcoholism Immune-suppressive illness (including therapy w/ corticosteroids) Multiple medical comorbidities Exposure to a child in a day care center Am J Respir Crit Care Med 163:1730-54, 2001

112. HAP – Modifying Factors Enteric gram-negatives Residence in a nursing home Underlying cardiopulmonary disease Multiple medical comorbidities Recent antibiotic therapy

113. HAP – Modifying Factors Pseudomonas aeruginosa Structural lung disease (bronchiectasis) Corticosteroid therapy (10 mg of prednisone per day) Broad-spectrum antibiotic therapy for > 7 d in the past month Malnutrition

114. Pneumonia: Risk Factors CAP Older adult Chronic/coexisting condition Recent history or exposure to viral or influenza infections History of tobacco or alcohol use HAP Older adult Chronic lung disease Aspiration ET, Trach , NG / GT Immunocompromised Mechanical ventilation

115. Pneumonia In The Immunocompromised Patient

116. Pneumonia in the immunocompromised patient… Patients immunocompromised by drugs or disease (particularly HIV) are at high risk of pulmonary infection. The majority of cases are caused by the same pathogens that cause pneumonia in non- immunocompromised individuals. Patients with more profound immunosuppressant, unusual organisms or those normally considered to be of low virulence or non-pathogenic may become ‘opportunistic’ pathogens.

117. Pneumonia in the immunocompromised patient… Patients with more profound immunosuppression , unusual organisms or those normally considered to be of low virulence or non-pathogenic may become ‘opportunistic’ pathogens. Infection is often due to more than one organism. Gram-negative bacteria, especially Pseudomonas aeruginosa, viral agents, fungi, mycobacteria, and less common organisms such as Nocardia asteroides has to be considered.

118. Causes of immune suppression-associated lung infection Defective Phagocytic function Causes Infecting organisms Acute leukaemia Cytotoxic drugs Agranulocytosis Gram-positive bacteria including Staph. aureus Gram-negative bacteria Fungi, e.g. Candida albicans , Aspergillus fumigatus

119. Causes of immune suppression-associated lung infection… Defects in cell-mediated immunity Causes Infecting organisms Immunosuppressive drugs Cytotoxic chemotherapy Lymphoma Thymic aplasia Viruses Cytomegalovirus , Herpesvirus , Adenovirus ,Influenza Fungi Pneumocystis jirovecii (formerly carinii ) Candida albicans Aspergillus fumigatus

120. Causes of immune suppression-associated lung infection… Defects in antibody production Causes Infecting organisms Multiple myeloma Chronic lymphocytic leukaemia Haemophilus influenzae Mycoplasma pneumoniae

121. Clinical features of Pneumonia in the immunocompromised patient… Influenced by the degree of immunosuppression . Symptoms are less specific in the more profoundly immunosuppressed . The speed of onset tends to be less rapid in patients with opportunistic organisms such as Pneumocystis jirovecii and mycobacterial infections than with bacterial infections Typically include fever, cough and breathlessness. In P. jirovecii pneumonia,symptoms of cough and breathlessness can be present for several days or weeks before the onset of systemic symptoms or the appearance of X-ray abnormalities.

122. Diagnosis of Pneumonia in the immunocompromised patient… The approach is informed by the clinical context and severity of the illness. Invasive investigations , such as bronchoscopy , BAL, transbronchial biopsy or surgical lung biopsy, are often impractical, as many patients are too ill to undergo these safely. ‘ Induced sputum ’ offers a relatively safe method of obtaining microbiological samples

123. Diagnosis of Pneumonia in the immunocompromised patient… HRCT is useful in differentiating the likely cause : Focal unilateral airspace opacification favours bacterial infection, mycobacteria or Nocardia . Bilateral opacification favours . P. jirovecii pneumonia, fungi, viruses and unusual bacteria, e.g. Nocardia . Cavitation may be seen with N. asteroides , mycobacteria and fungi. The presence of a ‘halo sign’ may suggest Aspergillus . Pleural effusions suggest a pyogenic bacterial infection and are uncommon in P. jirovecii pneumonia.

124. Diagnosis of Pneumonia in the immunocompromised patient… In theory, treatment should be based on the identified causative organism but in practice, this is frequently unknown and broad-spectrum antibiotic therapy is required, such as a third-generation cephalosporin or A quinolone , plus an antistaphylococcal antibiotic, or an antipseudomonal penicillin plus an aminoglycoside .

125. Management of Pneumonia in the immunocompromised patient… Thereafter, treatment may be tailored according to the results of investigations and the clinical response. These may dictate the addition of antifungal or antiviral therapies.

126. Suppurative Pneumonia, Aspiration Pneumonia And Pulmonary Abscess

127. Suppurative Pneumonia, Aspiration Pneumonia And Pulmonary Abscess Suppurative pneumonia is characterized by destruction of the lung parenchyma by the inflammatory process and micro abscess formation is a characteristic histological feature. Pulmonary abscess is usually taken to refer to lesions in which there is a large localized collection of pus, or a cavity lined by chronic inflammatory tissue, from which pus has escaped by rupture into a bronchus. Site: Dependent areas of the lung, such as the apical segment of the lower lobe in a supine patient.

128. Risk Factors Often develop after the inhalation of septic material during operations on the nose, mouth or throat under general anaesthesia , Vomitus during anaesthesia or coma, particularly if oral hygiene is poor. Bulbar or vocal cord palsy, Stroke, Achalasia or oesophageal reflux, Alcoholism.

129. Risk Factors may also complicate local bronchial obstruction from a neoplasm or foreign body. Bacterial infection of a pulmonary infarct or a collapsed lobe may also produce a suppurative pneumonia or lung abscess. Injecting drug-users are at particular risk of developing haematogenous lung abscess, often in association with endocarditis affecting the pulmonary and tricuspid valves.

130. Clinical features of suppurative pneumonia Symptoms Cough with large amounts of sputum, sometimes fetid and blood-stained Pleural pain common Sudden expectoration of copious amounts of foul sputum if abscess ruptures into a bronchus

131. Clinical features of suppurative pneumonia Clinical signs High remittent pyrexia. Profound systemic upset. Digital clubbing may develop quickly (10-14 days). Chest examination usually reveals signs of consolidation; signs of cavitations rarely found. Pleural rub common. Rapid deterioration in general health with marked weight loss if not adequately treated.

132. Organisms Infections are usually due to a mixture of anaerobes and aerobes in common with the typical flora encountered in the mouth and upper respiratory tract. Isolates of bacteroides melaninogenicus , fusobacterium necrophorum , anaerobic or micro- aerophilic cocci , and bacteroides fragilis may be identified.

133. Organisms… When suppurative pneumonia or a pulmonary abscess occurs in a previously healthy lung, the most likely infecting organism is staph.aureus or klebsiella pneumoniae . The organisms isolated from the sputum include strep. Pneumoniae , staph. Aureus , strep. Pyogenes , H. Influenzae and, in some cases, anaerobic bacteria. No pathogen can be isolated, particularly when antibiotics have been given. Strains of community-acquired mrsa (ca- mrsa ) responsible for suppurative skin infection but may be associated with rapidly progressive,severe , necrotising pneumonia.

134. Organisms… Lemierre’s syndrome is a rare cause of pulmonary abscesses. The usual causative agent is the anaerobe, F. necrophorum . The illness typically commences as a sore throat, painful swollen neck, fever, rigor, haemoptysis and dyspnoea, and spread into the jugular veins leads to thrombosis and metastatic spread of the organisms. A non-infective form of aspiration pneumonia – exogenous lipid pneumonia – may follow the aspiration of animal, vegetable, or mineral oils.

135. Investigation Radiological features of suppurative pneumonia include homogeneous lobar or segmental opacity consistent with consolidation or collapse. Abscesses are characterised by cavitation and fluid level. Occasionally, a preexisting emphysematous bulla becomes infected and appears as a cavity containing an air–fluid level.

136. Treatment Intravenous co- amoxiclav 1.2 g 3 times daily. If an anaerobic bacterial infection is suspected (e.g. from fetor of the sputum), oral metronidazole 400 mg 3 times daily should be added. Further modification of antibiotics may be required, depending on the clinical response and the microbiological results.

137. Treatment… CA-MRSA is usually susceptible to oral non-β- lactam antibiotics, such as trimethoprim / sulfamethoxazole , clindamycin , tetracyclines and linezolid . Parenteral therapy with vancomycin or daptomycin can also be considered. F.necrophorum is highly susceptible to β- lactam antibiotics, and to metronidazole , clindamycin and third-generation cephalosporins

138. Treatment… Prolonged treatment for 4–6 weeks may be required in some patients with lung abscess. Physiotherapy is of great value, especially when suppuration is present in the lower lobes or when a large abscess cavity has formed. Surgery should be contemplated if no improvement occurs, despite optimal medical therapy. Removal or treatment of any obstructing endobronchial lesion is essential.