Pneumonia

ppt

1. PNUEMONIA DR GORDHAN DAS FCPS 29/03/2016 Pneumonia 1

2. Introduction Pneumonia is an inflammation of the lung parenchyma (i.e. alveoli rather than the bronchi) of infective origin. 12/12/2011 Pneumonia 2

3. It is the most common infectious cause of death. It is usually characterized by consolidation. Consolidation is a pathological process in which the alveoli are filled with a mixture of inflammatory exudate , bacteria & WBC 12/12/2011 Pneumonia 3

4. EPIDEMIOLOGY Occurs throughout the year Results from different etiological agents varying with the seasons Occurs in persons of all ages Clinical manifestations severe in very young, elderly & in chronically ill patients 12/12/2011 Pneumonia 4

5. CLASSIFICATION Classified based on two types Type 1 Lobar pneumonia Bronchopneumonia 2. Type 2 Community- acquired pneumonia (CAP) Hospital-acquired pneumonia (HAP) 12/12/2011 Pneumonia 5

6. Lobar pneumonia Lobar pneumonia is acute bacterial infection of a part of lobe the entire lobe, or even two lobes of one or both the lungs. 12/12/2011 Pneumonia 6

7. Bronchopneumonia Bronchopneumonia is infection of the terminal bronchioles that extends into the surrounding alveoli resulting in patchy consolidation of the lung. 12/12/2011 Pneumonia 7

8. Community Acquired Pneumonia (CAP) Pneumonia which develops in an otherwise healthy person outside of hospital or have been in hospital for less than 48hrs 12/12/2011 Pneumonia 8

9. Nosocomial pneumonia (HAP) Pneumonia that was not incubating upon admission developing in a patient hospitalized for greater than 48 hrs. 12/12/2011 Pneumonia 9

10. PATHOPHYSIOLOGY Microbial invasion of the normally sterile lower respiratory tract Three routes- Inhaled as aerosolized particles Haematogenous spread from an extrapulmonary site of infection Aspiration of oropharyngeal contents 12/12/2011 Pneumonia 10

11. Various defence mechanisms that protects lung from infection Anatomic barriers –epiglottis, larynx Cough reflexes Tracheobronchial secretions Mucocilliary lining Cell & humoral mediated immunity Dual phagocytic system-alveolar macrophages & neutrophils 12/12/2011 Pneumonia 11

12. Invasion occurs as a result of Defect in host defence mechanism Overwhelming inocculum Lung infection with viruses suppress the antibacterial activity of the lung by impairing alveolar macrophage function & mucocilliary clearance thus setting the stage for secondary bacterial pneumonia. 12/12/2011 Pneumonia 12

13. Clinical Manifestations Indolent to fulminant in presentation Mild to fatal in severity Typical symptoms – Fever Chills Cough Rust coloured sputum Mucopurulent sputum Dyspnea ( shortness of breath) Pleuritic chest pain Elevated WBC Bacteraemic 12/12/2011 Pneumonia 13

14. Chest X-ray For Lobar Pneumonia 12/12/2011 Pneumonia 14 Lobarpneumonia Consolidation confined to one or more lobes (or segments of lobes) of lungs.

15. Chest X-ray For Bronchopneumonia 12/12/2011 Pneumonia 15 Bronchopneumonia Patchy consolidation usually in the bases of both lungs.

16. Diagnosis Clinical diagnosis History Signs & symptoms Chest x-ray CT 12/12/2011 Pneumonia 16

17. Diagnosis Etiological diagnosis Gram's Stain and Culture of Sputum Blood Cultures Antigen Tests Polymerase Chain Reaction Serology Bronchoalveolar lavage Bronchoscopy 12/12/2011 Pneumonia 17

18. Complications Possible complications include: Acute respiratory distress syndrome  (ARDS) Fluid around the lung ( pleural effusion ) Lung abscesses Respiratory failure (which requires a breathing machine or ventilator) Sepsis , which may lead to organ failure 12/12/2011 Pneumonia 18

19. COMMUNITY ACQUIRED PNEUMONIA Pneumonia is most common in winter because of seasonal increase in viral infections Mortality 1%- Non hospitalized patients 13.7%- Hospiatalized patients 19.6%- Bacteremic patients <36.5%- Intensive care unit 12/12/2011 Pneumonia 19

20. Risk factors Comorbidity - Neoplastic disease, neurological problem Alcoholism Advanced age Asthma Immunosuppression 12/12/2011 Pneumonia 20

21. Etiology Potential etiologic agents in CAP - Bacteria Viruses Fungi Protozoa Potential bacteriologic causes can be divided into two types Typical bacterial pathogens Atypical bacterial pathogens 12/12/2011 Pneumonia 21

22. Typical bacterial pathogens Streptococcus pneumoniae – 30% to 60% ,Severe illness, death Haemophilus influenzae - 10% S. aureus (in selected patients) gram-negative bacilli – Klebsiella pneumoniae Pseudomonas aeruginosa 12/12/2011 Pneumonia 22

23. Atypical bacterial pathogens Mycoplasma pneumoniae Chlamydophila pneumoniae Legionella pneumophillia These organisms are intrinsically resistant to all - B lactam agents macrolide , a fluoroquinolone , or a tetracycline. Poor dental hygiene-anaerobes HIV- p.carnii Birds- Chlamydia psittaci Cattle or parturient cat- Coxiella burnetti 12/12/2011 Pneumonia 23

24. HOSPITAL ACQUIRED PNEUMONIA Pneumonia that was not incubating upon admission developing in a patient hospitalized for greater than 48 hrs 10-15% of all hospital acquired pneumonia, usually presenting with sepsis or&/or respiratory failure 50% acquired on ICU 12/12/2011 Pneumonia 24

25. Predisposing features Reduced host defence against bacteria Reduced immune defences (Corticosteroid treatment, diabetes, malignancy) Reduced cough reflux (Post operative) Disordered mucocilliary clearance (Anaesthetic agents) Aspiration of nasopharyngeal or gastric secretions Immobility or reduced conscious level Vomiting, Dysphagia , Nasogastric intubation 12/12/2011 Pneumonia 25

26. Most bacterial nosocomial infection occur by microaspiration of bacteria colonizing the patients oropharynx or upper GI tract Most common pathogen – Aerobic gram negative bacilli Most commonly exposed to multiresistant hospital pathogen 86% nosocomial infection-mechanical ventilation Mortality-0 to 50% 12/12/2011 Pneumonia 26

27. Bacterial introduction into LRT Endotracheal intubation Infected ventillatiors / nebuliser / bronchoscopy Dental or sinus infection Bacteraemia Abdominal sepsis Intravenous canula 12/12/2011 Pneumonia 27

28. Causative organisms Common organisms Gram negative bacteria- Escherichia coli Klebsiella sp. Pseudomonas aeruginosa Gram positive bacteria- Streptococcus pneumoniae Staphylococcus aureus 12/12/2011 Pneumonia 28

29. Less common organisms 1 . Gram negative bacilli other coliforms:Enterobacter sp. Proteus sp. Seratia marcescens Citrobacter sp. Acinobacter sp. Legionella pneumophillia 2. Anaerobic bacteria 3. Fungi- Candida albicans Aspergillus fumigatus 4. Viruses- Cytomegalovirus (CMV), Herpes simplex 12/12/2011 Pneumonia 29

30. Treatment Goals of therapy- Eradication of the offending organism. Selection of an appropriate antibiotic. To minimize associated morbidity. 12/12/2011 Pneumonia 30

31. General approach to treatment Adequacy of respiratory function Humidified oxygen for hypoxemia Bronchodilators ( albuterol ) Chest physiotherapy with postural drainage Adequate hydration if necessary Expectorants such as guaifenesin Chest pain- analgesics 12/12/2011 Pneumonia 31

32. Selection of an antimicrobial agent Empirical use of relatively broad spectrum antibiotic Narrow spectrum antibiotics to cover specific pathogen Potential pathogens involved Age Previous &current medication history Underlying disease Present clinical status 12/12/2011 Pneumonia 32

33. Antibiotic doses for treating pneumonia 12/12/2011 Pneumonia 33

34. Treatment for special cases 1. Patient less than 60 years & without comorbidities :- Azithromycine ( 500mg OD) *1day ( 250mg OD) *4days Norfloxacin / Levofloxacin (400mg OD) *7days 2. Outpatient greater than 65 years:- Norfloxacin (400mg OD) *7days or Ceftriaxon (1-2 g/day) / Cifixim (2-4 g/day) 3 rd gen cefalosporins + 12/12/2011 Pneumonia 34

35. Macrolides like Azithromycin ( 500mg OD) *1day ( 250mg OD) *4days Patient is hospitalised but not severely ill:- Combination of 3 rd gen cefalosporins + Macrolides Ceftriaxone + Azithromycin OR Norfloxacin / Levofloxacin (400mg OD) If the patient is hospitalised but not severely ill:- Combination of 3 rd gen cefalosporins + Macrolides Ceftriaxone + Azithromycin and newer fluroquinolones ( Gatifloxacin ) 12/12/2011 Pneumonia 35

36. Patient hospitalised & severely ill:- Combination of 3 rd gen cefalosporins + Macrolides Ceftriaxone + Azithromycin and newer fluroquinolones ( Gatifloxacin ) We can add Vancomycin . Patient with icu admission :- 3 rd gen cefalosporins + Fluroquinolones ( Gatifloxacin ) + Nutritional supplements + Saline Vancomycin / Meropenam 12/12/2011 Pneumonia 36

37. For HAP:- Cephalosporins + Aminoglycocides For antipseudomons cephalosporins :- Ceftazidime + Cefexime 12/12/2011 Pneumonia 37

38. Drugs with usual doses 12/12/2011 Pneumonia 38

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