pneumonia

Dr . Bandar ghazal
• CAP

• HAP : 48 hrs after admission to hospital .

• VAP : 48 hrs after mechanical ventilation .

• Community acquired pneumonia :

Ranges from mild disease which managed as
ambulatory cases to fatal infection .
Rates of hospitalization increased with age
• Fever
• Cough
• Shortness of breath
• Chest plain
• In elderly or immunocompromised pt these
symptoms maybe mild or absent
• Bacterial and viral
• Less commonly fungal and mycobacterium
• pathogen causing CAP are listed below
• Strp pneumoniae .
• Staphylococcus aureus .

• H. Influenza .
• Legionellla .
• Enerobacteriaceae . ( E .COLI , Klebsiella pneumoniae )
• Moraxella catarrhalis .

• Anaerobes .

• Mycoplasma (Lack of cell wall ) .

• Viral ( influenza virus ,parainfluenza , rhinovirus )

• Fungal , mycobacterium
• Streptococcus pneumoniae was considered the
leading cause for pneumonia , but incidence
decreasing bz of vaccination strategy , accounting for
about 15 % of cases of hospitalized pt .

• Staph aureus and enterobacteriaceae are rising .

• EPIC trial : was done on CAP during hospitalization

more identified single or multiple viruses rather than
bacteria
• Typical pnuemonia

• Atypical pneumonia :
Caused by organism not cultured by standard
media including virus , legionella , mycoplasma
and chlamydia
 Diagnostic evaluation
• CBC
• KFT
• CRP
• Chest x-ray

• Sputum culture ( value in pseudo , staph)sensitivity about 80% of strp pneumoniae befor starting
AB

• Blood culture

• Nasopharyngeal swab for viral work up .(rapid test , PCR )

• ABG

• Pneumococcal antigen urinary test positive in 70 % of cases

• Legionella urinary antigen test positive in most pt with legio . pneumophilia serotype 1
• Chest xray :

• If x-ray is normal upon presentation , what

should I do ?
Lobar Right lower Lung absess , Interstital Pleural
pneumonia lobe cavitary lesion infiltrates effusion
pneumonia

Streptococcus Oral anaerobes Anaerobes Legionella Strep

pneumoniae (aspiration ) Staph, aurues Mycoplasma Staph .aurues
Alcoholic , Mycobacterium chlamydia Anaerobes
stroke , neuro Actinomyces
disease Klebsiella .
• If chest xray was not diagnostic upon
presentation :
we should repeat xray after 24 hours

• chest ct scan
• If concomitant pleural effusion thicker than
1 cm should go thoracocentesis to exclude
empyema requiring drainage .
 Management
• Clinical judgment is the most important , scoring system was
validated to help us in clinical judgment .
• CURB 65

• Confusion
• BUN > 20 mg / dl
• RR >or equal 30 / min
• SBP <90 , DBP <60
Age >or equal 65 years

One score for each

Ambulatory treatment is appropriate for most pt with score 0-1
• Did the pt receive any antibiotics in last 1
- 3 months ?
 ANTIMICROBIAL THERAPY
• Ambulatory pt : ( without significant comorbidities )

Treatment directed against strep. Haemophilus

influenzae and atypical bacteria .

Mono therapy with doxycycline or macrolides ( azithro ,

clairtho )
If suspicion of strep. macrolides resistance :
B lactam and macrolides or quinolones such as
levofloxacin or moxifloxacin .
• Is ciprofloxacin is suitable for pnuemonia ?

• Yes
• No
• If pt have significant comorbidities :

Quinolone

Or B -lactam plus macrolides

( high dose amoixicillin )
Second generation cephalosporines (cefuroxime ,
cefaclor ,

Doxycycline can replace quinolone and macrolides in

case of side effect .
• Pt requiring hospitalization :

Parenteral B lactam ( third generation

cephalosporine or ampicillin –sulbactam )

Plus macrolide or quinolone

Or monotherapy with quinolone

• CAP requiring ICU admission :

Mono therapy with quinolone is

contraindicated .

Parenteral therapy B lactam and macrolide

or quinolone
• MRSA :
Pt on dialysis
Critically ill pt
Preceding influenza infection
Drug abuser
Gram positive cocci in clusters
Failure of convential therapy
Pleural based lung nodules
Cavitary lesion

Vancomycin , linezolid ,

Can we use daptomycin ????

• Pseudomonas aeruginosa :
Most cases are HAP , but can occur as CAP

Immunocompromised pt
Underlying lung disease (cystic fibrosis , bronchiectasis )

Two anti pseudomonal therapy is indicated :

B lactam (piperacillin - tazobactam , cefepim , meronem )
And antipseudomonal quinolone (levofloxacin , ciprofloxacin
) or amino glycosides
 Duration of therapy
• Uncomplicated stable CAP
If pt improve in first 3 days , 5 to 7 days
course is enough .

For MRSA :, enterobacreriaceae , fungal

At least 14 days .
• Lack of response to treatment rise suspicion
of resistant organism or atypical organism ,
loculated infection (empyema ) or an
infection mimic (tumor , vasculitis ,
pulmonary embolism )

• Pt with significsant pleural effusion should

be conisdered for thoracocentesis
 Complications
• CAP has mortality rate of 10 -12 % among hospitalized pt .
• Localized lung inflammation .
• Empyema
• ARDS due to ( Vigorous immune response resulting in acute
respiratory distress syndrome )

• Delirium
• Cardiac arrhythmia ( A FIB )
• AKI
• Spread of infection
• Toxicity related to medications
• Adrenal insufficiency ( water house friderichsen syndrome
)occurring in setting of bacterial infection / septic shock .
• Recent meta analysis found that pt
hospitalized for sever CAP , glucocorticoids
administration was associated with reduced
mortality , reduced mechanical ventilation
need and shorter duration in hospital .
reducing ARDS .