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CURRENT APPROACHES IN

THE MANAGEMENT OF
PNEUMONIA

Daphne D. Bate, M.D.
Internal Medicine-Pulmonary
Case 1
• A 50 year old male, diagnosed COPD,
consulted the OPC because of fever, cough,
productive of whitish to yellowish phlegm
with difficulty of breathing. The RR was
28/min, the BP 110/80 and PR 100/min.
There were crackles in the left basal lung.
Case 1


• Segmental infiltrate
without a visible air
bronchogram in the
left lower lung field
Pneumonia
• Infection of the pulmonary
parenchyma
• Fever, cough with or without
dyspnea, pleuritic chest pain
• Abnormal chest findings:
diminished breath sounds,
rhonchi, crackles
Transmission of Bacteria
1. Aspiration of organisms from the:
a. Oropharynx - Strep., Mycoplasma,
Moraxella, H. influenza
b. Gingival crevices & plaques - Anaerobic
c. Stomach, nasogastric tubes, respiratory
equipments, hands of health worker,
contaminated food and water –
Gram-negative organisms
Transmission of Bacteria
2. Inhalation of Infectious Aerosol – M.
tuberculosis, H. influenzae, Legionella
3. Hematogenous dissemination from an
extrapulmonary site - Staphylococcus
4. Direct inoculation and contiguous spread
– Tracheal intubation, chest tube
thoracostomy and wounds of the chest
MICRO-ORGANISMS
TYPICAL
• S. pneumoniae
• H. influenzae
• Mixed aerobic
and anaerobic
organisms of the
oral flora
ATYPICAL
• Mycoplasma
• Legionella
• Chlamydia
• Others

Signs and Symptoms
Clinical
• Gradual to sudden
onset of fever
• cough, dry to
productive purulent
sputum
• pleuritic chest pain
P.E.
• rales
• bronchial BS
• dullness
• increased fremitus
Community Acquired Pneumonia
• A 50 year old male
• diagnosed COPD
• consulted OPD
• fever, productive
cough & DOB
• RR 28/m, BP 110/80
& PR 100/min.
• crackles in the left
basal lung.
What is your impression of
Case 1?
a. Community acquired pneumonia (CAP)
b. Nosocomial pneumonia
c. Pneumonia in an immunocompromised
host
d. Pulmonary tuberculosis

2. How will you categorize
this CAP?
a. Minimal risk
b. Low risk
c. Moderate risk
d. High risk
Classification of Pneumonia
Nonseverely Ill
Phil Practice Guidelines 2004
Low Risk
Mortality rate <5%
• Stable vital signs
• No or stable co-morbid
condition
• No extra-pulmonary sepsis
and aspiration
• No aspiration
• CXR is localized

Moderate Risk
Mortality rate 21%
• Unstable vital signs
• Unstable co-morbid
condition
• Extra-pulmonary sepsis
• Suspected aspiration
• CXR multilobar, abscess,
progressive in 24 hrs



Co-morbid Conditions

• COPD
• Neoplastic Disease
• Congestive Heart Failure
• Immunosuppressive therapy
• Renal insufficiency
• Diabetes Mellitus
• Chronic liver disease
Potential Pathogens
Phil Practice Guidelines 1998


LOW RISK
Streptococcus
H. Influenzae
Chlamydia
Mycoplasma
Moraxella catarrhalis
Enteric gram negative

MODERATE
RISK

Same plus as in low risk

Legionella pneumophilia
Anaerobes (with
aspiration)


0
1
2
3
4
5
6
7
#1 #2 #3 #4 #5
S. pneumoniae
H. influenzae
Legionella
Atypicals
Phil. Practice Guidelines
1998
Rank Order of Etiologic Agents
of CAP (10 studies)
Etiology in 103 cases of CAP, Lung
Center Phil., 1996
26%
16%
15%
10%
19%
1%
4%
9%
Chlamydia sp.
S. pneumoniae
Legionella
Mycoplasma
Gram negative
H. influenzae
Pseudomonas
Moraxella
Organisms isolated from sputum cultures
of CAP Patients, Lung Center Phil., 1996
14%
6%
18%
3%
1%
58%
Streptococcus
M. catarrhalis6
Gram - org
Pseudomonas
H.influenza
Unkown
3. How do confirm the
diagnosis?
a. Sputum gram staining
b. Sputum culture and sensitivity
c. Blood culture and sensitivity
d. Urinary antigen assay
Diagnostic studies

• Baseline assessment – Chest x-ray
• Outpatients – Sputum g/s and c/s are optional
• Inpatients –
a. CBC and blood chemistry
b. Blood cultures and sensitivity– 2x
c. Sputum gram stain with C/S
d. Urinary antigen assay for Legionella
e. Sputum AFB smears and C/S

Radiology
• Confirms the presence, location & extent of
pulmonary infiltrates
• detect pleural involvement, pulmonary
cavitation or hilar lymphadenopathy
• gauge response to antimicrobial therapy
Radiology
• Multicentric distribution in hematogenous
infection from septic embolization in
patients with thrombophlebitis or right-
sided endocarditis
• diffuse distribution in P. carinii, varicella
or cytomegalovirus
• diffuse lesions in immunocompromised
hosts due to legionellosis, tuberculosis,
histoplasmosis, Mycoplasma &
strongyloidiasis
Radiology
• Tissue necrosis and pulmonary cavities due
to Staph aureus, Strep pneumoniae serotype
III, aerobic gram negative bacilli, M.
tuberculosis and fungi
• Mucor and Aspergillus invade blood vessels
to cause pleura-based, wedge-shaped
pulmonary infarction that may cavitate
Computed Tomography
Differentiates between:
• pleural effusion versus pulmonary
consolidation
• hilar adenopathy versus mass
• pulmonary abscess versus empyema with
air-fluid level
Invasive Procedures
To bypass the oro-pharyngeal cavity that is
heavily contaminated with micro-organisms
• Tracheal biopsy
• Percutaneous transthoracic lung puncture
• Fiberoptic bronchoscopy with
protected double-sheathed brush
bronchoalveolar lavage
transbronchial biopsy
• Open lung biopsy
Ultrasound Serologic Tests
• Differentiates
between pleural
effusion versus
pulmonary
consolidation
• Mycoplasma
pneumoniae
• Chlamydia
pneumoniae
• Legionella
pneumoniae
4. What are the antibiotics empirically
used in Low Risk CAP?

a. Cotrimoxazole
b. Beta-lactams
c. Extended Macrolide
d. Ciprofloxacin
EMPIRICAL ORAL
ANTIMICROBIAL THERAPY FOR
OUTPATIENT MANAGEMENT OF CAP
Harrison’s Principle of Internal Medicine
Pathogen Co-
trimox
azole
Co-
Amoxi-
clav
Cefuro
xime
Erythro-
mycin
Cipro-
floxaci
n
S pneumoniae +/- + + + +/-
H. influenzae + + + +/- +
M catarrhalis + + + + +
Anaeobes - + - - -
Atypicals

- - - + +


Empiric Antibiotic Therapy
Phil Practice Guidelines 2004
Low Risk CAP
Previously healthy
Amoxycillin

or
Macrolide
(Extended)
Or
Co-trimoxazole


With stable co-morbidity
Co-Amoxiclav or
Sultamicillin or
2
nd
Gen.Cephal. or
Macrolide, Extended


Antimicrobial Therapy with
Anaerobic Coverage

• Ticarcillin/cluvalanate
• Piperacillin/tazobactam
• Imipenem
• Clindamycin
• Metronidazole

Harrison’s 15
th
Ed. Principles in Internal Medicine



CRITERIA FOR HOSPITALIZATION OF
PATIENTS WITH PNEUMONIA
• Elderly patient (>65 years of age)

• Significant co-morbidity (kidney, heart,
lungs, diabetes, neoplasm,
immunosuppression)
• Leukopenia (<5,000 WBC cells/ul) not
attributable to a known condition
• Staphylococcus aureus, gram-negative
bacilli, anaerobes as suspected cause
CRITERIA FOR HOSPITALIZATION OF
PATIENTS WITH PNEUMONIA
• Suppurative complications (empyema, arthritis,
miningitis, endocarditis)
• Failure of outpatient management
• Inability to take oral medication
• Tachypnea (>30/min); tachycardia (>125
beats/min); hypotension (<90 systolic);
hypoxemia (PaO2 <60 mmHg), acute alteration
of mental status

Phil Practice Guidelines 1998


Case 2
A 66 year old female diabetic was
admitted because of CVA. One day
later she developed fever, cough and
difficulty of breathing. P.E. revealed
RR of 34/min., PR of 135 beats/min.
Crackles & increased breath sounds
were heard in the right base of the
lung.

Case 2

Chest x-ray showed
a dense, homogeneous,
nonsegmental
consolidation in the
right lower lobe.
What is your impression of
Case 2?
• Community acquired pneumonia (CAP)
• Nosocomial pneumonia
• Pneumonia in an immunocompromised
host
• Pulmonary tuberculosis

Nosocomial pneumonia
• Hospital acquired pneumonia
• Developes 48 hours after admission
• New or progressive pulmonary
infiltrates, purulent tracheobronchial
secretions
• Fever and leukocytosis
2. How will you categorize
this CAP?
A. Minimal risk
b. Low risk
c. Moderate risk
d. High risk


Moderate Risk


• Or unstable vital signs
• Unstable co-morbid
condition

• mortality = 21%



• Bilateral or multilobar
involvement by CXR
• Progression of lesion
to 50% of initial
finding in 24 hours
• Pleural effusion,
abscess, aspiration
• Sepsis
High Risk
Severely Ill
• Impending or frank respiratory failure
(PaO2 < 60 mmHg, PaCO2 >50 mmHg)
• Hemodynamic alterations and hypoperfusion
(altered mental state, DBP<60 mmHg or SBP <90
mmHg, or urine output <30 ml/hr)
• Mortality rate – 36.5%
• Intensive care unit management
EMPIRICAL ORAL ANTIMICROBIAL THERAPY
FOR MANAGEMENT OF HOSPITALIZED CAP
+
+/-
+
-
+
+

Erythro-
mycin
-
-
-
+
-
-
+
+
+
-
+
+/-







+
+
+
-
-
-

+
+
+
+
-
-

S. Pneumon
H. Influenza
M. Catarrhali
Anaerobes
C. Pneumon
L. Pneumon
Metroni
dazole
3rd G
Quino
lones
2
nd
gen.
Ceph
Ampic
Sulbac
tam.

Pathogen
Treatment of Moderate Risk
(Inpatient)
Potential Pathogen

S. Pneumonia
H. Influenzae
C. Pneumoniae
M. Pneumoniae
Legionella
Gram-negative bacilli
Anaerobes


Moderate Risk

IV Beta-lactams
with/without
b lactamase inhibitor
+
Macrolide
Or
Flouroquinolone

High Risk CAP

Streptococcus
Influenzae
Chlamydia
Moraxella
Mycoplasma
Gram-negative bacilli
Legionella
Anaerobes
Staphylococcus
Pseudomonas


High Risk CAP
No Risk for P. aeruginosa
IV Beta-lactams
with/without
b lactamase inhibitor
+
Erythromycin IV
Or
Flouroquinolone

With risk for P. aeruginosa
Anti-pseudomonal
IV Beta-lactams
+/-
Aminoglycoside or
ciprofloxacin
+
Erythromycin IV or
IV Flouroquinolone


Antimicrobial Therapy in Hospital and
Institutional Acquired Pneumonia
• Co-amoxyclav, Nafcillin or
Vancomycin
1. Ceftazidime +/- aminoglycoside
2. Ticarcillin/cluvalanate +/-
aminoglycoside
3. Aztreonam +/- aminoglycoside
4. Imipenem +/- aminoglycoside
5. Flouroquinolone +/- aminoglyco

Staph aureus

Enteric aerobic gram –
bacilli or Pseudomonas
Regimen Etiology
FACTORS INVOLVED IN POOR
RESPONSE TO EMPIRICAL
ANTIMICROBIAL THERAPY
1. Incorrect microbiologic diagnosis
2. Inappropriate antimicrobial agent or
dosing regimen
3. Drug hypersensitivity or other
adverse effect

FACTORS INVOLVED IN POOR
RESPONSE TO EMPIRICAL
ANTIMICROBIAL THERAPY
3. Atelectasis, paraneumonic effusion,
phlebitis
4. Poor host defenses (co-morbidity)
5. Infectious complications: empyema,
metastatic spread, superinfection

Harrison’s 15
th
Ed. Principles in Internal Medicine

When can you shift to oral medications?

a. After 72 hours after start of antibiotics
b. Less cough and normalization of RR
c. Afebrile for >24 hours
d. The etiology is not a virulent/resistant
pathogen

When can you shift to oral medications?

e. There are no unstable co-morbid
conditions or life-threatening
complications
f. Oral medications are tolerated
g. There is no obvious reason for continued
hospitalization such as acute mental
changes, hypoxemia, etc.

Community Acquired Pneumonia
Summary
1. The most common etiologies identified are
Strep pneumoniae, H. influenzae, gram-
negative org., Mycoplasma, Chlamydia sps,
Moraxella and Enteric gram negative org.
2. An increased incidence of aerobic gram-
negative pneumonia having an almost the
same incidence with gram-positive aerobes
Community Acquired Pneumonia
Summary
3. The most common clinical
manifestations are cough, sputum
production, dyspnea and fever.

There are no distinctive clinical features
found to be diagnostic for any etiologic
agent
Community Acquired Pneumonia
Summary
4. The factors significantly associated with
mortality are severity of pneumonia,
presence of tachypnea, tachycardia,
hypotension and normal or decreased
WBC count

Community Acquired Pneumonia
Summary
5. Empiric antibiotic treatment for the two
groups of patients - the severely ill and
nonseverely ill patient.
6. A beta-lactam or macrolide feature for
the nonseverely ill and the combination
of a anti-pseudomonal beta-lactam (+/-
aminoglycoside or ciprofloxacin) plus
a macrolide for the severely ill patient
Summary
• Gram negative, Staph aureus & Legionella
are common in hospital acquired
pneumonia, pneumonia in immuno-
compromised host & the elderly in
institutional homes
• Treatment in these cases include beta-
lactam IV with erythromycin IV
(with/without aminoglycoside or
ciprofloxacin)
THANK YOU
Daphne D. Bate, M.D.