Pneumonias Up To Date

,Walid Daoud
MBBCh, MSc, MD, FCCP
Medical Doctorate (MD), Cairo University
Fellow of the American College of Chest Physicians
Head of Chest Department, Shifa Hospital
A. Professor of Chest Medicine
 Classification
____________________________

CAP: Community-acquired pneumonia

Outside hospital or extended-care facility
HAP: Hospital-acquired pneumonia
h from admission 48 ≥
VAP: Ventilator-associated pneumonia
h from endotracheal intubation 48 ≥
HCAP: Healthcare-associated pneumonia
Long-term care facility (NH), hemodialysis,
.outpatient chemo, wound care, etc
 Community-acquired pneumonia
_______________________________________________________________________________________________________________________________________________

A syndrome of infection usually bacterial with

symptoms and signs of consolidation of part
.(s) of the lung parenchyma
:Epidemiology
The 6th leading cause of death in UK & USA
and number 1 cause of death from infectious
. disease, in USA
.require hospitalization 40%
.Hospital Mortality 5-12%
Community-acquired pneumonia
____________________________________________________________________________________________________________________________________________

:Risk factors for CAP

.Aspiration (anaerobes and gram-negative) -1
Alcoholism and Diabetes -2
..Steroids / immunosuppression (legionella) -3
.COPD (H. influenza, M. catarralis) -4
.Nursing home residents (aspiration) -5
Community-acquired pneumonia
____________________________________________________________________________________________________________________________________________

:Organisms causing CAP

:Typical
.Streptococcus or pneumococcus pneumoniae
.Staphylococcus aureus
Gram negative bacteria and anaerobes
:Atypical
.Mycoplasma pneumoniae
.Chlamydia pneumoniae
.Mycoplasma pneumoniae
.Legionella pneumophilia
Viral pneumonia
Community-acquired pneumonia
____________________________________________________________________________________________________________________________________________

:Pathology
Stage of congestion: of pulmonary capillaries & -1
. exudation of cellular fluid in alveolar spaces
Stage of red hepatization: alveoli full with -2
coagulated exudate, fibrin and many red cells,
. PMNLs and pneumococci
Stage of grey hepatization: alveoli contain feww -3
. intact red cells and PMNLs
.Stage of resolution: exudate is absorbed -4
 Community-acquired pneumonia
____________________________________________________________________________________________________________________________________________

:Clinical Features of typical CAP

Fever with chills, tachycardia, tachypnea, dyspnea -
dry then productive cough, malaise, vomiting,
.pleuritic pain, grunting or acting ala nasi & herpes
:Examination
.mobility and chest expansion of affected side ↓-
. TVF and impaired percussion note and ↑ VR ↑-
breath sounds, bronchial breathing, bronchophony, ↓-
whispering pectoriliquy and medium-sized
consonating crepitations
Community-acquired pneumonia
____________________________________________________________________________________________________________________________________________

:Poor Prognostic Factors

Age (>65), Coexisting disease (cardiac, DM, -
COPD, stroke)
.RR > 30/min, confusion-
Systolic BP<90 mmHg, diastolic BP<60 mmHg-
Hypoxemia, urea>7mmol/l, albumin< 3.5 gm/dl-
-WBC > 20 or < 4 x 109/l
.CXR: bilateral or multilobar pneumonia-
.Microbiology: positive blood culture-
Community-acquired pneumonia
____________________________________________________________________________________________________________________________________________

:Severity Assessment
:CURB 65 score factors
.Confusion - mental confusion .
.Urea - ≥ 7 mmol/l .
.Respiratory rate ≥ 30/min .
Blood pressure syst ≤ 90 and/or diast ≤ 60 .
.Age ≥ 65 .
,factors = mortality 83%, 3 factors = 33% 4
,factors = 23%, one factor = 8% 2
no factors = 2.4%
 Hospital management of community acquired pneumonia (CAP) in the first 4 h.

Lim W S et al. Thorax 2009;64:iii1-iii55

Copyright © BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.
Pnemococcal pneumonia
H. Influenza pneumonia
Legionella pneumonia
Chamydia pneumonia
Mycoplasma pneumonia
Influenza virus pneumonia
Respiratory syncytial virus pneumonia
Aspiration pneumonia
Community-acquired pneumonia
____________________________________________________________________________________________________________________________________________

:Management
.Oxygen if sat < 92%-
.Fluid IV and monitor urine output-
.Analgesia and antipyretic-
.Bronchoscopy if lobar collapse or bronchial obst -
% Monitoring: T, RR, HR, BP, mental status, O2 sat-
ICU admission: resp. failure, metabolic acidosis, -
.hypotension despite of fluid resuscitation
.Antibiotics-
Community-acquired pneumonia
____________________________________________________________________________________________________________________________________________

:Treatment Failure
Incorrect initial diagnosis: embolism, edema, -
cancer, bronchiectasis, eosinophilic pneumonia,
.FB aspiration, alveolar hemorrhage, CT disease
:Secondary complications-
.Pulmonary: empyema, abscess, ARDS.
Extrapulmonary: septicemia, metastatic; meningitis, .
.endocarditis, septic arthritis, renal failure
.Inappropriate antibiotics or unexpected pathogen -
.Impaired immunity-
Resistant micro-organism-
 EVIDENCE-BASED GRADING SYSTEM
Definition
Evidence comes from well conducted, randomized Level I
controlled trials
Evidence comes from well designed, controlled trials Level II
without randomization (including cohort, patient
series, and case-control studies). Also any large
case series in which systematic analysis of disease
patterns and/or microbial etiology was conducted, as
well as reports of new therapies that were not
collected in a randomized fashion
Evidence comes from case studies and expert Level III
opinion. In some instances therapy
recommendations come from antibiotic susceptibility
data without clinical observations
 Site-of-Care Decisions
It depends on the initial assessment of severity
Hospital
.vs
Outpatient
vs
Intensive care unit [ICU]
vs
General ward
Hospital Admission Decision
:Severity-of-illness scores .1
)CURB-65 criteria(
Confusion, uremia, respiratory rate, low
.blood pressure, age 65 years or greater
:Prognostic model .2
)PSI( )pneumonia severity index(
Can be used to identify patients with CAP
.who are candidate for outpatient treatment
)Strong recommendation; level I evidence(
 Hospital Admission Decision
:Objective criteria or scores .3
Physician determination of the ability to
safely and reliably take oral medication and
the availability of outpatient support
.resources
)Strong recommendation; level II evidence(
Hospital Admission Decision
:For patients with CURB-65 scores ≥ 2 .4
,More intensive treatment - that is
hospitalization or, where appropriate and
available, intensive in-home health care
.services – is usually warranted
)Moderate recommendation; level III evidence(
 ICU Admission Decision
Direct admission to an ICU is required for patients .1
with septic shock requiring vasopressors or with
acute respiratory failure requiring intubation and
mechanical ventilation
)Strong recommendation; level II evidence(
 ICU Admission Decision
Direct admission to an ICU or high level monitoring .2
unit is recommended for patients with 3 of the
.minor criteria for severe CAP
)Moderate recommendation; level II evidence(
 Criteria for severe CAP
Minor criteria
Respiratory rate 30 breaths/min ●
PaO2/FiO2 ratio 250 ●
Multilobar infiltrates ●
Confusion/disorientation ●
Uremia (BUN level, 20 mg/dL) ●
Leukopeniac (!4000 cells/mm3) ●
Thrombocytopenia (!100,000 cells/mm3) ●
Hypothermia (core temperature, !36C) ●
Hypotension requiring aggressive fluid resuscitation ●
 Criteria for severe CAP
Other Minor criteria
Hypoglycemia in non-diabetic patient ●
Acute alcoholism withdrawal ●
Hyponatremia ●
Unexplained metabolic acidosis ●
Elevated lactate level ●
Liver cirrhosis ●
Asplenia ●
Major criteria
Invasive mechanical ventilation ●
Septic shock with the need for vasopressors ●
Recommended emperical
antibiotics for CAP
 Outpatient treatment
Previously healthy & no use of antimicrobials in the .1
:last 3 months
Macrolide (strong recommendation; level I evidence) ●
Doxycyline (weak recommendation; level III evidence) ●
,Presence of comorbidities such as chronic heart, lung .2
;liver or renal disease, diabetes mellitus; alcoholism
malignancies, asplenia; immunosuppressing conditions or
use of immunosuppressing drugs; or
:use of antimicrobials in the last 3 months
Fluoroquinolone (moxifloxacin, gemifloxacin or ●
levofloxacin (strong recommendation; level I evidence)
ß-lactam plus macrolide (strong recommendation; level I ●
evidence)
 .
:Inpatients, non-ICU treatment
Fluoroquinolone (moxifloxacin, gemifloxacin or ●
levofloxacin (strong recommendation; level I evidence)
ß-lactam plus macrolide (strong recommendation; level I ●
. evidence)

:Inpatients, ICU treatment

-ß-lactam (cefotaxime, ceftriaxone, or ampicillin ●
sulbactam) plus either Azithromycin
or )strong recommendation; level II evidence(
Fluoroquinolone (strong recommendation; level I evidence)
 .
:If Pseudomonas is considered
An antipneumococcal, antipseudomonal ß-lactam
(piperacillin, tazobactam, cefepime, imipenem, or
meropenem) plus either ciprofloxacin or levofloxacin
Or
The above b-lactam plus aminoglycoside and
azithromycin
Or
The above b-lactam plus aminoglycoside and
Antipsudomoal flouroquinolone
)Moderate recommendation; level III evidence(
 .
If Community-acquired methicillin-
resistant staphylococcal aureus
:(CA-MRSA)
ß-lactam plus
vancomycin or linezolid
)Moderate recommendation; level III evidence(
Hospital-acquired pneumonia
_________________________________________________________________________________________________________________________________________

Nosocomial pneumonia that is niether present nor

incubating at time of hospital admission with onset
.at least 72 hours after admission
.Forms 15% of hospital - acquired infections
:Pathophysiology
.Hematogenous spread of organism-
Aspiration of infected upper airway secretion or -
.Inhalation of bacteria from contaminated equipment -
Hospital-acquired pneumonia
_________________________________________________________________________________________________________________________________________

:Risk factors
.Age > 70 -
.Co-morbid illness: chronic lung disease, DM -
.Reduced conscious level: CVA -
.Chest/abdominal surgery -
.Mechanical ventilation, nasogastric feeding -
.Poor dental hygiene -
.Steroids and cytotoxic drugs -
.Previous antibiotic exposure -
Hospital-acquired pneumonia
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:Risk Factors for Specific Organisms

Streptococcus pneumoniae and Hemophilus -1
. influenza ↑ risk in trauma
Staphylococcus aureus ↑ risk in neurosurgical -2
. patients, blunt trauma and coma
Pseudomonas aeruginosa ↑ risk with intubation -3
. > 8 days, COPD and prolonged antibiotics
Acinetobacter species ↑ risk with prolonged -4
ventilation & previous broad spectrum antibiotics
.Anaerobic bacteria ↑ in abd. surgery & aspiration-5
Hospital-acquired pneumonia
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:Risk Factors for MDR pathogens

Antimicrobial therapy in preceding 90 d •
Current hospitalization of 5 d or more •
High frequency of antibiotic resistance in the •
community or in the specific hospital unit
Immunosuppressive disease and/or therapy •
:Presence of risk factors for HCAP •
Hospitalization for 2 d or more in the preceding 90 d
,nursing home, home infusion or wound care
chronic dialysis within 30 d, family member with
.MDR organism
Hospital-acquired pneumonia
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:Clinical Features
Fever, productive cough, raised inflammatory
parameters, new CXR infiltrate, deterioration
.in gas exchange
:Investigations
.CXR: nonspecific infiltrate-1
.Culture: blood, sputum and pleural fluid-2
.ABG to determine severity-3
.Renal & liver function for organ dysfunction-4
.Serological tests are of little value-5
Hospital-acquired pneumonia
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:Microbiology
.are mixed infection 50%-
.are aerobic bacteria (gram-ve & pseudomonas) 30%-
.are anaerobes alone 25%-
Pseudomonas & staphylococci are common causes-
.Acinetobacter is a new emerging pathogen-
.MRSA is increasing in prevalence-
.Viruses are recognized as causes-
Hospital-acquired pneumonia
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:Management
Pneumonia developing >48 hours after admission
need IV prolonged antibiotics to cover both gram-ve
.and anaerobes
.Supportive treatment: oxygen, fluid ± ventilation
.Prognosis: high mortality 20-50%
:Prevention
.Hygiene & hand washing of medical staff-
.Infection control measures-
Preoperative sterilization of respiratory equipment -
Ventilator-associated pneumonia
(VAP)
____________________________________________________________________________________________________________________________________________

VAP occurs in mechanically ventilated patient

.and develops 48 hours after intubation
.Prevalence up to 65% and mortality up to 50%
The major cause is bacterial contamination of
the lower respiratory tract from aspiration of
.oropharyngeal secretions
:Diagnosis
.New or progressive CXR infiltrate-
.Fever, high WBC, purulent secretions-
Ventilator-associated pneumonia
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:Investigations
.CXR: infiltrate with air bronchograms-
;Airway sampling for microbiology-
:Bronchoscopic .
Protected specimen brush (PSB)
.Bronchoalveolar lavage (BAL)
Non-bronchoscopic: blind bronchial or .
. serial sampling or tracheal aspiration
Ventilator-associated pneumonia
(VAP)
____________________________________________________________________________________________________________________________________________

:Antibiotic treatment
Emergence of resistant bacteria means that
.empirical antibiotic is less commonly used
:Risk of resistant organisms
.Ventilation > 7 days-
Prior broad spectrum antibiotic (3rd gen. ceph)-
Antibiotics should be chosen on the basis of local
policy, known local flora and culture data and
should cover anaerobes, MRSA, legionella,
.pseudomonas and acinetobacter
 Aspiration Pneumonia
____________________________________________________________________________________________________________________________________________

Pneumonia following aspiration of exogenous

material or endogenous secretions into the lower
.respiratory tract
:Predisposing Factors
Reduced conscious level: cough reflex and -1
impaired glottic closure: alcohol, drug, anesthesia
.Dysphagia: CVA, motor neuron disease-2
.Upper GIT disease: surgery, tracheostomy-3
.Increased reflux; nasogastric feeding-4
.Nursing home residents-5
 Aspiration Pneumonia
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:Chemical pneumonitis (Mendelson syndrome)-1

Aspiration of sterile gastric content pH < 2.5
initiates inflammatory reaction, atelectasis,
.pulmonary hemorrhage and edema
:Clinically
Rapid onset 1-2 hours, low grade fever, dyspnea ,
severe hypoxemia and diffuse lung infiltrate in CXR
:Treatment
Suction or bronchoscopy, IV fluids, O2, Ventilation,
.antibiotics against gram-ve and anaerobes
 Aspiration Pneumonia
____________________________________________________________________________________________________________________________________________

:Bacterial infection-2
Aspiration of bacteria flora resident in
stomach or upper airways.
Peptostreptococci, fusobacterium
nucleatum, prevotella and bacteroides
.species
.Clinically: occurs over weeks or months
Cough, with or without fever, purulent sputum,
.dyspnea, foul smell sputum
:Treatment
.Antibiotic to cover anaerobes
Initial emperic antibiotic therapy for HAP,
no risk factor, early onset & no risk of MDR
____________________________________________________________________________________________________________________________________________

S. pneumoniae, H. influenzae, MRSA,

Antibiotic-sensitive enteric gram-negative
:bacilli
Ceftriaxone
Or
Levofloxacin, moxifloxacin, or ciprofloxacin
Or
Ampicillin/sulbactam
Or
Ertapenem
 Initial empiric therapy for HAP, VAP, HCAP in
patient with late onset disease or risk factor for
MDR pathogens and all disease severity
____________________________________________________________________________________________________________________________________________

Antipseudomonal cephalosporin
)cefepime, ceftazidime(
Or
Antipseudomonal carbepenem
)imipenem or meropenem(
Or
β-Lactam / β-lactamase inhibitor
)piperacillin–tazobactam(
Or
Antipseudomonal fluoroquinolone
Levofloxacin, moxifloxacin, or ciprofloxacin
Or Aminoglycosides
 Initial empiric therapy for HAP, VAP, HCAP in
patient with late onset disease or risk factor for
MDR pathogens and all disease severity
____________________________________________________________________________________________________________________________________________

Antipseudomonal cephalosporin
)cefepime, ceftazidime(
Or
Antipseudomonal carbepenem
)imipenem or meropenem(
Or
β-Lactam / β-lactamase inhibitor
)piperacillin–tazobactam(
Or
Antipseudomonal fluoroquinolone
Levofloxacin, moxifloxacin, or ciprofloxacin
Or Aminoglycosides
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