Seminar presentation of Pneumonia

By Tajebe Taye
Endalk Elmneh

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 OUT LINE

Intoduction
Classification
Epidmology
 Ethiology
 Pathophysology
Clinical feature and diagnosis
Treatment
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 DEFINITIONS
Pneumonia is an infection of the pulmonary
parenchyma
To the pathologist, pneumonia is an infection of the
alveoli, distal airways, and interstitium of the lung that
is manifested by:
Increased weight of the lungs,
Replacement of normal lung’s sponginess by consolidation,
and
Alveoli filled with white blood cells, red blood cells and fibrin.

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 Cont…
To the clinician, pneumonia is a constellation of
symptoms and signs (fever, chills, cough, pleuritic
chest pain, sputum production, hyper- or
hypothermia, increased respiratory rate, dullness to
percussion, bronchial breathing, egophony,
crackles, wheezes, pleural friction rub)in
combination with at least one opacity on chest
radiography.

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 Classification
1. Etiologic
Infections
Inhalation of gastric contents
Immunological reactions
Inhalation of other toxic substances(such as dust or fumes)
2. Anatomic
Lobar or segmental: process is confined to the division of
the lung
Bronchopneumonia: small areas of the lung alveoli and
lobule around small terminal bronchi are affected

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 Classification#2
1. Community-acquired pneumonia (CAP):
 Cases of infectious pneumonia in patients living independently in the
community
 Patients who have been hospitalized for other reasons for less than 48
hours before the development of respiratory symptoms
2. Health care-associated pneumonia (HCAP)
a) Hospital-acquired pneumonia (HRevised Classification System
b) AP)
 Patients who have been hospitalized for at least 2 days
c) Ventilator-associated pneumonia (VAP)
 Patients contracting pneumonia >48 hours after the institution of
endotracheal intubation and mechanical ventilation

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 Pathogenesis
 Routes of Infection
Gross aspiration
Microaspiration
Hematogenous spread from a distant infected site
Direct spread from a contiguous infected site
 Host Factors
Hypogammaglobinemia
Defects in phagocytosis or ciliary function, neutropenia,
functional or anatomical asplenia, or a reduction in CD4+ T
lymphocyte counts
Anatomical defects such as obstructed bronchus,
bronchiectasis
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 Pathology
The pathology of pneumonia manifests as four general
patterns:
Lobar pneumonia

Bronchopneumonia

Interstitial pneumonia

Miliary pneumonia

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 Lobar Pneumonia:
Classically involves an entire lung lobe relatively
homogeneously, although in some patients a small portion
of the lobe may be unaffected or at an earlier stage of
involvement.
Four stages of lobar pneumonia may exist simultaneously
in the same lung
Congestion
Red hepatization
Gray hepatization
Resolution

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10 pneeumonia 03/08/2022
 Bronchopneumonia
A patchy consolidation involving one or several lobes,
usually involves the dependent lower and posterior
portions of the lung—a pattern attributable to the
distribution of aspirated oropharyngeal contents by
gravity.
The consolidated areas are usually poorly demarcated,
although in some cases there is an abrupt delimitation of
the pneumonia at interlobular septa.

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 Interstitial Pneumonia
Is defined by histopathologic identification of an
inflammatory process predominantly involving the
interstitium, including the alveolar walls and the
connective tissue around the bronchovascular tree.
The inflammation may be patchy or diffuse

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 Miliary Pneumonia
the resemblance of the diffusely distributed 2- to 3-
mm lesions of hematogenous tuberculosis to millet
seeds
Numerous discrete lesions resulting from the spread of
the pathogen to the lungs via the bloodstream

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 Complications
Necrotizing pneumonia
Abscesses
Vascular invasion with infarction
Cavitation
Empyema
Bronchopleural fistula.
Emphysema
Pneumothorax
ARDS

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 Community-Acquired Pneumonia
Epidemiology: With an annual cost of $9.7 billion, CAP
affects 4 million adults per year in the United States.
Rates of pneumonia are higher for men than for
women and for black than for white persons.
Risk factors: Independent risk factors for CAP include
alcoholism [RR 9], asthma (RR 4.2),
immunosuppression (RR 1.9), and an age of >70 years
(RR 1.5 vs. age of 60 to 69 years).

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 Etiology
The >100 documented microbial causes of CAP
include bacteria, fungi, viruses, and parasites
Most cases of pneumonia are caused by a few
common respiratory pathogens, including S.
pneumoniae, H. influenzae, S. aureus, M.
pneumoniae, C. pneumoniae, Moraxella catarrhalis,
Legionella spp., aerobic gram-negative bacteria,
influenza viruses, adenoviruses, and respiratory
syncytial virus.
Overall, S. pneumoniae accounts for 50% of all cases
of CAP requiring admission to the hospital
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 Cont …

Viruses most ften assocated with pneumonia are

Influenza A and B
Rhinoviruses
• HAP, VAP and HCAP may be caused by a wide range
of organisms.
• Early HAP and VAP commonly caused by enteic gram
negative bacilli
• Late onset HAP and VAP is because of resistant
strains P.auroginosa and Actinobacter spp.
• Rarly viruses and fungus cause HAP and VAP or HCAP.
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 Hospitalized Patients

Non-ICU
Microbial Causes of Community-Acquired
ICU
Pneumonia, by Site of Care
S. pneumoniae S. pneumoniae

M. pneumoniae S. aureus

C. pneumoniae Legionella spp.

H. influenzae Gram-negative bac

Legionella spp. H. influenzae

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 Clinical Manifestations
 Signs and symptoms
Abrupt onset of fever, chills, dyspnea, and productive cough
Rust-colored sputum or hemoptysis
Pleuritic chest pain
 Physical examination
Tachypnea and tachycardia
Dullness to percussion
Increased tactile fremitus, and egophony
Chest wall retractions and grunting respirations
Diminished breath sounds over affected area
Inspiratory crackles during lung expansion

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 Investigations
Chest radiograph
Dense lobar or segmental infiltrate
Etiologic diagnosis
Gram stain of sputum
Culture of sputum (< =50%)
Blood culture (~5–14%)
Antigen tests
PCR
Serology
Bronchoscopy

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 TREATMENT
Goals of Therapy
Eradication of the offending organism through
selection of the appropriate antibiotic
Complete clinical cure

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 General Approach to Treatment
Oxygen or, in severe cases, mechanical ventilation
and fluid resuscitation
Administration of bronchodilators (albuterol) when
bronchospasm is present, and chest physiotherapy
with postural drainage if evidence of retained
secretions
Adequate hydration (IV if necessary), optimal
nutritional support, and control of fever

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 Pharmacologic Therapy
Selection of Antimicrobial Agents
Initially involves the empirical use of a relatively broad-spectrum
antibiotic that is effective against probable pathogens
Therapy should be narrowed to cover specific pathogens after
the results of cultures are known.
Factors to define the potential pathogens:
Patient age
Previous and current medication history
Underlying disease(s)
Major organ function, and
Present clinical status.

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 Empirical Antibiotic Treatment of
CAP

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 Criteria for Hospitalization
Age >65
Co morbidity
Leukopenia (<5000/µl) not attributable to a known
conditions
S. aureus , G-ve bacilli, anaerobes suspected causes of
pneumonia
Suppurative complications
Failure of PO treatment
RR >30’, PR >120’, SBP<90/mmHg
PO2 < 60mmhg , acute alteration in mental status
Multiple lobe involvement

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 Switch from IV to PO Antibiotic
Switching from IV to oral antibiotics can be done
safely when:
The white blood cell count is returning toward
normal,
There are two normal temperature readings (37.5
0
C)16 hr apart, and
There is improvement in cough and shortness of
breath.

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 Discharge from the hospital
 Once physiologic stability is achieved:
An oral temperature of <37.50C for 24 h,
A heart rate of <100/min
A respiratory rate of <24/min
A systolic blood pressure of >90 mmHg,
An oxygen saturation of >90% while breathing room air
The ability to eat and drink well enough to maintain
hydration
Clinical deterioration requiring admission to a critical-care
unit

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 Health Care-associated Pneumonia
(HCAP)

Hospital-acquired pneumonia (HAP)

Patients who have been hospitalized for at least 2
days
Ventilator-associated pneumonia (VAP)
Patients contracting pneumonia greater than 48 to
72 hr hours after the institution of endotracheal
intubation and mechanical ventilation

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Non-MDR Pathogens MDR Pathogens

Streptococcus pneumoniae Pseudomonas aeruginosa

Microbiologic Causes of VAP
Other Streptococcus spp. MRSA

Haemophilus influenzae Acinetobacter spp.

MSSA Antibiotic-resistant Enterobacteriaceae

Antibiotic-sensitive Enterobacteriaceae Enterobacter spp.

Escherichia coli Klebsiella spp.

Klebsiella pneumoniae Legionella pneumophila

Proteus spp. Burkholderia cepacia

Enterobacter spp. Aspergillus spp.

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Serratia marcescens
Patients without Risk Factors for Patients with Risk Factors for MDR
MDR Pathogens Pathogens

1. A b-lactam:
Ceftazidime or cefepime or
Ceftriaxone or
Piperacillin/tazobactam, plus
2. A second agent active against
Moxifloxacin, ciprofloxacin, or
gram-negative bacteria:
levofloxacin or
Gentamicin or amikacin or
Ampicillin/sulbactam or Ciprofloxacin or levofloxacin plus
3. An agent active against gram-
Ertapenem positive bacteria:
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Vancomycin
 Aspiration

• Anaerobes and streptococcus spp are the primary pathogens if

a patient aspirates the oral contents and develop pneumonia
 Antibiotics
Penicillin G
Ampicillin sulbactam
Clindamycin
 If the patient aspirates oral and gastric contents then
anaerobes and GNB are primarily pathogens
Ampicillin/sulbactam
Amoxicillin / clavulanic acid
Piperacillin/ tazobactam
32
Ticarcillin / clavulanic
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 Duration of antimicrobial therapy

Should be kept as short as possible

The longer the antibiotic administered the greater
chance of toxicity from the agent , as well as increase
in cost.
If the cultures are positive , the duration of therapy
should be 2 weeks from the day blood culture become
negative

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 Resistance issue
S.pneumonia has developed resistance mechanism
againist many classes of antimicrobials and the
mechanism include
1. Alteration of PBP
2. Efflux or methylation of ribosomes inactivations
macrolides
3. Ribosome protection inactivating tetracyclins
4. Alteration of DNA gyrase or topoisomerase IV
inactivating fluoroquinolones
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 
Cont…
Risk factors for developing infection causd by
resistant pathogen are
1. antimicrobial therapy in the preceding 90 days
2. Current hospitalization of at least 5 day
3. High occurrence of antibiotic resistance in the
community or in the specific hospital unit
4. Immunosuppressive disease and/or therapy

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 Out come evaluation
Improvement of symptoms should be occurs with in 24 to
72 hours .
Response to therapy could be slowed in patients
underlying pulmonary disease Athma, COPD and
emphysema .

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 Prevention
• Regular influenza vaccine is approved for use in peoples older than 6
months of age including healthy people with chronic medical conditions
• The CDC identified high risk groups in which vaccination is especially
important

1. Pregnant women
2. Children younger than 5 but especially children younger then 2
years old
3. Peoples 50 years of age and older
4. Peoples of any age with certain chronic medical condition.
5. People who live in ……
6. Peoples who live with or care for those at high risk for complication
from flu

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 Reference
STG 2014
Dipiro 9th
Pharmacotherapy priciple and practice McGraw-
Hill(2016)

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 THANK YOU

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