everything about pneumonia

1. Pneumonia
Sriloy Mohanty
B.N.Y.S

2. Pneumonia – Definition
An acute infection of the pulmonary
parenchyma that is associated with at least
some symptoms of acute infection,
accompanied by some auscultatory findings
consistent with pneumonia and radiological
pulmonary shadowing

3. What happens ???
• Inflammatory condition where alveoli are
filled with fluid and blood cells
• Begins with infection of alveoli followed by
inflamed pulmonary membrane and becomes
highly porous
• Whole lobe or sometimes whole lungs is
consolidated

4. Pneumonia
I. Reduction in the total available surface area
of the respiratory membrane
II. Decreased ventilation-perfusion ratio
These two causes
 Hypoxemia
 hypercapnia

5. Pneumonia
• The major cause of death in the world
• The 6th
most common cause of death in the
U.S.
• Annually in U.S.: 2-3 million cases, ~10
million physician visits, 500,000
hospitalizations, 45,000 deaths, with average
mortality ~14% inpatient and <1%
outpatient

6. Risk factors
• Old age
• Recent influenza infection
• Pre-existing lung disease
• Lowered immune system due to corticosteroid
therapy,
• Alcohol,smoking

7. Pneumonia - Symptoms
• Cough (productive or
non-productive)
• Dyspnea
• Pleuritic chest pain
• Fever or hypothermia
• Myalgias
• Chills/Sweats
• Fatigue
• Headache
• Diarrhea (Legionella)
• Sinusitis
• Loss of appitite

8. Findings on Exam
• Physical:
 Vitals: Fever or hypothermia
 Pyrexia,techicardia,hypoxamia
 Lung Exam: Crackles, rhonchi, dullness to percussion
• Labs:
 Elevated WBC
 Hyponatremia – Legionella pneumonia
 Positive Cold-Agglutinin – Mycoplasma pneumonia

9. Investigations
• Chest X-ray
▫ Pulmonary shadow
• Microbiological investigation
▫ Strep. pneumo urinary antigen
▫ Legionella urinary antigen
▫ < 10 Squamous Epithelial Cells
• Arterial blood gas measurements
▫ PO2
• General blood test
▫ High neutrophil leucocytes

10. Investigation objectives
• To obtain a radiological conformation of the
diagnosis
• To exclude other condition that may mimic
pneumonia
• To obtain microbiological diagnosis
• To assess the severity of the pneumonia

11. Chest X-ray
RUL
RML
RLL
LUL
Lingula
LLL
RUL
RML
RLL
LUL
Lingula
LLL

12. Chest X-ray – Pneumonia

13. Chest X-ray - Pneumonia

14. Chest X-ray -- Pneumonia

15. Types of Pneumonia
• Community-Acquired (CAP)
• Hospital-Acquired Pneumonia (HAP)
▫ Pneumonia that develops after 5 days of hospitalization
▫ Includes:
 Ventilator-Associated Pneumonia (VAP)
 Aspiration Pneumonia

16. Common Bugs for Pneumonia
Community-Acquired
• Streptococcus pneumoniae
• Mycoplasma pneumoniae
• Chlamydophila psittaci or
pneumoniae
• Legionella pneumophila
• Haemophilus influenzae
• Moraxella catarrhalis
• Staphylococcus aureus
• Nocardia
• Mycobacterium tuberculosis
• Influenza
• RSV
• CMV
• Histoplasma, Coccidioides,
Blastomycosis
HCAP or HAP
• Pseudomonas aeruginosa
• Staphylococcus aureus
(Including MRSA)
• Klebsiella pneumoniae
• Serratia marcescens
• Acinetobacter baumanii

17. Special Clues on Chest X-ray
• Lobar pneumonia – Strep. Pneumonia
• Diffuse interstitial infiltrates – Pneumocystis
• RUL infiltrate – Tuberculosis
• Diffuse interstitial infiltrates – Tuberculosis
in HIV

18. PORT Score

19. PORT Score

20. Antibiotics treatment
• Amoxillin 500mg 8-hourly orally
• If patient allargic to penicilin
▫ Clarithromycin 500mg 12 hourly orally
▫ Erythromycin 500mg 6 hourly orally
• If staphylococcus is cultured
▫ Flucoxamin 1-2g 6 hourly orally
▫ Clarithromycin 500mg 12 hourly orally

21. Severe CAP
▫ Clarithromycin 500mg 12 hourly orally
▫ Erythromycin 500mg 6 hourly orally
▫ Amoxillin 500mg 8-hourly orally
▫ Co-amoxiclav 1.2mg 8 hourly i.v

22. Treatment of HCAP, HAP, VAP
• Antipseudomonal cephalosporin (Cefepime,
Ceftazidime) + Vancomycin
• Anti-pseudomonal Carbapenem (Imipenem,
Meropenem) + Vancomycin
• Beta-Lactamase/Beta-Lactamase Inhibitor (Pip-Tazo –
Zosyn) + Pseudomonal Fluoroquinolone (Cipro) +
Vancomycin
• Aminoglycoside (Gentamycin, Amikacin) + Vancomycin

23. HAP – Failure of Therapy
 Incorrect diagnosis – it is not pneumonia
– Atelectasis, CHF, PE with infarction, lung contusion,
chemical pneumonitis, ARDS, pulmonary hemorrhage
 Pathogen resistance
 Host factors that increase mortality
– Age > 60, prior pneumonia, chronic lung disease
– immunosuppression
 Antibiotic resistance

24. HAP - Prevention
 Hand washing
 Vaccination
– Influenza
– Pneumococcus
 Isolation of patients with resistant respiratory
tract infections
 Enteral nutrition
 Choice of GI prophylaxis
 Subglottoc secretion removal?

25. Special Cases!
• HIV
 Pneumocystis jirovecii
 Mycobacterium tuberculosis
 Cryptococcus
 Histoplasmosis
• Transplant Patients
 Fungi (Aspergillosis, Cryptococcus, Histoplasmosis)
 Nocardia
 CMV
• Neutropenic Patients
 Fungi ( Aspergillosis)
 Gram-negatives

26. More Special Cases
• Smokers: S. pneumo, H.
influenzae, M. catarrhalis
• Alcoholics: S. pneumo,
Klebsiella, anaerobes
• IV Drug User: S. aureus,
Pneumocystis, anaerobes
• Splenectomy: encapsulated
organisms (S. pneumo, H.
influenzae)
• Cystic fibrosis: Pseudomonas,
S. aureus
• Deer mouse exposure:
Hantavirus
• Bat exposure: Histoplasma
capsulatum
• Rat exposure: Yersinia pestis
• Rabbit exposure: Francisella
tularensis
• Bird Exposure: C. psitacci,
Cryptococcus neoformans
• Bioterrorism: Bacillus
anthracis, F. tularensis, Y.
pestis

27. Pneumococcal Vaccine
• What does it cover?
 Protects against 23 serotypes of Strep. Pneumoniae (90% of invasive pneumonia
infections)
• Who should get it?
 Anyone over age 65
 Anyone with chronic medical problem such as cancer, diabetes, heart disease, lung
disease, alcoholism, cirrhosis, sickle cell disease, kidney failure, HIV, damaged spleen
or no spleen, CSF leaks
 Anyone receiving cancer therapy, radiation, steroids
 Alaskan natives and certain Native American populations
• How often to get it?
 Give second dose if >5 years from first dose if > 65, cancer, damaged spleen, kidney
disease, HIV or any other condition lowering immune system function

28. Thank You