Pneumonia Diagnosis and treatment
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1
PneumoniaPrognosis & Treatment
12/12/2011
Presented
By :-
Vijit
Agarwal,
B.Pharm
Pharm.D.
(PB), 1st
year
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Pneumonia 2
Introduction
0 Pneumonia is an inflammation of the lung parenchyma (i.e. alveoli rather than the bronchi) of infective origin.
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Pneumonia 3
0 It is the most common infectious cause of death.
0 It is usually characterized by consolidation.
0 Consolidation is a pathological process in which the alveoli are filled with a mixture of inflammatory exudate, bacteria & WBC
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Pneumonia 4
EPIDEMIOLOGY
0Occurs throughout the year0Results from different etiological agents
varying with the seasons0Occurs in persons of all ages0Clinical manifestations severe in very
young, elderly & in chronically ill patients
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Pneumonia 5
CLASSIFICATIONClassified based on two types 1. Type 10 Lobar pneumonia0 Bronchopneumonia
2. Type 20 Community- acquired pneumonia (CAP)0 Hospital-acquired pneumonia (HAP)
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Pneumonia 6
Lobar pneumonia0 Lobar pneumonia is acute bacterial infection of a part of
lobe the entire lobe, or even two lobes of one or both the lungs.
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Pneumonia 7
Bronchopneumonia
0 Bronchopneumonia is infection of the terminal bronchioles that extends into the surrounding alveoli resulting in patchy consolidation of the lung.
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Pneumonia 8
Community Acquired Pneumonia (CAP)
Pneumonia which develops in an otherwise healthy person outside of hospital or have been in hospital for less than 48hrs
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Pneumonia 9
Nosocomial pneumonia(HAP)
Pneumonia that was not incubating upon admission developing in a patient hospitalized for greater than 48 hrs.
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Pneumonia 10
PATHOPHYSIOLOGY
Microbial invasion of the normally sterile lower respiratory tract
Three routes-0 Inhaled as aerosolized particles
0 Haematogenous spread from an extrapulmonary site of infection
0 Aspiration of oropharyngeal contents12/12/2011
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Pneumonia 11
Various defence mechanisms that protects lung from
infection0 Anatomic barriers –epiglottis, larynx0 Cough reflexes0 Tracheobronchial secretions0 Mucocilliary lining0 Cell & humoral mediated immunity0 Dual phagocytic system-alveolar macrophages &
neutrophils
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Pneumonia 12
Invasion occurs as a result of
0 Defect in host defence mechanism
0 Overwhelming inocculum
0Lung infection with viruses suppress the antibacterial activity of the lung by impairing alveolar macrophage function & mucocilliary clearance thus setting the stage for secondary bacterial pneumonia.
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Pneumonia 13
Clinical Manifestations0 Indolent to fulminant in presentation0 Mild to fatal in severity0 Typical symptoms –• Fever • Chills• Cough• Rust coloured sputum• Mucopurulent sputum• Dyspnea ( shortness of breath)• Pleuritic chest pain0 Elevated WBC0 Bacteraemic
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Pneumonia 14
Chest X-rayFor Lobar Pneumonia
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Lobarpneumonia
Consolidation confined to one or more lobes (or segments of lobes) of lungs.
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Pneumonia 15
Chest X-rayFor Bronchopneumonia
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Bronchopneumonia
•Patchy consolidation usually in the bases of both lungs.
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Pneumonia 16
Diagnosis
Clinical diagnosis0 History0 Signs & symptoms0 Chest x-ray0 CT
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Pneumonia 17
Diagnosis
Etiological diagnosis0 Gram's Stain and Culture of Sputum0 Blood Cultures0 Antigen Tests0 Polymerase Chain Reaction0 Serology0 Bronchoalveolar lavage0 Bronchoscopy
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Pneumonia 18
Complications
Possible complications include:0 Acute respiratory distress syndrome (ARDS)0 Fluid around the lung (pleural effusion)0 Lung abscesses0 Respiratory failure (which requires a breathing
machine or ventilator)0 Sepsis, which may lead to organ failure
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Pneumonia 19
COMMUNITY ACQUIRED PNEUMONIA
Pneumonia is most common in winter because of seasonal increase in viral infections
Mortality 1%- Non hospitalized patients 13.7%-Hospiatalized patients 19.6%-Bacteremic patients <36.5%- Intensive care unit
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Pneumonia 20
Risk factors
1. Comorbidity- Neoplastic disease, neurological problem
2. Alcoholism3. Advanced age4. Asthma5. Immunosuppression
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Pneumonia 21
Etiology
Potential etiologic agents in CAP - Bacteria Viruses
Fungi Protozoa Potential bacteriologic causes can be divided into two types
0 Typical bacterial pathogens0 Atypical bacterial pathogens
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Pneumonia 22
Typical bacterial pathogens
0 Streptococcus pneumoniae – 30% to 60% ,Severe illness, death
0 Haemophilus influenzae - 10%0 S. aureus (in selected patients)0 gram-negative bacilli – Klebsiella pneumoniae
Pseudomonas aeruginosa
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Pneumonia 23
Atypical bacterial pathogens
0 Mycoplasma pneumoniae0 Chlamydophila pneumoniae0 Legionella pneumophillia0 These organisms are intrinsically resistant to all - B lactam
agents macrolide, a fluoroquinolone, or a tetracycline.0 Poor dental hygiene-anaerobes0 HIV- p.carnii0 Birds- Chlamydia psittaci0 Cattle or parturient cat-Coxiella burnetti
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Pneumonia 24
HOSPITAL ACQUIRED PNEUMONIA
0 Pneumonia that was not incubating upon admission developing in a patient hospitalized for greater than 48 hrs
0 10-15% of all hospital acquired pneumonia, usually presenting with sepsis or&/or respiratory failure
0 50% acquired on ICU
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Pneumonia 25
Predisposing features
Reduced host defence against bacteria0 Reduced immune defences (Corticosteroid treatment,
diabetes, malignancy)0 Reduced cough reflux (Post operative)0 Disordered mucocilliary clearance (Anaesthetic agents)Aspiration of nasopharyngeal or gastric secretions0 Immobility or reduced conscious level0 Vomiting, Dysphagia,0 Nasogastric intubation
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Pneumonia 26
0 Most bacterial nosocomial infection occur by microaspiration of bacteria colonizing the patients oropharynx or upper GI tract
0 Most common pathogen – Aerobic gram negative bacilli0 Most commonly exposed to multiresistant hospital
pathogen0 86% nosocomial infection-mechanical ventilation0 Mortality-0 to 50%
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Pneumonia 27
Bacterial introduction into LRTEndotracheal intubationInfected ventillatiors / nebuliser /bronchoscopyDental or sinus infectionBacteraemiaAbdominal sepsisIntravenous canula
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Pneumonia 28
Causative organisms
Common organismsGram negative bacteria-0 Escherichia coli0 Klebsiella sp.0 Pseudomonas aeruginosaGram positive bacteria-0 Streptococcus pneumoniae0 Staphylococcus aureus
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Pneumonia 29
Less common organisms1. Gram negative bacilli other coliforms:Enterobacter sp.0 Proteus sp.0 Seratia marcescens0 Citrobacter sp.0 Acinobacter sp.0 Legionella pneumophillia2. Anaerobic bacteria3. Fungi- Candida albicans Aspergillus fumigatus4. Viruses- Cytomegalovirus (CMV), Herpes simplex
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Pneumonia 30
Treatment
Goals of therapy-
0 Eradication of the offending organism.
0 Selection of an appropriate antibiotic.
0 To minimize associated morbidity.
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Pneumonia 31
General approach to treatment
0 Adequacy of respiratory function0 Humidified oxygen for hypoxemia0 Bronchodilators (albuterol)0 Chest physiotherapy with postural drainage0 Adequate hydration if necessary0 Expectorants such as guaifenesin0 Chest pain- analgesics
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Pneumonia 32
Selection of an antimicrobial agent
0Empirical use of relatively broad spectrum antibiotic0Narrow spectrum antibiotics to cover specific
pathogen0Potential pathogens involved
0 Age0 Previous ¤t medication history0 Underlying disease0 Present clinical status
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Pneumonia 33
Antibiotic doses for treating pneumonia
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Pneumonia 34
Treatment for special cases
1. Patient less than 60 years & without comorbidities:- Azithromycine ( 500mg OD) *1day ( 250mg OD) *4days Norfloxacin/Levofloxacin (400mg OD) *7days
2. Outpatient greater than 65 years:- Norfloxacin (400mg OD) *7days or Ceftriaxon (1-2 g/day) / Cifixim (2-4 g/day) 3rd gen
cefalosporins +
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Pneumonia 35
Macrolides like Azithromycin ( 500mg OD) *1day ( 250mg OD) *4days3. Patient is hospitalised but not severely ill:- Combination of 3rd gen cefalosporins + Macrolides Ceftriaxone + Azithromycin OR Norfloxacin/Levofloxacin (400mg OD)4. If the patient is hospitalised but not severely ill:- Combination of 3rd gen cefalosporins + Macrolides Ceftriaxone + Azithromycin and newer fluroquinolones (Gatifloxacin)
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Pneumonia 36
5. Patient hospitalised & severely ill:- Combination of 3rd gen cefalosporins + Macrolides Ceftriaxone + Azithromycin and newer fluroquinolones (Gatifloxacin) We can add Vancomycin.6. Patient with icu admission:- 3rd gen cefalosporins + Fluroquinolones
(Gatifloxacin) + Nutritional supplements + Saline Vancomycin/Meropenam
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Pneumonia 37
7. For HAP:- Cephalosporins + Aminoglycocides
8. For antipseudomons cephalosporins:- Ceftazidime + Cefexime
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Pneumonia 38
Drugs with usual doses
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Pneumonia 3912/12/2011
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Pneumonia 4012/12/2011
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Pneumonia 4112/12/2011