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PneumoniaPrognosis & Treatment

12/12/2011

Presented

By :-

Vijit

Agarwal,

B.Pharm

Pharm.D.

(PB), 1st

year

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Introduction

0 Pneumonia is an inflammation of the lung parenchyma (i.e. alveoli rather than the bronchi) of infective origin.

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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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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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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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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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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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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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Nosocomial pneumonia(HAP)

Pneumonia that was not incubating upon admission developing in a patient hospitalized for greater than 48 hrs.

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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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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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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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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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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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Chest X-rayFor Bronchopneumonia

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Bronchopneumonia

•Patchy consolidation usually in the bases of both lungs.

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Diagnosis

Clinical diagnosis0 History0 Signs & symptoms0 Chest x-ray0 CT

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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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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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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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Risk factors

1. Comorbidity- Neoplastic disease, neurological problem

2. Alcoholism3. Advanced age4. Asthma5. Immunosuppression

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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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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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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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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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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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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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Bacterial introduction into LRTEndotracheal intubationInfected ventillatiors / nebuliser /bronchoscopyDental or sinus infectionBacteraemiaAbdominal sepsisIntravenous canula

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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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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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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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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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Selection of an antimicrobial agent

0Empirical use of relatively broad spectrum antibiotic0Narrow spectrum antibiotics to cover specific

pathogen0Potential pathogens involved

0 Age0 Previous &current medication history0 Underlying disease0 Present clinical status

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Antibiotic doses for treating pneumonia

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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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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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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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7. For HAP:- Cephalosporins + Aminoglycocides

8. For antipseudomons cephalosporins:- Ceftazidime + Cefexime

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Drugs with usual doses

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