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Pneumonia

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					  A 41 year old man known case of DM
presents with 2 day history of
productive cough , fever and associted
with pleuritic chest pain. His cough is
productive of thick yellowish color.
  Vitals show
temperature 39.4 , BP 118/68 , Heart
rate 98, Respiratory rate 24 & O2 Sat.
86% on room air
  A 41 year old man known case of DM
presents with 2 day history of
productive cough , fever and associted
with pleuritic chest pain. His cough is
productive of thick yellowish color.
  Vitals show
temperature 39.4 , BP 118/68 , Heart
rate 98, Respiratory rate 24 & O2 Sat.
86% on room air
Case
On Examination
Respiratory exam shows bronchial breathing
in left middle zone with egophony &
decrease breath sound in left lower lung
base
C.V , Abdominal & GU exam are normal
What is the next step?
 Oxygen
 Chest X ray
 CBC, chemistry, electrolyte, blood
 culture, sputum culture and gram
 stain, urine antigen test, ABG
What are the radiological finding?
left lower lobe opacity with
pleural effusion.
What is the next step
Admission ??
Aspiration of pleural effusion ??
Monitor & Control of sugar,
 electrolyte, acid base disturbance
 and vitals
Start empirical antibiotic and
 symptomatic ttt
CBC show WBC count of 18,400 with shift
to left
  A 52 year old man is admitted with one
week history of dry cough , fever and
headache. He appeared obtunded,
tachypneic and was hypotensive.
 Two of his workmates have been admitted
in hospital with pneumonia in last month .
What the history suggest?
 semi-conscious, hypotensive and tachypneic
 Two of his workmates have been admitted

Chest X-ray & ABG have been
requested & done
What are the radiological finding?
Chest radiograph shows dense
consolidation in both lower lobes.
 On admission ABG show a
    PaO2 of 53 mmHg, PaCO2 of 46 mmHg
    pH 7.32 , HCO3 , oxygen sat. 86 on room air



What is the most likely diagnosis?
What is the next step?
 ABC : Oxygen mask , IV fluid
 Admission
 start empirical antibiotic treatment
 Send CBC, Chemistry and electrolytes Sputum for
 gram stain and culture, urine antigen test & blood
 culture
Diagnostic approach to
 community-acquired
 pneumonia in adults
General consideration
 More cases occurring during the winter months.
 Mechanism : microaspiration
 more than 100 microbes (bacteria, viruses, fungi,
  and parasites)
 Most common cause of pneumonia is strept.
  pneumoni
 Never forget Mycobacterium tuberculosis
Risk Factors
 Alcoholism, malnutrition, chronic pulmonary disease
 of any kind, cigarette smoking, infection with HIV,
 diabetes mellitus, cirrhosis of the liver, anemia, prior
 hospitalization for any reason, renal insufficiency, and
 coronary artery disease (with or without recognized
 congestive heart failure) , prior viral infection
            Types of CAP
 Typical (40-60%)
    Strep. Pneumonia
    H. influenza

    Maroxella

 Atypical (10-30%)
    Legionella
    Mycoplasma

    Chlamydia
Natural history of atypical
pneumonia
M. pneumoniae or C. pneumoniae infection is often self-
  limited but can cause severe CAP
Mycoplasma pneumonia
Is the most common atypical pathogens responsible for
  CAP in adults
Legionella pneumonia
Hyponatremia (Na 125-130 mmol/L) is more common
  than with other forms of pneumonia.
Delayed treatment significantly increases the associated
  mortality rate
Clinical Evaluation
Clinical Evaluation
Clinical Evaluation
Clinical Evaluation
Investigation
1. Chest X-ray
    Clinical features and radiographic changes
        are usually enough to start treatment .
    False negative chest radiographs may occure
        if it taken very early (<24 hr’s), dehydrated
        or in immunocompromised patient.
Investigation
1. Chest X-ray
    Clinical features and radiographic changes
        are usually enough to start treatment .
    False negative chest radiographs may occure
        if it taken very early (<24 hr’s), dehydrated
        or in immunocompromised patient.
Investigation
                    Why?


   False negative chest radiographs may occure if
      it taken very early (<24 hr’s), dehydrated or
      in immunocompromised patient.
Chlamydia pneumonia. Chest radiograph shows
multifocal, patchy consolidation in the right upper,
middle, and lower lobes.
Mycoplasma pneumonia. Chest
radiograph shows a vague, ill-defined
opacity in the left lower lobe
.
Investigation
1. X-ray
2. CBC, chemistry, electrolytes, Sputum for gram stain
   and culture, Blood culture, and pulse oxymetry or
   ABG !! Why?
            positive for a pathogen in 7 to 16 percent of hospitalized
             patients
3. Specific tests
        Legionella , C. pneumonia and Mycoplasma
        Bronchoscopy and bronchoalveolar lavage
Investigation
1. X-ray
2. CBC, chemistry, electrolytes, Sputum for gram stain
   and culture, Blood culture, and pulse oxymetry or
   ABG !! Why?
            positive for a pathogen in 7 to 16 percent of hospitalized
             patients
3. Specific tests
        Legionella , C. pneumonia and Mycoplasma
        Bronchoscopy and bronchoalveolar lavage
Urin Antigen Test
 Advantage:
   Detect              & S. pneumoniae
   rapid and relatively inexpensive
   For Legionella the sensitivity of 70% and a specificity
    of approximately 95%
 Disadvantage:
   For S. pneumoniae the sensitivity and specificity may
    be less in patients without bacteremia
   Can confirm infection but cannot guied the antibiotic
    therapy.
  How to Make the Decision to
  Admit
 Most difficulty encountered in decision of the
 appropriate site of care
the decision to admit
 assessment of patient prognosis and
  selection of an appropriate site of care.
 The 2007 consensus guidelines from
  IDSA and the ATS recommend either
  the CURB-65 or Pneumonia Severity
  Index (PSI)
     CURB-65 uses five prognostic
              variables
 Confusion (based upon a specific mental test or
 disorientation to person, place, or time)
     CURB-65 uses five prognostic
              variables
 Confusion (based upon a specific mental test or
  disorientation to person, place, or time)
 Urea (blood urea nitrogen in the United States) >7
  mmol/L (20 mg/dL)
     CURB-65 uses five prognostic
              variables
 Confusion (based upon a specific mental test or
  disorientation to person, place, or time)
 Urea (blood urea nitrogen in the United States) >7
  mmol/L (20 mg/dL)
 Respiratory rate >30 breaths/minute
     CURB-65 uses five prognostic
              variables
 Confusion (based upon a specific mental test or
  disorientation to person, place, or time)
 Urea (blood urea nitrogen in the United States) >7
  mmol/L (20 mg/dL)
 Respiratory rate >30 breaths/minute
 Blood pressure [BP] (systolic <90 mmHg or diastolic
  <60 mmHg)
       CURB-65 uses five prognostic
                variables
 Confusion (based upon a specific mental test or
    disorientation to person, place, or time)
   Urea (blood urea nitrogen in the United States) >7
    mmol/L (20 mg/dL)
   Respiratory rate >30 breaths/minute
   Blood pressure [BP] (systolic <90 mmHg or diastolic
    <60 mmHg)
   Age >65 years
 Other requirement for hospital
 admission
 pneumonia complications (e.g. hypoxia persist &
  respiratory Acidosis )
 exacerbation of underlying disease
 inability to take oral medication
 issues affecting outpatient care like living
 situation
 Comorbid illness (e.g. HF, DM, RF, neurological
  dysfunction, Malnourished and postsplenectomy
  state…)
Pneumonia severity index
 This scoring system evaluates 20 different clinical and
 laboratory indices

Age                                         Coexisting Illnesses
Nursing home resident                       Neoplastic disease
Laboratory                                  Liver disease
                                            Congestive heart failure
Arterial pH <7.35                           Cerebrovascular disease
Blood urea nitrogen >30 mg/dL (11 mmol/L)   Renal disease
Sodium <130 mmol/L                          Physical Examination
Glucose >250 mg/dL (14 mmol/L)              Altered mental status
Hematocrit <30%                             Respiratory rate >30 breaths per min
                                            Systolic blood pressure <90 mm Hg
PaO2 <60 mm Hg                              Temperature <35°C (95°F) or >40°C (104°F
Pleural effusion                            Pulse rate >125 breaths per min
  Risk class I - Older than 50 years, no preexisting
    illness or vital sign abnormality
  Risk class II - < 70 points
  Risk class III - 71-90 points
  Risk class IV - 91-130 points
  Risk class V - > 131 points


classes I and II treated     with
planned outpatient follow-up
evaluations.
   Risk class I - Older than 50 years, no preexisting
     illness or vital sign abnormality
   Risk class II - < 70 points
   Risk class III - 71-90 points
   Risk class IV - 91-130 points
   Risk class V - > 131 points


class III observed                    before their
disposition is decided.
  Risk class I - Older than 50 years, no preexisting
    illness or vital sign abnormality
  Risk class II - < 70 points
  Risk class III - 71-90 points
  Risk class IV - 91-130 points
  Risk class V - > 131 points


classes IV and V require
to the hospital.
Management
 Close monitoring of vital signs, O2 saturation and ABG
  result
 If level of conscious deteriorate look for evidence of sepsis
  or organ dysfunction.
 suctioning of secretions & chest physiotherapy
 proper hydration, nutrition & early mobilization
 Treatment of underlying disese
Antibiotic Treatment

Antibiotic should be reevaluated
    based on lab. result and
        clinical response
Antibiotic Treatment
 for MRSA
   Vancomycin or linezolid(be aware of
    possibility of false positive)
 for Pseudomonas
    piperacillin/tazobactam, imipenem,
      meropenem, or cefepime
Antibiotic Treatment
  Follow up

Antibiotic therapy should not be stopped until
 the patient is afebrile for 48 to 72 hours and is
 clinically stable.
Follow up
Clinical improvement should be observed in 48-72
 hours.
cough resolves within 8 to 14 days and crackles heard
 on auscultation clear within 3 weeks.
The chest radiograph usually clears within 4 to 12
 weeks according to individual health state and
 underlying lung disease
             Follow up
When patient can be switched to oral
 therapy?
Follow up
If discharged to continue treatment as out patient:
    Patients should be instructed to return if their
     condition deteriorates.
    Patients should be told that some symptoms can last
     up to 30 days (e.g. fatigue, cough with or without
     sputum production, dyspnea & chest pain).
    follow-up chest radiograph in approximately 6 weeks
     to ensure resolution of consolidation to exclude
     endobronchial obstruction .
Follow up
If no improvement within 72 hours??

      Wrong drug
      Wrong dose
      Wrong Diagnosis
Follow up
If no improvement within 72 hours??
1. Organism that is not covered by the initial empiric
    antibiotic regimen
2. Secondary to drug resistance
3. Nonbacterial infection or unusual pathogens (e.g.
    PCP , TB)
4. Drug fever
5. Complication such as empyema or abscess.
6. Other differential diagnosis (e.g. malignancies,
    inflammatory conditions, PE, HF…)
Follow up
If no improvement within 72 hours??
1. Organism that is not covered by the initial empiric
    antibiotic regimen
2. Secondary to drug resistance
3. Nonbacterial infection or unusual pathogens (e.g.
    PCP , TB)
4. Drug fever
5. Complication such as empyema or abscess.
6. Other differential diagnosis (e.g. malignancies,
    inflammatory conditions, PE, HF…)
Re-evaluate
nonresponse is seen in about in 6 to 15%
  of whom require hospitalization
If Patients show no clinical improvement
  within 72 hours are considered
  nonresponders
Re-evaluate
     careful history, physical examination, and
 review of the medical record.
       careful observation with or without
 therapy is warranted for 4 to 8 weeks if no
 improving or progression of disease
       chest CT & fiberoptic bronchoscopy
 (diagnose 90% of cases) should be considered
      If negative, further evaluation with
 thoracoscopic or open lung biopsy may be
 necessary.
Immunocompromised
 Early imaging (CT scan) is critical, bronchoscopy &
  biopsy can be concedered
 Empiric therapy should started early
Immunocompromised
 In severely ill patients with Legionella pneumonia
  rifampin may be recommended for use in combination
  with macrolides .
 The duration of therapy can be extended to 21 day.
        General Consideration
 Patients without spleen may die of pneumococcal
  pneumonia and sepsis
 pulmonary consolidation is found only at autopsy (not x-
  ray)
defective clearance of pneumococci from the bloodstream,
death may occur in as little as 24 h


      Pattern of infection could be Community-
        acquired, Nosocomial or Reactivation
Clinical Evaluation
   In elderly & immunocompromised may have
    minimal cough, no sputum production, and no fever
    & minimal signs on physical exam
        1.   respiratory rate above 24 breaths/minute (45 to 70
             percent of patients)
        2.   Tachycardia
        3.   Tiredness & confusion.
Common organism
1.   Aspiration?
         Anaerobe
2. Alcoholic and drug abuser ?
         Increase incidence of Klebsiella
3. COPD ?
         Increase incidence of H. influenza & Pseudomonus.
4. Immunocompromised?
         Staph. , Viral , PCP…
A 52-year-old woman developed fever, cough, and dyspnea. She
also developed a rash that was prominent over the face and the
trunk. The chest radiograph showed interstitial infiltrates, with
suggestion of a micronodular process. The Tzanck smear results
from the skin vesicle suggest

				
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posted:2/19/2012
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